8 MUSCULOSKELETAL TRAUMA Injuries to the musculoskeletal system are common in trauma patients. The delayed recogni- tion and treatment of these injuries can result in life-threatening hemorrhage or limb loss.
chapter 8 outline other extremity injuries • Contusions and Lacerations objectives • Joint and Ligament Injuries • Fractures introduction principles of immobilization primary survey and resuscitation of patients • Femoral Fractures with potentially life-threatening extremity • Knee Injuries injuries • Tibial Fractures • Ankle Fractures • Major Arterial Hemorrhage and Traumatic Amputation • Upper Extremity and Hand Injuries • Bilateral Femur Fractures • Crush Syndrome pain control adjuncts to the primary survey associated injuries • Fracture Immobilization • X-ray Examination occult skeletal injuries secondary survey teamwork • History • Physical Examination chapter summary limb-threatening injuries bibliography • Open Fractures and Open Joint Injuries • Vascular Injuries • Compartment Syndrome • Neurologic Injury Secondary to Fracture Dislocation OBJECTIVES After reading this chapter and comprehending the knowledge 4. Describe key elements of the secondary survey of components of the ATLS provider course, you will be able to: patients with musculoskeletal trauma, including the history and physical examination. 1. Explain the significance of musculoskeletal injuries in patients with multiple injuries. 5. Explain the principles of the initial management of limb-threatening musculoskeletal injuries. 2. Outline the priorities of the primary survey and resuscitation of patients with extremity injuries, quickly 6. Describe the appropriate assessment and initial separating the potentially life-threatening injuries from management of patients with contusions, lacerations, those that are less urgent. joint and ligament injuries, and fractures. 3. Identify the adjuncts needed in the immediate 7. Describe the principles of proper immobilization of treatment of life-threatening extremity hemorrhage. patients with musculoskeletal injuries. ■■BBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 149
150 CHAPTER 8 ■ Musculoskeletal Trauma M any patients who sustain blunt trauma fractures and soft tissue injuries may not be initially also incur injuries to the musculoskeletal recognized in patients with multiple injuries. system. These injuries often appear dramatic, but only infrequently cause immediate threat to life Continued reevaluation of the patient is necessary or limb. However, musculoskeletal injuries have to identify all injuries. the potential to distract team members from more urgent resuscitation priorities. First, clinicians primary survey and need to recognize the presence of life-threatening resuscitation of extremity injuries during the primary survey and patients with potentially understand their association with severe thoracic l i f e-t h r e at e n i n g and abdominal injuries. The provider must also be extremity injuries familiar with extremity anatomy to be able to protect the patient from further disability, and anticipate and During the primary survey, it is imperative to recognize prevent complications. and control hemorrhage from musculoskeletal injuries. Major musculoskeletal injuries indicate that the Potentially life-threatening extremity injuries include body sustained significant forces (■ FIGURE 8-1). For major arterial hemorrhage, bilateral femoral fractures, example, a patient with long-bone fractures above and crush syndrome. (Pelvic disruption is described in and below the diaphragm is at increased risk for Chapter 5: Abdominal and Pelvic Trauma.) associated internal torso injuries. Unstable pelvic fractures and open femur fractures can be accompanied Deep soft-tissue lacerations may involve major by brisk bleeding. Severe crush injuries cause the vessels and lead to exsanguinating hemorrhage. release of myoglobin from the muscle, which can Hemorrhage control is best achieved with direct precipitate in the renal tubules and result in renal pressure. Hemorrhage from long-bone fractures can failure. Swelling into an intact musculofascial space be significant, and femoral fractures in particular can cause an acute compartment syndrome that, often result in significant blood loss into the thigh. if not diagnosed and treated, may lead to lasting Appropriate splinting of fractures can significantly impairment and loss of the extremity. Fat embolism, an decrease bleeding by reducing motion and enhancing uncommon but highly lethal complication of long-bone the tamponade effect of the muscle and fascia. If the fractures, can lead to pulmonary failure and impaired fracture is open, application of a sterile pressure cerebral function. dressing typically controls hemorrhage. Appropriate fluid resuscitation is an important supplement to these Musculoskeletal trauma does not warrant a re- mechanical measures. ordering of the ABCDE priorities of resuscitation, but its presence does pose a challenge to clinicians. pitfall prevention Musculoskeletal injuries cannot be ignored and treated at a later time; rather, clinicians must treat the whole Blood loss from • Recognize that femur patient, including musculoskeletal injuries, to ensure musculoskeletal fractures and any open an optimal outcome. Despite careful assessment, injuries is not long-bone fractures immediately with major soft-tissue recognized. involvement are potential sites of significant hemorrhage. n FIGURE 8-1 Major injuries indicate that the patient sustained major arterial hemorrhage and significant forces, and significant blood loss is possible. traumatic amputation ■ BACK TO TABLE OF CONTENTS Penetrating extremity wounds can result in major arterial vascular injury. Blunt trauma resulting in an extremity fracture or joint dislocation in close proximity to an artery can also disrupt the artery. These injuries may lead to significant hemorrhage through the open wound or into the soft tissues. Patients with
PRIMARY SURVEY AND RESUSCITATION 151 traumatic amputation are at particularly high risk of life- as 250 mm Hg in an upper extremity and 400 mm Hg threatening hemorrhage and may require application in a lower extremity. Ensure that the time of tourniquet of a tourniquet. application is documented. In these cases, immediate Assessment surgical consultation is essential, and early transfer to Assess injured extremities for external bleeding, loss a trauma center should be considered. of a previously palpable pulse, and changes in pulse quality, Doppler tone, and ankle/brachial index. The If time to operative intervention is longer than 1 ankle/brachial index is determined by taking the hour, a single attempt to deflate the tourniquet may systolic blood pressure value at the ankle of the injured be considered in an otherwise stable patient. The risks leg and dividing it by the systolic blood pressure of of tourniquet use increase with time; if a tourniquet the uninjured arm. A cold, pale, pulseless extremity must remain in place for a prolonged period to save a indicates an interruption in arterial blood supply. A life, the choice of life over limb must be made. rapidly expanding hematoma suggests a significant vascular injury. The use of arteriography and other diagnostic tools Management is indicated only in resuscitated patients who have no A stepwise approach to controlling arterial bleed- hemodynamic abnormalities; other patients with clear ing begins with manual pressure to the wound. vascular injuries require urgent operation. If a major (Bleedingcontrol.org provides lay public training in arterial injury exists or is suspected, immediately consult hemorrhage control.) A pressure dressing is then a surgeon skilled in vascular and extremity trauma. applied, using a stack of gauze held in place by a circumferential elastic bandage to concentrate pres- Application of vascular clamps into bleeding open sure over the injury. If bleeding persists, apply manual wounds while the patient is in the ED is not advised, pressure to the artery proximal to the injury. If bleed- unless a superficial vessel is clearly identified. If a ing continues, consider applying a manual tourniquet fracture is associated with an open hemorrhaging (such as a windlass device) or a pneumatic tourniquet wound, realign and splint it while a second person applied directly to the skin (■ FIGURE 8-2). applies direct pressure to the open wound. Joint dislocations should be reduced, if possible; if the joint Tighten the tourniquet until bleeding stops. A prop- cannot be reduced, emergency orthopedic intervention erly applied tourniquet must occlude arterial inflow, may be required. as occluding only the venous system can increase hemorrhage and result in a swollen, cyanotic extremity. Amputation, a severe form of open fracture that results A pneumatic tourniquet may require a pressure as high in loss of an extremity, is a traumatic event for the patient, both physically and emotionally. Patients with n FIGURE 8-2 The judicious use of a tourniquet can be lifesaving traumatic amputation may benefit from tourniquet and/or limb-saving in the presence of ongoing hemorrhage. application. They require consultation with and intervention by a surgeon. Certain mangled extremity injuries with prolonged ischemia, nerve injury, and muscle damage may require amputation. Amputation can be lifesaving in a patient with hemodynamic abnormalities resulting from the injured extremity. Although the potential for replantation should be considered in an upper extremity, it must be considered in conjunction with the patient’s other injuries. A patient with multiple injuries who requires intensive resuscitation and/or emergency surgery for extremity or other injuries is not a candidate for replantation. Replantation is usually performed on patients with an isolated extremity injury. For the required decision making and management, transport patients with traumatic amputation of an upper extremity to an appropriate surgical team skilled in replantation procedures. In such cases, thoroughly wash the amputated part in isotonic solution (e.g., Ringer’s lactate) and wrap it in moist sterile gauze. Then wrap the part in a similarly moistened sterile towel, place in a plastic bag, and transport with the patient in an insulated cooling chest with crushed ice. Be careful not to freeze the amputated part. ■ BACK TO TABLE OF CONTENTS
152 CHAPTER 8 ■ Musculoskeletal Trauma bilateral femur fractures Management Initiating early and aggressive intravenous fluid Patients who have sustained bilateral femur fractures therapy during resuscitation is critical to protecting are at significantly greater risk of complications the kidneys and preventing renal failure in patients and death. Such fractures indicate the patient has with rhabdomyolysis. Myoglobin-induced renal been subjected to significant force and should alert failure can be prevented with intravascular fluid clinicians to the possibility of associated injuries. expansion, alkalinization of the urine by intravenous Compared with patients with unilateral femur administration of bicarbonate, and osmotic diuresis. fractures, patients with bilateral femur fractures are at higher risk for significant blood loss, severe adjuncts to the primary associated injuries, pulmonary complications, multiple survey organ failure, and death. These patients should be assessed and managed in the same way as those with Adjuncts to the primary survey of patients with unilateral femur fractures. Consider early transfer to a musculoskeletal trauma include fracture immo- trauma center. bilization and x-ray examination, when fracture is suspected as a cause of shock. pitfall prevention fracture immobilization Delayed transfer to a • Transfer patients with trauma center vascular injury and The goal of initial fracture immobilization is to concomitant fracture realign the injured extremity in as close to anatomic to a trauma center with position as possible and prevent excessive motion at vascular and orthopedic the fracture site. This is accomplished by applying surgical capabilities. inline traction to realign the extremity and maintain- ing traction with an immobilization device (■ FIGURE 8-3). • Bilateral femur fractures Proper application of a splint helps control blood result in a significantly loss, reduces pain, and prevents further neurova- increased risk of compli- scular compromise and soft-tissue injury. If an open cations and death; these fracture is present, pull the exposed bone back into patients benefit from early the wound, because open fractures require surgical transfer to a trauma center. crush syndrome Crush syndrome, or traumatic rhabdomyolysis, refers to the clinical effects of injured muscle that, if left untreated, can lead to acute renal failure and shock. This condition is seen in individuals who have sustained a compression injury to significant muscle mass, most often to a thigh or calf. The muscular insult is a combination of direct muscle injury, muscle ischemia, and cell death with release of myoglobin. Assessment AB Myoglobin produces dark amber urine that tests positive for hemoglobin. A myoglobin assay may be n FIGURE 8-3 The goal of initial fracture immobilization is to realign requested to confirm its presence. Amber-colored urine the injured extremity in as close to anatomic position as possible in the presence of serum creatine kinase of 10,000 U/L and prevent excessive fracture-site motion. A. Shortening and or more is indicative of rhabdomyolysis when urine external rotation of right leg due to a mid-shaft femur fracture B. myoglobin levels are not available. Rhabdomyolysis can Application of in-line traction with stabilization of the leg in normal lead to metabolic acidosis, hyperkalemia, hypocalcemia, anatomic position. and disseminated intravascular coagulation. ■ BACK TO TABLE OF CONTENTS
