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Initial Assessment of the Initial Assessment of the Trauma and Burn PatientTrauma and Burn Patient

Don Reiff, MDDon Reiff, MDAssistant Professor, Section of Assistant Professor, Section of

Trauma/Burns/Critical CareTrauma/Burns/Critical CareSurgery Clerkship DirectorSurgery Clerkship Director

Magnitude of the ProblemMagnitude of the Problem

What was the greatest medical problem What was the greatest medical problem financially and/or related to Hospital financially and/or related to Hospital inpatient requirements during 1996?inpatient requirements during 1996? Heart Conditions ($58,030 / 2,519,000)Heart Conditions ($58,030 / 2,519,000) Cancer ($37,695 / 1,416,000)Cancer ($37,695 / 1,416,000) Trauma ($37,144 / 1,620,000)Trauma ($37,144 / 1,620,000) COPD, Asthma ($28,594 / 1,291,000)COPD, Asthma ($28,594 / 1,291,000)

Magnitude of the ProblemMagnitude of the Problem

How has this changed by 2003?How has this changed by 2003? Trauma ($75,571 / 2,332,000)Trauma ($75,571 / 2,332,000) Heart Conditions ($67,801 / 3,893,000)Heart Conditions ($67,801 / 3,893,000) Cancer ($48,428 / 545,000)Cancer ($48,428 / 545,000) Mental Disorders ($47,503 / 1,211,000)Mental Disorders ($47,503 / 1,211,000)

*Normal Birth (3,722,000)*Normal Birth (3,722,000)

Trauma/Burns ResuscitationTrauma/Burns Resuscitation

Where did the notion of “Trauma Where did the notion of “Trauma Resuscitation” come from?Resuscitation” come from? 1976 J.K. Styner, MD piloted a plane in SE 1976 J.K. Styner, MD piloted a plane in SE

NebraskaNebraska Crashed resulting in the death of his wife and Crashed resulting in the death of his wife and

two of three childrentwo of three children


What are the steps of the Trauma What are the steps of the Trauma Resuscitation? Resuscitation? Primary SurveyPrimary Survey Secondary SurveySecondary Survey Lines/Tubes in every orificeLines/Tubes in every orifice Labs and adjuvant studiesLabs and adjuvant studies

What are our goals?What are our goals?


What are the steps of the Primary Survey?What are the steps of the Primary Survey? AirwayAirway BreathingBreathing CirculationCirculation Neurologic DeficitNeurologic Deficit ExposureExposure

What are the goals of the primary survey?


AirwayAirway Most expeditious means to Most expeditious means to

evaluate the patency and evaluate the patency and ability to protect airwayability to protect airway

Should airway control be Should airway control be necessary, what is the necessary, what is the best means?best means?


AirwayAirway Rapid sequence intubationRapid sequence intubation

• CricothyroidotomyCricothyroidotomy


BreathingBreathing Assessing the presence of Assessing the presence of

breath sounds using breath sounds using auscultation auscultation

Life-threatening InjuriesLife-threatening InjuriesTension pneumothoraxTension pneumothorax

Open pneumothoraxOpen pneumothorax

Flail chestFlail chest

Massive HemothoraxMassive Hemothorax

Cardiac TamponadeCardiac Tamponade

Life-Threatening Chest InjuriesLife-Threatening Chest Injuries

Tension PneumothoraxTension Pneumothorax

PathophysiologyPathophysiology

Progressive entry of air into pleural Progressive entry of air into pleural spacespace

Collapse of ipsilateral lungCollapse of ipsilateral lung

Mediastinal shiftMediastinal shift

Compromised venous return to Compromised venous return to heartheart

Hypotension / decreased cardiac Hypotension / decreased cardiac outputoutputCardiovascular collapseCardiovascular collapse


Open PneumothoraxOpen Pneumothorax Physiologically, what’s Physiologically, what’s

the issuethe issue


Flail ChestFlail Chest Why is this dangerous?Why is this dangerous?

How would you manage How would you manage this problem?this problem?

Current management is to Current management is to ““internally” splint patientsinternally” splint patients


Massive HemothoraxMassive Hemothorax Obviously bad for several Obviously bad for several

reasonsreasons


Cardiac TamponadeCardiac Tamponade How do we make the How do we make the

diagnosis?diagnosis? What is the What is the

physiologic problem physiologic problem and how do you and how do you correct it?correct it?

