Trauma is the leading cause of death in the first four decades of life and the third leading cause of death overall, trailing only cancer and coronary artery disease. Approximately 60 million injuries occur annually in the United States. Although approximately 150,000 traumatic deaths occur annually, the rate of disability from trauma is three times greater than mortality. Therefore, issues relating to trauma care are of importance to all medical and surgical specialists, from the trauma surgeon to the rehabilitation specialist.
Death due to trauma has been shown to occur in a trimodal distribution, during three identifiable time periods. The first peak of death occurs within seconds to minutes of injury. Lethal injury to the body's vital anatomic structures leads to rapid death, unless immediate advanced intervention is performed. The second peak of death occurs within minutes to several hours after the injury. Death during this second period is usually due to progressive neurologic, cardiovascular, or pulmonary compromise. It is during this intermediate period that patients have the greatest chance of salvage and toward which organized trauma care is focused. Rapid resuscitation, coupled with the identification and treatment of potentially lethal injuries, is the goal. The final third peak of death occurs several days to weeks after initial injury, usually secondary to sepsis and multiorgan system failure.
This chapter discusses trauma management during the aforementioned second period. Specifically, the steps of the initial assessment performed when the trauma patient arrives at the hospital emergency room, the primary survey of the patient (ABCs), resuscitation, the secondary survey (head to toe), and the institution of definitive care are examined.
PRIMARY SURVEY
The focus of the primary survey is to identify immediately life-threatening conditions and to prevent death. Without a patent airway, adequate gas exchange, or sufficient intravascular volume, any patient will die. Therefore, a simple mnemonic—ABCDE—is used to direct the primary survey:
The principle here is that injuries are fixed as they are discovered, and this algorithm is to remind the physician not to get distracted by obvious injuries. For example, a common exam question goes something like this: "A patient is admitted to the emergency department after a crush injury to the left upper extremity such that three fingers have been severed and one is attached only by a thin piece of skin. What is your first intervention?" It is important to demonstrate awareness that the airway should be assessed first. This should take approximately 15 to 30 seconds if there are no abnormalities.
(A) AIRWAY
The airway is immediately inspected to ensure patency and that any causes of airway obstruction are identified (foreign body, facial fracture, tracheal/laryngeal disruption, cervical spine injury). Cervical spine control must be maintained at all times—patients with multitrauma
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must be assumed to have cervical spine injury until cleared radiographically. The chin thrust and jaw lift are methods of initially establishing airway patency while simultaneously protecting the cervical spine. Conscious patients should be asked to open their mouths, which should be inspected, and then to talk. This establishes at least a partially open conduit from the lungs to the outside world.
Airway control in the conscious patient can be achieved with an easily inserted nasopharyngeal trumpet; an oropharyngeal airway is used in the unconscious patient. Definitive control of the airway and enhanced ability to ventilate and oxygenate the patient are achieved with endotracheal intubation. Tube placement may be via the nasal or oral route. Nasotracheal intubation is a useful technique for patients with cervical spine injuries; however, it is contraindicated when midface or basilar skull fractures are suspected. When the trachea cannot be intubated, as might occur with severe swelling or multiple fractures, a surgical airway is indicated and should not be delayed. Jet insufflation of the airway after needle cricothyroidotomy can adequately oxygenate patients for 30 to 45 minutes. Surgical cricothyroidotomy with the insertion of a tracheostomy or endotracheal tube allows prolonged ventilation and oxygenation. This is best achieved via a longitudinal incision that avoids the anterior jugular veins, which can bleed significantly. The cricoid cartilage is palpated, and a transverse incision is made, into which a tracheostomy tube can be placed.
(B) BREATHING
Once airway patency is established, the patient's ability to breathe must be assessed. Normal function of the lungs, chest wall, and diaphragm is necessary for ventilation and gas exchange to occur. Four entities should be of particular concern: open pneumothorax, tension pneumothorax, hemothorax, and flail chest. Each can lead to rapid death resulting from respiratory compromise. A mnemonic to remember this is to repeat "open, tension, hemo, flail" a number of times. It has a regular cadence, and with enough repetition, it will come quickly back to you when performing the breathing survey.
Open pneumothorax occurs when the integrity of the chest wall is compromised so that diaphragmatic motion and decreased intrathoracic pressure cause air to enter the chest through the hole in the chest instead of through the mouth. In this case, the lung will not expand. Treatment requires closure of the chest wall defect and placement of a chest tube. Intubation will also solve this problem because the positive pressure will expand the lungs.
