09-Basic 20Trauma-Burn 20support 1

Basic Trauma and Burn Support
Copyright 2008 Society of Critical Care Medicine
Objectives
Prioritize and initiate assessment of the traumatized patient Initiate treatment of life-threatening traumatic injury Utilize radiography in identifying significant traumatic injury Identify and respond to changes in status of the injured patient Initiate early burn management
Case Study
Unrestrained man ejected after his car collided with a semitrailer Incoherent and unable to clear secretions Femur fracture, scalp laceration, chest and abdominal contusions BP 90/60 mm Hg, HR 125/min, RR 35/min Lethargic with cool, clammy skin
What does the primary survey indicate?

Trauma Management
Primary assessment Initial evaluation and resuscitation Secondary assessment Diagnosis and treatment of other injuries Tertiary assessment Ongoing evaluation
Primary Assessment
Airway maintenance with cervical spine precautions Breathing: oxygenation and ventilation Circulation with hemorrhage control Disability: brief neurologic examination Exposure/environment: undress, avoid hypothermia
Case Study
Incoherent, unable to clear secretions Femur fracture, scalp laceration, chest and abdominal contusions BP 90/60 mm Hg, HR 125/min, RR 35/min Moves all extremities Lethargic with cool, clammy skin
What does the primary survey indicate? What interventions are most important?
A B C D E
Airway and Breathing Issues

Establish airway patency Airway control: intubation, adjunctive device, surgical airway Oxygenation and ventilation C-spine stabilization
Case Study
Is this patient in shock? What interventions are indicated?
A B C D E
Shock in Trauma
Hemorrhagic Chest Abdomen Pelvis Nonhemorrhagic Obstructive: tension pneumothorax, cardiac tamponade Neurogenic: spinal cord injury Cardiac: blunt injury
Hemorrhage Classification
BP 90/60 mm Hg, HR 125/min, RR 35/min
Variable Systolic BP HR, beats/min RR, breaths/min Mental status Blood loss (mL) Blood loss (%) Class I N <100 14-20 anxious <750 <15 Class II N >100 20-30 agitated 750-1,500 15-30 Class III Class IV
>120 30-40 confused 1,500-2,000 30-40
>140 >35 lethargic >2,000 >40
Circulation Issues
Large bore peripheral IV cannulas (2) 2 L warmed lactated Ringers (>50 mL/kg) External hemorrhage control Diagnostic studies for hemorrhage source Red blood cell transfusion Transfusion of other blood products Monitoring
Case Study
How would you assess disability? What adverse effects occur from exposure?
A B C D E
Case Study
Patient is intubated and mechanically ventilated with 100% O2 Coarse 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?

Secondary Assessment
Detailed history Head-to-toe physical examination Laboratory studies Radiologic studies Other interventions FAST Diagnostic peritoneal lavage Naso- or orogastric tube Antibiotics
Case Study
Male with liver and mesenteric lacerations from vehicular accident Bowel resected and abdomen packed to control bleeding Fluid resuscitation continues Airway pressures and urine output after ICU admission What are possible causes of airway pressures and urine output?
Tertiary Assessment
Head injury Pulmonary injury Cardiac injury Abdominal injury Musculoskeletal injury Adequacy of resuscitation Transfer
Case Study
Male with full thickness burn injury to forearms and flash-burn injury to face after gasoline can explosion Thrown into tree stump No respiratory distress but complains of abdominal pain No fluids given What are initial evaluation priorities?
Burn Evaluation
Airway/breathing Inhalation injury Carbon monoxide Circulation Fluids Escharotomy Disability/Exposure Burn thickness and area
Burn Evaluation
Burn thickness First degree: superficial Second degree: partial thickness Third degree: full thickness Burn area Rule of nines
Case Study
Burn injury = 18% of body surface area HR 120/min, BP 110/50 mm Hg, RR 24/min SpO2 93% (2 L/min O2 nasal cannula) Agitated with complaints of abdominal pain
What interventions are needed?
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 control Other traumatic injuries
Other Burns
Chemical Brush off dry substances Irrigate Electrical Entrance, exit wounds Cutaneous burns from arc injury Flame exposure (clothing) Potential rhabdomyolysis Secondary injuries
Questions?
Key Points
Identify and treat life-threatening injuries first Airway control assumes an unstable Cspine after blunt trauma Tension pneumothorax is diagnosed by clinical criteria Hemorrhage is the most likely cause of shock Blood is added when crystalloid resuscitation is >50 mL/kg
Key Points
Secondary assessment includes a headto-toe examination CT scan is essential for head-injured patients with decreased level of consciousness Abdominal compartment syndrome may develop due to multiple etiologies Transfer to specialized care should not be delayed for additional radiologic studies
Key Points
Burn resuscitation is proportional to burn thickness and area Smoke inhalation injury places the patient at high risk for upper airway and lung injury

09-Basic 20Trauma-Burn 20support 1

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Basic Trauma and Burn Support

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

What does the primary survey indicate?

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Airway and Breathing Issues

Copyright 2008 Society of Critical Care Medicine

>120 30-40 confused 1,500-2,000 30-40

>140 >35 lethargic >2,000 >40

Copyright 2008 Society of Critical Care Medicine

Which laboratory and radiologic tests should be obtained?

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

Copyright 2008 Society of Critical Care Medicine

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