Trauma Thermal Injury Trauma Douglas M Maurer DO

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Trauma – Thermal Injury. Trauma Douglas M. Maurer, DO, MPH

Trauma – Thermal Injury. Trauma Douglas M. Maurer, DO, MPH

Learning Objectives • Recognize and respond appropriately to a patient with inhalational and thermal

Learning Objectives • Recognize and respond appropriately to a patient with inhalational and thermal injuries. • Appropriately treat carbon monoxide and cyanide toxicities. • Calculate and initiate appropriate fluid resuscitation for a patient with thermal injuries.

Introduction • • • Inhalational injury occurs in 20% of burns; high mortality Heat

Introduction • • • Inhalational injury occurs in 20% of burns; high mortality Heat injury to oropharyngeal area and lower airway Irritants result in: • • • Direct tissue injury Acute bronchospasm Mucosal damage and plugging Pulmonary edema Asphyxiation caused by: • • • Hypoxemia from low Fi. O 2 CO toxicity CN toxicity

Clinical Features and Work-up • • Voice changes/hoarseness Burns on face around mouth and

Clinical Features and Work-up • • Voice changes/hoarseness Burns on face around mouth and nose Singed nasal hair, carbonaceous sputum Airway soot, mucosal edema, blisters Respiratory distress Cherry red lips in CO toxicity Cherry red skin, bitter almonds in CN toxicity CXR and ABG

Major Burn Overview • Definition of “major burn” varies • Burn requiring fluid resuscitation,

Major Burn Overview • Definition of “major burn” varies • Burn requiring fluid resuscitation, or those with an inhalational component • Approach is the same as any other type of major trauma, the ABCDE’s • Early coordination with burn center is key

ABCDE’s of Burns • A – Airway • • B-Breathing • • Place IV’s

ABCDE’s of Burns • A – Airway • • B-Breathing • • Place IV’s through unburnt skin where possible Assess for circumferential burns to limbs Shock due to burns is uncommon D-Disability • • Give high flow O 2 via NRB Assess for constrictive chest wall burns Assess for CO and CN toxicity C-Circulation • • Don’t forget C-spine immobilization Assess for evidence of airway/neck burns Consider early intubation Mental status changes from hypoxia and CN/CO toxicity E-Exposure • • Risk of hypothermia especially in children Remove jewelry and burnt / wet clothes

Assessment of Burn % and Depth • Total Body Surface Area (TBSA) % of

Assessment of Burn % and Depth • Total Body Surface Area (TBSA) % of Burn • • • Palmar Surface Rule of Nines Lund & Browder Chart • Burn depth • • • Epidermal Superficial dermal Mid dermal Deep dermal Full thickness

Treatment of Burns • Airway • • If compromised, then RSI If intact, then

Treatment of Burns • Airway • • If compromised, then RSI If intact, then nasal endoscopy; low intubation threshold • Breathing • • High flow O 2 for 6 hours and until CO levels normal Bronchospasm: B 2 agonists, humidification • Circulation • Use resuscitation fluids if: • Adult: > 15 – 20% Total BSA • Children: > 10% Total BSA

Fluid Resuscitation for Burns • Estimation of fluid requirements: • Parkland or Modified Parkland

Fluid Resuscitation for Burns • Estimation of fluid requirements: • Parkland or Modified Parkland formula • Estimates fluid required for the first 24 hours • Place foley catheter • Urine output goals: • 0. 5 ml/kg/hr in adults • 1 ml/kg/hr in children • Discuss patient with burn center

Additional Burn Treatments • Remove jewelry, clothing; if stuck, leave it • Cool patient

Additional Burn Treatments • Remove jewelry, clothing; if stuck, leave it • Cool patient with running water for 20 minutes; risk of hypothermia • Dressings depends on local policy, resources • Clean wounds with mild soap and water • Topical antibiotics to all nonsuperficial burns • No role for prophylactic IV antibiotics • Pain control with opioids; benzos for anxiety • Tetanus prophylaxis

CO Toxicity • History: duration/mechanism of exposure, LOC, confusion, chest pain, HA, N/V •

CO Toxicity • History: duration/mechanism of exposure, LOC, confusion, chest pain, HA, N/V • PE: MSE, PE usually wnl. • Evaluation: check CO with co-oximetry, EKG, enzymes if risk factors, head CT if MS changes, consider CN toxicity • Treatment: secure airway, high flow O 2, consider hyperbaric O 2 tx

CN Toxicity • • • History: HA, MS changes, abdominal pain Physical: hypertension, tachycardia,

CN Toxicity • • • History: HA, MS changes, abdominal pain Physical: hypertension, tachycardia, tachypnea early then CV collapse; cherry red skin; seizures Evaluation: standard tox labs, check anion gap, lactate, ABG, carboxyhemoglobin and methemoglobin levels Treatment: secure airway (RSI usually required); high flow O 2; NO mouth to mouth If cyanide toxicity known or strongly suspected: • • • Sodium nitrite 10 mg/kg up to 300 mg slow IV infusion, may repeat Sodium thiosulfate (25%) 1. 65 ml/kg up to 50 ml IV, may repeat If cyanide toxicity possible but not certain or nitrite contra: • Sodium thiosulfate (25%) 1. 65 ml/kg up to 50 ml IV, may repeat