Tension pneumothorax occurs when an injury to the lung parenchyma allows air to escape into the pleural space. Often this will result in a simple pneumothorax, but if a valve effect occurs in which the air cannot escape out of the plural space back into the lung, pressure in the pleural space will continue to increase. This will render half of the lung useless for gas exchange, and cause tremendous pressure (tension) on the mediastinum, pushing all structures away from the side of the tension pneumothorax. This will impair venous return to the heart and will be fatal if not recognized and treated (Fig. 27-1). The clinical picture of hypotension, tachycardia, tracheal deviation, neck vein distention, and diminished unilateral breath sounds suggests the diagnosis of tension pneumothorax. Immediate decompression by inserting a needle catheter into the second intercostal space in the midclavicular line is indicated, followed by definitive treatment with chest tube insertion into the fifth intercostal space at the anterior axillary line just lateral to the nipple.
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Figure 27-1 • Chest x-ray reveals a right-sided tension pneumothorax. The right lung is collapsed and the increased pressure in the right chest displaces the heart and other mediastinal structures to the left. From Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2004. |
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Hemothorax occurs as a result of a ruptured blood vessel in the pleural space, which fills up with blood and compromises gas exchange (Fig. 27-2). This can cause life-threatening pulmonary compromise or hypotension. Treatment involves tube thoracostomy and operation if bleeding continues.
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Figure 27-2 • Chest film reveals a left-sided hemothorax. The left lung is compressed by the blood, and the mediastinum is shifted to the right. From Harwood-Nuss A, Wolfson AB, Lyndon CH, et al. The Clinical Practice of Emergency Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001. |
Flail chest occurs when multiple rib fractures prevent normal expansion of the lungs. In this case, there may be paradoxical collapse of a portion of the chest on inspiration (Fig. 27-3). This can be life-threatening if severe and is intensely painful. Often there is severe underlying lung contusion, which impairs gas exchange. Treatment of pain with rib blocks may improve ventilation. Intubation will allow lung expansion for the same reason for open pneumothorax.
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Figure 27-3 • Flail chest. The paradoxical motion of the chest cavity is shown. (top) As the patient inhales (diaphragm moves down), the flail segment collapses, because the compromised chest wall can no longer resist the decreased intrathoracic pressure. In contrast, on expiration (bottom), exhalation causes a bowing out of the flail segment. In these ways, flail chest results in dramatic impairments in lung function. Illustration by Neil O. Hardy, Westpoint, CT. |
Examination of the chest during the primary survey includes observation, palpation, and auscultation. Observation may reveal asymmetries in expansion, suggesting pneumothorax or hemothorax, or an open, sucking wound. Palpation of the trachea may reveal deviation, and palpation of the chest wall may reveal flail segments or asymmetrical excursion. Auscultation may reveal diminished breath sounds as occurs in pneumo- and hemothoraces.
(C) CIRCULATION
Hypotension in the trauma patient is caused by blood loss until proven otherwise. There are only five places to put enough blood to make someone hypotensive, so these areas require specific attention: chest, abdomen, retroperitoneum, thighs, and outside world. External hemorrhage can usually be identified and controlled by direct manual pressure. Tourniquets should be avoided, because they cause distal ischemia. Internal hemor-rhage is more difficult to identify. Therefore, hypotension
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without signs of external hemorrhage must be assumed to be due to intra-abdominal or intrathoracic injury or from fractures of the pelvis or long bones. The hypovo-lemic hypotensive patient usually exhibits a diminished level of consciousness as cerebral blood flow is reduced, the pulse is rapid and thready, and the skin is pale and clammy.
(D) DISABILITY
Traumatic injuries may cause damage to the central and peripheral nervous systems. Spinal cord injuries are most commonly seen in the cervical and lumbar regions. The thoracic spine is less prone to injury because of the rigidity of the bony thorax. Complete spinal cord injury affects all neurologic function below a specific level of the cord. Incomplete spinal cord injury exhibits sacral sparing and may involve the central portion of the cord, as in central cord syndrome; a single side of the cord, as in Brown-Séquard syndrome; or the anterior portion of the cord, as in anterior cord syndrome. A rapid assessment of disability and neurologic function is vital so that drug therapy and physical maneuvers can be initiated to prevent further neurologic injury.
