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Basic Trauma And Burn Management
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Basic Trauma And Burn Management

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  • Thanks for sharing! I did not know you needed to avoid succh's with burn patient's (never dealt w/ burn patient's) but I did know it causes hyperkalemia & therefore that makes since! Thanks again!
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  • http://www.fioricetsupply.com is the place to resolve the price problem. Buy now and make a deal for you.
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  • Dear sir,
    i am a trainer from india.i wouldrequest you to kindly permit me to use your slides to teach nurses and paramedicalassistants.
    Thank you
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  • Lots of Medical / Nursing Slides and animation can be found at http://NurseReview.org
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  • 1. Trauma and Burn Management ®
    • D.F.Naylor, Jr., MD, FACS, FCCS
    • Staff Intensivist
    • September 13,2007
  • 2. 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
    ®
  • 3. 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
    ®
  • 4. 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
    ®
  • 5. 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
    ®
  • 6. 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
  • 7. 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)
    ®
  • 8. 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
  • 9. 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)
  • 10. 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
    ®
  • 11. 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
  • 12. 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
  • 13. 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 !
    ®
  • 14. 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
  • 15. Compartment Syndromes
    • Extremity
      • Serial examinations
      • Pain, pallor, pulselessness, paresthesias, paralysis
      • Fasciotomy
      • Know Sensory only sites Thumb Web, Great Toe 1st Metatarsal
  • 16. Burn Injury – Primary Assessment
    • Airway/breathing
      • Upper and lower airway injury
      • Carbon monoxide exposure
      • Bronchoscopy for evaluation
      • Consider early intubation
      • Avoid succinylcholine
    ®
  • 17. 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
    ®
  • 18. 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
  • 19. 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
    ®
  • 20. 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
  • 21.
    • 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
  • 22. 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 +
    ®
  • 23. 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
  • 24. 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
  • 25. 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
    ®
  • 26. 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
    ®
  • 27. 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 !
    ®
  • 28. Key Points