General Surgery (Board Review Series) 1st Edition

8

Trauma and Burns

Jeffrey A. Claridge

1. Introduction
2. Trauma

• is a leading cause of deathin the first four decades of life.

1. Head injury

• is the most common cause of immediate death in trauma.

1. Nearly 150,000 trauma deaths

• occur annuallyin the United States.

1. Primary survey and resuscitation of the trauma patient
2. There are 5 stepsof the primary survey (the ABC's)

• Airway.
• Breathing.
• Circulation.
• Disability.
• Exposure.

2. The objectives of the primary surveyare

• to identify immediately life-threatening conditions.
• to initiate resuscitation.

3. Life-threatening problems

• discovered during the primary survey are treated before proceeding to each consecutive step.

1. Secondary survey (see IV)
2. Definitive care (see V)

P.164

1. The Primary Survey
2. Airway and cervical spine (C-spine) control
3. Assessing the airway
4. If the person can speak

• this is generally a sign that the airway is patent.

1. The tongue

• is the most common cause of upper airway obstruction, particularly in an unconscious patient.

1. If the airway is not adequately open, immediate sequential stepsmay include

• chin lift and/or the jaw thrust maneuver.
• placement of an oral or nasal airway.
• endotracheal intubation.

2. When endotracheal intubation cannot be performed(i.e., severe facial trauma) a cricothyroidotomy can be quickly done.

• An incision is made directly through the skin and cricothyroid membrane and a small tube placed through the incised membrane (Figure 8-1).

3. C-spine immobilizationshould be maintained at all times (e.g., neck collar).

• Complete evaluation of the cervical, thoracic, and lumbar spines after trauma is discussed in BRS Surgical Specialties, Chapter 7.

Figure 8-1. Cricothyroidotomy. (A) Front view. (B) Side view; scalpel is inserted and turned counterclockwise. (Adapted with permission from Lawrence PF: Essentials of General Surgery, 2nd ed. Baltimore, Williams & Wilkins, 1992, p 151.)

1. Breathing
2. Establishing airway patency
3. Once airway is open, the next step isto assess for air movement.
4. Clinical signsthat should initially be evaluated include

• symmetric chest movement.
• cyanosis.

P.165

• open chest wounds.
• jugular venous distention (JVD).
• respiratory rate.
• use of accessory muscles of respiration (e.g., sternocleidomastoid).

2. During auscultationone should assess for

• bilateral breath sounds.
• wheezing.
• stridor.

3. Palpationshould be performed to assess for

• tracheal position (a deviated trachea may indicate a tension pneumothorax).
• gross deformities.
• subcutaneous emphysema.
• flail segments.

1. Circulation
2. Evaluate

• peripheral pulses.
• heart rate.
• blood pressure.
• mental status.
• the appearance of the skin.

1. A palpable radial pulse

• suggests that the systolic pressure ≥ 80 mm Hg.

1. Femoral and carotid plus

• can be felt down to a systolic pressure of 60.

1. Tachycardia

• is generally the most sensitive indicator of hypovolemia.

1. A fall in blood pressure

• is a late manifestationof hypovolemia.

1. Hypovolemia

• can cause mental status changes varying from increased agitation to unconsciousness.

1. The skinin a patient with hypovolemic shock

• often feels cold and clammy with slow capillary refill(normal is less than 2 seconds).

2. Aggressive fluid resuscitation

• should be initiated at this time.

1. In adults

• an initial 2 L bolus of crystalloid (e.g., lactated Ringer's) should be given through two large-bore intravenous (IV) lines (i.e., 14–16 gauge).

P.166

1. In children

• an appropriate initial bolus is 20 mL/kg.

1. A type and crossmatch

• should be performed immediately, although Type O negative (O—;universal donor) blood should also be immediately available.

1. Transfusion with packed red blood cellsis necessary in the case of obvious vigorous hemorrhage or in cases where hematocrit falls below 25 mg/dL with ongoing bleeding.
2. Disability (gross, rapid neurologic evaluation)
3. A rapid assessmentshould be performed of

• mental status.
• gross motor function.
• gross sensory function.

2. The AVPU mnemonic

• is a quick method to describe the patient's level of consciousness.
• A= Alert.
• V= responds to Vocal stimuli.
• P= responds to Painful stimuli.
• U= Unresponsive.

3. The Glasgow Coma scale (GCS)

• is essential for quantitative assessment of the patient's neurologic status (see BRS Surgical Specialties, Chapter 7).

4. Asymmetry in pupillary size and reactivity

• suggests the presence of an intracranial injury.

5. The main disabilities discoveredduring this phase include

• head injury.
• altered level of consciousness secondary to ethanol or other drugs (diagnosis of exclusion).

1. Exposure/environmental control
2. Remove the patient's clothes

• to facilitate a thorough examination.

2. Examine the entire body surface

• including log-rolling the patient to view the back and buttocks for potential injuries.

3. Maintain normothermia

• with warm IV fluids, loose application of warm blankets, and a warm environment.

4. Consider tetanus immunization

• and antibiotic administration, if necessary.

5. Perform initial chest and pelvic radiographs.

P.167

III. Initial Management of Life-Threatening Conditions

1. Airway obstruction (see II A 1)
2. Pneumothorax

Figure 8-2. Tension pneumothorax. The arrows identify the edge of the collapsed lung and the displacement of the mediastinum toward the left. Note the slight shift of the trachea toward the left. (Reprinted with permission from Daffner RH: Clinical Radiology: The Essentials, 2nd ed. Baltimore, Williams & Wilkins, 1999, p 153.)

• is air in the pleural space, causing collapse of the lung, frequently caused by lung parenchymal injury secondary to fractured ribs.

1. A tension pneumothorax

• is air in the pleural space at higher than or equal to atmospheric pressure.
• causes compression of adjacent structures (e.g,. superior vena cava) (Figure 8-2).