SECONDARY SURVEY 153 debridement. Remove gross contamination and The clinician should mentally reconstruct the injury particulate matter from the wound, and administer scene, consider other potential injuries the patient weight-based dosing of antibiotics as early as possible may have sustained, and determine as much of the in patients with open fractures. (See Appendix G: following information as possible: Circulation Skills.) 1. Where was the patient located before the crash? Qualified clinicians may attempt reduction of joint In a motor vehicle crash, the patient’s precrash dislocations. If a closed reduction successfully relocates location (i.e., driver or passenger) can suggest the joint, immobilize it in the anatomic position with the type of fracture—for example, a lateral prefabricated splints, pillows, or plaster to maintain compression fracture of the pelvis may result the extremity in its reduced position. from a side impact collision. If reduction is unsuccessful, splint the joint in the 2. Where was the patient located after the crash— position in which it was found. Apply splints as soon as inside the vehicle or ejected? Was a seat belt or possible, because they can control hemorrhage and pain. airbag in use? This information may indicate certain patterns of injury. If the patient was However, resuscitation efforts must take priority ejected, determine the distance the patient over splint application. Assess the neurovascular was thrown, as well as the landing conditions. status of the extremity before and after manipulation Ejection generally results in unpredictable and splinting. patterns of injury and more severe injuries. x-ray examination 3. Was the vehicle’s exterior damaged, such as having its front end deformed by a head-on Although x-ray examination of most skeletal injuries collision? This information raises the suspicion is appropriate during the secondary survey, it may be of a hip dislocation. undertaken during the primary survey when fracture is suspected as a cause of shock. The decisions regarding 4. Was the vehicle’s interior damaged, such as a which x-ray films to obtain and when to obtain them deformed dashboard? This finding indicates a are based on the patient’s initial and obvious clinical greater likelihood of lower-extremity injuries. findings, the patient’s hemodynamic status, and the mechanism of injury. 5. Did the patient fall? If so, what was the distance of the fall, and how did the patient land? This secondary survey information helps identify the spectrum of injuries. Important elements of the secondary survey of patients with musculoskeletal injuries are the history and 6. Was the patient crushed by an object? If so, physical examination. identify the weight of the crushing object, the site of the injury, and duration of weight history applied to the site. Depending on whether a subcutaneous bony surface or a muscular area Key aspects of the patient history are mechanism of was crushed, different degrees of soft-tissue injury, environment, preinjury status and predisposing damage may occur, ranging from a simple factors, and prehospital observations and care. contusion to a severe degloving extremity injury with compartment syndrome and Mechanism of Injury tissue loss. Information obtained from the patient, relatives, prehospital and transport personnel, and bystanders 7. Did an explosion occur? If so, what was the at the scene of the injury should be documented magnitude of the blast, and what was the and included as a part of the patient’s history. It is patient’s distance from the blast? An individual particularly important to determine the mechanism close to the explosion may sustain primary of injury, which can help identify injuries that may not blast injury from the force of the blast wave. A be immediately apparent. (See Biomechanics of Injury.) secondary blast injury may occur from debris and other objects accelerated by the blast (e.g., fragments), leading to penetrating wounds, lacerations, and contusions. The patient may also be violently thrown to the ground or against other objects by the blast effect, leading to blunt musculoskeletal and other injuries (i.e., a tertiary blast injury). ■ BACK TO TABLE OF CONTENTS
154 CHAPTER 8 ■ Musculoskeletal Trauma n FIGURE 8-4 Impact points vary based on vehicle and individual, i.e., height of bumper and patient's age and size. 8. Was the patient involved in a vehicle-pedestrian Prehospital Observations and Care collision? Musculoskeletal injuries follow predictable patterns based on the patient’s size All prehospital observations and care must be reported and age (■ FIGURE 8-4). and documented. Findings at the incident site that may help to identify potential injuries include Environment When applicable, ask prehospital care personnel • The time of injury, especially if there is ongoing for the following information about the post- bleeding, an open fracture, and a delay in crash environment: reaching the hospital 1. Did the patient sustain an open fracture in a • Position in which the patient was found contaminated environment? • Bleeding or pooling of blood at the scene, 2. Was the patient exposed to temperature extremes? including the estimated amount 3. Were broken glass fragments, which can also • Bone or fracture ends that may have been exposed injure the examiner, at the scene? 4. Were there any sources of bacterial • Open wounds in proximity to obvious or suspected fractures contamination, such as dirt, animal feces, and fresh or salt water? • Obvious deformity or dislocation This information can help the clinician anti- cipate potential problems and determine the initial • Any crushing mechanism that can result in a antibiotic treatment. crush syndrome Preinjury Status and Predisposing Factors • Presence or absence of motor and/or sensory When possible, determine the patient’s baseline function in each extremity condition before injury. This information can enhance understanding of the patient’s condition, help • Any delays in extrication procedures or transport determine treatment regimen, and affect outcome. An AMPLE history should be obtained, including • Changes in limb function, perfusion, or neuro- information about the patient’s exercise tolerance logic state, especially after immobilization or and activity level, ingestion of alcohol and/or other during transfer to the hospital drugs, emotional problems or illnesses, and previous musculoskeletal injuries. • Reduction of fractures or dislocations during extrication or splinting at the scene • Dressings and splints applied, with special attention to excessive pressure over bony prominences that can result in peripheral nerve compression or compartment syndrome • Time of tourniquet placement, if applicable ■ BACK TO TABLE OF CONTENTS
SECONDARY SURVEY 155 physical examination table 8-1 common joint dislocation deformities For a complete examination, completely undress the patient, taking care to prevent hypothermia. Obvious JOINT DIRECTION DEFORMITY extremity injuries are often splinted before the patient arrives at the ED. The three goals for assessing the Shoulder Anterior Squared off extremities are: Posterior Locked in internal 1. Identify life-threatening injuries (primary survey). rotation 2. Identify limb-threatening injuries (secondary survey). 3. Conduct a systematic review to avoid missing Elbow Posterior Olecranon prominent any other musculoskeletal injury (i.e., posteriorly continuous reevaluation). Hip Anterior Extended, abducted, Assessment of musculoskeletal trauma includes externally rotated looking at and talking to the patient, palpating the patient’s extremities, and performing a logical, system- Posterior Flexed, adducted, atic review of each extremity. Extremity assessment internally rotated must include the following four components to avoid missing an injury: skin, which protects the patient Knee Anteroposterior Loss of normal from excessive fluid loss and infection; neuromuscular contour, extended function; circulatory status; and skeletal and ligament- ous integrity. (See Appendix G: Secondary Survey.) *May spontaneously reduce prior to Look and Ask evaluation Visually assess the extremities for color and perfusion, wounds, deformity (e.g., angulation or shortening), Ankle Lateral is most Externally rotated, swelling, and bruising. common prominent medial malleolus A rapid visual inspection of the entire patient will help identify sites of major external bleeding. A pale Subtalar Lateral is most Laterally displaced or white distal extremity is indicative of a lack of joint common os calcis (calcaneus) arterial inflow. Extremities that are swollen in the region of major muscle groups may indicate a crush patient, trauma team members can assess active injury with an impending compartment syndrome. voluntary muscle and peripheral nerve function by Swelling or ecchymosis in or around a joint and/or asking the patient to contract major muscle groups. over the subcutaneous surface of a bone is a sign of The ability to move all major joints through a full range a musculoskeletal injury. Extremity deformity is an of motion usually indicates that the nerve-muscle unit obvious sign of major extremity injury. ■ TABLE 8-1 is intact and the joint is stable. outlines common joint dislocation deformities. Feel Inspect the patient’s entire body for lacerations Palpate the extremities to determine sensation to and abrasions. Open wounds may not be obvious on the skin (i.e., neurologic function) and identify areas the dorsum of the body; therefore, carefully logroll of tenderness, which may indicate fracture. Loss patients to assess for possible hidden injuries. (See of sensation to pain and touch demonstrates the Logroll video on MyATLS mobile app.) Any open wound presence of a spinal or peripheral nerve injury. Areas to a limb with an associated fracture is considered of tenderness or pain over muscles may indicate a to be an open fracture until proven otherwise by muscle contusion or fracture. If pain, tenderness, and a surgeon. swelling are associated with deformity or abnormal motion through the bone, fracture should be suspected Observe the patient’s spontaneous extremity motor function to help identify any neurologic and/or muscular impairment. If the patient is unconscious, absent spontaneous extremity movement may be the only sign of impaired function. With a cooperative ■ BACK TO TABLE OF CONTENTS
156 CHAPTER 8 ■ Musculoskeletal Trauma Do not attempt to elicit crepitus or demonstrate abnormal motion. Joint stability can be determined only by clinical examination. Abnormal motion through a joint segment is indicative of a tendon or ligamentous rupture. Palpate the joint to identify any swelling and tenderness of the ligaments as well as intraarticular fluid. Following this, cautious stressing of the specific ligaments can be performed. Excessive pain can mask abnormal ligament motion due to guarding of the joint by muscular contraction or spasm; this condition may need to be reassessed later. Circulatory Evaluation n FIGURE 8-5 Blanched skin associated with fractures and Palpate the distal pulses in each extremity, and assess dislocations will quickly lead to soft tissue necrosis. The purpose of capillary refill of the digits. If hypotension limits digital promptly reducing this injury is to prevent pressure necrosis on the examination of the pulse, the use of a Doppler probe lateral ankle soft tissue. may detect blood flow to an extremity. The Doppler the arterial blood supply and reduce the pressure on signal must have a triphasic quality to ensure no the skin. Alignment can be maintained by appropriate proximal lesion. Loss of sensation in a stocking or glove immobilization techniques. distribution is an early sign of vascular impairment. limb-threatening injuries In patients with normal blood pressure, an arterial injury can be indicated by pulse discrepancies, Extremity injuries that are considered potentially coolness, pallor, paresthesia, and even motor function limb-threatening include open fractures and joint abnormalities. Open wounds and fractures close injuries, ischemic vascular injuries, compartment to arteries can be clues to an arterial injury. Knee syndrome, and neurologic injury secondary to fracture dislocations can reduce spontaneously and may or dislocation. not present with any gross external or radiographic anomalies until a physical exam of the joint is open fractures and open joint performed and instability is detected clinically. injuries An ankle/brachial index of less than 0.9 indicates abnormal arterial flow secondary to injury or Open fractures and open joint injuries result from peripheral vascular disease. Expanding hematomas communication between the external environment and pulsatile hemorrhage from an open wound also and the bone or joint (■ FIGURE 8-6). Muscle and indicate arterial injury. skin must be injured for this to occur, and the degree of soft-tissue injury is proportional to the X-ray Examination energy applied. This damage, along with bacterial The clinical examination of patients with musculo- contamination, makes open fractures and joint skeletal injuries often suggests the need for x-ray injuries prone to problems with infection, healing, examination. Tenderness with associated bony and function. deformity likely represents a fracture. Obtain x-ray films in patients who are hemodynamically normal. Assessment Joint effusion, abnormal joint tenderness, and joint The presence of an open fracture or an open joint injury deformity indicate a joint injury or dislocation that should be promptly determined. The diagnosis of an must also be x-rayed. The only reason to forgo x-ray open fracture is based on a physical examination of examination before treating a dislocation or a fracture the extremity that demonstrates an open wound on is the presence of vascular compromise or impending skin breakdown. This condition is commonly seen with fracture-dislocations of the ankle (■ FIGURE 8-5). If a delay in obtaining x-rays is unavoidable, imme- diately reduce or realign the extremity to reestablish ■ BACK TO TABLE OF CONTENTS
LIMB-THREATENING INJURIES 157 necessary. The patient should be adequately resuscitated and, if possible, hemodynamically normal. Wounds may then be operatively debrided, fractures stabilized, and distal pulses confirmed. Tetanus prophylaxis should be administered. (See Tetanus Immunization.) pitfall prevention Failure to give timely • Recognize that infection is antibiotics to patients a significant risk in patients with open fractures with open fractures. n FIGURE 8-6 Example of an open fracture. Open fractures and joint • Administer weight-based injuries are prone to problems with infection, healing, and function. doses of appropriate antibiotics as soon as an open fracture is suspected. the same limb segment as an associated fracture. At vascular injuries no time should the wound be probed. In patients who manifest vascular insufficiency Documentation of the open wound begins during associated with a history of blunt, crushing, twisting, the prehospital phase with the initial description of or penetrating injury or dislocation to an extremity, the injury and any treatment rendered at the scene. clinicians should strongly suspect a vascular injury. If an open wound exists over or near a joint, it should be assumed that the injury connects with or enters Assessment the joint. The presence of an open joint injury may be The limb may initially appear viable because extremities identified using CT. The presence of intraarticular gas often have some collateral circulation that provides on a CT of the affected extremity is highly sensitive adequate flow. Non-occlusive vascular injury, such and specific for identifying open joint injury. If CT as an intimal tear, can cause coolness and prolonged is not available, consider insertion of saline or dye capillary refill in the distal part of the extremity, as into the joint to determine whether the joint cavity well as diminished peripheral pulses and an abnormal communicates with the wound. If an open joint is ankle/brachial index. Alternatively, the distal extremity suspected, request consultation by an orthopedic may have complete disruption of flow and be cold, pale, surgeon, as surgical exploration and debridement may and pulseless. be indicated. Management Management It is crucial to promptly recognize and emergently Management decisions should be based on a com- treat an acutely avascular extremity. plete history of the incident and assessment of the injury. Treat all patients with open fractures as Early operative revascularization is required to soon as possible with intravenous antibiotics using restore arterial flow to an ischemic extremity. Muscle weight-based dosing. First-generation cephalosporins necrosis begins when there is a lack of arterial blood are necessary for all patients with open fractures flow for more than 6 hours. Nerves may be even (■ TABLE 8-2). Delay of antibiotic administration more sensitive to an anoxic environment. If there is beyond three hours is related to an increased risk an associated fracture deformity, correct it by gently of infection. pulling the limb out to length, realigning the fracture, and splinting the injured extremity. This maneuver Remove gross contamination and particulates from often restores blood flow to an ischemic extremity when the wound as soon as possible, and cover it with a moist the artery is kinked by shortening and deformity at the sterile dressing. Apply appropriate immobilization fracture site. after accurately describing the wound and determining any associated soft-tissue, circulatory, and neurologic involvement. Prompt surgical consultation is ■ BACK TO TABLE OF CONTENTS
