09-basic 20trauma-burn 20support 1

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Copyright 2008 Society of Critical Care Medicine

Basic Trauma

and Burn Support


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Objectives

Prioritize and initiate assessment ofthe traumatized patientInitiate treatment of life-threateningtraumatic injuryUtilize radiography in identifyingsignificant traumatic injuryIdentify and respond to changes instatus of the injured patientInitiate early burn management


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Case Study

Unrestrained man ejected after his carcollided with a semitrailer

Incoherent and unable to clear secretions

Femur fracture, scalp laceration, chestand abdominal contusions

BP 90/60 mm Hg, HR 125/min, RR 35/min

Lethargic with cool, clammy skin

What does the primary survey

indicate?


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Trauma Management

Primary assessment Initial evaluation and resuscitation

Secondary assessment

Diagnosis and treatment of otherinjuries

Tertiary assessment Ongoing evaluation


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Primary Assessment

Airway maintenance with cervicalspine precautions

Breathing: oxygenation andventilation

Circulation with hemorrhage control

Disability: brief neurologicexamination

Exposure/environment: undress,avoid hypothermia


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Case Study

Incoherent, unable to clear secretions


BP 90/60 mm Hg, HR 125/min,RR 35/min

Moves all extremities


What does the primary survey indicate?

What interventions are most important?

A

B

C

DE


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Case Study


Femur fracture, scalp laceration,chest and abdominal contusions




Is this patient in shock?

What interventions are indicated?

A

B

C

DE


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Shock in Trauma

Hemorrhagic Chest Abdomen

PelvisNonhemorrhagic Obstructive: tension

pneumothorax, cardiac

tamponade Neurogenic: spinal cord injury Cardiac: blunt injury


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Hemorrhage Classification

BP 90/60 mm Hg, HR 125/min, RR 35/min

Variable Class I Class II Class III Class IV

Systolic BP N N

HR, beats/min 100 >120 >140

RR, breaths/min 14-20 20-30 30-40 >35

Mental status anxious agitated confused lethargic

Blood loss (mL) 2,000

Blood loss (%) 40


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Circulation Issues

Large bore peripheral IV cannulas (2)2 L warmed lactated Ringers (>50mL/kg)

External hemorrhage controlDiagnostic studies for hemorrhagesource

Red blood cell transfusion

Transfusion of other blood products

Monitoring


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Case Study






A

B

C

DE

How would you assess disability?

What adverse effects occur from exposure?


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Case Study

Patient is intubated and mechanicallyventilated with 100% O2Coarse rhonchi bilaterally

2 L lactated Ringers administered

BP 104/78 mm Hg, HR 110/min, RR 18/min,SpO2 95%

What are the next steps in assessment?

Which laboratory and radiologic tests

should be obtained?


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Secondary Assessment

Detailed historyHead-to-toe physical examination

Laboratory studies

Radiologic studiesOther interventions FAST Diagnostic peritoneal lavage

Naso- or orogastric tube Antibiotics


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Case Study

Male with liver and mesentericlacerations from vehicular accident

Bowel resected and abdomenpacked to control bleeding

Fluid resuscitation continues

Airway pressures and urine output after ICU admissionWhat are possible causes ofairwaypressures and urine output?


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Tertiary Assessment

Head injuryPulmonary injury

Cardiac injury

Abdominal injuryMusculoskeletal injury

Adequacy of resuscitation

Transfer


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Case Study

Male with full thickness burn injuryto forearms and flash-burn injury toface after gasoline can explosion

Thrown into tree stump

No respiratory distress butcomplains of abdominal pain

No fluids given

What are initial evaluation priorities?


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Burn Evaluation

Airway/breathing Inhalation injury Carbon monoxide

Circulation Fluids Escharotomy

Disability/Exposure

Burn thickness and area


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Burn Evaluation

Burn thickness First degree:

superficial Second degree:

partial thickness Third degree: full

thickness

Burn area Rule of nines


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Case Study

Burn injury = 18% of body surfacearea

HR 120/min, BP 110/50 mm Hg, RR24/min

SpO2 93% (2 L/min O2 nasal cannula)

Agitated with complaints ofabdominal pain

What interventions are needed?


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Burn Issues

Carbon monoxide exposure 100% oxygen

Fluid resuscitation

2-4 mL/kg/% burn area (2nd

and 3rd

degree) 50% in first 8 h, 50% in next 16 h

Burn wound care

Pain controlOther traumatic injuries


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Other Burns

Chemical Brush off dry substances Irrigate

Electrical Entrance, exit wounds Cutaneous burns from

arc injury

Flame exposure (clothing) Potential rhabdomyolysis Secondary injuries


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Questions?


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Key Points

Identify and treat life-threatening injuriesfirst

Airway control assumes an unstable C-spine after blunt trauma

Tension pneumothorax is diagnosed byclinical criteria

Hemorrhage is the most likely cause of

shockBlood is added when crystalloidresuscitation is >50 mL/kg


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Key Points

Secondary assessment includes a head-to-toe examination

CT scan is essential for head-injuredpatients with decreased level ofconsciousness

Abdominal compartment syndrome maydevelop due to multiple etiologies

Transfer to specialized care should not bedelayed for additional radiologic studies


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Key Points

Burn resuscitation is proportional to burnthickness and area

Smoke inhalation injury places the patientat high risk for upper airway and lunginjury

09-basic 20trauma-burn 20support 1

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