Trauma – Thermal InjuryTrauma

Trauma – Thermal InjuryTrauma

Douglas M. Maurer, DO, MPH

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 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 FiO2• CO toxicity• CN toxicity

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, 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

• Don’t forget C-spine immobilization• Assess for evidence of airway/neck burns• Consider early intubation

• B-Breathing• Give high flow O2 via NRB• Assess for constrictive chest wall burns• Assess for CO and CN toxicity

• C-Circulation• Place IV’s through unburnt skin where possible• Assess for circumferential burns to limbs• Shock due to burns is uncommon

• D-Disability• 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 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 nasal endoscopy; low intubation threshold

• Breathing• High flow O2 for 6 hours and until CO levels normal• Bronchospasm: B2 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 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 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

• 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 O2, consider hyperbaric O2 tx

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 O2;

NO mouth to mouth• If cyanide toxicity known or strongly suspected:

• Sodium nitrite 10mg/kg up to 300mg 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 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 O2 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 thermal burns in adults. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.

• Mandell J, Hales CA. Smoke inhalation. In: UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.

• Nickson C. “Trauma! Major burns.” Weblog entry. Life in the Fastlane Blog. http://lifeinthefastlane.com/2012/09/trauma-tribulation-032/

• Nickson C. “Smoking is deadly.” Weblog entry. Life in the Fastlane Blog. http://lifeinthefastlane.com/2010/09/toxicology-conundrum-038/

• American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.

Simulation Training Assessment Tool (STAT)– Thermal InjuryTrauma

Douglas M. Maurer, DO, MPH, FAAFP

CRITICAL ACTIONS ME NI M SUSTAIN IMPROVECompletes Primary Survey: recognizes inhalation injury

MK2

Safety net – IV, O2, monitor MK2

Initiates RSI to secure airway MK2

Completes Secondary Survey: recognizes significant burns and inhalation toxicities

PC5

Bedside labs: ABG w/ co-oximetry, CBC, CMP, lactate, BAL/Tox, cyanide, EKG, enzymes

PC5

Bedside rads: port cxr, lat C-spine, AP pelvis PC5

Recognizes respiratory distress and gives bronchodilators

MK2

Recognizes CO toxicity and gives high flow O2 (FIO2 100%), considers hyperbaric O2

MK2

Suspects CN toxicity and gives sodium thiosulfate and hydroxocobalamin; calls toxicology/poison control

MK2

Calculates and initiates proper fluid resuscitation for burns

MK2

Transfers patient to burn center MK2

TOTAL SB4

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, SpO2

90% on 15L NRB, GCS 15

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

PRIMARY SURVEY:A – talking hoarsely, soot around mouth, singed nasal

hairs, burns on face/mouthB – 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 – 2nd and 3rd degree burns to face, neck, chest, hands/arms; cherry red lips/skin, blisters in mouth

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 negativeLabs – WBC 14, H/H 12/40, platelets 200, ETOH/Tox-neg; lactate 2, ABG: 7.25/35/50/90%/-4 OxyHgb: ,

carboxyHgb: 7% ,metHgb: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

Simulation Training Assessment Tool (STAT) – Thermal Injury TraumaDate: 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.

ME = Meets Expectations; NI = Needs Improvement, M = Milestones