Trauma ResuscitationTrauma Resuscitation

CirculationCirculationShock is most simply defined as…Shock is most simply defined as…

inadequate delivery of oxygen and inadequate delivery of oxygen and nutrients necessary for normal tissue and nutrients necessary for normal tissue and cellular functioncellular function

Equating shock and blood pressure is inaccurateEquating shock and blood pressure is inaccurateCompensatory mechanisms result in Compensatory mechanisms result in shuntingshunting

Reduction in renal blood-flowReduction in renal blood-flowReduction in splanchnic blood-flowReduction in splanchnic blood-flow


Causes of shockCauses of shock ObstructiveObstructive CardiogenicCardiogenic NeurogenicNeurogenic SepticSeptic Hemorrhagic/HypovolemicHemorrhagic/Hypovolemic

Non-hemorrhagicNon-hemorrhagic

ShockShock

Classification of shockClassification of shock

Signs/SymptomsSigns/Symptoms

Narrowing of pulse pressureNarrowing of pulse pressureTachycardiaTachycardiaTachypneaTachypneaHypotensionHypotensionOliguria/AnuriaOliguria/AnuriaMental Status changesMental Status changes


• Large bore peripheral IVLarge bore peripheral IV Poiseuille’s law Poiseuille’s law

• Bolus two liters of warm fluidBolus two liters of warm fluid• Blood and/or coagulation factorsBlood and/or coagulation factors• Frequently monitor vital signs/UOP for responseFrequently monitor vital signs/UOP for response

Q=Pr4

8 l

What about patients who don’t respond appropriately toWhat about patients who don’t respond appropriately toour initial fluid bolus?our initial fluid bolus?

Clinical intervention for hemorrhagic shockClinical intervention for hemorrhagic shock

• Large bore peripheral IVLarge bore peripheral IV Poiseuille’s law Poiseuille’s law

• Bolus two liters of warm fluidBolus two liters of warm fluid• Blood and/or coagulation factorsBlood and/or coagulation factors• Frequently monitor vital signs/UOP for responseFrequently monitor vital signs/UOP for response

Q=Pr4

8 l

AlgorithmAlgorithm

Hemorrhagic ShockHemorrhagic Shock Where has the blood gone?Where has the blood gone?

• SceneScene •Extremity fractures•Extremity fractures• ThoraxThorax •Peritoneum•Peritoneum• RetroperitoneumRetroperitoneum

How can we quickly eliminate several of the How can we quickly eliminate several of the potential sources of blood loss?potential sources of blood loss?

AlgorithmAlgorithm

Hemorrhagic shockHemorrhagic shock With two of five eliminated, how to work up last With two of five eliminated, how to work up last

three?three?• CXR/Pelvic X-rayCXR/Pelvic X-ray

• Physical examinationPhysical examination

• DPL/USDPL/US Once identified, institute appropriate therapyOnce identified, institute appropriate therapy

• Reduce fracturesReduce fractures

• Pelvic binderPelvic binder

• Chest tubeChest tube

• Operating roomOperating room

ResuscitationResuscitation

EndpointsEndpoints Classically, restoration of BP,HR and UOPClassically, restoration of BP,HR and UOP Using only these parameters will leave 50-Using only these parameters will leave 50-

85% patients in “compensated” shock85% patients in “compensated” shock Recent data suggestsRecent data suggests

• Correction of lactate levelsCorrection of lactate levels• Correction of base deficitsCorrection of base deficits• TonomotryTonomotry

Case PresentationCase Presentation

38 year old male38 year old male Unrestrained driverUnrestrained driver Initially unresponsive, Initially unresponsive,

largely obtundedlargely obtunded

Initial vital signs:Initial vital signs: HR – 130’sHR – 130’s SBP – 105SBP – 105 O2 sats – 92% on NRBO2 sats – 92% on NRB

Approach to the Evaluation of Shock

ABC’s Intubate

Tachycardic/hypotensive/hypoxic w/ absent BS

Needle decompression w/concurrent fluid resuscitation

No rush of air/vital signs showno improvement

“Non-responder”Go through check list of etiologies


Primary surveyPrimary survey Airway controlledAirway controlled Decreased breath sounds Decreased breath sounds

on righton right Severe shock with HR Severe shock with HR

now 140’s to 150’s and now 140’s to 150’s and SBP below 100SBP below 100

Non-hemorrhagic sources- Sepsis- Cardiogenic- Neurogenic- Obstructive

Approach to the Evaluation of Shock

Primary survey

Needle decompressed/volume resuscitation

Non-responder - Sepsis - Cardiogenic - Neurogenic - Obstructive

Eliminated

CXR has ruled outTension pneumothorax

Use ultrasound to rule outpericardial tamponade

All that remains is hypovolemic/hemorrhagic shock

Approach to the Evaluation of Shock Assess external losses

Extremities Radiologic survey

US/DPL/CT Scanning


Right sided 40F chest tube with blood Right sided 40F chest tube with blood auto-transfusedauto-transfused

