Trauma – Thermal InjuryTrauma

1. Trauma – Thermal InjuryTrauma Douglas M. Maurer, DO, MPH

2. 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.

3. 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

4. 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

5. 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

6. 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

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

9. 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

10. 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

11. 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 • Topicalantibiotics to all nonsuperficialburns • No role for prophylactic IV antibiotics • Pain control with opioids; benzos for anxiety • Tetanus prophylaxis

12. 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

13. CN Toxicity • History: HA, MS changes, abdominal pain • Physical: hypertension, tachycardia, tachypneaearly then CV collapse; cherry red skin; seizures • Evaluation: standard tox labs, check anion gap, lactate, ABG, carboxyhemoglobin and methemoglobinlevels • 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

14. 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

15. 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

16. 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.

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

18. Simulation Training Assessment Tool (STAT) – Thermal Injury Trauma • 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. Date: Instructor(s): Learner(s): ME = Meets Expectations; NI = Needs Improvement, M = Milestones