158 CHAPTER 8 ■ Musculoskeletal Trauma table 8-2 intravenous antibiotic weight-based dosing guidelines OPEN FRACTURES FIRST-GENERATION IF ANAPHYLACTIC AMINOGLYCOCIDE PIPERACILLIN/ CEPHALOSPORINS PENICILLIN (GRAM-NEGATIVE TAZOBACTAM Wound <1 cm; (GRAM-POSITIVE ALLERGY (BROAD-SPECTRUM minimal con- (INSTEAD OF COVERAGE) GRAM-POSITIVE tamination or soft COVERAGE) GENTAMICIN AND NEGATIVE tissue damage FIRST- GENERATION COVERAGE) CEFAZOLIN CEPHALOSPORIN) Loading dose in ER: Wound 1–10 cm; 2.5 mg/kg for child 3.375 gm Q 6 hr moderate soft <50 kg: 1 gm Q 8 hr CLINDAMYCIN (or <50 kg) (<100 kg) tissue damage; 50–100 kg: 2 gm Q 8 hr 5 mg/kg for adult 4.5 gm Q 6 hr (>100 comminution of >100 kg: 3 gm Q 8 hr <80 kg: 600 mg Q 8 hr (i.e., 150-lb pt = 340 mg) kg) fracture >80 kg: 900 mg Q 8 hr <50 kg: 1 gm Q 8 hr Severe soft- 50–100 kg: 2 gm Q 8 hr <80 kg: 600 mg Q 8 hr tissue damage >100 kg: 3 gm Q 8 hr >80 kg: 900 mg Q 8 hr and substantial contamination with <50 kg: 1 gm Q 8 hr <80 kg: 600 mg Q 8 hr associated vascular 50–100 kg: 2 gm Q 8 hr >80 kg: 900 mg Q 8 hr injury >100 kg: 3 gm Q 8 hr Farmyard, soil or standing water, irrespective of wound size or severity **If anaphylactic penicillin allergy consult Infectious Disease Department or Pharmacy Data from: Schmitt SK, Sexton DJ, Baron EL. Treatment and Prevention of Osteomyelitis Following Trauma in Adults. UpToDate. http://www. uptodate.com/contents/treatment-and-prevention-of-osteomyelitis-following-trauma-in-adults. October 29, 2015; O’Brien CL, Menon M, Jomha NM. Controversies in the management of open fractures. Open Orthop J 2014;8:178–184. When an arterial injury is associated with dislocation The potential for vascular compromise also exists of a joint, a clinician may attempt gentle reduction whenever an injured extremity is splinted. It is maneuvers. Otherwise, the clinician must splint therefore important to perform and document a careful the dislocated joint and obtain emergency surgical neurovascular examination of the injured extremity consultation. CT angiography may be used to evaluate before and after reduction and application of a splint. extremity vascular injuries, but it must not delay Vascular compromise can be identified by loss of or reestablishing arterial blood flow and is indicated only change in the distal pulse, but excessive pain after after consultation with a surgeon. splint application must be investigated. Patients in ■ BACK TO TABLE OF CONTENTS
LIMB-THREATENING INJURIES 159 casts can also have vascular compromise Promptly • Injuries immobilized in tight dressings or casts release splints, casts, and any other circumferential • Severe crush injury to muscle dressings upon any sign of vascular compromise, and • Localized, prolonged external pressure to then reassess vascular supply. an extremity compartment syndrome • Increased capillary permeability secondary to Compartment syndrome develops when increased reperfusion of ischemic muscle pressure within a musculofascial compartment causes • Burns ischemia and subsequent necrosis. This increased • Excessive exercise pressure may be caused by an increase in compartment content (e.g., bleeding into the compartment or swelling ■ BOX 8-1 details the signs and symptoms of compart- after revascularization of an ischemic extremity) or a ment syndrome. Early diagnosis is the key to successful decrease in the compartment size (e.g., a constrictive treatment of acute compartment syndrome. A high dressing). Compartment syndrome can occur wherever degree of awareness is important, especially if the muscle is contained within a closed fascial space. patient has an altered sensorium and is unable to Remember, the skin acts as a restricting layer in certain respond appropriately to pain. The absence of a circumstances. Common areas for compartment palpable distal pulse is an uncommon or late finding syndrome include the lower leg, forearm, foot, hand, and is not necessary to diagnose compartment gluteal region, and thigh (■ FIGURE 8-7). syndrome. Capillary refill times are also unreliable for diagnosing compartment syndrome. Weakness or Delayed recognition and treatment of compartment paralysis of the involved muscles in the affected limb syndrome is catastrophic and can result in neurologic is a late sign and indicates nerve or muscle damage. deficit, muscle necrosis, ischemic contracture, infection, Clinical diagnosis is based on the history of injury and delayed healing of fractures, and possible amputation. physical signs, coupled with a high index of suspicion. If pulse abnormalities are present, the possibility of a Assessment proximal vascular injury must be considered. Any injury to an extremity can cause compartment syndrome. However, certain injuries or activities are Measurement of intracompartmental pressure can considered high risk, including be helpful in diagnosing suspected compartment syndrome. Tissue pressures of greater than 30 mm • Tibia and forearm fractures Hg suggest decreased capillary blood flow, which can result in muscle and nerve damage from anoxia. Blood Anterior Tibia pressure is also important: The lower the systemic compartment pressure, the lower the compartment pressure that Lateral Deep posterior causes a compartment syndrome. compartment compartment Compartment syndrome is a clinical diagnosis. Fibula Nerves and Pressure measurements are only an adjunct to aid blood vessels in its diagnosis. Superficial posterior box 8-1 signs and symptoms of compartment compartment syndrome • Pain greater than expected and out of proportion to the stimulus or injury • Pain on passive stretch of the affected muscle • Tense swelling of the affected compartment • Paresthesias or altered sensation distal to the affected compartment n FIGURE 8-7 Compartment Syndrome. This condition develops Management when increased pressure within a compartment causes ischemia and Compartment syndrome is a time- and pressure- subsequent necrosis. The illustration of a cross section of the lower dependent condition. The higher the compartment leg shows the anatomy and relations of the four musculofasical compartments. ■ BACK TO TABLE OF CONTENTS
160 CHAPTER 8 ■ Musculoskeletal Trauma pressure and the longer it remains elevated, the greater Assessment the degree of resulting neuromuscular damage and A thorough examination of the neurologic system resulting functional deficit. If compartment syndrome is essential in patients with musculoskeletal injury. is suspected, promptly release all constrictive dressings, Determination of neurologic impairment is important, casts, and splints applied over the affected extremity and progressive changes must be documented. and immediately obtain a surgical consultation. The only treatment for a compartment syndrome is Assessment usually demonstrates a deformity of a fasciotomy (■ FIGURE 8-8). A delay in performing a the extremity. Assessment of nerve function typi- fasciotomy may result in myoglobinuria, which may cally requires a cooperative patient. For each signi- cause decreased renal function. Immediately obtain ficant peripheral nerve, voluntary motor function surgical consultation for suspected or diagnosed and sensation must be confirmed systematically. compartment syndrome. ■ TABLE 8-3 and ■ TABLE 8-4 outline peripheral nerve assessment of the upper extremities and lower neurological injury secondary to extremities, respectively. (Also see Peripheral Nerve fracture or dislocation Assessment of Upper Extremities and Peripheral Nerve Assessment of Lower Extremities on MyATLS mobile Fractures and particularly dislocations can cause sig- app.) Muscle testing must include palpation of the nificant neurologic injury due to the anatomic rela- contracting muscle. tionship and proximity of nerves to bones and joints (e.g., sciatic nerve compression from posterior hip In most patients with multiple injuries, it is diffi- dislocation and axillary nerve injury from anterior shoul- cult to initially assess nerve function.However, der dislocation). Optimal functional outcome depends assessment must be continually repeated, especially on prompt recognition and treatment of the injury. after the patient is stabilized. Progression of neurologic findings is indicative of continued nerve compression. pitfall prevention The most important aspect of any neurologic assess- ment is to document the progression of neurologic Delayed • Maintain a high index of suspicion findings. It is also an important aspect of surgical diagnosis of for compartment syndrome in decision making. compartment any patient with a significant syndrome. musculoskeletal injury. Management Reduce and splint fracture deformities. Qualified • Be aware that compartment syn- clinicians may attempt to carefully reduce dis- drome can be difficult to recognize in locations, after which neurologic function should patients with altered mental status. be reevaluated and the limb splinted. If reduction is successful, the subsequent treating doctor • Frequently reevaluate patients with must be notified that the joint was dislocated and altered mental status for signs of successfully reduced. compartment syndrome. AB n FIGURE 8-8 Fasciotomy to Treat Compartment Syndrome. A. Intraoperative photo showing fasciotomy of upper extremity compartment syndrome secondary to crush injury. B. Postsurgical decompression of compartment syndrome of the lower leg, showing medial incision. ■ BACK TO TABLE OF CONTENTS
OTHER EXTREMITY INJURIES 161 other extremity injuries neral, lacerations require debridement and closure. If a laceration extends below the fascial level, it may require Other significant extremity injuries include contusions operative intervention to more completely debride the and lacerations, joint injuries, and fractures. wound and assess for damage to underlying structures. contusions and lacerations Contusions are usually recognized by pain, localized swelling, and tenderness. If the patient is seen early, Assess simple contusions and/or lacerations to rule contusions are treated by limiting function of the out possible vascular and/or neurologic injuries. In ge- injured part and applying cold packs. Crushing and internal degloving injuries can be subtle and must be suspected based on the mechanism of injury. With crush injury, devascularization and table 8-3 peripheral nerve assessment of upper extremities NERVE MOTOR SENSATION INJURY Ulnar Index and little finger abduction Little finger Elbow injury Median distal Thenar contraction with opposition Distal tip of index finger Wrist fracture or dislocation Median, anterior Index tip flexion None Supracondylar fracture of interosseous humerus (children) Musculocutaneous Elbow flexion Radial forearm Anterior shoulder dislocation Radial Thumb, finger metocarpo- First dorsal web space Distal humeral shaft, anterior phalangeal extension shoulder dislocation Axillary Deltoid Lateral shoulder Anterior shoulder dislocation, proximal humerus fracture table 8-4 peripheral nerve assessment of lower extremities NERVE MOTOR SENSATION INJURY Femoral Knee extension Anterior knee Pubic rami fractures Obturator Hip adduction Medial thigh Obturator ring fractures Posterior tibial Toe flexion Sole of foot Knee dislocation Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture, knee dislocation Deep peroneal Ankle/toe dorsiflexion Dorsal first to second Fibular neck fracture, web space compartment syndrome Sciatic nerve Ankle dorsiflexion or plantar flexion Foot Posterior hip dislocation Superior gluteal Hip abduction Upper buttocks Acetabular fracture Inferior gluteal Gluteus maximus hip extension Lower buttocks Acetabular fracture ■ BACK TO TABLE OF CONTENTS
162 CHAPTER 8 ■ Musculoskeletal Trauma necrosis of muscle can occur. Soft-tissue avulsion can curred and placed the limb at risk for neurovascular shear the skin from the deep fascia, allowing for the injury. Surgical consultation is usually required for significant accumulation of blood in the resulting cavity joint stabilization. (i.e., Morel-Lavallée lesion). Alternatively, the skin may be sheared from its blood supply and undergo necrosis fractures over a few days. This area may have overlying abrasions or bruised skin, which are clues to a more severe degree Fractures are defined as a break in the continuity of the of muscle damage and potential compartment or crush bone cortex. They may be associated with abnormal syndromes. These soft-tissue injuries are best evaluated motion, soft-tissue injury, bony crepitus, and pain. A by knowing the mechanism of injury and by palpating fracture can be open or closed. the specific component involved. Consider obtaining surgical consultation, as drainage or debridement may Assessment be indicated. Examination of the extremity typically demonstrates pain, swelling, deformity, tenderness, crepitus, and The risk of tetanus is increased with wounds that are abnormal motion at the fracture site. Evaluation for more than 6 hours old, contused or abraded, more than crepitus and abnormal motion is painful and may 1 cm in depth, from high-velocity missiles, due to burns increase soft-tissue damage. These maneuvers are or cold, and significantly contaminated, particularly seldom necessary to make the diagnosis and must not wounds with denervated or ischemic tissue (See be done routinely or repetitively. Be sure to periodically Tetanus Immunization.) reassess the neurovascular status of a fractured limb, particularly if a splint is in place. joint and ligament injuries X-ray films taken at right angles to one another When a joint has sustained significant ligamentous confirm the history and physical examination findings injury but is not dislocated, the injury is not usually of fracture (■ FIGURE 8-9). Depending on the patient’s limb-threatening. However, prompt diagnosis and hemodynamic status, x-ray examination may need to treatment are important to optimize limb function. be delayed until the patient is stabilized. To exclude occult dislocation and concomitant injury, x-ray films Assessment must include the joints above and below the suspected With joint injuries, the patient usually reports ab- fracture site. normal stress to the joint, for example, impact to the anterior tibia that subluxed the knee posteriorly, impact to the lateral aspect of the leg that resulted in a valgus strain to the knee, or a fall onto an outstretched arm that caused hyperextension of the elbow. Physical examination reveals tenderness throughout the affected joint. A hemarthrosis is usually present unless the joint capsule is disrupted and the bleeding diffuses into the soft tissues. Passive ligamentous testing of the affected joint reveals instability. X-ray examination is usually negative, although some small avulsion fractures from ligamentous insertions or origins may be present radiographically. Management AB Immobilize joint injuries, and serially reassess the vascular and neurologic status of the limb distal n FIGURE 8-9 X-ray films taken at right angles to one another to the injury. Knee dislocations frequently return confirm the history and physical examination findings of fracture. to near anatomic position and may not be ob- A. AP view of the distal femur. B. Lateral view of the distal femur. vious at presentation. In a patient with a multi- Satisfactory x-rays of an injured long bone should include two ligament knee injury, a dislocation may have oc- orthogonal views, and the entire bone should be visualized. Thus the images alone would be inadequate. ■ BACK TO TABLE OF CONTENTS
