Trauma

26.1 Burns

Cause: Thermal (majority of burn unit admissions), chemical (3-16% of burn unit admissions) or electrical (3-4% of burn unit admissions) (Clin Plast Surg 2000;27:133) injury with subsequent tissue damage.

Epidem: Annually, a minority of pts with massive (> 75% of total body surface area) burns, approximately 3% in children (Jama 2000;283:69). Major burns with worse outcomes in infants and the elderly (Burns 2000;26:49). Scald burns of the perineum and lower extremities are common and preventable injuries in infants and the elderly (Burns 2000;26:251).

Pathophys: Tissue (skin) damage from the three above mentioned causes is inherent in their physical properties—that of heat, acidic or alkaline extremes, or electrical destruction. Thermal burns can cause acute or subacute ocular and airway damage that is linked to the initial insult or steam generation with consequent inhalation. Steam injury to the lungs can be quickly overwhelming (Burns 1996;22:313). Chemical burns have a predisposition for ocular and oropharyngeal damage. Chemical burns to the lungs can occur from hydrocarbon source as seen in huffing, if linked with smoking (Burns 1996;22:566). For associated electrical injury problems, see p85.

Major burns are those involving > 20% total body surface area (TBSA) or any fourth degree burns; or those with associated
airway, fracture, or other secondary injury problems. Burns in infants or the elderly are at higher risk for secondary complications; as well as burns that involve the hands, feet, perineum, cross major joints, or are circumferential.

Moderate burns are those involving 10-20% TBSA, with none of the aforementioned concerns of hands, feet, perineum, crossing a major joint, or circumferential locations. Moderate burns may be more concerning in infants, the elderly, or those with secondary medical concerns.

Minor burns are those with TBSA involvement of < 10% of second degree, < 2% of third degree, no fourth degree, and none of the concerns mentioned above.

Sx: Pain, hoarseness, dyspnea, visual problems.

Si: Tissue damage. Do a full evaluation, with particular attention to the head and neck looking for singed hair (including nasal), pharyngeal edema, soot deposits in oropharynx, and circumferential neck burns; look for circumferential burns on any extremities or for places where burns cross joints; inspect perineum, as this is very thin skin; look for burn patterns, and photograph, if any concern for abuse; look for secondary injuries, such as fractures. TBSA should be calculated with a burn chart [most accurate (Burns 2000;26:156), such as the Lund and Browder], rules of nines in adults, and modified for children. For adults, 9% (one portion or multiples) of body surface for each of the following areas:

Head and neck is 1 portion (9%)
Anterior torso is 2 portions (18%)
Posterior torso is 2 portions (18%)
Each upper extremity is one portion
Each lower extremity is 2 portions (18% each)
1% for perineum

In children, may approximate burn size with dorsum of pt’s hand, including digits, as approximately 1% or by referring
to burn chart. An infant’s head and neck is approximately 2½ portions (22%), and each lower extremity is one portion (9%).
1st Degree: Erythematous skin, no blisters, not part of the TBSA calculation.
2nd Degree: Blister formation, tender; superficial second is erythematous and blistered; deep second is with charring but not quite full thickness—may be leathery texture to the skin.
3rd Degree: Full thickness with anesthesia, venous thrombosis and extends down to the sc fat layer.
4th Degree: With involvement of sc fat, muscle or bone.

Crs: Burns with > 20% TBSA cause systemic inflammatory response.

Cmplc: Airway compromise, hypovolemia, systemic inflammatory response, later secondary infection, including tetanus, or aeromonas if immersion injury post burn (Burns 2000;26:478); ischemic bowel disease (Arch Surg 1997;132:440); aggressive fluid resuscitation with consequent pulmonary edema (Ann Surg 1977;185:100); electrolyte imbalance.

Diff Dx: Blistering skin diseases such as Toxic epidermolysis necrosis, Stevens-Johnson Syndrome, Staphylococcal scalded skin syndrome, and others that are all rare (Burns 2000;26:82) and should be differentiated by hx.

Lab: Those with minor and moderate burns usually do not require any laboratory evaluation, whereas those with major burns should receive the following: CBC with diff; metabolic profile; CO level; ABG, if airway involvement; PT/PTT; total CPK; UA; urine for myoglobin. Elevated serum calcitonin correlates with mortality and pulmonary injury, whereas elevated TNF-α and TNF receptor I and II levels also correlate with mortality; threshold values unknown (J Burn Care Rehabil 1992;13:605; Burns 2000;26:239).