(E) EXPOSURE
Exposure of the trauma patient is important for the entire body to be examined and injuries diagnosed. Complete exposure entails removing all clothing from the patient so a thorough examination can be performed, allowing for identification of entry and exit wounds, extremity deformities, contusions, or lacerations; sometimes this is considered part of the secondary survey. The patient should be rolled onto one side with the neck and back supported in a rigid position to determine whether there are additional injuries. If there is suggestion of spinal injury and no obvious hemorrhage is coming from the back, this maneuver can be postponed. After the examination, attention should be paid to maintaining the patient's core body temperature.
EMERGENCY DEPARTMENT THORACOTOMY
In the severely injured, hypotensive patient, the question sometimes arises whether to perform thoracotomy in the emergency department as a life-saving maneuver. In the blunt trauma patient, this intervention is rarely successful and should be avoided, unless the vital signs are lost just before or during the resuscitation and all other measures have failed to improve the situation. In victims of penetrating trauma, this maneuver can be successful, especially if cardiac tamponade is found. This can temporize until the patient can be taken to the operating room for definitive repair.
VOLUME RESUSCITATION
Hemorrhage leading to hypovolemic shock is the most common cause of postinjury death in the trauma patient. Rapid fluid resuscitation and hemorrhage control are the keys to restoring adequate circulating blood volume. The fluid status of patients can be quickly evaluated by assessing their hemodynamics (hypotension and tachycardia), their level of consciousness (adequacy of cerebral perfusion), the color of their skin (pale skin indicates significant exsanguination), and the presence and character of the pulse (absent central pulses indicate profound hypovolemic shock). All sources of external hemorrhage must be identified and treated by applying direct pressure. Indiscriminate hemostat usage should be avoided, because it may crush and damage surrounding neurovascular structures. Sources of internal hemorrhage are usually hidden and are suspected by unstable hemodynamics. Internal bleeding may occur in the thorax as a result of cardiovascular or pulmonary injury, in the abdomen from splenic or liver lacerations, or into the soft tissues surrounding femur or pelvic fractures.
Fluid resuscitation of the hypovolemic, hypotensive patient requires establishing adequate intravenous access. Two large-bore catheters (14 gauge) should be placed in upper extremity veins and rapid infusion of a balanced salt solution (Lactated Ringer's or normal saline) initiated. If the pattern of injury allows, central access via the femoral vein approach using larger-diameter catheters maximizes the rate of fluid administration. If percutaneous access is unsuccessful, a cut-down of the greater saphenous vein at the anteromedial ankle is required. After intravenous access is established, bolus infusion of crystalloid solution should be replaced with O-negative or type-specific blood, once it becomes available.
TRAUMA RADIOGRAPHS
For patients with blunt trauma (automobile crashes, falls), three standard radiographic studies are required to assess the neck, chest, and pelvis: cross-table lateral cervical spine, anteroposterior chest, and anteroposterior
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pelvis. Obtaining these three x-rays early in the resuscitation process allows potentially neurologically disabling cervical spine injuries, life-threatening chest wall and cardiopulmonary injuries, and pelvic injuries to be identified and immediately treated. For patients with penetrating trauma (gunshot, stabbing, impaling), an anteroposterior chest film and other films pertaining to the site of injury should be obtained.
SECONDARY SURVEY
The secondary survey begins after the airway, breathing, and circulation have been assessed and resuscitation has been initiated. This secondary survey is a head-to-toe evaluation of the body, during which additional areas of injury are identified. A meticulous examination during this phase of the trauma evaluation minimizes the chance of missing an important finding.
The final phase of acute trauma care is instituting definitive treatment. This may entail simple wound care in the emergency room for minor injuries or, if the injuries warrant, transportation to the operating room for surgical treatment.
THORACIC TRAUMA
Because of the great importance of the structures in the chest, thoracic trauma is second only to head trauma as a cause of death in injured patients. After the interventions described in the primary survey, many injures will remain that will require expeditious repair.
Open pneumothorax will generally require chest wall repair. The timing of this depends on whether the defect can be controlled, how large it is, and the severity of the patient's other injuries.
Tension pneumothorax, after emergent decompression, will require chest tube placement.