PAIN CONTROL 163 Management compartment syndrome. If readily available, plaster Immobilization must include the joint above and splints immobilizing the lower thigh, knee, and ankle below the fracture. After splinting, be sure to reassess are preferred. the neurologic and vascular status of the extremity. Surgical consultation is required for further treatment. ankle fractures principles of immobilization Ankle fractures may be immobilized with a well-padded splint, thereby decreasing pain while avoiding pressure Unless associated with life-threatening injuries, over bony prominences (■ FIGURE 8-10). splinting of extremity injuries can typically be accomplished during the secondary survey. However, pitfall prevention all such injuries must be splinted before a patient is transported. Assess the limb’s neurovascular status Application of traction to • Avoid use of traction before and after applying splints or realigning an extremity with a tibia/ in extremities with a fracture. fibula fracture can result in combined femur and a neurovascular injury. tibia/fibula fractures. femoral fractures • Use a long-leg posterior Femoral fractures are immobilized temporarily with splint with an additional traction splints (see ■ FIGURE 8-3; also see Traction Splint sugar-tong splint for the video on MyATLS mobile app). The traction splint’s force lower leg. is applied distally at the ankle. Proximally, the post is pushed into the gluteal crease to apply pressure to the upper extremity and hand injuries buttocks, perineum, and groin. Excessive traction can cause skin damage to the foot, ankle, and perineum. The hand may be temporarily splinted in an ana- Because neurovascular compromise can also result tomic, functional position with the wrist slightly from application of a traction splint, clinicians must dorsiflexed and the fingers gently flexed 45 degrees assess the neurovascular status of the limb before at the metacarpophalangeal joints. This position and after applying the splint. Do not apply traction typically is accomplished by gently immobilizing in patients with an ipsilateral tibia shaft fracture. Hip the hand over a large roll of gauze and using a fractures can be similarly immobilized with a traction short-arm splint. splint but are more suitably immobilized with skin traction or foam boot traction with the knee in slight The forearm and wrist are immobilized flat on padded flexion. A simple method of splinting is to bind the or pillow splints. The elbow is typically immobilized injured leg to the opposite leg. in a flexed position, either by using padded splints or by direct immobilization with respect to the body knee injuries using a sling-and-swath device. The upper arm may be immobilized by splinting it to the body or Application of a commercially available knee immo- applying a sling or swath, which can be augmented bilizer or a posterior long-leg plaster splint is effect- by a thoracobrachial bandage. Shoulder injuries are ive in maintaining comfort and stability. Do not managed by a sling-and-swath device or a hook- and- immobilize the knee in complete extension, but with loop type of dressing. approximately 10 degrees of flexion to reduce tension on the neurovascular structures. pain control tibial fractures The appropriate use of splints significantly decreases a patient’s discomfort by controlling the amount Immobilize tibial fractures to minimize pain and of motion that occurs at the injured site. If pain is further soft-tissue injury and decrease the risk of not relieved or recurs, the splint should be removed and the limb further investigated. Analgesics are indicated for patients with joint injuries and fractures. Patients who do not appear to have significant pain ■ BACK TO TABLE OF CONTENTS
164 CHAPTER 8 ■ Musculoskeletal Trauma AB n FIGURE 8-10 Splinting of an ankle fracture. Note extensive use of padding with posterior and sugartong splints. A. Posterior and sugartong plaster splints being secured in place with an elastic bandage wrap. B. Completed splint. or discomfort from a major fracture may have other table 8-5 musculoskeletal injuries: associated injuries which interfere with sensory common missed or associated injuries perception (e.g., intracranial or spinal cord lesions) or be under the influence of alcohol and/or drugs. INJURY MISSED/ASSOCIATED INJURY Effective pain relief usually requires the admin- istration of narcotics, which should be given in • Clavicular fracture • Major thoracic injury, small doses intravenously and repeated as needed. • Scapular fracture especially pulmonary Administer sedatives cautiously in patients with • Fracture and/or contusion and rib isolated extremity injuries, such as when reducing fractures a dislocation. Whenever analgesics or sedatives are dislocation of shoulder administered to an injured patient, the potential exists • Scapulothoracic for respiratory arrest. Consequently, appropriate dissociation resuscitative equipment and naloxone (Narcan) must be immediately available. • Fracture/dislocation • Brachial artery injury of elbow • Median, ulnar, and radial Regional nerve blocks play a role in pain relief and the reduction of appropriate fractures. It is essential to nerve injury assess and document any peripheral nerve injury before administering a nerve block. Always keep the risk of • Femur fracture • Femoral neck fracture compartment syndrome in mind, as this condition • Ligamentous knee injury may be masked in a patient who has undergone a • Posterior hip dislocation nerve block. • Posterior knee • Femoral fracture associated injuries dislocation • Posterior hip dislocation Because of their common mechanism, certain • Knee dislocation • Popliteal artery and musculoskeletal injuries are often associated with • Displaced tibial plateau nerve injuries other injuries that are not immediately apparent or may be missed (■ TABLE 8-5). • Calcaneal fracture • Spine injury or fracture • Fracture-dislocation of Steps to ensure recognition and management of these injuries include: talus and calcaneus • Tibial plateau fracture 1. Review the injury history, especially the mechanism of injury, to determine whether • Open fracture • 70% incidence of another injury is present. associated nonskeletal injury ■ BACK TO TABLE OF CONTENTS
CHAPTER SUMMARY 165 2. Thoroughly reexamine all extremities, with • Because potentially life-threatening special emphasis on the hands, wrists, feet, and musculoskeletal injuries can be detected during the joints above and below fractures the assessment of circulation, the team leader and dislocations. must rapidly direct the team to control external hemorrhage using sterile pressure dressings, 3. Visually examine the patient’s back, including splints, or tourniquets as appropriate. The the spine and pelvis. trauma team’s ability to work on different tasks simultaneously is particularly relevant in 4. Document open injuries and closed soft-tissue this scenario. injuries that may indicate an unstable injury. • More than one team member may be required 5. Review the x-rays obtained in the secondary to apply a traction splint, and the team leader survey to identify subtle injuries that may be may direct other assistants or specialist team associated with more obvious trauma. members (e.g., vascular and orthopedic surgeons) to assist the team. occult skeletal injuries • The team must be able to recognize limb- Not all injuries can be diagnosed during the initial threatening injuries and report these accurately assessment. Joints and bones that are covered or well- to the team leader so decisions can be made for padded within muscular areas may contain occult managing these injuries in conjunction with injuries. It can be difficult to identify nondisplaced life-threatening problems involving airway, fractures or joint ligamentous injuries, especially if the breathing, and circulation. patient is unresponsive or has other severe injuries. In fact, injuries are commonly discovered days after the • Ensure that the trauma team performs a injury incident—for example, when the patient is being complete secondary survey, so injuries are not mobilized. Therefore, it is crucial to reassess the patient overlooked. Occult injuries are particularly repeatedly and to communicate with other members common in patients with a depressed level of of the trauma team and the patient’s family about the consciousness, and the team leader should possibility of occult skeletal injuries. ensure timely reevaluation of the limbs to minimize missed injuries. pitfall prevention chapter summary Occult injuries may not • Logroll the patient and be identified during the remove all clothing 1. Musculoskeletal injuries can pose threats to both primary assessment or to ensure complete life and limb. secondary survey. evaluation and avoid missing injuries. 2. The initial assessment of musculoskeletal trauma is intended to identify those injuries that pose a • Repeat the head-to- threat to life and/or limb. Although uncommon, toe examination once life-threatening musculoskeletal injuries must the patient has been be promptly assessed and managed. A staged stabilized to identify approach to hemorrhage control is utilized by occult injuries. applying direct pressure, splints, and tourniquets. teamwork 3. Most extremity injuries are appropriately diagnosed and managed during the secondary survey. A • Musculoskeletal injuries, especially open thorough history and careful physical examination, fractures, often appear dramatic and can including completely undressing the patient, is potentially distract team members from more essential to identify musculoskeletal injuries. urgent resuscitation priorities. The team leader must ensure that team members focus on life- 4. It is essential to recognize and manage arterial threatening injuries first injuries, compartment syndrome, open fractures, crush injuries, and dislocations in a timely manner. ■ BACK TO TABLE OF CONTENTS
166 CHAPTER 8 ■ Musculoskeletal Trauma 5. Knowledge of the mechanism of injury and history 10. Kobbe P, Micansky F, Lichte P, et al. Increased of the injury-producing event can guide clinicians morbidity and mortality after bilateral femoral to suspect potential associated injuries. shaft fractures: myth or reality in the era of damage control? Injury 2013Feb;44(2):221–225. 6. Early splinting of fractures and dislocations can prevent serious complications and late sequelae. 11. Konda SR, Davidovich RI, Egol KA. Computed Careful neurovascular examination must be tomography scan to detect traumatic arthrotomies performed both prior to and after application of and identify periarticular wounds not requiring a splint or traction device. surgical intervention: an improvement over the saline load test. J Trauma 2013;27(9):498–504. Special thanks to Julie Gebhart, PA-C, Lead Orthopedic Physician Assistant, and Renn Crichlow, MD, Orthopedic 12. Kostler W, Strohm PC, Sudkamp NP. Acute Trauma Surgeon, OrthoIndy and St. Vincent Trauma compartment syndrome of the limb. Injury Center, for all their help and collaboration with this project, 2004;35(12):1221–1227. as well as provision of many of the photographs used in the chapter. 13. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the bibliography battlefield: a 4-year accumulated experience. J Trauma 2003;54(5 Suppl):S221–S225. 1. Beekley AC, Starnes BW, Sebesta JA. Lessons learned from modern military surgery. Surg Clin 14. Mabry RL. Tourniquet use on the battlefield. Mil North Am 2007;87(1):157–184, vii. Med 2006;171(5):352–356. 2. Brown CV, Rhee P, Chan L, et al. Preventing 15. Medina O, Arom GA, Yeranosian MG, et al. renal failure in patients with rhabdomyolysis: Vascular and nerve injury after knee dislocation: do bicarbonate and mannitol make a difference? a systematic review. Clin Orthop Relat Res J Trauma 2004;56:1191. 2014Oct;472(1):2984–2990. 3. Bulger EM, Snyder D, Schoelles C, et al. An 16. Mills WJ, Barei DP, McNair P. The value of the evidence-based prehospital guideline for ankle-brachial index for diagnosing arterial external hemorrhage control: American College injury after knee dislocation: a prospective study. of Surgeons Committee on Trauma. Prehospital J Trauma 2004;56:1261–1265. Emergency Care 2014;18:163–173. 17. Natsuhara KM. Yeranosian MG, Cohen JR, et 4. Clifford CC. Treating traumatic bleeding in a al. What is the frequency of vascular injury combat setting. Mil Med 2004;169(12 Suppl): after knee dislocation? Clin Orthop Relat Res 8–10, 14. 2014Sep;472(9):2615–2620. 5. Elliot GB, Johnstone AJ. Diagnosing acute 18. Ododeh M. The role of reperfusion-induced injury compartment syndrome. J Bone Joint Surg Br in the pathogenesis of the crush syndrome. N 2003;85:625–630. Engl J Med 1991;324:1417–1421. 6. German Trauma Society. Prehospital (section 19. Okike K, Bhattacharyya T. Trends in the 1). Emergency room, extremities (subsection management of open fractures. A critical analysis. 2.10). In: S3—Guideline on Treatment of Patients J Bone Joint Surg Am 2006;88:2739–2748. with Severe and Multiple Injuries. (English version AWMF-Registry No. 012/019). Berlin: German 20. Olson SA, Glasgow RR. Acute compartment Trauma Society (DGU). syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005;13(7):436–444. 7. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open 21. O’Brien CL, Menon M, Jomha NM. Controversies fractures: a new classification of type III open in the management of open fractures. Open fractures. J Trauma 1985;24:742. Orthop J 2014;8:178–184. 8. Inaba K, Siboni S, Resnick S, et al. Tourniquet 22. O’Toole RV, Lindbloom BJ, Hui E, et al. Are use for civilian extremity trauma. J Trauma bilateral femoral fractures no longer a marker 2015:79(2):232–237. for death? J Orthoped Trauma 2014 Feb;28(2): 77–81. 9. King RB, Filips D, Blitz S, et al. Evaluation of possible tourniquet systems for use in the 23. Schmitt SK, Sexton DJ, Baron EL. Treatment and Canadian Forces. J Trauma 2006;60(5):1061–1071. Prevention of Osteomyelitis Following Trauma in Adults. UpToDate. http://www.uptodate. com/contents/treatment-and-prevention-of- osteomyelitis-following-trauma-in-adults. October 29, 2015. 24. Steinhausen E, Lefering R, Tjardes T, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures ■ BACK TO TABLE OF CONTENTS
BIBLIOGRAPHY 167 in multiple trauma patients: an analysis based 28. Walters TJ, Wenke JC, Kauvar DS, et al. Effectiv- on the trauma registry of the German Trauma eness of self-applied tourniquets in human Society. J Trauma 2014;76(5):1288– 1293. volunteers. Prehosp Emerg Care 2005;9(4):416–422. 25. Tornetta P, Boes MT, Schepsis AA, et al. How effective is a saline arthrogram for wounds 29. Welling DR, Burris DG, Hutton JE, et al. A balanced around the knee? Clin Orthop Relat Res. approach to tourniquet use: lessons learned and 2008;466:432–435. relearned. J Am Coll Surg 2006;203(1):106–115. 26. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings 30. Willett K, Al-Khateeb H, Kotnis R, et al. Risk predictive of the disorder? J Orthop Trauma of mortality: the relationship with associated 2002;16(8):572–577. injuries and fracture. Treatment methods in 27. Walters TJ, Mabry RL. Issues related to the patients with unilateral or bilateral femoral shaft use of tourniquets on the battlefield. Mil Med fractures. J Trauma 2010 Aug;69(2):405–410. 2005;170(9):770–775. ■ BACK TO TABLE OF CONTENTS
9 THERMAL INJURIES The most significant difference between burns and other injuries is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury.
