Initial Assessment and Management

Committee on Trauma Presents

Thermal

Injuries

Types of Thermal Injuries

Burn Injuries Cold Injuries

Burn Injuries

Case Scenario

● A 54-year-old is rescued from a smoke-filled room in a burning house.

● He fell asleep on a couch while smoking.

● Patient is conscious, agitated, and coughing carbonaceous sputum.

● His upper body appears extensively burnt.

What are your priorities in managing this patient?

Objectives

● Outline the principles of initial assessment and treatment of thermal injuries.

● Discuss the importance of the size of burn injury and associated injuries.

● Identify special problems and methods of treatment.

● Specify criteria for transfer of patients with burns.

Priorities

Assess the patient’s ABCs

AND

Stop the burning!

What is my first priority?

A B D EC

Priorities

Manage Airway and Breathing

●Consider direct thermal or inhalation injury.

●Establish and maintain patent airway early and consider early ET intubation.

●Oxygenate and ventilate.

●Obtain ABGs and CO levels.

Assessment and Management

How do I identify inhalation injury?

Assessment and Management

●Carbonaceous sputum

●Carbon deposits

●CoHb > 10%

●Face and neck burns

●Hair singeing

●Inflamed oropharynx and hoarseness

How do I identify inhalation injury?

Assessment and Management

●Adequate venous access

●Monitor vital signs

●Hourly urine output●Adult: 0.5 – 1.0 mL / kg / hour

●Child: 1.0 mL / kg / hour

● Infant: 2.0 mL / kg / hour

Maintain Organ Perfusion

Assessment and Management

How do I estimate burn size and depth?

Assessment and Management

How do I estimate burn size and depth?

Assessment and Management

Second-Degree Burn

Assessment and Management

Third-Degree Burn

Assessment and Management

●4 mL warmed balanced crystalloid solution / kg / %BSA in first 24 hours (global only)

●Administer ½ in first 8 hours

●Administer ½ in next 16 hours

●Base calculations on time from injury

●Monitor heart rate and urinary output

What is the rate and type of fluids administered to patients with burns?

Assessment and Management

●AMPLE history

●Tetanus status

Other Information

Other Management●Baseline blood analyses and chest

x-ray

●Gastric intubation

●Narcotic analgesia

●Antibiotics

●Wound care

●Flow sheet documentation

Assessment and Management

Flush with copious amounts of water for 20 – 30 minutes

Management of Chemical Burns

Assessment and Management

Management of Electrical Burns

●Fascia and muscle damage; may spare overlying skin

●Myoglobinuria: Increase fluids, administer mannitol

●Maintain adequate perfusion

●Sodium bicarbonate

Transfer Criteria

Transfer Criteria for Second-Degree and Third-Degree Burns

●> 10% BSA in ages < 10 and > 50 years

●20% BSA (all ages)

●Unique areas (any size burn)●Face

●Eyes

●Ears

●Hands

●Feet

●Genitalia

●Perineum

●Major joints

Transfer Criteria

Transfer Criteria for Second-Degree and Third-Degree Burns

●Third-degree burns > 5% BSA (all ages)

●Electrical and chemical burns

●Inhalation injury

●Preexisting illnesses, associated injuries

●Children

●Special situations

Transfer Procedures

●Coordinate with burn center physician

●Transfer with:

● Documentation / information

● Laboratory results

Cold Injuries

Case Scenario

● A 72-year-old female is found lying in her garden outside her back door.

● It is winter, and the outside temperature is just above freezing.

● The patient’s right leg is shortened and externally rotated.

● She appears confused.

What factors should you consider in her early management?

Objectives

● Outline the principles of initial assessment and treatment of localized and systemic cold injuries.

● Identify special problems and methods of treatment.

● Discuss the importance of hypothermia in the resuscitation of the injured patient.

Local Tissue Effects

● Temperature

● Duration of exposure

● Environmental conditions

How does cold affect my patient?

●Immobilization

●Moisture

●Vascular disease

●Open wound

Recognition

● Frostnip

● Frostbite

● Nonfreezing injury

How do I recognize a local cold injury?

Treatment

● Do not delay

● Remove clothing

● Warmed blankets

● Rewarm frozen part

● Preserve damaged tissue

How do I treat a local cold injury?

●Prevent infection

●Elevate exposed part

●Analgesics, tetanus, and antibiotics

Recognition

● Rapid or slow drop in core temperature to < 35°C

● Elderly and children at greater risk

● Low-range thermometer required

How do I recognize hypothermia?

Recognition

How do I recognize hypothermia?

What are the clinical findings associated with hypothermia?

Recognition

● Depressed level of consciousness

● Gray, cyanotic

● Variable vital signs

● Absence of cardiorespiratory activity

How do I recognize hypothermia?

What are the clinical findings associated with hypothermia?

Treatment

● ABCDE

● Rewarm

● Assess for associated disorders

● Blood analyses, including K+ and Ca++

How do I treat a systemic cold injury?

Treatment

● Passive external rewarming: Warmed environment, blankets, and IV fluids

● Active core rewarming: Surgical rewarming techniques

● Do not delay transfer

Treatment of Hypothermia

Not dead until warm and dead

Summary

●Recognize and treat inhalation injury

●Appropriate fluid resuscitation

●Early identification of burn injuries requiring transfer

Burn Injuries

Summary

●Diagnose type of local injury

●Measure core temperature

●Treat hypothermia with appropriate rewarming techniques

Cold Injuries