1. The diagnosisshould be based on a combination of clinical findings including

• dyspnea.
• jugular venous distension (JVD).
• tachypnea.
• anxiety.
• pleuritic chest pain.

P.168

• unilateral, decreased or absent breath sounds.
• tracheal shiftaway from the affected side.
• hyperresonance on the affected side.

1. Hypotension may result

• secondary to decreased venous return to the heart.

1. Treatmentinvolves

• immediate decompression by chest tube placement or by needle thoracostomyif no experienced personnel are present.

1. A chest tube thoracostomy

• should then be performed (Figure 8-3).

Figure 8-3. Chest tube thoracostomy (chest tube placement). (Adapted with permission from Donovan AJ: Trauma Surgery: Techniques in Thoracic, Abdominal, and Vascular Surgery. St. Louis, Mosby, 1994, p 59.)

2. An open pneumothorax

• (“sucking chest wound”) is diagnosed by inspection.

1. Air moves through the chest wall defect

• during breathing, thereby inhibiting lung expansion and normal respiration.

1. Treatment involves

• insertion of a chest tube.
• placement of an occlusive dressingover the open wound.
• intubation with positive pressure ventilation, if needed.

P.169

1. Flail chest

• is caused by the multiple fractures of 4 or more ribs.

1. Normal respiration

• causes paradoxical motionof the affected chest wall.
• The flail segment moves in with inspiration.

2. Treatment
3. Treatment involves providing adequate pain control (e.g., epidural).
4. In the presence of respiratory failure, endotracheal intubation and positive pressure ventilationare essential.
5. Massive hemothorax
6. This is a clinical diagnosis characterized by

• hypotension.
• unilateral decreased or absent breath sounds.
• dullness to percussion on the affected side.

2. Chest radiographs

• may reveal blood on the affected side.

3. Treatment

• involves fluid resuscitation and chest tube placement.

1. Removal of the blood

• will allow apposition of the pleura, sealing the defect and slowing the bleeding.

1. If bleeding continues

• at more than 200 mL per hour, surgical exploration should be performed to identify the source of bleeding.

1. Cardiac tamponade

• is caused by bleeding into the pericardial sac, resulting in inhibition of cardiac function.

1. Tamponade is diagnosed clinicallyby

• the presence of decreased heart sounds.
• JVD.
• hypotension.
• These three make up Beck's triad.

2. Initial treatmentinvolves decompression and fluid resuscitation.

• If suspected, the pericardial sac is formally explored and a “pericardial window” is placed surgically to allow for decompression.

1. Secondary Survey
2. To reevaluate the patient during the secondary survey

• perform a thorough examination from the head to the feet.

P.170

1. Key elements

• to look for are listed in Table 8-1.

2. To rely on the abdominal examinationthe patient must be

• alert and oriented.
• withoutevidence of head or spinal cord injury, or drug or alcohol intoxication.

3. An abbreviated history

• should be taken (Table 8-2).

Table 8-1. Key Elements of the Secondary Survey

Head Examine for lacerations, contusions, burns, or fractures Reevaluate pupils Reevaluate level of consciousness Evaluate the eye for hemorrhage, penetrating injury, acuity, and hyphema Inspect the ear for hemotypanum (associated with basilar skull fractures) Look for evidence of CSF leak from ears (otorrhea) or nose (rhinorrhea) Examine the mouth for dental injuries, fractures, and lacerations N/G tube placement, OG tube placement if one suspects maxillofacial injury Neck Maintain C-spine immobilization (cervical collar) Assess for subcutaneous emphysema Examine tracheal position (tension hemo- or pneumothorax associated with tracheal deviation away from side of injury) Palpate the spine for tenderness, swelling, or bony deformity Chest Reevaluate the chest as was done in the primary survey Obtain chest radiograph Abdomen Examine and evaluate for evidence of blunt and penetrating injury Percuss and palpate the abdomen for evidence of rebound and/or guarding Obtain pelvic radiograph if indicated Musculoskeletal Evaluate for gross evidence of injury Assess for distal pulses Palpate for evidence of fracture: crepitation, tenderness, and swelling Obtain necessary films Remember to log-roll the patient and evaluate the back Perineum Examine for contusions, hematomas, lacerations, blood at the urethral meatus Rectum Evaluate sphincter tone (loss of tone associated with severe neurologic injury such as spinal cord injury) Feel for gross bony fragments Palpate the prostate position Evaluate for blood Vagina Evaluate for blood or lacerations in the vault Neurologic Reevaluate the pupils and level of consciousness Examine for extremities for motor and sensory responses Determine the GCS score CSF = cerebrospinal fluid; N/G = nasogastric; OG = orogastric; C-spine = cervical spine; GCS = Glasgow coma scale.

4. During the secondary survey

P.171

• it is important to continually reevaluate the ABC's, looking for any potential changes.

5. It is also essential to place a Foley catheter

• to monitor fluid status.

1. Contraindications to Foley placementinclude

• blood at the urethral meatus.
• high riding or “boggy” prostatein a male.
• severe pelvic fracture.
• obvious perineal injury.

1. If a urethral injury is suspected

• a retrograde urethrogram (RUG)should be performed (see BRS Surgical Specialties, Chapter 6).

1. Laboratory tests

• frequently obtained during the trauma evaluation are listed in Table 8-3.

Table 8-2. Brief History During Trauma Evaluation

AMPLE History Specific Issues A: Allergies Medications and IV contrast M: Medications Antihypertensives, coumarin (Coumadin), insulin, etc. P: Past illnesses Surgeries, chronic illness, heart or respiratory problems L: Last meal When they last ate (assessing aspiration risk) E: Events or Environment related to injury Mechanism of injury, need to know if other people were involved IV = intravenous.

