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  1. 1. Initial Assessment of the Trauma and Burn Patient Don Reiff, MD Assistant Professor, Section of Trauma/Burns/Critical Care Surgery Clerkship Director
  2. 2. Magnitude of the Problem <ul><li>What was the greatest medical problem financially and/or related to Hospital inpatient requirements during 1996? </li></ul><ul><ul><li>Heart Conditions ($58,030 / 2,519,000) </li></ul></ul><ul><ul><li>Cancer ($37,695 / 1,416,000) </li></ul></ul><ul><ul><li>Trauma ($37,144 / 1,620,000) </li></ul></ul><ul><ul><li>COPD, Asthma ($28,594 / 1,291,000) </li></ul></ul>
  3. 3. Magnitude of the Problem <ul><li>How has this changed by 2003? </li></ul><ul><ul><li>Trauma ($75,571 / 2,332,000) </li></ul></ul><ul><ul><li>Heart Conditions ($67,801 / 3,893,000) </li></ul></ul><ul><ul><li>Cancer ($48,428 / 545,000) </li></ul></ul><ul><ul><li>Mental Disorders ($47,503 / 1,211,000) </li></ul></ul><ul><ul><li>*Normal Birth (3,722,000) </li></ul></ul>
  4. 4. Trauma/Burns Resuscitation <ul><li>Where did the notion of “Trauma Resuscitation” come from? </li></ul><ul><ul><li>1976 J.K. Styner, MD piloted a plane in SE Nebraska </li></ul></ul><ul><ul><li>Crashed resulting in the death of his wife and two of three children </li></ul></ul>
  5. 5. Trauma/Burns Resuscitation <ul><li>What are the steps of the Trauma Resuscitation? </li></ul><ul><ul><li>Primary Survey </li></ul></ul><ul><ul><li>Secondary Survey </li></ul></ul><ul><ul><li>Lines/Tubes in every orifice </li></ul></ul><ul><ul><li>Labs and adjuvant studies </li></ul></ul><ul><ul><li>What are our goals? </li></ul></ul>
  6. 6. Trauma/Burns Resuscitation <ul><li>What are the steps of the Primary Survey? </li></ul><ul><ul><li>Airway </li></ul></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><li>Neurologic Deficit </li></ul></ul><ul><ul><li>Exposure </li></ul></ul>What are the goals of the primary survey?
  7. 7. Trauma/Burns Resuscitation <ul><li>Airway </li></ul><ul><ul><li>Most expeditious means to evaluate the patency and ability to protect airway </li></ul></ul>Should airway control be necessary, what is the best means?
  8. 8. Trauma/Burns Resuscitation <ul><li>Airway </li></ul><ul><ul><li>Rapid sequence intubation </li></ul></ul><ul><li>Cricothyroidotomy </li></ul>
  9. 9. Trauma/Burns Resuscitation <ul><li>Breathing </li></ul><ul><ul><li>Assessing the presence of breath sounds using auscultation </li></ul></ul><ul><ul><li>Life-threatening Injuries </li></ul></ul><ul><ul><li>Tension pneumothorax </li></ul></ul><ul><ul><li>Open pneumothorax </li></ul></ul><ul><ul><li>Flail chest </li></ul></ul><ul><ul><li>Massive Hemothorax </li></ul></ul><ul><ul><li>Cardiac Tamponade </li></ul></ul>
  10. 10. Life-Threatening Chest Injuries <ul><li>Tension Pneumothorax </li></ul><ul><ul><li>Pathophysiology </li></ul></ul><ul><ul><ul><li>Progressive entry of air into pleural space </li></ul></ul></ul><ul><ul><ul><li>Collapse of ipsilateral lung </li></ul></ul></ul><ul><ul><ul><li>Mediastinal shift </li></ul></ul></ul><ul><ul><ul><li>Compromised venous return to heart </li></ul></ul></ul><ul><ul><ul><li>Hypotension / decreased cardiac output </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular collapse </li></ul></ul></ul>
