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Tuesday, October 9, 2007

Critical Care Nursing: Basic Trauma And Burn Management

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Critical Care Nursing: Basic Trauma And Burn Management Slides Transcript
Slide 1: Trauma and Burn Management • D.F.Naylor, Jr., MD, FACS, FCCS • Staff Intensivist • September 13,2007 ®

Slide 2: Objectives • Review initial assessment of the trauma patient • Outline treatment of life-threatening injury • Discuss use of radiography to identify injury • Outline response to changes in patient’s status • Discuss early burn management ®

Slide 3: Trauma Care Principles • Simultaneous assessment and treatment through a standardized approach • If no improvement or decline in status, start over at primary assessment • Early surgical involvement ®

Slide 4: Primary Assessment – Airway / Breathing • Assume cervical spine injury • Airway assessment and management • Effects of facial/mandibular fracture • Laryngeal/tracheal injury – ecchymosis, hoarseness, edema, subcutaneous air • Flail chest from rib fractures • Pneumo- / hemothoraces ®

Slide 5: Primary Assessment – Circulation • Hemorrhage is most common cause of shock • Establish large-bore venous access • Initiate fluid resuscitation with lactated Ringer’s solution • Follow with packed red blood cells after 2–3 L of crystalloid • Control external hemorrhage by compression • Monitoring – data flow sheet, vital signs, ECG, pulse oximetry, CVP, arterial line ®

Slide 6: Hemorrhage Classification Hemorrhage Blood Blood class loss loss (mL) (%) I <750 <15 II 750–1500 15–30 III 1500–2000 30–40 IV >2000 >40

Slide 7: Hemorrhagic Shock • Chest – hemothorax; drain and monitor • Abdominal – Intraperitoneal (lavage or sonography) FAST – Retroperitoneal (CT scan) STABLE YES/NO  – Operative intervention • Pelvis – usually venous; consider embolization, external stabilization ( Wrap with Sheet) ®

Slide 8: Nonhemorrhagic Shock • Tension pneumothorax – Tube thoracostomy – AFTER NEEDLE DECOMPRESSION ! • Cardiac tamponade – Consider mechanism of injury – Venous hypertension with shock – Pericardial window preferred over needle pericardiocentesis

Slide 9: Nonhemorrhagic Shock • Blunt cardiac injury – Consider mechanism of injury – ECG nonspecific – Cardiac enzymes rarely helpful – Monitor at least 4 hours • Neurogenic shock – Cervical/thoracic spinal cord injury – Associated bradycardia, (warm and slow)

Slide 10: Secondary Assessment • Identify potentially life-threatening injuries • History of event, medical history, drugs, allergies, tetanus immunization • AMPLE • Head to toe examination – Fully expose patient – Correct and prevent hypothermia – Assess for signs of urethral injury • FINGER OR TUBE IN EVERY ORFICE ! – Neurovascular integrity ®

Slide 11: Secondary Assessment • Laboratory data – arterial blood gas, blood counts, electrolytes, coagulation studies, type and cross-match, urinalysis, toxicology, etc • Radiograph review – Cervical spine – complete survey – Chest – mediastinal evaluation; tubes/catheters – Pelvis – major fractures – Cystogramurethrogram – Skeletal exam

Slide 12: Secondary Assessment • CT scan of head • CT scan of abdomen if indicated • Other issues – Nasogastric tube – Tetanus prophylaxis • Prior Immune Status HyperTet? – Antibiotic indications – Specialty consultation

Slide 13: Tertiary Assessment • Detailed examination to detect all injuries • Serial examinations over time to detect change and occult injuries • Return to primary/secondary survey strategies for worsening status • Surgical consultation/transfer planning – DOCTORS SPEAK TO DOCTORS ! ®

Slide 14: Compartment Syndromes • Abdomen – Compromise of venous return due to high intra-abdominal pressure – Secondary to free blood, fluid, edema of abdominal contents – Evaluate with measure of intrabladder pressure – Surgical decompression – ACS = IAH > 25 + Organ Dysfunction

Slide 15: Compartment Syndromes • Extremity – Serial examinations – Pain, pallor, pulselessness, paresthesias, paralysis – Fasciotomy – Know Sensory only sites Thumb Web, Great Toe 1st Metatarsal

Slide 16: Burn Injury – Primary Assessment • Airway/breathing – Upper and lower airway injury – Carbon monoxide exposure – Bronchoscopy for evaluation – Consider early intubation – Avoid succinylcholine ®

Slide 17: Burn Injury –Primary Assessment • Circulation – Establish intravenous access – Crystalloid resuscitation based upon extent and severity of burns – Assess for circumferential injury – Evaluate for other injuries ®

Slide 18: Assessment of Burn Severity • First-degree – Erythema and pain • Second-degree (partial- thickness) – Red, swollen, blisters, weeping, painful • Third-degree (full-thickness) Rule of Nines – White, leathery, painless

Slide 19: Resuscitation –Burn Shock • Primary fluid loss from wound • Secondary nonburn edema SIRS • Principles – Avoid excess fluid resuscitation but maintain organ perfusion – Replace components of fluids lost as well as volume • Replace blood as needed ®

Slide 20: Resuscitation – Burn Shock • Lactated Ringer’s solution – crystalloid of choice • Various formulae for amount and type of crystalloid and colloid resuscitation • Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs • TIme0 = Time of Injury not arrival in ED • Aim for urine output 0.5-1 ml/kg/hr • Cautious use of analgesia

Slide 21: 80 KG Male involved in Closed space Fire 50 % TBSA 2nd Degree Burns arrives instantaneously in ED Calculate Parkland Fluid Requirements Parkland formula: 4 mL/kg  % of second- and third-degree burn estimates  body weight in first 24 hrs; deliver one-half calculated volume in first 8 hrs SO 4 x 50 x 80 = 16000 ccs/first 24 hours ONE LITER /hour for 8 hours IF he arrived after an 8 hour transport from OSH— without IVF 8000 ccs + 500 cc’s first hour

Slide 22: Burn Wound Care • Gently wash and cover prior to transport • Remove rings, bracelets • Burn dressings controversial before transfer – When in Doubt 0.9 NS Dampened Gauze • Consultation for specific wound care – Ask about Dressings, Mention Airway, Chemicals + ®

Slide 23: Chemical Burns • Injury is caused by concentration of agent and duration of exposure • Remove patient from source • Remove clothing • Brush off dry agent • Irrigate copiously with water • Protect Good Guys

Slide 24: Electrical Injury • Entry and exit wounds • Secondary skin burns at distant sites • Flame burns from clothes • Cardiac arrest • Secondary injury –falls, muscle contraction, etc. • Rhabdomyolysis and compartment syndromes

Slide 25: Pediatric Considerations • Same general principles as for adults • Orotracheal intubation with in-line stabilization • Greater risk of injury after cricothyrotomy • Diagnostic peritoneal lavage used less frequently • Body surface area/body mass so higher risk of hypothermia ®

Slide 26: Pediatric Considerations • Initial crystalloid bolus 20 mL/kg • Hypotension is late finding of severe hypovolemia • Blood added when crystalloid infusion >40 mL/kg • Initial blood transfusion = 10 mL/kg ®

Slide 27: Pediatric Considerations • Consider child abuse when discrepancies exist between history and physical examination – Laboratory – Skull and skeletal radiographs – Fundoscopic exam for hemorrhage – WHEN IN DOUBT REPORT IT OUT ! ®

Slide 28: Key Points

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