ADVANCED TRAUMA LIFE SUPPORT

FOR DOCTORS

American College Of Surgeons Committee On Trauma

Presents

Dr. RIDHA JAWAD AL-BASRICONSULTANT SURGEONCONSULTANT SURGEON

ALKINDI TEACHIN HOSPITALALKINDI TEACHIN HOSPITAL

The skin, the largest organ of the body, consists of two layers-the epidermis and dermis. The depth or degree of burn depends on which layers of skin are damaged or destroyed. The epidermis is the outer layer that forms the protective covering. The thicker or inner layer of the dermis contains blood vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the dermis is destroyed, so are the nerve endings that allow a person to feel pain, temperature, and tactile sensation.

The most important function of the skin is to act as a barrier against infection. The skin prevents loss of body fluids, thus preventing dehydration. The skin also regulates the body temperature by controlling the amount of evaporation of fluids from the sweat glands. The skin serves a cosmetic effect by giving the body shape.

When the skin is burned, these functions are impaired or lost completely. The severity of the skin injury depends upon the size of the injury, depth of the wound, part of the body injured, age of the patient, and past medical history. Because of the importance of the skin, it becomes clear that injury can be traumatic and life threatening.

OBJECTIVES

• To estimate burn size & to determine the presence of associated injuries.

• To learn the initial assessment & treatment of thermal injuries.

• To identify problems encountered in Rx of patients with thermal injuries & how to solve them.

• Criteria for transfer burned patients.

Thermal inj. are major causes of morbidity & mortality & to minimize them basic principles of initial trauma resuscitation & timely applied simple emergency measures should be followed. These include:

1. Smoke inhalation ? Airway compromise.

2. Identify & Mx associated mechanical injuries.

3. Maintenance of haemodynamic normality & volume resuscitation.

4. Prevent & Rx of potential complications , e.g. rhabdomyolysis.

5. Temp. control.

6. Removal from inj. Site.

Immediate Lifesaving Measures For Burn Injuries

Priorities Airway

Stopping burning process

Establishing I.V. access

Airway The airway is extremely susceptible to obstruction as a consequence of heat. This obstruction may not be immediately obvious, but signs may warn to such obstruction.

Q & AQ- If there is inhalation injury what should I do?A- Transfer to a burn center.Q- If the transfer time is prolonged?A- intubate before transfer to protect airway.Q- what are other indications of intubation?A- 1- stridor 2-circumferential burns of neck.

Q & AQ- If there is inhalation injury what should I do?A- Transfer to a burn center.Q- If the transfer time is prolonged?A- intubate before transfer to protect airway.Q- what are other indications of intubation?A- 1- stridor 2-circumferential burns of neck.

I.V. Access:

• Any patient with burn > 20% of BSA requires fluid.

• After establishing airway & Rx immediately life threatening injuries ,I.V. access established in a peripheral V. with large caliber line (#16 gauge).

• Begin with isotonic crystalloids.

Assessment of Burned Patient:A- HISTORY

B- BODY SURFACE AREA(BSA)

Rule of Nines is a useful & practical guide to determine SA of burn.

In infants & young children a helpful guide is the palmar surface (including fingers) of patient’s hand representing about 1% of BSA.

Improper use, handling, and storage of hazardous materials can lead to a different type of scoring… it’s called burn scoring which measures the percentage of the body burned. The score you rate on this chart can last you a lifetime.

Are you one of those people that stays up to date on the latest sports scores and plays?

Recovery from burn injury involves four major aspects:

1.Burn wound management. 2.Physical therapy.3.Nutrition.4.Emotional support.

Superficial (1Superficial (1stst

degree) degree)

Partial-thickness (2Partial-thickness (2ndnd

degree) degree)

Full-thickness (3Full-thickness (3rdrd

degree) degree)

Very painful, dry, red burns which blanch with pressure.

They usually take 3 to 7 days to heal without scarring.

Also known as first-degree burns. The most common type

of first-degree burn is sunburn. First-degree burns are

limited to the epidermis, or upper layers of skin.

Very painful burns sensitive to temperature change and air

exposure. More commonly referred to as second-degree

burns. Typically, they blister and are moist, red, weeping

burns which blanch with pressure. They heal in 7 to 21 days.

Scarring is usually confined to changes in skin pigment.

Burns which cause the skin to be waxy

white to a charred black and tend to be

painless. Healing is very slow, if at all,

and may require skin grafting. Severe

scarring usually occurs.

1. Treatment should begin immediately to cool the area of the burn. This will help alleviate pain.

2. For deep partial-thickness burns or full- thickness burns, begin immediate plans to transport the victim to competent medical care. For any burn involving the face, hands, feet, or completely around an extremity, or deep burns; immediate medical care should be sought.

3. Remove any hot or burned clothing.

Primary resuscitation

1. AIRWAY2.BREATHING 3.CICULATORY

BLOOD VOLUME

CIRCULATION : ?Type of fluid ? Rate.

Monitoring hrly UOP insert a catheter .