1. Management of Other Specific Injuries

Table 8-3. Commonly Obtained Laboratory Tests During Trauma Evaluation

Complete blood count (CBC) Serum chemistries Arterial blood gas (ABG) Prothrombin time (PT) and partial thromboplastin time (PTT) Ethyl alcohol (EtOH) level Urine toxicology screen Lactic acid Amylase β-human chorionic gonadotropin (HCG) for females of childbearing age Type and cross

1. Penetrating neck trauma (see BRS Surgical Specialties, Chapter 4)
2. The neck is anatomically divided

• into 3 zones(Figure 8-4).

1. Zone I

• extends from the clavicle to the cricoid cartilage.

1. Zone II

P.172

• extends from the cricoid cartilage to the angle of the mandible.

1. Zone III

• extends from the angle of the mandible to the base of the skull.

Figure 8-4. Zones of the neck. (Adapted with permission from Lawrence PF: Essentials of General Surgery, 2nd ed. Baltimore, Williams & Wilkins, 1992, p 156.)

2. Patients

• with symptoms, hemodynamic instability, or signs of underlying injury (e.g., expanding or pulsatile hematoma) require immediate surgical exploration.

3. Management of asymptomatic patients

• with penetrating neck trauma generally depends on the zone injured.

1. Zone I and III injuries

• may initially be evaluated nonoperatively.

2. For potential vascular injuries, use angiography.
3. To assess potential injuries to the oropharynxand esophagus, perform endoscopy.

• Endoscopic evaluation of the larynx and tracheobronchial tree should also be performed to rule out potential injuries to these structures.

1. Zone II injuries

• are traditionally managed by performing an urgent neck exploration, although some centers are now evaluating some of these patients nonoperatively.

1. Aortic arch injuries
2. The need for further evaluation of aortic arch injuriesshould be done if

• there is radiographic evidence of injury.
• the mechanism of injurywarrants further evaluation (i.e., fall from higher than 12 feet or high-speed motor vehicle accident).

P.173

2. Chest radiograph findingssuggestive of thoracic vessel injuries include

• widened mediastinum.
• first rib fracture.
• apical pleural capping.
• loss of aortic contour/knob.
• depression of left main stem bronchus.
• nasogastric (N/G) tube/trachea deviation.
• pleural effusion.

3. A normal chest radiograph

• will appear in 10% of patients with aortic arch injuries.

4. An aortogram

• is the gold standard for evaluating potential arch injuries.

5. Chest computed tomography (CT) scans

• are now being used by some centers to evaluate for arch injuries.

1. Penetrating injury to the “box” (Figure 8-5)
2. Hemodynamically unstable patients

• require immediate explorationof the pericardial space via a left lateral thoracotomy or sternotomy.

2. Otherwise, patients with penetrating injuries

• to this area generally require exploration of the pericardial sac via a subxiphoid window.

Figure 8-5. The anatomical “box.”

3. If there is gross blood in the pericardium

P.174

• a sternotomy is indicated to assess for injuries to the pericardium, heart, or major vessels.

1. Abdominal injuries
2. Blunt abdominal injury
3. Suspect this type of injury in patients

• involved in significant deceleration accidents.
• when the abdominal examination is unreliable (e.g., ethyl alcohol [EtOH] intoxication).

1. Indicationsfor immediate surgical exploration without further diagnostic evaluation of the abdomen include

• peritonitis.
• hypotension with a distended abdomen.

1. Both CTand diagnostic peritoneal lavage (DPL)

• may be used to evaluate patients with suspected abdominal injury (Table 8-4).

1. Diagnostic peritoneal lavage
2. A Foley catheter and N/G tubemust be placed before performing DPL.
3. A catheteris placed into the peritoneal cavity below the umbilicus and the contents aspirated.

• If gross blood or succusare initially aspirated, surgical exploration is indicated.
• If initial syringe aspiration is negative, 1 L of crystalloid is infused through the catheter and then the fluid is drained.

3. The criteria for surgical explorationbased upon the analysis of the DPL fluid are listed in Table 8-5.
4. Rapid ultrasound evaluation

• of the abdomen may also be used in this setting.

Table 8-4. Diagnostic Peritoneal Lavage (DPL) versus Computed Tomography (CT) Scan for Assessment of Potential Abdominal Injuries

Advantages Disadvantages DPL Faster Can be done at the bedside Very sensitive Invasive Results in approximately 15% nontherapeutic laparotomies Cannot evaluate retroperitoneum CT Greater specificity Allows visualization of retroperitoneal structures Allows evaluation of solid organ injuries Noninvasive Requires more time Patient must be transported Patient must be stable More costly and requires more personnel Poor sensitivity for early hollow viscus injury

2. Penetrating abdominal trauma
3. Penetrating injury to the thorax

• at or below the fourth intercostal space(at the nipple in men) needs to be evaluated for concomitant abdominal injury.
• The diaphragm may extend to that level during expiration.

P.175

1. Stab wounds
2. In a hemodynamically unstable patientwith a stab wound to the abdomen, immediate surgical exploration is indicated.
3. Stable, asymptomatic patientsmay undergo local wound exploration.

• After wound exploration, laparotomy or laparoscopy is performed if the fascia has been violated or if the tract cannot be visualized.

1. Abdominal gunshot wounds(GSWs)
2. GSWs to the abdomenrequire immediate exploratory laparotomy.
3. The amount of damagecaused is related to the kinetic energy (K.E. = 1/2 MV²) and the surface area of the bullet.

Table 8-5. Findings of a Positive Diagnostic Peritoneal Lavage (DPL)

Immediate or Macroscopic Findings Delayed or Microscopic Findings 5 mL gross blood on aspirate Enteric or succus on aspiration Classic: inability to read newsprint through the lavage fluid in the tube Lavage fluid noted to be draining from Chest tube (diaphragm injury) Foley catheter (bladder injury) N/G tube (injury to viscera) RBC > 100,000 mm3 WBC > 500/mm3 Elevated amylase Bile present Bacteria present Vegetable matter present RBC = red blood cells; WBC = white blood cells; N/G = nasogastric.