chapter 9 outline unique burn injuries • Chemical Burns objectives • Electrical Burns • Tar Burns introduction • Burn Patterns Indicating Abuse primary survey and resuscitation of patients patient transfer with burns • Criteria for Transfer • Transfer Procedures • Stop the Burning Process • Establish Airway Control cold injury: local tissue effects • Ensure Adequate Ventilation • Types of Cold Injury • Manage Circulation with Burn Shock Resuscitation • Management of Frostbite and Nonfreezing Cold Injuries patient assessment cold injury: systemic hypothermia • History • Body Surface Area teamwork • Depth of Burn chapter summary secondary survey and related adjuncts • Documentation bibliography • Baseline Determinations for Patients with Major Burns • Peripheral Circulation in Circumferential Extremity Burns • Gastric Tube Insertion • Narcotics, Analgesics, and Sedatives • Wound Care • Antibiotics • Tetanus OBJECTIVES After reading this chapter and comprehending the knowledge management of the patient’s injuries. components of the ATLS provider course, you will be able to: 5. Describe the unique characteristics of burn injury 1. Explain how the unique pathophysiology of burn that affect the secondary survey. injury affects the approach to patient management when compared with other traumatic injuries. 6. Describe common mechanisms of burn injuries, and explain the impact of specific mechanisms on 2. Identify the unique problems that can be management of the injured patients. encountered in the initial assessment of patients with burn injuries. 7. List the criteria for transferring patients with burn injuries to burn centers. 3. Describe how to manage the unique problems that can be encountered in the initial assessment of 8. Describe the tissue effects of cold injury and the patients with burn injuries. initial treatment of patients with tissue injury from cold exposure. 4. Estimate the extent of the patient’s burn injury, including the size and depth of the burn(s), 9. Describe the management of patients with hypothermia, and develop a prioritized plan for emergency including rewarming risks. ■■BBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 169
170 CHAPTER 9 ■ Thermal Injuries T hermal injuries are major causes of morbidity clothing. Synthetic fabrics can ignite, burn rapidly and mortality, but adherence to the basic at high temperatures, and melt into hot residue that principles of initial trauma resuscitation and continues to burn the patient. At the same time, take care the timely application of simple emergency measures to prevent overexposure and hypothermia. Recognize can help minimize their impact. The major principles that attempts made at the scene to extinguish the fire of thermal injury management include maintaining (e.g., “stop, drop, and roll”), although appropriate, a high index of suspicion for the presence of airway can lead to contamination of the burn with debris or compromise following smoke inhalation and secondary contaminated water. to burn edema; identifying and managing associated mechanical injuries; maintaining hemodynamic Exercise care when removing any clothing that was normality with volume resuscitation; controlling contaminated by chemicals. Brush any dry chemical temperature; and removing the patient from the in- powders from the wound. Caregivers also can be injured jurious environment. Clinicians also must take and should avoid direct contact with the chemical. After measures to prevent and treat the potential com- removing the powder, decontaminate the burn areas by plications of specific burn injuries. Examples include rinsing with copious amounts of warm saline irrigation rhabdomyolysis and cardiac dysrhythmias, which can or rinsing in a warm shower when the facilities are be associated with electrical burns; extremity or truncal available and the patient is able. compartment syndrome, which can occur with large burn resuscitations; and ocular injuries due to flames Once the burning process has been stopped, cover or explosions. the patient with warm, clean, dry linens to pre- vent hypothermia. The most significant difference between burns and other injuries is that the consequences of burn injury establish airway control are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, The airway can become obstructed not only from the worse the inflammation. Depending on the cause, direct injury (e.g., inhalation injury) but also from the energy transfer and resultant edema may not be the massive edema resulting from the burn injury. evident immediately; for example, flame injury is Edema is typically not present immediately, and signs more rapidly evident than most chemical injuries— of obstruction may initially be subtle until the patient an important factor in burn injury management. is in crisis. Early evaluation to determine the need for Monitor intravenous lines closely to ensure they do endotracheal intubation is essential. not become dislodged as the patient becomes more edematous. Regularly check ties securing endotracheal Factors that increase the risk for upper airway and nasogastric tubes to ensure they are not too tight, obstruction are increasing burn size and depth, burns and check that identification bands are loose or not to the head and face, inhalation injury, associated circumferentially affixed. trauma, and burns inside the mouth (■ FIGURE 9-1). Burns localized to the face and mouth cause more localized Note: Heat injuries, including heat exhaustion and heat stroke, are discussed in Appendix B: Hypothermia and Heat Injuries. primary survey and resuscitation of patients with burns Lifesaving measures for patients with burn injuries include stopping the burning process, ensuring that airway and ventilation are adequate, and managing circulation by gaining intravenous access. stop the burning process n FIGURE 9-1 Factors that increase the risk for upper airway obstruction are increasing burn size and depth, burns to the head Completely remove the patient’s clothing to stop the and face, inhalation injury, associated trauma, and burns inside burning process; however, do not peel off adherent the mouth. ■ BACK TO TABLE OF CONTENTS
PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 171 edema and pose a greater risk for airway compromise. can lead to swelling of the tissues around the airway; Because their airways are smaller, children with burn therefore, early intubation is also indicated for full- injuries are at higher risk for airway problems than thickness circumferential neck burns. their adult counterparts. pitfall prevention A history of confinement in a burning environment or early signs of airway injury on arrival in the emergency Airway obstruction • Recognize smoke inhalation department (ED) warrants evaluation of the patient’s in a patient with burn as a potential cause of airway airway and definitive management. Pharyngeal thermal injury may not be obstruction from particulate injuries can produce marked upper airway edema, and present immediately. and chemical injury. early protection of the airway is critical. The clinical manifestations of inhalation injury may be subtle and • Evaluate the patient for frequently do not appear in the first 24 hours. If the circumferential burns of provider waits for x-ray evidence of pulmonary injury the neck and chest, which or changes in blood gas determinations, airway edema can compromise the airway can preclude intubation, and a surgical airway may and gas exchange. be required. When in doubt, examine the patient’s oropharynx for signs of inflammation, mucosal injury, • Patients with inhalation soot in the pharynx, and edema, taking care not to injure injury are at risk for the area further. bronchial obstruction from secretions and Although the larynx protects the subglottic airway debris, and they may from direct thermal injury, the airway is extremely sus- require bronchoscopy. ceptible to obstruction resulting from exposure to heat. Place an adequately sized airway—preferably a size 8 American Burn Life Support (ABLS) indications for mm internal diameter (ID) early intubation include: endotracheal tube (min- imum 7.5 mm ID in adults). • Signs of airway obstruction (hoarseness, stridor, accessory respiratory muscle use, sternal ensure adequate ventilation retraction) Direct thermal injury to the lower airway is very • Extent of the burn (total body surface area rare and essentially occurs only after exposure to burn > 40%–50%) superheated steam or ignition of inhaled flammable gases. Breathing concerns arise from three general • Extensive and deep facial burns causes: hypoxia, carbon monoxide poisoning, and smoke inhalation injury. • Burns inside the mouth Hypoxia may be related to inhalation injury, poor • Significant edema or risk for edema compliance due to circumferential chest burns, or thoracic trauma unrelated to the thermal injury. In • Difficulty swallowing these situations, administer supplemental oxygen with or without intubation. • Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor Always assume carbon monoxide (CO) exposure oxygenation or ventilation in patients who were burned in enclosed areas. The diagnosis of CO poisoning is made primarily from • Decreased level of consciousness where airway a history of exposure and direct measurement of protective reflexes are impaired carboxyhemoglobin (HbCO). Patients with CO levels of less than 20% usually have no physical symptoms. • Anticipated patient transfer of large burn with Higher CO levels can result in: airway issue without qualified personnel to intubate en route • headache and nausea (20%–30%) • confusion (30%–40%) A carboxyhemoglobin level greater than 10% in • coma (40%–60%) a patient who was involved in a fire also suggests • death (>60%) inhalation injury. Transfer to a burn center is indicated for patients suspected of experiencing inhalation injury; however, if the transport time is prolonged, intubate the patient before transport. Stridor may occur late and indicates the need for immediate endotrach- eal intubation. Circumferential burns of the neck ■ BACK TO TABLE OF CONTENTS
172 CHAPTER 9 ■ Thermal Injuries Cherry-red skin color in patients with CO exposure is Products of combustion, including carbon parti- rare, and may only be seen in moribund patients. Due cles and toxic fumes, are important causes of inha- to the increased affinity of hemoglobin for CO—240 lation injury. Smoke particles settle into the distal times that of oxygen—it displaces oxygen from the bronchioles, leading to damage and death of the hemoglobin molecule and shifts the oxyhemoglobin mucosal cells. Damage to the airways then leads to dissociation curve to the left. CO dissociates very slowly, an increased inflammatory response, which in turn and its half-life is approximately 4 hours when the leads to an increase in capillary leakage, resulting in patient is breathing room air. Because the half-life increased fluid requirements and an oxygen diffusion of HbCO can be reduced to 40 minutes by breathing defect. Furthermore, necrotic cells tend to slough 100% oxygen, any patient in whom CO exposure could and obstruct the airways. Diminished clearance of have occurred should receive high-flow (100%) oxygen the airway produces plugging, which results in an via a non-rebreathing mask. increased risk of pneumonia. Not only is the care of It is important to place an appropriately sized patients with inhalation injury more complex, but endotracheal tube (ETT), as placing a tube that is too their mortality is doubled compared with other burn small will make ventilation, clearing of secretions, and injured individuals. bronchoscopy difficult or impossible. Efforts should be made to use endotracheal tubes at least 7.5 mm ID The American Burn Association has identified two or larger in an adult and size 4.5 mm ID ETT in a child. requirements for the diagnosis of smoke inhalation Arterial blood gas determinations should be obtained injury: exposure to a combustible agent and signs as a baseline for evaluating a patient’s pulmonary of exposure to smoke in the lower airway, below the status. However, measurements of arterial PaaCOO2 vocal cords, seen on bronchoscopy. The likelihood do not reliably predict CO poisoning, because of smoke inhalation injury is much higher when the partial pressure of only 1 mm Hg results in an HbCO injury occurs within an enclosed place and in cases of level of 40% or greater. Therefore, baseline HbCO prolonged exposure. levels should be obtained, and 100% oxygen should be administered. If a carboxyhemoglobin level is As a baseline for evaluating the pulmonary status not available and the patient has been involved in a of a patient with smoke inhalation injury, clinicians closed-space fire, empiric treatment with 100% oxygen should obtain a chest x-ray and arterial blood gas for 4 to 6 hours is reasonable as an effective treatment determination. These values may deteriorate over time; for CO poisoning and has few disadvantages. An normal values on admission do not exclude inhalation exception is a patient with chronic obstructive lung injury. The treatment of smoke inhalation injury is disease, who should be monitored very closely when supportive. A patient with a high likelihood of smoke 100% oxygen is administered. inhalation injury associated with a significant burn (i.e., Pulse oximetry cannot be relied on to rule out carbon greater than 20% total body surface area [TBSA] in an monoxide poisoning, as most oximeters cannot adult, or greater than 10% TBSA in patients less than distinguish oxyhemoglobin from carboxyhemoglo- 10 or greater than 50 years of age) should be intubated. bin. In a patient with CO poisoning, the oximeter If the patient’s hemodynamic condition permits and may read 98% to 100% saturation and not reflect the spinal injury has been excluded, elevate the patient’s true oxygen saturation of the patient, which must be head and chest by 30 degrees to help reduce neck and obtained from the arterial blood gas. A discrepancy chest wall edema. If a full-thickness burn of the anterior between the arterial blood gas and the oximeter may and lateral chest wall leads to severe restriction of chest be explained by the presence of carboxyhemoglobin wall motion, even in the absence of a circumferential or an inadvertent venous sample. burn, chest wall escharotomy may be required. Cyanide inhalation from the products of combustion is possible in burns occurring in confined spaces, manage circulation with burn in which case the clinician should consult with a shock resuscitation burn or poison control center. A sign of potential cyanide toxicity is persistent profound unexplained Evaluation of circulating blood volume is often difficult metabolic acidosis. in severely burned patients, who also may have There is no role for hyperbaric oxygen therapy in the accompanying injuries that contribute to hypovole- primary resuscitation of a patient with critical burn mic shock and further complicate the clinical pic- injury. Once the principles of ATLS are followed to ture. Treat shock according to the resuscitation princi- stabilize the patient, consult with the local burn center ples outlined in Chapter 3: Shock, with the goal of for further guidance regarding whether hyperbaric maintaining end organ perfusion. In contrast to resus- oxygen would benefit the patient. citation for other types of trauma in which fluid deficit is typically secondary to hemorrhagic losses, burn ■ BACK TO TABLE OF CONTENTS
PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 173 resuscitation is required to replace the ongoing losses pitfall prevention from capillary leak due to inflammation. Therefore, clinicians should provide burn resuscitation fluids for Intravenous catheters • Remember that edema takes deep partial and full-thickness burns larger than 20% and endotracheal time to develop. TBSA, taking care not to over-resuscitate (■ FIGURE 9-2). tubes can become dislodged after • Use long IV catheters to After establishing airway patency and identifying resuscitation. account for the inevitable and treating life-threatening injuries, immediately swelling that will occur. establish intravenous access with two large-caliber (at least 18-gauge) intravenous lines in a peripheral • Do not cut endotracheal vein. If the extent of the burn precludes placing the tubes, and regularly assess catheter through unburned skin, place the IV through their positioning. the burned skin into an accessible vein. The upper extremities are preferable to the lower extremities as using the traditional Parkland formula. The current a site for venous access because of the increased risk consensus guidelines state that fluid resuscitation of phlebitis and septic phlebitis when the saphenous should begin at 2 ml of lactated Ringer’s x patient’s body veins are used for venous access. If peripheral IVs weight in kg x % TBSA for second- and third-degree burns. cannot be obtained, consider central venous access or intraosseous infusion. The calculated fluid volume is initiated in the following manner: one-half of the total fluid is provided Begin infusion with a warmed isotonic crystalloid in the first 8 hours after the burn injury (for example, solution, preferably lactated Ringer’s solution. Be a 100-kg man with 80% TBSA burns requires 2 × 80 × aware that resulting edema can dislodge peripheral 100 = 16,000 mL in 24 hours). One-half of that volume intravenous lines. Consider placing longer catheters (8,000 mL) should be provided in the first 8 hours, so in larger burns. the patient should be started at a rate of 1000 mL/hr. The remaining one-half of the total fluid is administered Blood pressure measurements can be difficult to during the subsequent 16 hours. obtain and may be unreliable in patients with severe burn injuries. Insert an indwelling urinary catheter It is important to understand that formulas provide a in all patients receiving burn resuscitation fluids, and starting target rate; subsequently, the amount of fluids monitor urine output to assess perfusion. Osmotic provided should be adjusted based on a urine output diuresis (e.g., glycosuria or use of mannitol) can target of 0.5 mL/kg/hr for adults and 1 mL/kg/hr for interfere with the accuracy of urine output as a marker children weighing less than 30 kg. In adults, urine of perfusion by overestimating perfusion. output should be maintained between 30 and 50 cc/ hr to minimize potential over-resuscitation. The initial fluid rate used for burn resuscitation has been updated by the American Burn Association The actual fluid rate that a patient requires depends to reflect concerns about over-resuscitation when on the severity of injury, because larger and deeper burns require proportionately more fluid. Inhalation n FIGURE 9-2 Patients with burns require resuscitation with injury also increases the amount of burn resuscitation Ringer's lactate solution starting at 2 mL per kilogram of body required. If the initial resuscitation rate fails to produce weight per percentage BSA of partial-thickness and full-thickness the target urine output, increase the fluid rate until the burns during the first 24 hours to maintain adequate perfusion, urine output goal is met. However, do not precipitously titrated hourly. decrease the IV rate by one-half at 8 hours; rather, base the reduction in IV fluid rate on urine output and titrate to the lower urine output rate. Fluid boluses should be avoided unless the patient is hypotensive. Low urine output is best treated with titration of the fluid rate. Resuscitation of pediatric burn patients (■ FIGURE 9-3) should begin at 3 mL/kg/% TBSA; this balances a higher resuscitation volume requirement due to larger surface area per unit body mass with the smaller pediatric intravascular volume, increasing risk for volume overload. Very small children (i.e., < 30 kg), should receive maintenance fluids of D5LR (5% dextrose in Lactated Ringers), in addition to the burn resuscitation fluid. ■ TABLE 9-1 outlines the adjusted fluid rates and target urine output by burn type. ■ BACK TO TABLE OF CONTENTS
174 CHAPTER 9 ■ Thermal Injuries pitfall prevention Under- or over- • Titrate fluid resuscitation resuscitation of burn to the patient’s physiologic patients. response, adjusting the fluid rate up or down based n FIGURE 9-3 Resuscitation of pediatric burn patients must balance on urine output. a higher resuscitation volume requirement due to larger surface area per unit body mass with the smaller pediatric intravascular • Recognize factors that volume, which increases the risk for volume overload. affect the volume of resuscitation and urine It is important to understand that under-resuscitation output, such as inhalation results in hypoperfusion and end organ injury. Over- injury, age of patient, resuscitation results in increased edema, which can renal failure, diuretics, lead to complications, such as burn depth progression and alcohol. or abdominal and extremity compartment syndrome. The goal of resuscitation is to maintain the fine balance • Tachycardia is a poor of adequate perfusion as indicated by urine output. marker for resuscitation in the burn patient. Use Cardiac dysrhythmias may be the first sign of hypoxia other parameters to discern and electrolyte or acid-base abnormalities; therefore, physiologic response. electrocardiography (ECG) should be performed for cardiac rhythm disturbances. Persistent acidemia in including under-resuscitation or infusion of large patients with burn injuries may be multifactorial, volumes of saline for resuscitation. patient assessment In addition to a detailed AMPLE history, it is important to estimate the size of the body surface area burned and the depth of the burn injury. table 9-1 burn resuscitation fluid rates and target urine output by burn type and age CATEGORY OF BURN AGE AND WEIGHT ADJUSTED FLUID RATES URINE OUTPUT Flame or Scald Adults and older 2 ml LR x kg x % TBSA 0.5 ml/kg/hr children (≥14 years old) 30–50 ml/hr Children (<14 years old) 3 ml LR x kg x % TBSA 1 ml/kg/hr Infants and young 3 ml LR x kg x % TBSA 1 ml/kg/hr children (≤30kg) Plus a sugar-containing solution at maintenance rate Electrical Injury All ages 4 ml LR x kg x % TBSA until urine clears 1-1.5 ml/kg/hr until urine clears LR, lactated Ringer’s solution; TBSA, total body surface area ■ BACK TO TABLE OF CONTENTS
PATIENT ASSESSMENT 175 history known allergies and/or drug sensitivities. Check the status of the patient’s tetanus immunization. Be aware The injury history is extremely valuable when treating that some individuals attempt suicide through self- patients with burns. Burn survivors can sustain immolation. Match the patient history to the burn associated injuries while attempting to escape a fire, pattern; if the account of the injury is suspicious, and explosions can result in internal injuries (e.g., consider the possibility of abuse in both children central nervous system, myocardial, pulmonary, and and adults. abdominal injuries) and fractures. It is essential to establish the time of the burn injury. Burns sustained body surface area within an enclosed space suggest the potential for inhalation injury and anoxic brain injury when there The rule of nines is a practical guide for determining the is an associated loss of consciousness. extent of a burn using calculations based on areas of partial- and full-thickness burns (■ FIGURE 9-4). The adult The history, whether obtained from the patient or body configuration is divided into anatomic regions other individuals, should include a brief survey of preexisting illnesses and drug therapy, as well as any Pediatric 9% 9% 4.5% 4.5% 4.5% 18% 4.5% 13% 2.5% 2.5% 7% 7% 7% 7% Adult 4.5% 4.5% n FIGURE 9-4 Rule of Nines. This practical guide is used to evaluate the severity of burns and determine fluid management. The adult body is generally divided into surface areas of 9% each and/or fractions or multiples of 9%. 18% 18% 4.5% 4.5% 4.5% 4.5% 1% 9% 9% 9% 9% ■ BACKSAdtuTvdaOenncteTCdAoTuBrrasLuemEMaOaLniFufeaClS, u8OpepNortTfoErNDoTcStors American College of Surgeons Figure# 09.01
176 CHAPTER 9 ■ Thermal Injuries that represent multiples of 9%. BSA distribution differs pliable and elastic it becomes; therefore these areas considerably for children, because a young child’s head may appear to be less swollen. represents a larger proportion of the surface area, and the lower extremities represent a smaller proportion secondary survey and than an adult’s. The palmar surface (including the related adjuncts fingers) of the patient’s hand represents approximately 1% of the patient’s body surface. The rule of nines helps Key aspects of the secondary survey and its related estimate the extent of burns with irregular outlines or adjuncts include documentation, baseline trauma distribution and is the preferred tool for calculating bloodwork, including carboxyhemoglobin levels, and documenting the extent of a burn injury. and x-rays, maintenance of peripheral circulation in circumferential extremity burns, gastric tube insertion, pitfall prevention narcotic analgesics and sedatives, wound care, and tetanus immunization. Overestimating or • Do not include superficial burns underestimating in size estimation. documentation burn size • Use the rule of nines, recogniz- A flow sheet or other report that outlines the patient’s ing that children have a pro- treatment, including the amount of fluid given and a portionately larger head than pictorial diagram of the burn area and depth, should adults do. be initiated when the patient is admitted to the ED. This flow sheet should accompany the patient when • For irregular or oddly sized transferred to the burn unit. burns, use the patient’s palm and fingers to represent 1% BSA. • Remember to logroll the patient to assess their posterior aspect. depth of burn baseline determinations for patients with major burns The depth of burn is important in evaluating the severity of a burn, planning for wound care, and predicting Obtain blood samples for a complete blood count functional and cosmetic results. (CBC), type and crossmatch/screen, an arterial blood gas with HbCO (carboxyhemoglobin), serum glucose, Superficial (first-degree) burns (e.g., sunburn) are electrolytes, and pregnancy test in all females of characterized by erythema and pain, and they do childbearing age. Obtain a chest x-ray in patients not blister. These burns are not life threatening and who are intubated or suspected of having smoke generally do not require intravenous fluid replacement, inhalation injury, and repeat films as necessary. because the epidermis remains intact. This type of Other x-rays may be indicated for appraisal of burn is not discussed further in this chapter and is not associated injuries. included in the assessment of burn size. peripheral circulation in Partial-thickness burns are characterized as either circumferential extremity burns superficial partial thickness or deep partial thickness. Superficial partial-thickness burns are moist, painful- The goal of assessing peripheral circulation in a patient ly hypersensitive (even to air current), potentially with burns is to rule out compartment syndrome. blistered, homogenously pink, and blanch to touch Compartment syndrome results from an increase in (■ FIGURE 9-5 A and B). Deep partial-thickness burns pressure inside a compartment that interferes with are drier, less painful, potentially blistered, red or perfusion to the structures within that compartment. mottled in appearance, and do not blanch to touch In burns, this condition results from the combination (■ FIGURE 9-5 C). of decreased skin elasticity and increased edema in the soft tissue. In extremities, the main concern is Full-thickness burns usually appear leathery (■ FIGURE perfusion to the muscle within the compartment. Al- 9-5 D). The skin may appear translucent or waxy white. though a compartment pressure greater than systolic The surface is painless to light touch or pinprick and blood pressure is required to lose a pulse distal generally dry. Once the epidermis is removed, the underlying dermis may be red initially, but it does not blanch with pressure. This dermis is also usually dry and does not weep. The deeper the burn, the less ■ BACK TO TABLE OF CONTENTS
SECONDARY SURVEY AND RELATED ADJUNCTS 177 A C BD n FIGURE 9-5 Depth of Burns. A. Schematic of superficial partial-thickness burn injury. B. Schematic of deep partial-thickness burn. C. Photograph of deep partial-thickness burn. D. Photograph of full-thickness burn. to the burn, a pressure of > 30 mm Hg within the • Paresthesias or altered sensation distal to the compartment can lead to muscle necrosis. Once the affected compartment pulse is gone, it may be too late to save the muscle. Thus, clinicians must be aware of the signs and symptoms of A high index of suspicion is necessary when patients compartment syndrome: are unable to cooperate with an exam. • Pain greater than expected and out of Compartment syndromes may also present with proportion to the stimulus or injury circumferential chest and abdominal burns, leading to increased peak inspiratory pressures or abdominal • Pain on passive stretch of the affected muscle compartment syndrome. Chest and abdominal escha- • Tense swelling of the affected compartment rotomies performed along the anterior axillary lines with a cross-incision at the clavicular line and the ■ BACK TO TABLE OF CONTENTS
178 CHAPTER 9 ■ Thermal Injuries junction of the thorax and abdomen usually relieve wound care the problem. Partial-thickness burns are painful when air currents To maintain peripheral circulation in patients with pass over the burned surface, so gently covering the circumferential extremity burns, the clinician should: burn with clean sheets decreases the pain and deflects air currents. Do not break blisters or apply an antiseptic • Remove all jewelry and identification or allergy agent. Remove any previously applied medication bands on the patient’s extremities. before using antibacterial topical agents. Application of cold compresses can cause hypothermia. Do not • Assess the status of distal circulation, checking apply cold water to a patient with extensive burns (i.e., for cyanosis, impaired capillary refill, and > 10% TBSA). A fresh burn is a clean area that must progressive neurologic signs such as paresthesia be protected from contamination. When necessary, and deep-tissue pain. Assessment of peripheral clean a dirty wound with sterile saline. Ensure that pulses in patients with burns is best performed all individuals who come into contact with the wound with a Doppler ultrasonic flow meter. wear gloves and a gown, and minimize the number of caregivers within the patient’s environment without • Relieve circulatory compromise in a circumfer- protective gear. entially burned limb by escharotomy, always with surgical consultation. Escharotomies usually are pitfall prevention not needed within the first 6 hours of a burn injury. Patient develops deep- • Remember that edema • Although fasciotomy is seldom required, it may tissue injury from takes time to develop. be necessary to restore circulation in patients constricting dressings with associated skeletal trauma, crush injury, and ties. • Reassess or avoid or high-voltage electrical injury. circumferential ties Patient develops deep- and dressings. • Although standard escharotomy diagrams are tissue injury from generally followed, always attempt to incise constricting burn eschar. • Remove constricting the skin through the burned, not the unburned rings and clothing early. skin (if unburned skin is present), as the burned skin will likely be debrided by the burn center. • Recognize that burned skin is not elastic. gastric tube insertion Circumferential burns may require Insert a gastric tube and attach it to a suction setup if escharotomies. the patient experiences nausea, vomiting, or abdomin- al distention, or when a patient’s burns involve more antibiotics than 20% total BSA. To prevent vomiting and possible aspiration in patients with nausea, vomiting, or There is no indication for prophylactic antibiotics in abdominal distention, or when a patient’s burns involve the early postburn period. Reserve use of antibiotics more than 20% total BSA, insert a gastric tube and for the treatment of infection. ensure it is functioning before transferring the patient. tetanus narcotics, analgesics, and sedatives Determination of the patient’s tetanus immunization Severely burned patients may be restless and anxious status and initiation of appropriate management from hypoxemia or hypovolemia rather than pain. is very important. (See Tetanus Immunization.) Consequently, manage hypoxemia and inadequate fluid resuscitation before administering narcotic unique burn injuries analgesics or sedatives, which can mask the signs of hypoxemia and hypovolemia. Narcotic analgesics Although the majority of burn injuries are thermal, and sedatives should be administered in small, frequent there are other causes of burn injury that warrant special doses by the intravenous route only. Remember that simply covering the wound will decrease the pain. ■ BACK TO TABLE OF CONTENTS