Hemothorax, after initial chest tube placement, requires careful monitoring to decide whether the patient needs emergent thoracotomy. If the initial blood removed from the chest is >1,500 mL, or if ongoing blood loss is >200 mL/hr, the patient should be explored in the operating room for hemorrhage control. Even if the patient does not require emergent thoracotomy, many centers will aggressively clean the pleural space of blood with thoracoscopy at some point in the future when the patient is stable.
Flail chest is often a sign of significant pulmonary contusion, which will cause a ventilation perfusion mismatch. These patients can be very difficult to oxygenate. Treatment consists of diuresis, pain control, and if necessary, prolonged intubation with positive end-expiratory pressure. The flail chest itself can be stabilized operatively, but this is rarely necessary.
Cardiac tamponade is a life-threatening condition in which blood escapes into the pericardium. Because the pericardium does not expand well, the blood compresses the heart and dramatically decreases venous return and cardiac output. The diagnosis is made from the Beck's triad of hypotension, distant heart sounds, and elevated central venous pressure. Pericardiocentesis can remove blood from the space and temporarily restore normal hemodynamics. These patients should generally be taken to the operating room to diagnose and repair cardiac injuries or other sources of the bleeding.
Severe impact on the sternum can cause blunt cardiac injury or cardiac contusion. This lesion can decrease cardiac output and predispose patients to arrhythmias. Although there is no specific therapy, these patients should be monitored and supported if the cardiac output is inadequate to perfuse the body.
Thoracic aortic injury from blunt trauma usually involves disruption of the aorta just distal to the takeoff of the left subclavian artery where the aorta is tethered by the ligamentum arteriosum. This lesion requires tremendous energy to produce and is most commonly due to falls or high-speed frontal impacts. This lesion should be suspected in the appropriate clinical circumstances. Chest radiograph may reveal a wide mediastinum, loss of aortic knob contour, nasogastric tube deviation to the right, first or second rib fracture, or pleural cap, which is an accumulation of blood above the pleura. Aortography, contrast computed tomography (CT), or transesophageal echocardiogram can be used in diagnosis.
Diaphragmatic rupture may occur from penetrating or blunt trauma. Tremendous force is required to cause this injury. Diagnosis is made with chest x-ray, demonstrating a nasogastric tube or bowel in the chest, or with CT scan or contrast study. On the right side, the liver prevents most cases, so that the left diaphragm is most commonly affected. Operative exploration is indicated for repair and evaluation of other injuries.
Esophageal injury is diagnosed on contrast swallow or endoscopy. In general, operative repair with wide drainage is necessary to prevent mediastinitis, which can be fatal.
Tracheal injury can present on physical examination with crepitus, difficulty speaking, respiratory distress, or hemoptysis. Bronchoscopy is necessary to
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define the lesion. Treatment is expectant or operative depending on the nature and severity of the injury.
ABDOMINAL TRAUMA
Complete examination of the abdomen is extremely difficult in the emergency department because of the noise and number of people. Although classic teaching is to listen, observe, palpate, and auscultate bowel sounds, findings can be unreliable because of altered states of consciousness of the patient, ambient noise, and multiple procedures occurring at the same time. The abdominal examination is best thought of in the context of all of the patient's injuries, and it may be necessary to act definitively in spite of physical examination findings. For example a hypotensive patient with no other injuries with a significant mechanism and no abdominal tenderness may still have a hemoperitoneum. A soft abdomen does not preclude a hollow viscous injury.
In addition to examination of the abdomen, rectal examination is performed to look for blood, indicative of a rectal or colonic injury, and tone, lack of which may suggest a spinal cord injury. In the male, a high-riding or nonpalpable prostate may suggest a urethral injury, and a suprapubic tube should be placed instead of a Foley catheter. Blood at the urinary meatus or a scrotal hematoma in the male also suggests a urethral injury, and again, a Foley should be avoided. Pressure should be placed on the anterior-superior iliac spine to test for fractures.
Patients who are stable with a suspected abdominal injury should undergo abdominal CT scan. Other options include focused assessment by sonography in trauma (FAST) ultrasound examination or diagnostic peritoneal lavage. Diagnostic peritoneal lavage is performed through a small infraumbilical incision. A supraumbilical incision is preferred if there is significant pelvic trauma because of the possibility of a hematoma in the preperitoneal space below the umbilicus. A catheter is placed in the abdomen, it is aspirated, and 1 L of Lactated Ringer's solution is instilled. The test result is considered positive if the initial aspiration returns blood or bowel contents, the aspirate after the liter contains >100,000 red blood cells or 500 white blood cells/mL, if bacteria or bowel contents are returned, or if the fluid has a high amylase.