3. Specific abdominal organ injuries
4. The small bowel

• is the most commonly injured organ in penetrating trauma.

1. Minor injuriescan be repaired primarily with simple suture closure.
2. Larger injuries can be resected and repairedwith a primary anastomosis.
3. The spleen and liver

• are the most commonly injured organs in blunt trauma.

1. Minor injuriesin stable and asymptomatic patients may be managed with bedrest, followed by 6 weeks of limited activity.
2. Symptomatic or large injuries to the liverrequire immediate repair or packing.
3. Symptomatic or large splenicinjuries generally require splenectomy (see Chapter 17).

• Postsplenectomy sepsismay occur in 1%–5% of patients after splenectomy.

1. Colon injuries

• are managed according to several factors.

1. These include

• size of the injury.

P.176

• location of the injury.
• amount of fecal soilage.
• presence of associated injuries.
• hemodynamic stability of the patient.

2. Small injurieswith minimal associated injuries in stable patients can be repaired primarily.
3. Unstable patientsor patients with multiple associated injuries will likely require a colostomy following resection of the injured bowel.
4. Larger injuries to the right or transverse colonwith minimal associated injuries can be repaired with resection and primary anastomosis.
5. Large left-sided colon injuriesgenerally require performance of a colostomy after resection of the injured bowel.
6. Rectal injuries

• are generally caused by penetrating injury.
• may require a proximal diverting colostomy, placement of a presacral drain, and repair of the injury if possible.

1. Pancreatic and duodenal injuries

• are frequently missed and can be the most complicated injuries to repair.

1. Isolated smallduodenal injuries can be repaired by primary closure.
2. Larger injuriesmay require duodenal resection and gastric diversion.
3. Injuries to the pancreatic ductdistal to the head of the pancreas can be managed with a distal pancreatectomy.
4. Severe injuries to the head of the pancreaswith severe associated duodenal injuries may need a pancreaticoduodenectomy (Whipple's operation).
5. Pelvic Injuries
6. Pelvic injuries

• are common in victims of blunt trauma (see BRS Surgical Specialties, Chapter 5).

1. Fractures

• can cause retroperitoneal or preperitoneal hematomasthat are large enough to cause hemodynamic instability.

1. Treatment depends mainly on

• the hemodynamic stabilityof the patient.
• the presence or absence of intra-abdominal bleeding.

1. Pelvic fixation

• is important to reduce bleeding in unstable fractures.

2. Patients who are hemodynamically unstable

P.177

• with a grossly negative DPL may undergo angiographyto evaluate for pelvic arterial bleeding, which may be controlled with embolization.

3. A grossly positive DPL

• in association with a pelvic injury still requires immediate exploratory laparotomy.
• With pelvic injuries, DPL should be performed above the umbilicus.

VII. Burns

1. Anatomy
2. Depth
3. First degree burns

• involve damage to the epidermis only.

2. The skin is erythematous and very tender(e.g., minor sunburn).
3. There is no blistering and no permanent damageto the underlying dermal layer.
4. Second degree, or partial-thicknessburns

• are intradermal injuries.
• can be further subdivided into superficial and deep.

2. In superficial partial-thickness burns

• the hair follicles, the sweat glands, and the sebaceous glands are intact.
• the areas affected are very painfuland hypersensitive to touch.
• the wound appears red and mottled with edema and blistering.
• the surface is typically moist and weepy.

3. Deep partial-thickness burns

• have necrosis well into the dermis and skin appendages are involved.
• are slightly tougher and firmer, and are less sensitive to touch.

1. Third degree, or full-thicknessburns

• involve the entire depth of the dermis.

1. All dermal elements are destroyed including nerve endings, dermal appendages, and blood vessels.
2. The wound surface appears waxy-white or gray, dark and leathery, or charred.
3. The affected area is often dry, and thrombosed vessels may be visible.
4. The lesions are painless and insensate to touch.
5. Extent of injury
6. The severity of burn damage

• is also based on the percent of total body surface area (TBSA) involved.

1. TBSA is determined in adultsby the “rule of nines.”

• The proportions in infantsand children are slightly different (Figure 8-6).

P.178

2. The genitalia and palmare roughly equivalent to 1% TBSA each.
3. Burns are considered serious

• regardless of the total extent of the burn in certain locations such as the face, hands, perineum, and joints.

Figure 8-6. Estimation of percent of body surface area affected by burn injury. (A) In adults, each designated area is divisible by 9 (“rule of nines”). (B) The estimates are slightly different in infants because of the proportionately larger head. (Adapted with permission from Lawrence PF: Essentials of General Surgery, 2nd ed. Baltimore, Williams & Wilkins, 1992, p 163.)

1. Initial management
2. Airway
3. Evaluation for signssuggestive of inhalation injury (Table 8-6) is absolutely necessary.

• One must have a very low threshold for intubation.

2. Early intubationis essential because airway management becomes

P.179

more difficult as swelling rapidly increases over the first 24 hours.

3. Sloughing of the mucosa with occlusion of the airway can also occur.
4. Bronchoscopy

• may also be used in the initial evaluation of the airway.

Table 8-6. Evidence of Possible Inhalation Injury

Confinement in a closed space History of explosion History of decreased level or loss of consciousness Charring or carbon deposits around the mouth, nose, or in the oropharynx Carbonaceous sputum Dyspnea Inflammatory changes to the oropharynx Facial burns Singed facial or nasal hair Circumferential burns of the trunk Alteration in the patient's voice Low oxygen saturation

2. Breathing
3. Arterial blood gas

• should be obtained in severely burned patients.

1. Carbon monoxide levels

• should be obtained if there is a history of exposure to noxious fumes or smoke inhalation.

