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Basic Trauma And Burn Management

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Information about Basic Trauma And Burn Management

Published on September 18, 2007

Author: shivabirdi

Source: slideshare.net

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Trauma and Burn Management ® D.F.Naylor, Jr., MD, FACS, FCCS Staff Intensivist September 13,2007

D.F.Naylor, Jr., MD, FACS, FCCS

Staff Intensivist

September 13,2007

Objectives Review initial assessment of the trauma patient Outline treatment of life-threatening injury Discuss use of radiography to identify injury Outline response to changes in patient’s status Discuss early burn management ®

Review initial assessment of the trauma patient

Outline treatment of life-threatening injury

Discuss use of radiography to identify injury

Outline response to changes in patient’s status

Discuss early burn management

Trauma Care Principles Simultaneous assessment and treatment through a standardized approach If no improvement or decline in status, start over at primary assessment Early surgical involvement ®

Simultaneous assessment and treatment through a standardized approach

If no improvement or decline in status, start over at primary assessment

Early surgical involvement

Primary Assessment – Airway / Breathing Assume cervical spine injury Airway assessment and management Effects of facial/mandibular fracture Laryngeal/tracheal injury – ecchymosis, hoarseness, edema, subcutaneous air Flail chest from rib fractures Pneumo- / hemothoraces ®

Assume cervical spine injury

Airway assessment and management

Effects of facial/mandibular fracture

Laryngeal/tracheal injury – ecchymosis, hoarseness, edema, subcutaneous air

Flail chest from rib fractures

Pneumo- / hemothoraces

Primary Assessment – Circulation Hemorrhage is most common cause of shock Establish large-bore venous access Initiate fluid resuscitation with lactated Ringer’s solution Follow with packed red blood cells after 2–3 L of crystalloid Control external hemorrhage by compression Monitoring – data flow sheet, vital signs, ECG, pulse oximetry, CVP, arterial line ®

Hemorrhage is most common cause of shock

Establish large-bore venous access

Initiate fluid resuscitation with lactated Ringer’s solution

Follow with packed red blood cells after 2–3 L of crystalloid

Control external hemorrhage by compression

Monitoring – data flow sheet, vital signs, ECG, pulse oximetry, CVP, arterial line

Hemorrhage Classification Hemorrhage Blood Blood class loss loss (mL) (%) I <750 <15 II 750–1500 15–30 III 1500–2000 30–40 IV >2000 >40

Hemorrhagic Shock Chest – hemothorax; drain and monitor Abdominal Intraperitoneal (lavage or sonography) FAST Retroperitoneal (CT scan) STABLE YES/NO  Operative intervention Pelvis – usually venous; consider embolization, external stabilization ( Wrap with Sheet) ®

Chest – hemothorax; drain and monitor

Abdominal

Intraperitoneal (lavage or sonography) FAST

Retroperitoneal (CT scan) STABLE YES/NO 

Operative intervention

Pelvis – usually venous; consider embolization, external stabilization ( Wrap with Sheet)

Nonhemorrhagic Shock Tension pneumothorax Tube thoracostomy AFTER NEEDLE DECOMPRESSION ! Cardiac tamponade Consider mechanism of injury Venous hypertension with shock Pericardial window preferred over needle pericardiocentesis

Tension pneumothorax

Tube thoracostomy

AFTER NEEDLE DECOMPRESSION !

Cardiac tamponade

Consider mechanism of injury

Venous hypertension with shock

Pericardial window preferred over needle pericardiocentesis

Nonhemorrhagic Shock Blunt cardiac injury Consider mechanism of injury ECG nonspecific Cardiac enzymes rarely helpful Monitor at least 4 hours Neurogenic shock Cervical/thoracic spinal cord injury Associated bradycardia, (warm and slow)

Blunt cardiac injury

Consider mechanism of injury

ECG nonspecific

Cardiac enzymes rarely helpful

Monitor at least 4 hours

Neurogenic shock

Cervical/thoracic spinal cord injury

Associated bradycardia, (warm and slow)

Secondary Assessment Identify potentially life-threatening injuries History of event, medical history, drugs, allergies, tetanus immunization AMPLE Head to toe examination Fully expose patient Correct and prevent hypothermia Assess for signs of urethral injury FINGER OR TUBE IN EVERY ORFICE ! Neurovascular integrity ®

Identify potentially life-threatening injuries

History of event, medical history, drugs, allergies, tetanus immunization

AMPLE

Head to toe examination

Fully expose patient

Correct and prevent hypothermia

Assess for signs of urethral injury

FINGER OR TUBE IN EVERY ORFICE !