A good rule to follow is :

In children of BWT < 30 KG 1 ML of urine / KG BWT / hr

In adults 0.5 -1 ML of urine KG BWT / hr

Fluid resuscitation 2 – 4 ML * KG BWT * % burn of BSA

In children calculated fluid + maintenance.

Special Burns Requirement :

Chemical B. Acid, Alkalis, Petroleum.

Alk. Penetrate > than acids.

severity --- conc., amount & time

of contact.

Mx rinse with large amount of water for 20-30 M.

powder ……. brush then wash.

Alk. Eye burn ---- continuous irrigation

Electrical B. More sever than they appear Rhabdomyolysis ARF

Patient transfer to a burn centercriteria for transfer ( ABA) :

1. Partial & full thickness burn >10% of BSA in patients<10 y or >50 y.

2. As above > 20% in other age groups.3. Same as above in face, eyes, ears, hands, feet, genitalia,

perineum & skin over maj. Joints.4. Full thickness > 5% in any age group.5. Significant elect. Burn.6. = chemical burn.7. Inhalation inj.8. Preexisting illness.9. Associated sign. Trauma.10. Hosp. not qualified for children11. Burn needs rehab., social or emotional care, e.g. child

abuse.

COLD INJURY : Systemic Hypothermia

Hypothermia Core body temp. < 35 degrees.

Mild --- 35 – 32

Moderate --- 32 -30

Severe ---- < 30

Susceptible pat. Are elderly , children & trauma pat.. Effects

can be by administer warm I.V. fluids & blood , exposure & warm environment.

Signs 1- core body temp. 2- level of

consciousness.

3- change in vital signs ( resp. & cardiac activ ity)

4- pat. Is gray & cyanotic. 5- cold to touch.

Blistering or easily unroofed burns which are wet or

waxy dry, and are painful to pressure. Their color may

range from patchy, cheesy white to red, and they do

not blanch with pressure. They take over 21 days to

heal and scarring may be severe. It is sometimes

difficult to differentiate these burns from full-thickness

burns.

4. Use cool (54 degree F.) saline solution to cool the area for 15-30 minutes. Avoid ice or freezing the injured tissue. Be certain to maintain the victim’s body temperature while treating the burn.

5. Wash the area thoroughly with plain soap and water. Dry the area with a clean towel. Ruptured blisters should be removed, but the management of clean, intact blisters is controversial. You should not attempt to manage blisters but should seek competent medical help.

6. If immediate medical care is unavailable or unnecessary, antibiotic ointment may be applied after thorough cleaning and before the clean gauze dressing is applied.

Scalding-typically result from hot water, grease, oil or tar. Immersion scalds tend to be worse than spills, because the contact with the hot solution is longer. They tend to be deep and severe and should be evaluated by a physician. Cooking oil or tar tends to be full- thickness requiring prolonged medical care.

a. Remove the person from the heat source.

b. Remove any wet clothing which is retaining heat.

c. With tar burns, after cooling, the tar should be removed by repeated applications of petroleum ointment and dressing every 2 hours.

Looks and tastes great, right? You should see what a hot liquid will do to a child’s skin when the two come into contact.

Be sure to keep hot liquids out of reach of small children.

Flamea. Remove the person from the source of the heat.

b. If clothes are burning, make the person lie down to keep smoke away from their face.

c. Use water, blanket or roll the person on the ground to smother the flames.

d. Once the burning has stopped, remove the clothing.

e. Manage the persons airway, as anyone with a flame burn should be considered to have an inhalation injury.

Electrical burns: are thermal injuries resulting from high intensity heat. The skin injury area may appear small, but the underlying tissue damage may be extensive. Additionally, there may be brain or heart damage or musculoskeletal injuries associated with the electrical injuries.

a. Safely remove the person from the source of the electricity. Do not become a victim.

b. Check their Airway, Breathing and Circulation and if necessary begin CPR using an AED (Automatic External Defibrillator) if available and EMS is not present. If the victim is breathing, place them on their side to prevent airway obstruction.

c. Due to the possibility of vertebrae injury secondary to intense muscle contraction, you should use spinal injury precautions during resuscitation.

d. Elevate legs to 45 degrees if possible.e. Keep the victim warm until EMS arrives.

Chemical burns- Most often caused by strong acids or alkalis. Unlike thermal burns, they can cause progressive injury until the agent is inactivated.

a. Flush the injured area with a copious amount of water while at the scene of the incident. Don’t delay or waste time looking for or using a neutralizing agent. These may in fact worsen the injury by producing heat or causing direct injury themselves.

Conclusion

Burns are serious injuries. If you have received a burn injury, please seek appropriate medical attention. Medical questions concerning burn injuries and their treatment should be directed to your personal physician, University Health Services or other appropriate medical professionals.

For information on fire safety and prevention, please contact the University of Georgia Fire Safety Program (369-5706), or the National Fire Protection Association website @ www.nfpa.org

Credits

• The Fire Safety Program extends its thanks to the following for providing the information in this presentation:

• Dr. Ronald Forehand-University Health Center, University of Georgia.

• www.healthseek.com