1. Carboxyhemoglobinof greater than 10% is considered significant.
2. Treatmentinvolves administration of 100% oxygen.
3. Circulation
4. Early and aggressive volume resuscitationis essential.
5. The “Parkland Formula”is an estimate of the volume of crystalloid (lactated Ringer's) necessary for resuscitation in the first 24 hours: Volume = % TBSA burned x body weight (kg) x 4 mL.

• TBSA of second and third degree burns are used in this calculation.

1. Half of the estimated volumeshould be given in the first 8 hours after injury.

• The remainder is given over the next 16 hours.

1. Measurement of urine output

• via a Foley catheter is the most sensitive indicator of the adequacy of volume resuscitation.

1. Adult patientsshould have a minimum urine output of 0.5 mL/kg/hour.

• Children should have an output of 1–2 mL/kg/hour.

2. Adjustments to the rateestimated by the Parkland formula may be necessary to achieve these goals (see VII B 3 a).

P.180

1. Monitoring central venous and pulmonary capillary pressure

• may be necessary in the severely injured patient.

1. After the first 24 hours

• colloid (e.g., albumin solution) may be used, as capillary permeability returns to near baseline.

1. Distal pulses must be monitored

• especially in the presence of circumferential burns, because swelling may compress vessels.

1. Escharotomiesare performed to prevent circulatory compromise of the extremity.
2. This involves making longitudinal incisions through the eschar to healthy adipose tissue with a scalpel or electrocautery (Figure 8-7).

Figure 8-7. Escharotomy lines represented by the dark lines. (Adapted with permission from Sabiston D: Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 15th ed. Philadelphia, WB Saunders, 1997, p 230.)

P.181

1. Truncal escharotomies

• may be necessary in circumferential chest burns to prevent inhibition of inspiratory capacity and respiratory compromise.

4. After the initial ABC's, determine

• the mechanism of injury.
• if other disabilities or injuries exist.

5. It is also essential to ensure that the burning process has been stopped.

. Clothing, especially synthetic fabrics, may continue to burn or smolder.

• Clothing must be extinguished and removed.

1. Other hot adherent substancessuch as grease or tar need to be removed.
2. Chemical burns or corrosive injuriesrequire copious irrigation.
3. Burn patients are at a significant risk

• for severe heat lossand hypothermia.
• Care should be taken to maintain normothermia (see II E 3).

1. Criteria for hospitalization

• or transfer to a specialized burn treatment center are outlined in Table 8-7.

Table 8-7. Admission Criteria for Burn Injured Victims

All burns > 10 % TBSA in children and the elderly Any suspected inhalation injury All burns of face, hands, feet, and perineum Full-thickness burns > 10% TBSA Partial-thickness burns > 20% TBSA Partial- or full-thickness burns of major flexion creases Burns with associated trauma Electrical burns Chemical burns If there are reasons to believe that the burn injury was a result of abuse TBSA = total body surface area.

1. Burn wound care
2. First degree burns

• can be treated by applying bacitracin to the area.

1. Analgesics

• may be needed for pain.

1. Healing is complete

• and without scar formation or skin discoloration.

2. Superficial partial-thickness burns

• are initially cleaned with an antiseptic soap to remove foreign material and dead skin.

1. Blistersare generally unroofed.

P.182

• Topical antibiotics are applied before dressing the wounds.

1. These wounds can be very painful

• and require treatment with analgesics.

1. There is little or no scar formation

• with no major change in skin pigmentation.

3. Deep partial-thickness burnsand full-thickness burns

. These are initially managed like superficial second degree burns with

• cleansing.
• topical antibiotic agents.
• dressing changes.

1. However, these wounds will need

• frequent surgical débridement and skin graftingto minimize complications of the burn injury.

1. Complications include

• contracture formation.
• infection.
• severe scar formation.
• prolonged hospitalization.

1. Excision of wounds and coverage

• should be performed early.

2. Excision and coverage within 72 hours decreases the rate of development of burn wound sepsis.

• Early excision and coverage also allows for early mobilization and rehabilitation, improved joint function, and shorter hospitalization.

3. Delay excision if the patient is hemodynamically unstable.
4. Burns are tangentially excised until a healthy bed of tissue is reached.
5. Wound closure

• is best accomplished immediately after excision.

1. The gold standardof burn wound closure is split-thickness skin graft (autograft-skin obtained from a nonburned area on the patient).
2. Reasons to delay closuremay include

• inadequate recipient tissue bed(e.g., persistent infection).
• unwillingness to create donor sites.
• insufficient donor sitesavailable for autograft coverage.

3. Other choicesused to close excised burn wounds include temporary and permanent coverings.
4. Grafts(See Chapter 6)

• Allograftis a cadaveric skin graft from an individual of the same species.
• Xenograftis a skin graft from a different species (e.g., pig, shark).

1. Silastic and other commercially produced membranesare also available, but are used less commonly.

P.183

1. Permanent coversinclude cultured epithelial autografts and composites of Silastic and collagen.
2. All of these tend to be more costly than autografts, with inferior results.
3. Other aspects of the burn care
4. Nutrition

• is very important in treating the burn patient (see Chapter 3).

1. A burn patient is in a hypermetabolic state

• that is unsurpassed by any other form of trauma or illness.

1. Recommended protein requirements

• are 1.5–3.0 g of protein/kg/day.

1. Early enteral feeding

• is essential and is favored over parenteral nutrition.

2. Prophylaxis against gastrointestinal ulceration

• is important (e.g., H2-blockers) because burn patients are at an increased risk of developing acute erosive gastritis (Curling's ulcer).

3. Electrolytes abnormalitiesfrequently occur.

• Close monitoring and adequate treatment are essential.

4. The burn patientis at high risk

• for infectious complications.

1. Pneumonia

• Aggressive pulmonary toilet is important to minimize the risk of developing pneumonia.
• N/G decompression is important because of the increased risk of developing gastric ileus, which can potentially lead to aspiration.

1. Burn wound infections

• can lead to sepsis and death.