X-ray: CXR if airway involvement, although findings may be delayed (Brit J Radiol 1994;67:751); assessment for secondary fractures.

Emergency Management:

Major Burns:

Secure airway if obvious or impending obstruction—ET intubation. Inhalation injuries need not have extensive obvious tissue involvement to be severe (J Emerg Med 1988;6:471), but look for evidence of insult, such as oral or nasal signs or carbanaceous sputum. Consider early intubation before edema makes this difficult.
Wet chemical burns should be irrigated with water usually (J Burn Care Rehabil 2000;21:40) and use a mild liquid detergent if water solubility in question. Sodium metals, other metals, and phenol will do better with mineral oil. Dry chemicals should be brushed or lifted for removal. Cover burns with dry gauze or opt for synthetic semipermeable membrane, such as Biobrane (Plast Reconstr Surg 2000;105:62), Opsite, Tagaderm or Duoderm as barrier—avoid hypothermia by not wetting the dressings.
Iv access and bladder catheter, Parkland formula: 4 cc of LR/kg/% TBSA, with half in the first 8 hr and half in the following 16 hr (Ann N Y Acad Sci 1968;150:874; Heart Lung 1973;2:707) for fluid resuscitation with urine output goal of 0.3-0.5 cc/kg/hr. Avoid excessive resuscitation if pulmonary involvement (J Trauma 1982;22:869). Sodium bicarbonate drip if rhabdomyolysis (see Compartment Syndrome p484).
Iv narcotics/benzodiazepines for pain control and anxiolysis; splint fractures.
Update tetanus and antibiotic eye ointment if ocular involvement.
Do not debride intact blisters (Acad Emerg Med 2000;7:114).
< 18 yr of age with burn > 40% of TBSA benefit from β-blocker treatment—this attenuates hypermetabolism (Nejm 2001;345:1223).
Chest plate escharotomy, if trained to do so and cannot ventilate pt.

Moderate or minor burns:

Moderate burns are major if occurring in infants, the elderly, or those with significant secondary medical problems.
If isolated burn that crosses a joint in an otherwise healthy pt, may splint the joint in anticipation of next day follow-up (Burns 1998;24:493).
Update Tetanus, if needed.
Do not debride intact blisters (Acad Emerg Med 2000;7:114).
Remove foreign body, cover wounds with ointment of choice—do not put silver sulfadiazine on the face because it will stain, and all ointments have equal efficacy. Topical neomycin may cause a contact dermatitis. May opt for synthetic semipermeable membrane, such as Biobrane (Plast Reconstr Surg 2000;105:62), Opsite, Tagaderm, or Duoderm. Perhaps topical octylcyanoacrylate as cover (Acad Emerg Med 2000;7:222; Burns 2000;26:388).
Honey (Burns 1996;22:491; Infection 1992;20:227) and papaya fruit are appropriate wound salves (Burns 2003;29:15); honey better than Opsite (Brit J Plast Surg 1993;46:322).
Ibuprofen [which increases tissue perfusion and limits burn extension (Burns 2000;26:341)] and oral narcotics for pain control, if needed.
Follow-up in 24 hr for burn recheck, consider debridement if broken blisters at this time, and then in 5-7 d if no complications. Daily dressing changes at home if able, otherwise through health care provider.
Topical heparin may have a future role (Burns 2001;27:349).

26.2 C-spine

J Accid Emerg Med 1999;16:208; Orthop Clin N Am 1999;30:457

Cause: Trauma from any cause may cause fracture, subluxation, soft-tissue hyperextension injury, spinal cord trauma, or radiculopathy; increased risk in those with Down syndrome (Clin Neuropathol 1999;18:250) or other disease states that affect the integrity of the neck.

Epidem: Age-related injuries, with children having spinal cord injury without radiographic abnormalities—this only relates to plain radiographs, will be apparent on MRI (J Trauma 1989;29:654; Am J Emerg Med 1999;17:230), and the elderly having a lower incidence of C-spine fractures, but a higher group percentage of C1-C2 fractures (Spinal Cord 1999;37:560) and perhaps more difficult plain films to interpret secondary to arthritis. Blunt trauma fracture incidence is approximately 1-3%, with primarily males in their third or fourth decade of life. Pure subluxation is rare (J Trauma 2000;48:724). Those with blunt cervical trauma unlikely to have intra-abdominal pathology if not consistent with mechanism and if patient hemodynamically stable (< 1%) (J Spinal Disord 1992;5:476).

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