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BURN AND BLAST INJURIES Capt Regan Miller CSTARS

BURN AND BLAST INJURIES Capt Regan Miller CSTARS. American Association of Critical Care Nurses. Unclassified. INTEGRITY—SERVICE—EXCELLENCE. Reviewed 22 Jan 2010. BURN AND BLAST INJURIES OBJECTIVES. - Go over trauma principles in the Primary survey

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BURN AND BLAST INJURIES Capt Regan Miller CSTARS

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  1. BURN AND BLAST INJURIESCapt Regan MillerCSTARS American Association of Critical Care Nurses Unclassified INTEGRITY—SERVICE—EXCELLENCE Reviewed 22 Jan 2010 Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  2. BURN AND BLAST INJURIES OBJECTIVES • - Go over trauma principles in the Primary survey • - Summarize Primary Survey adjunctive tests • - Briefly discuss the secondary survey • - Discuss burn principles and how they apply to the primary survey/fluid resuscitation • - Go over blast principles/management specifically primary, secondary, and tertiary Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  3. BURN AND BLAST INJURIESPrimary Survey • AIRWAY w/C-Spine protection • BREATHING • CIRCULATION • DISABILITY • EXPOSURE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  4. BURN AND BLAST INJURIESPrimary Survey Vertical vs. Horizontal resuscitation of a trauma patient Vertical = ATLS model (more time) Horizontal = Team Leader with assigned tasks (less time) Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  5. BURN AND BLAST INJIRESPrimary Survey Airway = establish patency; decide if patient needs definitive or not. Everyone gets O2 Breathing = absent or decrease breath sounds Circulation = stop obvious bleeds and check pulses Disability = GCS and pupils Exposure = completely expose, log roll, rectal exam, and burn calculations Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  6. BURN AND BLAST INJURIESPrimary Survey Adjuncts • EKG Monitoring • Urinary and gastric catheters • Contraindications • X-rays and diagnostic studies • Chest, and Pelvic X-Rays • FAST (Focused Abdominal Sonogram for Trauma) • Bedside procedure of choice for free intraperitoneal/pericardial fluid • Operator dependent • Consider need for transfer Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  7. BURN AND BLAST INJURIESSecondary Survey - Head to toe examination - Fingers and tubes in every orifice (if needed) - AMPLE history (allergies, meds, past med, last meal, events leading up to) Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  8. BURN AND BLAST INJURIES Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  9. BURN AND BLAST INJURIESBURN ASSESSMENT • All burn patients are trauma patients • Do not be distracted by the burn • Rarely immediately life threatening Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  10. BURN AND BLAST INJURIESASSESSMENT • Stop the burning process! • Airway/C-spine: soot, sloughed tissue, edema • Anticipate need for early intubation • C-spine precautions esp with electrical burns • Breathing: restrictive circumferential chest burns • Circulation: extremity perfusion, compartment syndrome, I.V. access • Disability: neurologic (GCS) prior to RSI • Expose: calculate burn size %TBSA, remove clothing and jewelry, elevate burned extremity • Fluids: Parkland formula, two 16 ga I.V.s Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  11. BURN AND BLAST INJURIESBURNS - AIRWAY • Inhalation injury is the most frequent cause of death in thermal injuries • Anticipate need for early intubation • Severe facial burns, smoke inhalation- confined space, stridor, hoarseness, cough, carbonaceous sputum, cinged facial hair • Use large (8mm) ETT to facilitate bronchoscopy • Prophylacticallyintubate prior to transport • Closed vs open space Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  12. BURN AND BLAST INJURIESBURNS - AIRWAY Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  13. BURN AND BLAST INJURIESBURNS - AIRWAY 13 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  14. BURN AND BLAST INJURIESBURNS BREATHING • Physiologic tourniquet • ↑ airway pressures • ↑ pCO2 • ↓ SaO2 • Escharotomy • Bilateral anterior axillary lines • Subcostal margin 14 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  15. BURN AND BLAST INJURIESBURNS CIRCULATION • Control hemorrhage • Establish two 16 ga I.V.s • Through burned tissue if necessary • Fluid resuscitation with LR • Monitor for compartment syndromes • Extremity and abdomen • Absent distal pulses, etc.. • Usually happens in first few hours of admission 15 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  16. BURN AND BLAST INJURIESBURNS • % TBSA x wt (kg) x 2-4 cc • LR over first 24 hours • ½ Volume in first 8 hrs • ½ Volume in next 16 hrs • TBSA • Based on the Rule of Nines for adults • Doesn’t apply for infants, children • Patient’s hand = 1% TBSA • Adjust fluid • Based on urine output/MAPs 16 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  17. BURN AND BLAST INJURIESBURNS – TBSA ESTIMATION • “Rule of Nines”- good for adults • Each upper ext 9% • Head, neck 9% • Lower ext 18% • Ant and post trunk 18% • Perineum, genitalia 1% • Palm of hand 1% Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  18. BURN AND BLAST INJURIESBURNS – TBSA ESTIMATION, INFANTS & CHILDREN 18 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  19. BURN AND BLAST INJURIESBURNS – EXTREMITY CARE • Circumferential burn • Assess for distal perfusion • If decreasing, escharotomy • Exercise burned extremities hourly • Sulfamylon solution soaked dressings 19 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  20. BURN AND BLAST INJURIESBURNS – WOUND CARE • IV pain management • Remove foreign bodies • Debridement / unroof blisters • Clean with surgical soap • Topical antimicrobials • Scalp, trunk, neck, and • extremities in sulfamylon • solution soaked dressings (painful) • Silvadene cream first choice for awake pt, no eschar penetration • Sulfamylon cream to burns on ears, nose • Bacitracin to face burns • Tetanus 