2. The most common infectious organisms are

• Staphylococcus aureus.
• Pseudomonasspecies.
• Streptococcusspecies.
• Candida albicans.

3. The diagnosiscan be confirmed by culturing a biopsy section of the wound for quantitative burn wound bacterial count.

• More than 10⁵organisms/g of tissue is considered significant.
• Organism identification can also be determined.

4. Specific signsof burn wound infection include

• the conversion of second degree burns to full-thickness burns
• green pigmentation.
• discoloration or change of burned areas.

P.184

Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

1. A 20-year-old man presents to the emergency room after being involved in a bar fight. Other than some abrasions on his face and hands, the patient has a laceration on the side of his neck. Exploration of this wound at the bedside reveals a large superficial laceration that does not penetrate the platysma muscle. Which of the following is most appropriate in the initial management of this patient?

(A) Immediate surgical neck exploration

(B) Angiography to evaluate for vascular injury

(C) Aggressive irrigation and local wound care

(D) Evaluation of the esophagus via endoscopy

(E) Evaluation of the esophagus via esophagography

1–C. A stab wound that does not penetrate the platysma needs no further evaluation. Meticulous wound care and local irrigation are needed, however significant injury to the deep structures of the neck is unlikely without penetration of the platysma. If the stab wound did penetrate the platysma, evaluation and treatment would be determined by the zone of the neck injured, as well as the presence or absence of signs suggestive of an injury to vital structures. Such signs include frank arterial bleeding, hematoma formation, bruit, cerebral changes indicative of an ischemic or embolic event, stridor, dysphonia, hemoptysis, hematemesis, dysphagia, odynophagia, or subcutaneous air.

2. A 16-year-old man is brought to the emergency room after his clothes caught on fire. He has severe burns to both his upper extremities. What signs would indicate the need for an escharotomy?

(A) Circumferential burns with severe blistering and erythema

(B) Circumferential burns with severe pain over the affected area

(C) Circumferential partial-thickness burns over the elbow joint

(D) Circumferential burns with an absence of the left radial pulse

(E) Circumferential superficial burns over the elbow joint

2–D. An escharotomy is a procedure that involves placement of full-thickness longitudinal incisions over sites of severe burn injury to prevent and treat vascular compromise and ischemia secondary to swelling and edema formation at the burn site. Full-thickness incisions to the level of healthy adipose tissue are necessary for adequate compartmental decompression. Indications for escharotomy in an extremity include circumferential burns with absent distal pulses or with significant neurologic changes. Superficial burns generally do not result in such an injury and the presence of partial-thickness burns over a joint does not mandate performance of an escharotomy. Blistering, erythema, and pain are not indications for escharotomy.

3. A 58-year-old woman presents to the emergency room after a motor vehicle accident. Despite 2 liters of intravenous fluid, her heart rate is still 130 beats per minute and her systolic blood pressure is 86 mm Hg. Her chest radiograph reveals normal lung fields with no evidence of pneumothorax or hemothorax, although there is a small amount of air noted between the diaphragm and the liver. Pelvic radiograph also reveals a fracture of the pubic symphysis and the right sacroiliac. Which of the following is most appropriate initial step in the evaluation and treatment of this patient?

(A) Obtain an immediate angiogram of the pelvis.

(B) Obtain an abdominal/pelvis computed tomography scan.

(C) Perform immediate diagnostic peritoneal lavage.

(D) Perform abdominal ultrasound and pelvic fixation.

(E) Perform immediate exploratory laparotomy.

3–E. Free air seen under the diaphragm after a motor vehicle accident is an indication for immediate surgical exploration of the abdomen because of the likelihood of a visceral injury. Performance of an abdominal computed tomography (CT) scan, abdominal ultrasound, or diagnostic peritoneal lavage is not necessary when free air is present in the abdomen. Operative pelvic fixation and angiography of the pelvis may be important in the management of this patient but should not precede performance of a laparotomy.

4. An 18-year-old man is admitted to the hospital after sustaining a burn injury from a gasoline fire. His entire anterior trunk, left upper extremity, and both complete anterior thighs are affected. All areas appear to be at least partial-thickness burns. What is the estimated total body surface area of burn injury involvement?

(A) 18%

(B) 27%

(C) 36%

(D) 55%

(E) 60%

4–C. Total body surface area (TBSA) estimates used to quantify the extent of burn injuries in adults is based on the “rule of nines.” The anterior trunk is equal to 18%. The left upper extremity is equal to 9%. Each lower extremity is equal to 18%, thus each anterior thigh is approximately 4.5%, and making a total of 9% TBSA involved in the lower extremity. Therefore 18 + 9 + 2(4.5) = 36%.

5. After being hit on the left side, a 24-year-old football player becomes unconscious. He regains consciousness and is brought emergently to the hospital. After initial resuscitation, performance of an abdominal computed tomography (CT) scan reveals a splenic injury involving the vessels within the hilum with significant intraperitoneal bleeding. Which of the following statements is true regarding the management of this patient?

(A) Nonoperative management with bedrest is indicated for this splenic injury.

(B) This patient will need to be immunized with vaccines against Haemophilus, Pneumococcus, and Neisseria.

(C) If a splenectomy is performed, this patient will require lifelong antibiotic therapy.

(D) This injury is a grade 1 splenic injury because of the involvement of the hilum.

(E) If nonoperative treatment is performed, this patient could return to play football in 2 weeks.

5–B. A severe splenic injury involving the splenic hilum requires immediate splenectomy and should not be managed with observation and bedrest. Some minor splenic injuries can be managed nonoperatively with bedrest and observation if there is no hemodynamic instability or significant intraperitoneal hemorrhage. Conservative treatment of minor splenic injuries with strict bedrest for 5 days would still require avoidance of contact sports with limited activity for approximately 6 weeks. Patients undergoing a splenectomy should receive immunization against encapsulated organisms, specifically Haemophilus, Pneumococcus, and Neisseria. Grading of splenic injuries is complex although grade 1 injuries are characterized by small (< 1 cm) lacerations not involving the capsule while grade V injuries include those with complete devascularization or avulsion of the spleen or a completely shattered spleen.