Injuries to the liver and spleen are generally treated conservatively unless there is ongoing hemorrhage, making the patient unstable. Hollow viscous injuries are fixed immediately by resection and either diversion or primary anastomosis, depending on the situation. Pancreatic injuries can be treated by simple drainage or resection of a portion of the gland with or without pancreaticojejunostomy. In general, "damage control" is used to describe the initial operation in the multi-injured patient. Life-threatening injures are treated, and definitive treatment is delayed in favor of resuscitation in the intensive care unit as necessary. This is to prevent ongoing hypothermia and worsening coagulopathy, which can be fatal.
OPHTHALMIC TRAUMA
More than 1 million cases of ophthalmic trauma after penetrating or blunt injury are reported annually in the United States. Prompt and appropriate care of many ophthalmic injuries may prevent much visual disability.
CHEMICAL BURNS
Chemical burns to the eye represent an ophthalmologic emergency. If treatment is not begun immediately, irreversible damage may occur. Alkaline substances (e.g., household cleaners, fertilizers, and pesticides) cause the most severe damage, but acids may cause significant ocular morbidity as well.
Treatment
A detailed history is not required before beginning copious irrigation with any available water source for at least 15 to 20 minutes. After initial irrigation, visual acuity and pH should be measured. If the pH has not returned to the normal value of 7.5, irrigation should be continued. Prompt ophthalmologic referral should be obtained in all cases of acid or alkali burns and for patients with decreased visual acuity, severe conjunctival swelling, or corneal clouding. All other patients should see an ophthalmologist within 24 hours.
SUPERFICIAL FOREIGN BODIES
Foreign bodies that have an impact on the surface of the cornea or conjunctiva represent approximately 25% of all ocular injuries.
History
An accurate history often provides the diagnosis and should be used to judge the risk of intraocular foreign body (see below). Symptoms range from mild ocular irritation to severe pain. If symptoms began gradually
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rather than suddenly, other causes, such as infectious keratitis, should be considered.
Diagnostic Evaluation
Careful inspection of the cornea and conjunctiva using bright light and magnification often reveals the foreign body.
Treatment
One should always measure visual acuity before making any attempt at removing the foreign body. Superficial foreign bodies can usually be removed using topical anesthesia and a cotton swab. After the foreign body is removed, Wood's lamp examination with fluorescein should be performed to ascertain the size of any residual corneal epithelial defect. Eversion of the upper eyelid should be carried out to look for residual foreign material under the lids. Ophthalmologic referral is indicated when a foreign body cannot be safely removed or for any patient with a large corneal epithelial defect.
BLUNT OR PENETRATING INJURY
Blunt or penetrating trauma to the eye represents a leading cause of vision loss in young people. Blunt trauma most often causes ocular contusion or damage to the surrounding orbit. Penetrating trauma causes corneal or scleral laceration (a ruptured globe) and represents an ophthalmologic emergency requiring early intervention and repair. The possibility of a retained intraocular foreign body should always be considered (see below). A high degree of suspicion must be maintained in all cases of head and facial injuries.
History
History should include the mechanism of injury, the force of impact, the likelihood of a retained foreign body, and any associated ocular or visual complaints.
Diagnostic Evaluation
Eyelid integrity, ocular motility, and pupillary reaction should be tested. Use a penlight to detect conjunctival swelling or hemorrhage, corneal or scleral laceration, or hyphema (blood behind the cornea obscuring details of the underlying iris or pupil). Pain and decreased vision with a history of trauma should always lead to suspicion of perforation of the globe. Severe subconjunctival hemorrhage, a shallow anterior chamber or space between the cornea and iris, hyphema, and limitation of extraocular motility are often, but not invariably, present. Radiologic studies, including CT of the head and orbits, should be obtained in cases of suspected blowout fracture or to rule out a retained intraocular foreign body (see below).
Treatment
If the eye is lacerated or the pupil or iris is not visible, a shield should be placed over the eye, and the patient should be referred immediately to an ophthalmologist. Eyelid lacerations that involve the lid margin or lacrimal apparatus require meticulous repair to avoid severe functional and cosmetic morbidity. If the eyelid margin and inner one sixth of the eyelid are not damaged, the wound can be closed with fine sutures. If the eyelid margin is lacerated, accurate realignment of the lid margin must be ensured before wound closure. Disruption of the inner one sixth of the eyelid requires intubation of the lacrimal drainage system, with stent placement before surgical repair, and should be carried out by an ophthalmologist or other appropriately trained physician. Ophthalmologic referral after trauma is determined by ocular symptoms and findings, as set forth in Table 27-1.