Initial ABG returns with 7.15/35/98/-10/8.5Initial ABG returns with 7.15/35/98/-10/8.5

In addition to auto-transfusion, 4u pRBC’s givenslowing HR to 130’s and SBP improves to 115

Repeat ABG finds 7.26/38/135/-9/9.2


Package and run to CTPackage and run to CT


Package and run to operating roomPackage and run to operating room

BURNSBURNS

PresentationPresentation

ABC’sABC’s Determine mechanismDetermine mechanism

Flame, chemical, electricalFlame, chemical, electrical Associated traumaAssociated trauma

Complete history and examinationComplete history and examination Labs and chest x-rayLabs and chest x-ray

ABG with COABG with CO

PresentationPresentation

ResuscitationResuscitation Tetanus ProphylaxisTetanus Prophylaxis HypothermiaHypothermia Antibiotics/steroids NOT indicatedAntibiotics/steroids NOT indicated

Severity of InjurySeverity of Injury

Dependent on the depth and extent of Dependent on the depth and extent of burn injury.burn injury.

DepthDepth 11stst, 2, 2ndnd, 3, 3rdrd degree degree

ExtentExtent Estimated total burn surface areaEstimated total burn surface area

Burn DepthBurn Depth


11stst Degree Degree Partial thicknessPartial thickness Sun BurnSun Burn Spontaneous healingSpontaneous healing


22ndnd Degree Degree Partial thicknessPartial thickness Usually heals spontaneouslyUsually heals spontaneously Involve epidermis and varying thickness of Involve epidermis and varying thickness of

dermisdermis


33rdrd Degree Degree Full thickness burnFull thickness burn Will not heal spontaneouslyWill not heal spontaneously Excision and GraftingExcision and Grafting Involves epidermis and dermisInvolves epidermis and dermis


44thth degree degree Involves epidermis, dermis, and underlying Involves epidermis, dermis, and underlying

structuresstructures Fat, fascia, muscle, boneFat, fascia, muscle, bone Associated most commonly with electrical Associated most commonly with electrical

burnsburns

Extent of BurnExtent of Burn

Rule of 9’sRule of 9’s Lund and BrowderLund and Browder

ResuscitationResuscitation

Fluid is determined by the severity of injuryFluid is determined by the severity of injury mount of 2mount of 2ndnd and 3 and 3rdrd degree burn degree burn

Lactated ringersLactated ringers Initial fluid determined by parkland formulaInitial fluid determined by parkland formula

2-4cc/kg/%TBSA2-4cc/kg/%TBSA ½ over the first 8 hours½ over the first 8 hours

DO NOT BOLUSDO NOT BOLUS Titrate fluid to urine outputTitrate fluid to urine output

30-50cc/hour30-50cc/hour

EscharotomyEscharotomy

Full-thickness, circumferential burns to Full-thickness, circumferential burns to extremity or trunkextremity or trunk Diminished blood flow to extremityDiminished blood flow to extremity Decreased pulmonary complianceDecreased pulmonary compliance

Medial and lateral incisions on the Medial and lateral incisions on the extremitiesextremities

Anterior axillary line on trunkAnterior axillary line on trunk

Inhalation injuryInhalation injury

Most common cause of deathMost common cause of death 80% of burn related deaths80% of burn related deaths

Several mechanisms involvedSeveral mechanisms involved OropharyngealOropharyngeal Tracheo-bronchialTracheo-bronchial Toxic absorptionToxic absorption

• CyanideCyanide• Carbon monoxideCarbon monoxide

Inhalation injuryInhalation injury

HistoryHistory Enclosed spaceEnclosed space Loss of consciousnessLoss of consciousness Drugs and alcoholDrugs and alcohol

Physical examPhysical exam Facial burns, singed nasal hairsFacial burns, singed nasal hairs StridorStridor Carbonaceous sputumCarbonaceous sputum Depressed mental statusDepressed mental status

Carbon MonoxideCarbon Monoxide

Most frequent cause of death at the scene.Most frequent cause of death at the scene. Very high affinity for hemoglobin.Very high affinity for hemoglobin. Impairs oxygen availability and use in the Impairs oxygen availability and use in the

tissues.tissues.

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