6. A 46-year-old woman suffered a full-thickness burn to 10% of her body, a partial-thickness burn to 30% of her body, and first degree burns to an additional 20% of her body. She weighs 50 kg and the burn occurred just before admission. What is the estimated amount of fluids she will need for the first 24 hours?

(A) 2 liters

(B) 3.6 liters

(C) 8.0 liters

(D) 12.4 liters

(E) 14.4 liters

6–C. Resuscitation fluid is determined using the Parkland formula, which estimates the volume of fluid to be administered during the first 24 hours after a severe burn injury. The formula is: volume = (% TBSA burned) × (weight in kg) × (4 mL), where TBSA = total body surface area. It is important to calculate the TBSA in this formula using only second and third degree burns. First degree burns are not used in calculating fluid resuscitation. So for this patient, the calculation is volume = (10% [full-thickness] + 30% [partial-thickness]) × 50 kg × 4 mL = 8000 kg/mL, which = 8.0 L.

7. A 27-year-old man sustains a gunshot wound to the abdomen with a small caliber handgun. There is a small entrance wound in the right lower quadrant and an exit wound on the back directly posterior to the entrance wound. His blood pressure is 120/60 mm Hg and his heart rate is 95 beats per minute. Exploratory laparotomy reveals a 1.5-cm laceration on the antimesenteric border of the ascending colon with no other injuries discovered. There is minimal fecal leakage. Which statement is true regarding the management of this patient?

(A) A pelvic angiogram should be performed postoperatively.

(B) A right colectomy and a diverting ileostomy should be performed.

(C) A completely diverting colostomy should be performed.

(D) This patient's injury can be managed with primary repair.

(E) If hematuria is present a nephrectomy should be performed.

7–D. Historically, a colostomy was performed in most patients with colonic injuries to avoid anastomotic leaking and wound infection. Recently, it has become evident that for many colon injuries a colostomy is not required. Patients with small injuries, especially to the right-sided colon, with minimal fecal soilage, and who are hemodynamically stable are appropriately managed with primary repair or closure of the injured segment. A pelvic injury is not indicated based on the clinical and intraoperative findings. Hematuria alone would not be an indication for nephrectomy, although the renal system and kidney should be carefully inspected intraoperatively for potential injury after a gunshot wound (GSW) to this area. The absence of other injuries at exploratory laparotomy warrant no further surgery or radiologic tests.

8. A 19-year-old cross country runner presents to the emergency room after falling off a 9-foot ridge and landing on his right side. He is complaining of some tenderness over his right lower ribs with no abdominal tenderness to palpation. His blood pressure is 128/74 mm Hg with a pulse of 96 beats per minute. An abdominal computed tomography (CT) scan is performed, which reveals a grade III liver injury with intra-abdominal bleeding. Which statement is true regarding this patient?

(A) Hypotension and tachycardia are often late findings of shock in young athletes.

(B) Hepatic arteriography is the preferred examination in the evaluation of liver injuries.

(C) A 9-foot fall is not sufficient enough to cause a severe liver injury.

(D) The lack of abdominal tenderness is inconsistent with intra-abdominal bleeding.

(E) A diagnostic peritoneal lavage should be performed to confirm bleeding.

8–A. Because of the well-adapted cardiovascular response, young athletes may frequently develop significant hypotension and tachycardia only as a late finding even in the presence of severe hypovolemia or blood loss. Patients on β blockers also can have a blunted tachycardic response to hypovolemia. The fact that abdominal tenderness was not present is not abnormal. Acute bleeding in the abdomen does not always cause peritoneal irritation. Hepatic arteriography may be used in some situations to treat hepatic injuries, however it is generally not preferred over computed tomography (CT) scan for evaluation. There is no need to perform diagnostic peritoneal lavage when bleeding is seen on CT scan.

9. An elderly male is involved in a motor vehicle accident. He states he was going approximately 45 mph when his car struck a car that stopped abruptly in front of him. His blood pressure is 110/74 mm Hg, with a heart rate of 87 beats per minute. After thorough examination his only injuries include a nondisplaced right femur fracture with intact peripheral pulses and some minor abrasions. Which of the following would be appropriate to confirm the absence of a cervical spine injury in this patient?

(A) A normal lateral neck film with no cervical tenderness or pain during examination

(B) A normal anterior posterior film with no cervical tenderness or pain during examination

(C) A normal computed tomography (CT) scan of the cervical spine with pain upon lateral neck motion

(D) Lateral, anterior-posterior, and odontoid views with no cervical tenderness or pain during examination

(E) Physical examination alone with no cervical tenderness or pain during examination

9–D. To adequately confirm the absence of a cervical spine injury in a patient at a potential risk for such injury (i.e., high-speed motor vehicle accident) radiographs must be performed. To rely on the physical examination alone, the patient must be alert and oriented and have no distracting injuries (e.g., femur fracture) or be under the influence of drugs. Radiographs needed to evaluate the cervical spine are a lateral, anterior-posterior, and open mouth odontoid views. It is important to visualize all seven cervical vertebrae. If a physical examination is reliable and negative for tenderness or pain with full range of motion, no further evaluation needs to be performed. Even with a normal computed tomography (CT) scan, however, the presence of pain during range of motion testing should prompt an evaluation for a potential ligamentous injury.

10. A 4-year-old girl is brought in by her parents after she apparently was burned during her bath. Her feet, buttocks, and perineum are badly scalded with blistering skin. Her legs have no blistering, but are mildly red and somewhat tender to the touch. Which of the following is true regarding admission criteria for burn injured victims?

(A) Children with deep partial-thickness burns on ≤ 30% total body surface area (TBSA) can be managed as outpatients with close follow-up.