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TABLE 27-1 Management of Ophthalmic Trauma |
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INTRAOCULAR FOREIGN BODIES
A high-speed missile may penetrate the cornea or sclera while causing minimal symptoms or physical findings. Foreign-body composition is important, because certain metals, such as iron, steel, and copper, produce a severe inflammatory reaction if left in the eye, whereas other materials, such as glass, lead, and stone, are relatively inert and may not require surgical removal. Retained vegetable matter is especially dangerous and may cause a severe purulent endophthalmitis. A retained foreign body should be suspected in all cases of perforating injuries of the eye or whenever the history suggests high-risk activities, such as drilling, sawing, or hammering.
History
One should inquire about high-risk activities, a sensation of sudden impact on the eyelids or eye, and any complaint of pain or decreased vision.
Physical Examination
Visual acuity should always be recorded before any manipulation of the eye or eyelids. Inspection may reveal an entry wound, although this may be quite subtle and easily overlooked. Specifically, one should look for a hyphema, pupillary distortion, or any alteration of the red reflex on funduscopic examination.
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Diagnostic Evaluation
Accurate localization may require soft tissue radiographs, orbital ultrasound, or CT. Magnetic resonance imaging is contraindicated in all cases of suspected intraocular foreign body.
Treatment
If the history strongly suggests the possibility of a retained foreign body, urgent ophthalmologic referral is indicated, even in the absence of physical findings. Prompt surgical removal of intraocular debris is usually indicated to avoid the toxic effect of metallic foreign bodies on intraocular tissue and secondary intraocular infection from retained organic material.
BURNS
Burns are characterized by their thickness and the extent of the body surface area they cover. First-degree burns are limited to the dermis, do not blister, and are red and painful. Because the dermis is intact, they heal without scarring. Second-degree burns extend partially into the dermis and form blisters which are red and painful. The extent of dermal involvement determines the extent of scar formed. Third-degree burns occur when the entire dermis is destroyed. These areas of burn are insensate, because the nerve endings have also been destroyed. They generally require skin grafting for healing.
Patients presenting with burns must be evaluated for inhalation injury if the burn was caused by a fire. Carbon monoxide inhalation, heat causing edema of the oropharynx and larynx, and damage caused by inhalation of hot embers can also be fatal. Patients with significant injury of this type should be intubated early to maximize respiratory support and prevent airway compromise.
Severely burned patients will lose tremendous amounts of fluid, and resuscitation forms a major portion of the care of these patients. Percentage of body burn can be estimated by the rule of nines: the head has 9% of body-surface area, the dorsal and ventral torso each 18%, each arm 9%, and each leg 18%. On this basis, the Parkland formula determines the amount of fluid given and should be initiated for patients with >10% to 15% of total body-surface affected. This is calculated as the body weight in kilograms × percent of total body surface with second- or third-degree burns × 4 mL. Half of this total should be given as Lactated Ringer's solution in the first 8 hours after injury, and the rest over the next 16 hours. Urine output and blood pressure should be carefully monitored and infusions adjusted accordingly.
As treatment begins, eschars in the torso may constrict breathing, or eschars in the extremities may compromise circulation. In this case, escharotomy should be performed to relieve the compression (Fig. 27-4). In
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this procedure, full-thickness incisions are made in the skin to release the constriction.
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Figure 27-4 • Incisions for escharotomy. From Blackbourne LH. Advanced Surgical Recall. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2004 |
Sepsis is an ongoing problem for burn patients. The burn itself sterilizes the skin, but bacterial repopulation occurs quickly. Great improvements in burn care have come from early excision and grafting, which decrease the risk of infection. In this procedure, thin slices of skin are removed with a dermatome until viable tissue is encountered, as determined by bleeding. At this point, skin grafting is performed. For large burns, this procedure is limited by hypothermia and blood loss, and is often done in sequential fashion. Local care with topical antibiotics and frequent dressing changes is critical.
Burn patients often have tremendous nutritional requirements, with calorie and protein requirements approaching twice normal. Enteral feeding should be initiated as quickly as possible.
KEY POINTS