Burn Center Referral • • • Burns and trauma in whom the burn poses

Burn Center Referral • • • Burns and trauma in whom the burn poses the greater risk Burns in children at hospitals without qualified personnel Burns in patients requiring special social, emotional, or rehab Burns in patients with preexisting medical disorders Burns to face, hands, feet, genitalia, perineum, or major joints Chemical burns Electrical burns, including lightning injury Inhalation injury Partial-thickness burns on >10% TBSA Third-degree (full-thickness) burns in any age group

Summary • Recognize and treat inhalation and thermal injury aggressively • Give high flow

Summary • Recognize and treat inhalation and thermal injury aggressively • Give high flow O 2 to CO/CN toxicity • Give appropriate antidotes for CN toxicity • Use Parkland or Modified Parkland formulas • Contact burn center early in evaluation

References • • • Rice PL, Orgill DP. Emergency care of moderate and severe

References • • • Rice PL, Orgill DP. Emergency care of moderate and severe thermal burns in adults. In: Up. To. Date, Hockberger RS, Moreira ME (Ed), Up. To. Date, Waltham, MA, 2012. Mandell J, Hales CA. Smoke inhalation. In: Up. To. Date, Hockberger RS, Moreira ME (Ed), Up. To. Date, Waltham, MA, 2012. Nickson C. “Trauma! Major burns. ” Weblog entry. Life in the Fastlane Blog. http: //lifeinthefastlane. com/2012/09/traumatribulation-032/ Nickson C. “Smoking is deadly. ” Weblog entry. Life in the Fastlane Blog. http: //lifeinthefastlane. com/2010/09/toxicologyconundrum-038/ American College of Surgeons. ATLS Textbook, 9 th Edition. 1 September 2012.

Simulation Training Assessment Tool (STAT)– Thermal Injury. Trauma Douglas M. Maurer, DO, MPH, FAAFP

Simulation Training Assessment Tool (STAT)– Thermal Injury. Trauma Douglas M. Maurer, DO, MPH, FAAFP

Simulation Training Assessment Tool (STAT) – Thermal Injury Trauma SCENARIO ALGORITHM SET UP: “Rural”

Simulation Training Assessment Tool (STAT) – Thermal Injury Trauma SCENARIO ALGORITHM SET UP: “Rural” ER Simulated Room Real or simulated patient with simulated burns to skin and inhalation injury PRE ARRIVAL: FP in rural ER, lab, rad, OR 65 y/o male s/p explosion of basement kerosene heater in home. VS BP 160/110, HR 110, RR 30, Sp. O 2 90% on 15 L NRB, GCS 15 Date: Instructor(s): Learner(s): Learning Objectives: 1. Recognize and respond appropriately to a patient with inhalational and thermal injuries. 2. Appropriately treat carbon monoxide and cyanide toxicities. 3. Calculate and initiate appropriate fluid resuscitation for a patient with thermal injuries. CRITICAL ACTIONS ME NI M Completes Primary Survey: recognizes inhalation injury MK 2 ARRIVAL: Full spinal precautions, has 1 IV in place. Pt awake, alert, hoarse voice, SOB, in moderate distress, BP , HLP meds, no allergies, PMHx of HTN, HLP, no PSHx Safety net – IV, O 2, monitor MK 2 Initiates RSI to secure airway MK 2 PRIMARY SURVEY: A – talking hoarsely, soot around mouth, singed nasal hairs, burns on face/mouth B – labored, RR 30, dec BS w/rhonchi bilat w/wheezing/stridor. C – BP 140/90, HR 80, warm extremities D – GCS 14, struggling to speak/coughing, mild confusion E – 2 nd and 3 rd degree burns to face, neck, chest, hands/arms; cherry red lips/skin, blisters in mouth Completes Secondary Survey: recognizes significant burns and inhalation toxicities PC 5 Bedside labs: ABG w/ co-oximetry, CBC, CMP, lactate, BAL/Tox, cyanide, EKG, enzymes PC 5 Bedside rads: port cxr, lat C-spine, AP pelvis PC 5 Recognizes respiratory distress and gives bronchodilators MK 2 Recognizes CO toxicity and gives high flow O 2 (FIO 2 100%), considers hyperbaric O 2 MK 2 Suspects CN toxicity and gives sodium thiosulfate and hydroxocobalamin; calls toxicology/poison control MK 2 Calculates and initiates proper fluid resuscitation for burns MK 2 Transfers patient to burn center MK 2 SECONDARY SURVEY: Other exam normal, c-spine non tender, abd soft, pelvis stable, rectal guaiac negative, rhonchi/rales/wheezing/stridor on lung exam LABS & IMAGES: Chest: bilat atelectasis, ? Pulm edema c-spine, pelvis negative Labs – WBC 14, H/H 12/40, platelets 200, ETOH/Toxneg; lactate 2, ABG: 7. 25/35/50/90%/-4 Oxy. Hgb: , carboxy. Hgb: 7% , met. Hgb: Blood cyanide: Pending EKG: Sinus tachy, neg cardiac enzymes DISPOSITION: Must RSI, must tx CO and CN toxicity, give proper fluids, transfer patient to burn center TOTAL SUSTAIN SB 4 ME = Meets Expectations; NI = Needs Improvement, M = Milestones IMPROVE