UNIQUE BURN INJURIES 179 consideration, including chemical, electrical, and tar small-caliber cannula can be fixed in the palpebral burns, as well as burn patterns that indicate abuse. sulcus for irrigation. Certain chemical burns (such as hydrofluoric acid burns) require specialized burn unit chemical burns consultation. It is important to ascertain the nature of the chemical and if possible obtain a copy of the Chemical injury can result from exposure to acids, Material Safety Data Sheet to address any systemic alkalies, and petroleum products. Acidic burns cause a toxicity that may result. Providers must also take care to coagulation necrosis of the surrounding tissue, which protect themselves from inadvertent exposure during impedes the penetration of the acid to some extent. the decontamination process. Alkali burns are generally more serious than acid burns, as the alkali penetrates more deeply by liquefaction electrical burns necrosis of the tissue. Electrical burns result when a source of electrical Rapid removal of the chemical and immediate power makes contact with a patient, and current is attention to wound care are essential. Chemical transmitted through the body. The body can also serve burns are influenced by the duration of contact, as a volume conductor of electrical energy, and the concentration of the chemical, and amount of the agent. heat generated results in thermal injury to tissue. If dry powder is still present on the skin, brush it away Different rates of heat loss from superficial and deep before irrigating with water. Otherwise, immediately tissues allow for relatively normal overlying skin to flush away the chemical with large amounts of warmed coexist with deep-muscle necrosis. Therefore, electrical water, for at least 20 to 30 minutes, using a shower burns frequently are more serious than they appear on or hose (■ FIGURE 9-6). Alkali burns require longer the body surface, and extremities, particularly digits, irrigation. Neutralizing agents offer no advantage over are especially at risk. In addition, the current travels water lavage, because reaction with the neutralizing inside blood vessels and nerves and can cause local agent can itself produce heat and cause further tissue thrombosis and nerve injury. Severe electrical injuries damage. Alkali burns to the eye require continuous usually result in contracture of the affected extremity. irrigation during the first 8 hours after the burn. A A clenched hand with a small electrical entrance wound should alert the clinician that a deep soft-tissue pitfall prevention injury is likely much more extensive than is visible to the naked eye (■ FIGURE 9-7). Patients with severe Patient presents with • Obtain the manu- electrical injuries frequently require fasciotomies and chemical burn and facturer’s Material Safety should be transferred to burn centers early in their exposure to unfamiliar Data Sheet or contact a course of treatment. compound. poison center to identify potential toxicities. n FIGURE 9-6 Chemical Burn. Immediately flush away the chemical n FIGURE 9-7 Electrical Burn. A clenched hand with a small with large amounts of water, continuing for at least 20 to 30 minutes. electrical entrance wound should alert the clinician that a deep soft-tissue injury is likely much more extensive than is visible to the naked eye. This patient has received a volar forearm fasciotomy to decompress the muscle. ■ BACK TO TABLE OF CONTENTS
180 CHAPTER 9 ■ Thermal Injuries Immediate treatment of a patient with a significant molten tar can be very high—up to 450°F (232°C)— electrical burn includes establishing an airway and if it is fresh from the melting pot. A complicating ensuring adequate oxygenation and ventilation, factor is adherence of the tar to skin and infiltration placing an intravenous line in an uninvolved extremity, into clothing, resulting in continued transfer of heat. ECG monitoring, and placing an indwelling bladder Treatment includes rapid cooling of the tar and care catheter. Electricity can cause cardiac arrhythmias that to avoid further trauma while removing the tar. A may produce cardiac arrest. Prolonged monitoring is number of methods are reported in the literature; reserved for patients who demonstrate injury from the the simplest is use of mineral oil to dissolve the tar. burn, loss of consciousness, exposure to high voltage The oil is inert, safe on injured skin, and available in (>1,000 volts) or cardiac rhythm abnormalities or large quantities. arrhythmias on early evaluation. burn patterns indicating abuse Because electricity causes forced contraction of muscles, clinicians need to examine the patient for It is important for clinicians to maintain awareness associated skeletal and muscular damage, including that intentional burn injury can occur in both children the possibility of fracture of the spine. Rhabdomyolysis and adults. Patients who are unable to control their from the electricity traveling through muscle results environment, such as the very young and the very in myoglobin release, which can cause acute renal old, are particularly vulnerable to abuse and neglect. failure. Do not wait for laboratory confirmation before Circular burns and burns with clear edges and unique instituting therapy for myoglobinuria. If the patient’s patterns should arouse suspicion; they may reflect a urine is dark red, assume that hemochromogens are cigarette or other hot object (e.g., an iron) being held in the urine. ABA consensus formula guidelines are against the patient. Burns on the soles of a child’s to start resuscitation for electrical burn injury at 4 feet usually suggest that the child was placed into hot mL/kg/%TBSA to ensure a urinary output of 100 water versus having hot water fall on him or her, as mL/hr in adults and 1–1.5 mL/kg/hr in children contact with a cold bathtub can protect the bottom of weighing less than 30 kg. Once the urine is clear of the foot. A burn to the posterior aspect of the lower pigmentation, titrate the IV fluid down to ensure a extremities and buttocks may be seen in an abused standard urine output of 0.5cc/kg/hr. Consult a local elder patient who has been placed in a bathtub with burn unit before initiating a bicarbonate infusion or hot water in it. Old burn injuries in the setting of a using mannitol. new traumatic injury such as a fracture should also raise suspicion for abuse. Above all, the mechanism tar burns and pattern of injury should match the history of the injury. In industrial settings, individuals can sustain injuries secondary to hot tar or asphalt. The temperature of patient tr ansfer pitfall prevention The criteria for transfer of patients to burn centers has been developed by the American Burn Association. Patient with an • Remember, with electrical burns, electrical burn that muscle injury can occur with criteria for transfer develops acute few outward signs of injury. renal failure. The following types of burn injuries typically require • Test urine for hemochromogen, transfer to a burn center: and administer proper volume to ensure adequate urine output. 1. Partial-thickness burns on greater than 10% TBSA. • Repeatedly assess the patient for the development of 2. Burns involving the face, hands, feet, genitalia, compartment syndrome, perineum, and major joints recognizing that electrical burns may need fasciotomies. 3. Third-degree burns in any age group 4. Electrical burns, including lightning injury • Patients with electrical injuries may develop cardiac arrhythmias and should have a 12-lead ECG and continuous monitoring. ■ BACK TO TABLE OF CONTENTS
COLD INJURY: LOCAL TISSUE EFFECTS 181 5. Chemical burns pitfall prevention 6. Inhalation injury 7. Burn injury in patients with preexisting medical Patient loses airway • Reassess airway frequently during transfer. before transfer. disorders that could complicate management, prolong recovery, or affect mortality (e.g., • When the patient has risk diabetes, renal failure) factors for inhalation injury 8. Any patient with burns and concomitant trauma or has received significant (e.g., fractures) in which the burn injury poses amounts of resuscitation the greatest risk of morbidity or mortality. fluid, contact the receiving In such cases, if the trauma poses the greater facility to discuss intu- immediate risk, the patient may be initially bation before transfer. stabilized in a trauma center before being transferred to a burn unit. Physician judgment Patient experiences • Provide adequate is necessary in such situations and should be severe pain with analgesia before considered in concert with the regional medical dressing change. manipulating burns. control plan and triage protocols. 9. Burned children in hospitals without qualified • Use non-adherent personnel or equipment for the care of children dressings or burn sheets 10. Burn injury in patients who will require special to protect burn from con- social, emotional, or rehabilitative intervention tamination before transfer. Because these criteria are so comprehensive, cli- The receiving hospital • Ensure that appropriate nicians may elect to consult with a burn center is unable to discern the information is relayed and determine a mutually agreeable plan other burn wound size from by using transfer forms than transfer. For example, in the case of a partial- the documentation. or checklist. thickness hand or face burn, if adequate wound care can be taught and oral pain control tolerated, follow- The receiving hospital is • Ensure that the flow up at an outpatient burn clinic can avoid the costs of unable to discern the sheets documenting IV immediate transfer to a burn center. amount of fluid resus- fluids and urinary output citation provided from are sent with the patient. the documentation. transfer procedures types of cold injury Transfer of any patient must be coordinated with the Two types of cold injury are seen in trauma patients: burn center staff. All pertinent information regarding frostbite and nonfreezing injury. test results, vital signs, fluids administered, and urinary output should be documented on the burn/trauma Frostbite flow sheet that is sent with the patient, along with any Damage from frostbite can be due to freezing of tissue, other information deemed important by the referring ice crystal formation causing cell membrane injury, and receiving doctors. microvascular occlusion, and subsequent tissue anoxia (■ FIGURE 9-8). Some of the tissue damage also can result cold injury: local tissue from reperfusion injury that occurs on rewarming. effects Frostbite is classified into first-degree, second-degree, third-degree, and fourth-degree according to depth The severity of cold injury depends on temperature, of involvement. duration of exposure, environmental conditions, amount of protective clothing, and the patient’s gene- 1. First-degree frostbite: Hyperemia and edema are ral state of health. Lower temperatures, immobilizat- present without skin necrosis. ion, prolonged exposure, moisture, the presence of peripheral vascular disease, and open wounds all 2. Second-degree frostbite: Large, clear vesicle increase the severity of the injury. formation accompanies the hyperemia and edema with partial-thickness skin necrosis. ■ BACK TO TABLE OF CONTENTS
182 CHAPTER 9 ■ Thermal Injuries local infection, cellulitis, lymphangitis, and gangrene can occur. Proper attention to foot hygiene can prevent the occurrence of most such complications. n FIGURE 9-8 Frostbite. Frostbite is due to freezing of tissue with management of frostbite and intracellular ice crystal formation, microvascular occlusion, and nonfreezing cold injuries subsequent tissue anoxia. Treatment should begin immediately to decrease the 3. Third-degree frostbite: Full-thickness and duration of tissue freezing. Do not attempt rewarming subcutaneous tissue necrosis occurs, commonly if there is a risk of refreezing. Replace constricting, with hemorrhagic vesicle formation. damp clothing with warm blankets, and give the patient hot fluids by mouth, if he or she is able to drink. Place 4. Fourth-degree frostbite: Full-thickness skin the injured part in circulating water at a constant necrosis occurs, including muscle and bone with 40°C (104°F) until pink color and perfusion return later necrosis. (usually within 20 to 30 minutes). This treatment is best accomplished in an inpatient setting in a large tank, Although the affected body part is typically hard, cold, such as a whirlpool tank, or by placing the injured limb white, and numb initially, the appearance of the lesion into a bucket with warm water running in. Excessive changes during the course of treatment as the area dry heat can cause a burn injury, as the limb is usually warms up and becomes perfused. The initial treatment insensate. Do not rub or massage the area. Rewarming regimen applies to all degrees of insult, and the initial can be extremely painful, and adequate analgesics classification is often not prognostically accurate. The (intravenous narcotics) are essential. Warming of final surgical management of frostbite depends on large areas can result in reperfusion syndrome, with the level of demarcation of the perfused tissue. This acidosis, hyperkalemia, and local swelling; therefore, demarcation may take from weeks to months to reach monitor the patient’s cardiac status and peripheral a final stage. perfusion during rewarming. Nonfreezing Injury Local Wound Care of Frostbite Nonfreezing injury is due to microvascular endothelial The goal of wound care for frostbite is to preserve damage, stasis, and vascular occlusion. Trench foot or damaged tissue by preventing infection, avoiding cold immersion foot (or hand) describes a nonfreezing opening uninfected vesicles, and elevating the injured injury of the hands or feet—typically in soldiers, sailors, area. Protect the affected tissue by a tent or cradle, and fishermen, and the homeless—resulting from long- avoid pressure to the injured tissue. term exposure to wet conditions and temperatures just above freezing (1.6°C to 10°C, or 35°F to 50°F). When treating hypothermic patients, it is important Although the entire foot can appear black, deep- to recognize the differences between passive and active tissue destruction may not be present. Alternating rewarming. Passive rewarming involves placing the arterial vasospasm and vasodilation occur, with the patient in an environment that reduces heat loss (e.g., affected tissue first cold and numb, and then progress using dry clothing and blankets), and relies on the to hyperemia in 24 to 48 hours. With hyperemia comes patient’s intrinsic thermoregulatory mechanism to intense, painful burning and dysesthesia, as well as generate heat and raise body temperature. This method tissue damage characterized by edema, blistering, is used for mild hypothermia. Active rewarming redness, ecchymosis, and ulcerations. Complications of involves supplying additional sources of heat energy to the patient (e.g., warmed IV solution, warmed packs to areas of high vascular flow such as the groin and axilla, and initiating circulatory bypass). Active rewarming is used for patients with moderate and severe hypothermia. Only rarely is fluid loss massive enough to require resuscitation with intravenous fluids, although patients may be dehydrated. Tetanus prophylaxis depends on the patient’s tetanus immunization status. Systemic antibiotics are not indicated prophylactically, but are ■ BACK TO TABLE OF CONTENTS