Neurovascular integrity

Secondary Assessment Laboratory data – arterial blood gas, blood counts, electrolytes, coagulation studies, type and cross-match, urinalysis, toxicology, etc Radiograph review Cervical spine – complete survey Chest – mediastinal evaluation; tubes/catheters Pelvis – major fractures Cystogram  urethrogram Skeletal exam

Laboratory data – arterial blood gas, blood counts, electrolytes, coagulation studies, type and cross-match, urinalysis, toxicology, etc

Radiograph review

Cervical spine – complete survey

Chest – mediastinal evaluation; tubes/catheters

Pelvis – major fractures

Cystogram  urethrogram

Skeletal exam

Secondary Assessment CT scan of head CT scan of abdomen if indicated Other issues Nasogastric tube Tetanus prophylaxis Prior Immune Status HyperTet? Antibiotic indications Specialty consultation

CT scan of head

CT scan of abdomen if indicated

Other issues

Nasogastric tube

Tetanus prophylaxis

Prior Immune Status HyperTet?

Antibiotic indications

Specialty consultation

Tertiary Assessment Detailed examination to detect all injuries Serial examinations over time to detect change and occult injuries Return to primary/secondary survey strategies for worsening status Surgical consultation/transfer planning DOCTORS SPEAK TO DOCTORS ! ®

Detailed examination to detect all injuries

Serial examinations over time to detect change and occult injuries

Return to primary/secondary survey strategies for worsening status

Surgical consultation/transfer planning

DOCTORS SPEAK TO DOCTORS !

Compartment Syndromes Abdomen Compromise of venous return due to high intra-abdominal pressure Secondary to free blood, fluid, edema of abdominal contents Evaluate with measure of intrabladder pressure Surgical decompression ACS = IAH > 25 + Organ Dysfunction

Abdomen

Compromise of venous return due to high intra-abdominal pressure

Secondary to free blood, fluid, edema of abdominal contents

Evaluate with measure of intrabladder pressure

Surgical decompression

ACS = IAH > 25 + Organ Dysfunction

Compartment Syndromes Extremity Serial examinations Pain, pallor, pulselessness, paresthesias, paralysis Fasciotomy Know Sensory only sites Thumb Web, Great Toe 1st Metatarsal

Extremity

Serial examinations

Pain, pallor, pulselessness, paresthesias, paralysis

Fasciotomy

Know Sensory only sites Thumb Web, Great Toe 1st Metatarsal

Burn Injury – Primary Assessment Airway/breathing Upper and lower airway injury Carbon monoxide exposure Bronchoscopy for evaluation Consider early intubation Avoid succinylcholine ®

Airway/breathing

Upper and lower airway injury

Carbon monoxide exposure

Bronchoscopy for evaluation

Consider early intubation

Avoid succinylcholine

Burn Injury –  Primary Assessment Circulation Establish intravenous access Crystalloid resuscitation based upon extent and severity of burns Assess for circumferential injury Evaluate for other injuries ®

Circulation

Establish intravenous access

Crystalloid resuscitation based upon extent and severity of burns

Assess for circumferential injury

Evaluate for other injuries

Assessment of Burn Severity First-degree Erythema and pain Second-degree (partial-thickness) Red, swollen, blisters, weeping, painful Third-degree (full-thickness) White, leathery, painless Rule of Nines

First-degree

Erythema and pain

Second-degree (partial-thickness)

Red, swollen, blisters, weeping, painful

Third-degree (full-thickness)

White, leathery, painless

Resuscitation –  Burn Shock Primary fluid loss from wound Secondary nonburn edema SIRS Principles Avoid excess fluid resuscitation but maintain organ perfusion Replace components of fluids lost as well as volume Replace blood as needed ®