  11. 11. Life-Threatening Chest Injuries <ul><li>Open Pneumothorax </li></ul><ul><ul><li>Physiologically, what’s the issue </li></ul></ul>
  12. 12. Life-Threatening Chest Injuries <ul><li>Flail Chest </li></ul><ul><ul><li>Why is this dangerous? </li></ul></ul><ul><li>Current management is to </li></ul><ul><li>“ internally” splint patients </li></ul><ul><li>How would you manage </li></ul><ul><li>this problem? </li></ul>
  13. 13. Life-Threatening Chest Injuries <ul><li>Massive Hemothorax </li></ul><ul><ul><li>Obviously bad for several reasons </li></ul></ul>
  14. 14. Life-Threatening Chest Injuries <ul><li>Cardiac Tamponade </li></ul><ul><ul><li>How do we make the diagnosis? </li></ul></ul><ul><ul><li>What is the physiologic problem and how do you correct it? </li></ul></ul>
  15. 15. Trauma Resuscitation <ul><li>Circulation </li></ul><ul><li>Shock is most simply defined as… </li></ul><ul><li>inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular function </li></ul><ul><li>Equating shock and blood pressure is inaccurate </li></ul><ul><ul><li>Compensatory mechanisms result in shunting </li></ul></ul><ul><ul><ul><li>Reduction in renal blood-flow </li></ul></ul></ul><ul><ul><ul><li>Reduction in splanchnic blood-flow </li></ul></ul></ul>
  16. 16. Trauma Resuscitation <ul><li>Causes of shock </li></ul><ul><ul><li>Obstructive </li></ul></ul><ul><ul><li>Cardiogenic </li></ul></ul><ul><ul><li>Neurogenic </li></ul></ul><ul><ul><li>Septic </li></ul></ul><ul><ul><li>Hemorrhagic/Hypovolemic </li></ul></ul>Non-hemorrhagic
  17. 17. Shock <ul><li>Classification of shock </li></ul><ul><li>Signs/Symptoms </li></ul><ul><li>Narrowing of pulse pressure </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Oliguria/Anuria </li></ul></ul><ul><ul><li>Mental Status changes </li></ul></ul>
  18. 18. Trauma Resuscitation <ul><ul><ul><li>Large bore peripheral IV </li></ul></ul></ul><ul><ul><ul><ul><li>Poiseuille’s law </li></ul></ul></ul></ul><ul><ul><ul><li>Bolus two liters of warm fluid </li></ul></ul></ul><ul><ul><ul><li>Blood and/or coagulation factors </li></ul></ul></ul><ul><ul><ul><li>Frequently monitor vital signs/UOP for response </li></ul></ul></ul>What about patients who don’t respond appropriately to our initial fluid bolus? <ul><li>Clinical intervention for hemorrhagic shock </li></ul>Q=  Pr 4 8  l <ul><ul><ul><li>Large bore peripheral IV </li></ul></ul></ul><ul><ul><ul><ul><li>Poiseuille’s law </li></ul></ul></ul></ul><ul><ul><ul><li>Bolus two liters of warm fluid </li></ul></ul></ul><ul><ul><ul><li>Blood and/or coagulation factors </li></ul></ul></ul><ul><ul><ul><li>Frequently monitor vital signs/UOP for response </li></ul></ul></ul>Q=  Pr 4 8  l
  19. 19. Algorithm <ul><li>Hemorrhagic Shock </li></ul><ul><ul><li>Where has the blood gone? </li></ul></ul><ul><ul><ul><li>Scene •Extremity fractures </li></ul></ul></ul><ul><ul><ul><li>Thorax •Peritoneum </li></ul></ul></ul><ul><ul><ul><li>Retroperitoneum </li></ul></ul></ul><ul><ul><li>How can we quickly eliminate several of the potential sources of blood loss? </li></ul></ul>