20 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  21. BURN AND BLAST INJURIESBURNS – WOUND CARE • Prevent hypothermia • Patch corneal abrasions • Bacitracin to eyelids • E-mycinoint to eyes • Inspect daily: • Chemical cellulitis • Burn-wound infection • Avoid definitive burn surgery in combat zone Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  22. BURN AND BLAST INJURIESBURNS – FURTHER CARE • Stress ulcer prophylaxis • Early enteral nutrition • Monitor for abdominal compartment syndrome • Anticipate persistent hypermetabolic state • Assess airway prior to extubation 22 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  23. BURN AND BLAST INJURIESBURNS – ELECTRICAL • High-voltage injury (>1,000 Volts) • Deep muscle injury • Rhabdomyolysiswith myoglobinuria • Hyperkalemia • Acute renal failure • Compartment syndrome • Treat for rhabdomyolysis • At risk for spine fracture 20 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  24. BURN AND BLAST INJURIESBURNS – CHEMICAL • Remove offending agent immediately • Brush-off dry material • Copious lavage • Alkali burns require several hours water lavage • Resuscitate and manage as thermal burn 24 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  25. BURN AND BLAST INJURIESBURNS – TRIAGE CONSIDERATIONS • Immediate • Inhalation, chemical or electrical, trauma • Delayed • 15-20% TBSA • Minimal • <15% TBSA (1° or 2°) • Not face, hands, genitalia • Expectant • >80% 25 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  26. BURN AND BLAST INJURIESBLAST INJURIES • Blasts occur from multiple causes • Military weapons • Terrorist bombings • Natural disasters • Man-made disasters 26 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  27. BURN AND BLAST INJURIESBLAST INJURIES • http://www.youtube.com/watch?v=PVG_WftW73E Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  28. BURN AND BLAST INJURIESBLAST INJURIES Civilian, as well as military http://www.youtube.com/watch?v=jtde8GOCbtI Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  29. BURN AND BLAST INJURIESBLAST INJURIES Explosion • Primary • Secondary • Tertiary • Burns 29 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  30. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Primary Blast Injuries • Caused by the direct effect of the blast wave upon the body through energy transfer (barotrauma) • Injury is seen almost exclusively in gas containing structures • Ear: most sensitive • Respiratory system: most common cause of early morbidity and mortality • Gastrointestinal tract: most common cause of delayed morbidity and mortality 30 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  31. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Ear Injuries • Tympanic membrane rupture • Foreign material in ear • Inner ear damage • Hearing loss • Care: varies by injuries from observation to specialist consultation 31 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  32. BURN AND BLAST INJURIESBLAST - PRIMARY INJURIES • Lung Injuries • Pulmonary contusions • Pneumothorax • Traumatic lung cyst • Pneumomediastinum • Interstitial emphysema • Subcutaneous emphysema • Air emboli Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  33. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Lung Treatment • ABC’s • Chest tube for pneumothorax • Supportive care • Oxygen • Respiratory care • Mechanical ventilation • Watch for tension pneumothorax or air emboli 33 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  34. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Air Emboli • Symptoms / severity depend on which vascular bed has been compromised • Retinal vessels • Coronary arteries • Cerebral circulation • Most common cause sudden death • Treatment • Supportive by system involved • Hyperbaric O2 34 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  35. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Gastrointestinal Tract Injuries • Hematomas and perforations of the bowel • Hematomas and tears of the mesentery • Rupture of the hollow abdominal viscera • Presentation delayed • Underwater blast can cause pure primary blast injury to gastrointestinal tract 33 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  36. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Gastrointestinal Tract • Examination • Serial exams (presentation can be delayed) • Diagnostic peritoneal lavagevs FAST exam • Treatment • Abdominal exploration and definitive repair 34 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  37. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES • Secondary Blast Injuries • From fragments or secondary missiles propelled by the blast • Treat the same as other penetrating injuries 37 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  38. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES 38 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  39. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES 37 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  40. BURN AND BLAST INJURIESBLAST – TERTIARY INJURIES • Tertiary Blast Injuries • Occurs when the victim is thrown against the ground or solid objects • Injuries are similar to blunt trauma or falls • Care follows blunt trauma guidelines • Multiple mechanism, multiple trauma • Common to see all three components of blast injury in varying degrees at once • Plus -- can get thermal, chemical, and biological injuries 40 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  41. BURN AND BLAST INJURIES SUMMARY • A, B, C, D, E, Fs of burn care • TBSA calculation • Wound care • Electrical and chemical • Transfer criteria • Burn triage • Burn record Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  42. BURN AND BLAST INJURIES SUMMARY • IDENTIFIED THE GENERAL PRINCIPLES OF BURN MANAGEMENT • DISCUSSED THE PRINCIPLES OF TRAUMA MANAGEMENT FOR BLAST INJURIES 40 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  43. BURN AND BLAST INJURIES QUESTIONS ?????? 41 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

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