Primary fluid loss from wound

Secondary nonburn edema SIRS

Principles

Avoid excess fluid resuscitation but maintain organ perfusion

Replace components of fluids lost as well as volume

Replace blood as needed

Resuscitation – Burn Shock Lactated Ringer’s solution – crystalloid of choice Various formulae for amount and type of crystalloid and colloid resuscitation Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs TIme 0 = Time of Injury not arrival in ED Aim for urine output 0.5-1 ml/kg/hr Cautious use of analgesia

Lactated Ringer’s solution – crystalloid of choice

Various formulae for amount and type of crystalloid and colloid resuscitation

Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs

TIme 0 = Time of Injury not arrival in ED

Aim for urine output 0.5-1 ml/kg/hr

Cautious use of analgesia

80 KG Male involved in Closed space Fire 50 % TBSA 2 nd Degree Burns arrives instantaneously in ED Calculate Parkland Fluid Requirements Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs SO 4 x 50 x 80 = 16000 ccs/first 24 hours ONE LITER /hour for 8 hours IF he arrived after an 8 hour transport from OSH— without IVF 8000 ccs + 500 cc’s first hour

80 KG Male involved in Closed space Fire 50 % TBSA 2 nd Degree Burns arrives instantaneously in ED

Calculate Parkland Fluid Requirements

Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs

SO 4 x 50 x 80 = 16000 ccs/first 24 hours ONE LITER /hour for 8 hours

IF he arrived after an 8 hour transport from OSH— without IVF

8000 ccs + 500 cc’s first hour

Burn Wound Care Gently wash and cover prior to transport Remove rings, bracelets Burn dressings controversial before transfer When in Doubt 0.9 NS Dampened Gauze Consultation for specific wound care Ask about Dressings, Mention Airway, Chemicals + ®

Gently wash and cover prior to transport

Remove rings, bracelets

Burn dressings controversial before transfer

When in Doubt 0.9 NS Dampened Gauze

Consultation for specific wound care

Ask about Dressings, Mention Airway, Chemicals +

Chemical Burns Injury is caused by concentration of agent and duration of exposure Remove patient from source Remove clothing Brush off dry agent Irrigate copiously with water Protect Good Guys

Injury is caused by concentration of agent and duration of exposure

Remove patient from source

Remove clothing

Brush off dry agent

Irrigate copiously with water

Protect Good Guys

Electrical Injury Entry and exit wounds Secondary skin burns at distant sites Flame burns from clothes Cardiac arrest Secondary injury –  falls, muscle contraction, etc. Rhabdomyolysis and compartment syndromes

Entry and exit wounds

Secondary skin burns at distant sites

Flame burns from clothes

Cardiac arrest

Secondary injury –  falls, muscle contraction, etc.

Rhabdomyolysis and compartment syndromes

Pediatric Considerations Same general principles as for adults Orotracheal intubation with in-line stabilization Greater risk of injury after cricothyrotomy Diagnostic peritoneal lavage used less frequently  Body surface area/body mass so higher risk of hypothermia ®

Same general principles as for adults

Orotracheal intubation with in-line stabilization

Greater risk of injury after cricothyrotomy

Diagnostic peritoneal lavage used less frequently

 Body surface area/body mass so higher risk of hypothermia

Pediatric Considerations Initial crystalloid bolus 20 mL/kg Hypotension is late finding of severe hypovolemia Blood added when crystalloid infusion >40 mL/kg Initial blood transfusion = 10 mL/kg ®

Initial crystalloid bolus 20 mL/kg

Hypotension is late finding of severe hypovolemia

Blood added when crystalloid infusion >40 mL/kg

Initial blood transfusion = 10 mL/kg

Pediatric Considerations Consider child abuse when discrepancies exist between history and physical examination Laboratory Skull and skeletal radiographs Fundoscopic exam for hemorrhage WHEN IN DOUBT REPORT IT OUT ! ®

Consider child abuse when discrepancies exist between history and physical examination

Laboratory

Skull and skeletal radiographs

Fundoscopic exam for hemorrhage

WHEN IN DOUBT REPORT IT OUT !

Key Points

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