  20. 20. Algorithm <ul><li>Hemorrhagic shock </li></ul><ul><ul><li>With two of five eliminated, how to work up last three? </li></ul></ul><ul><ul><ul><li>CXR/Pelvic X-ray </li></ul></ul></ul><ul><ul><ul><li>Physical examination </li></ul></ul></ul><ul><ul><ul><li>DPL/US </li></ul></ul></ul><ul><ul><li>Once identified, institute appropriate therapy </li></ul></ul><ul><ul><ul><li>Reduce fractures </li></ul></ul></ul><ul><ul><ul><li>Pelvic binder </li></ul></ul></ul><ul><ul><ul><li>Chest tube </li></ul></ul></ul><ul><ul><ul><li>Operating room </li></ul></ul></ul>
  21. 21. Resuscitation <ul><li>Endpoints </li></ul><ul><ul><li>Classically, restoration of BP,HR and UOP </li></ul></ul><ul><ul><li>Using only these parameters will leave 50-85% patients in “compensated” shock </li></ul></ul><ul><ul><li>Recent data suggests </li></ul></ul><ul><ul><ul><li>Correction of lactate levels </li></ul></ul></ul><ul><ul><ul><li>Correction of base deficits </li></ul></ul></ul><ul><ul><ul><li>Tonomotry </li></ul></ul></ul>
  22. 22. Case Presentation <ul><li>38 year old male </li></ul><ul><ul><li>Unrestrained driver </li></ul></ul><ul><ul><li>Initially unresponsive, largely obtunded </li></ul></ul><ul><li>Initial vital signs: </li></ul><ul><ul><li>HR – 130’s </li></ul></ul><ul><ul><li>SBP – 105 </li></ul></ul><ul><ul><li>O2 sats – 92% on NRB </li></ul></ul>
  23. 23. Approach to the Evaluation of Shock ABC’s Intubate Tachycardic/hypotensive/ hypoxic w/ absent BS Needle decompression w/ concurrent fluid resuscitation No rush of air/vital signs show no improvement “ Non-responder” Go through check list of etiologies
  24. 24. Case Presentation <ul><li>Primary survey </li></ul><ul><ul><li>Airway controlled </li></ul></ul><ul><ul><li>Decreased breath sounds on right </li></ul></ul><ul><ul><li>Severe shock with HR now 140’s to 150’s and SBP below 100 </li></ul></ul>Non-hemorrhagic sources - Sepsis - Cardiogenic - Neurogenic - Obstructive
  25. 25. Approach to the Evaluation of Shock Primary survey Needle decompressed/volume resuscitation Non-responder - Sepsis - Cardiogenic - Neurogenic - Obstructive Eliminated CXR has ruled out Tension pneumothorax Use ultrasound to rule out pericardial tamponade All that remains is hypovolemic/hemorrhagic shock
  26. 26. Approach to the Evaluation of Shock <ul><li>Assess external losses </li></ul><ul><li>Extremities </li></ul><ul><li>Radiologic survey </li></ul><ul><li>US/DPL/CT Scanning </li></ul>
  27. 27. Case Presentation <ul><li>Right sided 40F chest tube with blood auto-transfused </li></ul><ul><li>Initial ABG returns with 7.15/35/98/-10/8.5 </li></ul>In addition to auto-transfusion, 4u pRBC’s given slowing HR to 130’s and SBP improves to 115 Repeat ABG finds 7.26/38/135/-9/9.2
  28. 28. Case Presentation <ul><li>Package and run to CT </li></ul>
  29. 29. Case Presentation <ul><li>Package and run to operating room </li></ul>
  30. 30. BURNS
  31. 31. Presentation <ul><li>ABC’s </li></ul><ul><li>Determine mechanism </li></ul><ul><ul><li>Flame, chemical, electrical </li></ul></ul><ul><ul><li>Associated trauma </li></ul></ul><ul><li>Complete history and examination </li></ul><ul><li>Labs and chest x-ray </li></ul><ul><ul><li>ABG with CO </li></ul></ul>