(B) Patients with full-thickness burns to the perineum only can be managed as outpatients with close follow-up.

(C) Children with full-thickness burns to the feet only can be managed as outpatients with close follow-up.

(D) All patients with superficial burns to the entire torso region and both lower extremities require inpatient treatment.

(E) All children with burn injuries and a concern of possible abuse should be admitted for inpatient treatment.

10–E. Partial-thickness burns to the face, perineum, hands, or feet are criteria for admission and inpatient management. The total body surface area (TBSA) burned in this patient is greater than 10% and she is only 4 years old. This is also criteria for admission. Although this could simply be an unintentional accident, the question of abuse or neglect needs to be addressed and is an adequate indication for admission in any child regardless of extent of injury. Patients with superficial burns (e.g., minor sunburn) generally do not require inpatient treatment and can be managed appropriately as outpatients.

11. A 43-year-old patient who has been in the intensive care unit for 7 days following a severe 70% total body surface area (TBSA) burn has become increasingly tachycardic and mildly hypotensive with a decrease in urine output. Based upon changes in the color and odor of the burn wound, you suspect burn wound sepsis. Which organisms are most likely to be involved?

(A) Staphylococcus aureus, Pseudomonas species, and Bacteroides species

(B) Staphylococcus aureus, Streptococcus species, and Pseudomonas species

(C) Candida albicans, Bacteroides species, and Escherichia coli

(D) Candida albicans, E. coli, and Proteus species

(E) E. coli, Bacteroides species, and Clostridium difficile

11–B. Changes in burn wound color and odor may occur when burn wound sepsis is occurring. The most common organisms involved in burn wound infections include Staphylococcus aureus, Pseudomonas species, Streptococcus species, and Candida albicans. Confirmation of significant burn wound infection requires performing quantitative cultures of a biopsy specimen of the affected burn area.

12. A patient is complaining of shortness of breath after falling off his tractor and getting run over by the rear wheel. Physical examination reveals a blood pressure of 82/40 mm Hg, a heart rate of 122 beats per minute, short shallow respirations, breath sounds louder on the left than on the right, and tracheal shifting toward the patient's left. What is the most likely diagnosis?

(A) Right tension pneumothorax

(B) Left tension pneumothorax

(C) Cardiac tamponade

(D) Severe tracheal injury

(E) Right flail chest

12–A. The most likely diagnosis in this patient is a tension pneumothorax. Injury to the lung parenchyma caused by rib fractures from blunt chest trauma may result in development of a pneumothorax. As air continues to enter the pleural space with each inspiration, the intrapleural pressure continues to rise, resulting in lung collapse and even compression of vascular structures within the mediastinum (e.g., superior vena cava). This results in decreased venous return to the heart and rapid development of shock. This may also cause shifting of mediastinal structures such as the trachea away from the side of the pneumothorax. Cardiac tamponade is not associated with unilateral decreased breath sounds. Tracheal injuries are rare after blunt trauma to the chest. A flail chest can cause shallow respirations and unilateral decreased breath sounds but it is not always associated with development of a pneumothorax.

13. A 49-year-old man presents to the emergency room after being hit by a car while walking down the road. Minimal history is available from the emergency medical technicians. He is conscious upon arrival and moving all 4 extremities. The most appropriate initial step in the evaluation of this patient is to

(A) Remove all clothing and inspect for injuries.

(B) Ask the patient his name.

(C) Place a Foley catheter after a rectal examination.

(D) Evaluate the patient's pupils.

(E) Obtain chest and pelvis radiographs.

13–B. Although all of the procedures listed are important in the evaluation of the traumatized patient within the first few minutes, it is essential to proceed systematically with the ABC's (Airway, Breathing, Circulation), in that order. One of the easiest ways to assess for airway patency in a conscious patient is by determining the patient's ability to talk. If a patient can verbalize normally, the airway is likely patent.

14. A 17-year-old woman is seen in the emergency room with severe burns to both of her hands. She seems very responsible, and is with her parents who are very willing to help take care of her at home. She is not complaining of any pain and wonders if she can be treated as an outpatient. Which of the following statements is true regarding the management of this patient?

(A) This patient can be adequately managed as an outpatient with close follow-up.

(B) Skin grafting should be performed in 1–2 months to provide the best outcome.

(C) Her burns are likely to be superficial partial-thickness burns.

(D) Early skin grafting (within days) will decrease contracture formation.

(E) Wound cleansing and application of antibiotic ointment is adequate treatment.

14–D. The fact that these burns are painless makes it highly likely that they are a full-thickness burn. Any burn of that degree to the hands requires inpatient treatment. If left untreated, deep partial-thickness and full-thickness burns will heal slowly with significant scar formation and contracture formation. The gold standard is to do a split-thickness skin grafting within days after adequate excision and débridement of the burn.

15. A 52-year-old, 60-kg woman is admitted to the hospital immediately after being involved in a house fire. She has approximately 50% total body surface area (TBSA) burns that are at least partial-thickness burns. She has not received any intravenous (IV) fluids up to this point. Which of the following is the most appropriate IV fluid and rate of administration that should initially be given to this patient?

(A) Lactated Ringer's at 500 mL/hr

(B) 5% Dextrose in H₂O at 750 mL/hr

(C) Lactated Ringer's at 1000 mL/hr

(D) 5% Dextrose in H₂O at 1000 mL/hr

(E) Lactated Ringer's at 750 mL/hr

15–E. The Parkland formula is used to calculate an estimated volume of intravenous (IV) fluids to administer during the first 24 hours after a burn. Thus, 12 liters of IV fluids will need to be given to this patient during the first 24 hours. However, half of the fluid needs to be given in the first 8 hours after the injury; this means that approximately 6 liters will need to be given over an 8-hour period (750 mL/hr). Initial losses are isotonic, and therefore need to be replaced with an isotonic crystalloid such as lactated Ringer's.