  32. 32. Presentation <ul><li>Resuscitation </li></ul><ul><li>Tetanus Prophylaxis </li></ul><ul><li>Hypothermia </li></ul><ul><li>Antibiotics/steroids NOT indicated </li></ul>
  33. 33. Severity of Injury <ul><li>Dependent on the depth and extent of burn injury. </li></ul><ul><li>Depth </li></ul><ul><ul><li>1 st , 2 nd , 3 rd degree </li></ul></ul><ul><li>Extent </li></ul><ul><ul><li>Estimated total burn surface area </li></ul></ul>
  34. 34. Burn Depth
  35. 35. Burn Depth <ul><li>1 st Degree </li></ul><ul><ul><li>Partial thickness </li></ul></ul><ul><ul><li>Sun Burn </li></ul></ul><ul><ul><li>Spontaneous healing </li></ul></ul>
  36. 37. Burn Depth <ul><li>2 nd Degree </li></ul><ul><ul><li>Partial thickness </li></ul></ul><ul><ul><li>Usually heals spontaneously </li></ul></ul><ul><ul><li>Involve epidermis and varying thickness of dermis </li></ul></ul>
  37. 39. Burn Depth <ul><li>3 rd Degree </li></ul><ul><ul><li>Full thickness burn </li></ul></ul><ul><ul><li>Will not heal spontaneously </li></ul></ul><ul><ul><li>Excision and Grafting </li></ul></ul><ul><ul><li>Involves epidermis and dermis </li></ul></ul>
  38. 41. Burn Depth <ul><li>4 th degree </li></ul><ul><ul><li>Involves epidermis, dermis, and underlying structures </li></ul></ul><ul><ul><li>Fat, fascia, muscle, bone </li></ul></ul><ul><ul><li>Associated most commonly with electrical burns </li></ul></ul>
  39. 43. Extent of Burn <ul><li>Rule of 9’s </li></ul><ul><li>Lund and Browder </li></ul>
  40. 45. Resuscitation <ul><li>Fluid is determined by the severity of injury </li></ul><ul><ul><li>mount of 2 nd and 3 rd degree burn </li></ul></ul><ul><li>Lactated ringers </li></ul><ul><li>Initial fluid determined by parkland formula </li></ul><ul><ul><li>2-4cc/kg/%TBSA </li></ul></ul><ul><ul><li>½ over the first 8 hours </li></ul></ul><ul><li>DO NOT BOLUS </li></ul><ul><li>Titrate fluid to urine output </li></ul><ul><ul><li>30-50cc/hour </li></ul></ul>
  41. 46. Escharotomy <ul><li>Full-thickness, circumferential burns to extremity or trunk </li></ul><ul><ul><li>Diminished blood flow to extremity </li></ul></ul><ul><ul><li>Decreased pulmonary compliance </li></ul></ul><ul><li>Medial and lateral incisions on the extremities </li></ul><ul><li>Anterior axillary line on trunk </li></ul>
  42. 48. Inhalation injury <ul><li>Most common cause of death </li></ul><ul><ul><li>80% of burn related deaths </li></ul></ul><ul><li>Several mechanisms involved </li></ul><ul><ul><li>Oropharyngeal </li></ul></ul><ul><ul><li>Tracheo-bronchial </li></ul></ul><ul><ul><li>Toxic absorption </li></ul></ul><ul><ul><ul><li>Cyanide </li></ul></ul></ul><ul><ul><ul><li>Carbon monoxide </li></ul></ul></ul>
  43. 49. Inhalation injury <ul><li>History </li></ul><ul><ul><li>Enclosed space </li></ul></ul><ul><ul><li>Loss of consciousness </li></ul></ul><ul><ul><li>Drugs and alcohol </li></ul></ul><ul><li>Physical exam </li></ul><ul><ul><li>Facial burns, singed nasal hairs </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Carbonaceous sputum </li></ul></ul><ul><ul><li>Depressed mental status </li></ul></ul>
  44. 50. Carbon Monoxide <ul><li>Most frequent cause of death at the scene. </li></ul><ul><li>Very high affinity for hemoglobin. </li></ul><ul><li>Impairs oxygen availability and use in the tissues. </li></ul>