CHAPTER SUMMARY 183 reserved for identified infections. Keep the wounds core temperature below 32°C (89.6°F). Hypothermia is clean, and leave uninfected nonhemmorhagic blisters common in severely injured individuals, but further loss intact for 7 to 10 days to provide a sterile biologic of core temperature can be limited by administering dressing to protect underlying epithelialization. only warmed intravenous fluids and blood, judiciously Tobacco, nicotine, and other vasoconstrictive agents exposing the patient, and maintaining a warm must be withheld. Instruct the patient to minimize environment. Avoid iatrogenic hypothermia during weight bearing until edema is resolved. exposure and fluid administration, as hypothermia can worsen coagulopathy and affect organ function. Numerous adjuvants have been attempted in an effort to restore blood supply to cold-injured tissue. The signs of hypothermia and its treatment are Unfortunately, most are ineffective. Sympathetic explained in more detail in Appendix B: Hypothermia blockade (e.g., sympathectomy or drugs) and vaso- and Heat Injuries. dilating agents have generally not proven helpful in altering the progression of acute cold injury. Heparin teamwork and hyperbaric oxygen also have failed to demonstrate substantial treatment benefit. Retrospective case series The team leader must: have suggested that thrombolytic agents may show some promise, but only when thrombolytic therapy was • Ensure that the trauma team recognizes the administered within 23 hours of the frostbite injury. unique aspects of applying the ATLS principles to treating burn-injured patients. Occasionally patients arrive at the ED several days after suffering frostbite, presenting with black, clearly • Help the team recognize the importance of dead toes, fingers, hands, or feet. In this circumstance, limiting exposure to minimize hypothermia in rewarming of the tissue is not necessary. the patient and infection of the burn. With all cold injuries, estimations of depth of injury • Encourage the trauma team to communicate and extent of tissue damage are not usually accurate early and regularly regarding concerns until demarcation is evident. This often requires about the challenges of resuscitating a burn- several weeks or months of observation. Dress these injured patient (e.g., IV access and need for wounds regularly with a local topical antiseptic to escharotomies). help prevent bacterial colonization, and debride them once demarcation between live and dead tissue has developed. Early surgical debridement or amputation is seldom necessary, unless infection occurs. cold injury: systemic chapter summary hypothermia 1. Burn injuries are unique; burn inflammation/ede- Trauma patients are susceptible to hypothermia, ma may not be immediately evident and requires and any degree of hypothermia in them can be comprehension of the underlying pathophysiology. detrimental. Hypothermia is any core temperature below 36°C (96.8°F), and severe hypothermia is any 2. Immediate lifesaving measures for patients with burn injury include stopping the burn process, pitfall prevention recognizing inhalation injury and assuring an adequate airway, oxygenation and ventilation, Patient becomes • Remember, thermoregulation and rapidly instituting intravenous fluid therapy. hypothermic. is difficult in patients with burn injuries. 3. Fluid resuscitation is needed to maintain perfusion in face of the ongoing fluid loss from • If irrigating the burns, use warmed inflammation. The inflammatory response that saline. drives the circulatory needs is directly related to the size and depth of the burn. Only partial and full • Warm the ambient temperature. thickness burns are included in calculating burn • Use heating lamps and warming size. The rule of nines is a useful and practical guide to determine the size of the burn, with children blankets to rewarm the patient. having proportionately larger heads. • Use warmed IV fluids. ■ BACK TO TABLE OF CONTENTS
184 CHAPTER 9 ■ Thermal Injuries 4. Attention must be paid to special problems unique 7. Gentilello LM, Cobean RA, Offner PJ, et al. to thermal injuries. Carbon monoxide poisoning Continuous arteriovenous rewarming: rapid should be suspected and identified. Circumferential reversal of hypothermia in critically ill patients. burns may require escharotomy. J Trauma 1992;32(3):316–327. 5. Nonthermal causes of burn injury should be 8. Gonzaga T, Jenebzadeh K, Anderson CP, recognized and appropriate treatment started. Mohr WJ, Endorf FW, Ahrenholz DH. Use of Chemical burns require immediate removal intraarterial thrombolytic therapy for acute of clothing to prevent further injury, as well treatment of frostbite in 62 patients with review as copious irrigation. Electrical burns may of thrombolytic therapy in frostbite. J Burn Care be associated with extensive occult injuries. Res, 2015. Patients sustaining thermal injury are at risk for hypothermia. Judicious analgesia should not 9. Halebian P, Robinson N, Barie P, et al. Whole be overlooked. body oxygen utilization during carbon monoxide poisoning and isocapneic nitrogen hypoxia. J 6. The American Burn Association has identified Trauma 1986;26:110–117. types of burn injuries that typically require referral to a burn center. Transfer principles are 10. Jurkovich GJ. Hypothermia in the trauma patient. similar to non-burned patients but include an In: Maull KI, Cleveland HC, Strauch GO, et al., eds. accurate assessment of the patient’s burn size Advances in Trauma. Vol. 4. Chicago, IL: Yearbook; and depth. 1989:11–140. 7. Early management of cold-injured patients in- 11. Jurkovich GJ, Greiser W, Luterman A, et al. Hy- cludes adhering to the ABCDEs of resuscitation, pothermia in trauma victims: an ominous identifying the type and extent of cold injury, predictor of survival. J Trauma 1987;27: measuring the patient’s core temperature, pre- 1019–1024. paring a patient-care flow sheet, and initiating rapid rewarming techniques. 12. Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med 2009 Oct;37 bibliography (10):2819–2826. 1. Baxter CR. Volume and electrolyte changes 13. Moss J. Accidental severe hypothermia. Surg in the early postburn period. Clin Plast Surg Gynecol Obstet 1986;162:501–513. 1974;4:693–709. 14. Mozingo DW, Smith AA, McManus WF, 2. Bruen KJ, Ballard JR, Morris SE, et al. Reduction et al. Chemical burns. J Trauma 1988;28: of the incidence of amputation in frostbite 642–647. injury with thrombolytic therapy. Arch Surg 2007 Jun;142(6):546–551; discussion 15. Perry RJ, Moore CA, Morgan BD, et al. Determining 551–553. the approximate area of burn: an inconsist- ency investigated and reevaluated. BMJ 1996; 3. Cancio L. Airway management and smoke 312:1338. inhalation injury in the burn patient. Clin Plast Surg 2009 Oct;36(4):555–567. 16. Pham TN, Gibran NS. Thermal and electrical injuries. Surg Clin North Am 2007 Feb;87(1):185– 4. Cancio LC. Initial assessment and fluid re- 206, vii–viii. Review. suscitation of burn patients. Surg Clin North Am 2014 Aug;94(4):741–754. 17. Pruitt BA. Fluid and electrolyte replacement in the burned patient. Surg Clin North Am 1978, 5. Cancio LC, Lundy JB, Sheridan RL. Evolving 58;6:1313–1322. changes in the management of burns and envi- ronmental injuries. Surg Clin North Am 2012 18. Reed R, Bracey A, Hudson J, et al. Hypothermia Aug;92(4):959–986, ix. and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ 6. Carta T, Gawaziuk J, Liu S, et al. Use of mineral Shock 1990;32:141–152. oil Fleet enema for the removal of a large tar burn: a case report, J Burns, 2015 Mar;41(2): 19. Saffle JR, Crandall A, Warden GD. Cataracts: a e11-4. long-term complication of electrical injury. J Trauma 1985;25:17–21. 20. Schaller M, Fischer A, Perret C. Hyperkalemia: a prognostic factor during acute severe hypo-thermia. JAMA 1990;264: 1842–1845. 21. Sheehy TW, Navari RM. Hypothermia. Ala J Med Sci 1984;21(4):374–381. 22. Sheridan RL, Chang P. Acute burn procedures. Surg Clin North Am 2014 Aug;94(4):755–764. ■ BACK TO TABLE OF CONTENTS
BIBLIOGRAPHY 185 23. Stratta RJ, Saffle JR, Kravitz M, et al. Management 24. Vercruysse GA, Ingram WL, Feliciano DV. The of tar and asphalt injuries. Am J Surg 1983;146: demographics of modern burn care: should most 766–769. burns be cared for by the non-burn surgeon? Am J Surg 2011;201:91–96. ■ BACK TO TABLE OF CONTENTS
10 PEDIATRIC TRAUMA Injury remains the most common cause of death and disability in childhood. Injury morbidity and mortality surpass all major diseases in children and young adults, making trauma the most serious public health and health care problem in this population.
chapter 10 outline abdominal trauma • Assessment objectives • Diagnostic Adjuncts • Nonoperative Management introduction • Specific Visceral Injuries types and patterns of injury head trauma • Assessment unique characteristics of pediatric patients • Management • Size, Shape, and Surface Area • Skeleton spinal cord injury • Psychological Status • Anatomical Differences • Long-Term Effects of Injury • Radiological Considerations • Equipment musculoskeletal trauma airway • History • Anatomy • Blood Loss • Management • Special Considerations of the Immature Skeleton • Fracture Splinting breathing • Breathing and Ventilation child maltreatment • Needle and Tube Thoracostomy prevention circulation and shock • Recognition of Circulatory Compromise teamwork • Determination of Weight and Circulating Blood Volume • Venous Access chapter summary • Fluid Resuscitation and Blood Replacement • Urine Output bibliography • Thermoregulation cardiopulmonary resuscitation chest trauma OBJECTIVES After reading this chapter and comprehending the knowledge pediatric patients, the anatomic and physiologic components of the ATLS provider course, you will be able to: differences that affect resuscitation, and the different equipment needs when compared with 1. Identify the unique characteristics of children as adult trauma patients. trauma patients, including common types and patterns of injuries, the anatomic and physiologic 3. Identify the injury patterns associated with child differences from adults, and the long-term effects maltreatment, and describe the factors that lead to of injury. suspicion of child maltreatment. 2. Describe the primary management of trauma 4. List the ABCDEs of injury prevention. in children, including related issues unique to ■■BBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 187
188 CHAPTER 10 ■ Pediatric Trauma I njury remains the most common cause of death table 10-1 common mechanisms of and disability in childhood. Each year, more than 10 injury and associated patterns of million children—nearly 1 of every 6 children—in injury in pediatric patients the United States require emergency department care for the treatment of injuries. Each year, more than MECHANISM COMMON PATTERNS 10,000 children in the United States die from serious OF INJURY OF INJURY injury. Injury morbidity and mortality surpass all major diseases in children and young adults, making trauma Pedestrian struck • Low speed: Lower-extremity the most serious public health and healthcare problem by motor vehicle fractures in this population. Globally, road traffic accidents are the leading cause of adolescent deaths. Failure • High speed: Multiple trauma, to secure a compromised airway, support breathing, head and neck injuries, lower- and recognize and respond to intra-abdominal and extremity fractures intracranial hemorrhage are the leading causes of unsuccessful resuscitation in pediatric patients with Occupant in • Unrestrained: Multiple trauma, severe trauma. Therefore, by applying ATLS principles motor vehicle head and neck injuries, scalp and to the care of injured children, trauma team members collision facial lacerations can significantly affect ultimate survival and long- term outcomes. • Restrained: Chest and abdominal injuries, lower spine fractures Fall from a height • Low: Upper-extremity fractures • Medium: Head and neck injuries, types and patterns of injury upper- and lower-extremity Injuries associated with motor vehicles are the most fractures common cause of death in children of all ages, whether • High: Multiple trauma, head and they are occupants, pedestrians, or cyclists. Deaths due neck injuries, upper- and lower- to drowning, house fires, homicides, and falls follow extremity fractures in descending order. Child maltreatment accounts for the great majority of homicides in infants (i.e., Fall from a • Without helmet: Head and neck children younger than 12 months of age), whereas bicycle lacerations, scalp and facial lacera- firearm injuries account for most of the homicides in tions, upper-extremity fractures children (over age 1) and adolescents. Falls account for the majority of all pediatric injuries, but infrequently • With helmet: Upper-extremity result in death. fractures Blunt mechanisms of injury and children’s unique • Striking handlebar: Internal physical characteristics result in multisystem injury abdominal injuries being the rule rather than the exception. Clinicians should presume, therefore, that multiple organ systems unique characteristics may be injured until proven otherwise. ■ TABLE 10-1 of pediatric patients outlines common mechanisms of injury and associated patterns of injury in pediatric patients. The priorities for assessing and managing pediatric trauma patients are the same as for adults. However, The condition of the majority of injured children the unique anatomic and physiologic characteristics will not deteriorate during treatment, and most of this population combine with the common injured children have no hemodynamic abnormal- mechanisms of injury to produce distinct injury ities. Nevertheless, the condition of some children patterns. For example, most serious pediatric trauma with multisystem injuries will rapidly deteriorate, is blunt trauma that involves the brain. As a result, and serious complications will develop. Therefore, apnea, hypoventilation, and hypoxia occur five times early transfer of pediatric patients to a facility capa- more often than hypovolemia with hypotension in ble of treating children with multisystem injuries children who have sustained trauma. Therefore, is optimal. treatment protocols for pediatric trauma patients emphasize aggressive management of the airway The Field Triage Decision Scheme (see Figure 1-2 in and breathing. Chapter 1) and Pediatric Trauma Score ■ TABLE 10-2 are both useful tools for the early identification of pediatric patients with multisystem injuries. ■ BACK TO TABLE OF CONTENTS
UNIQUE CHARACTERISTICS OF PEDIATRIC PATIENTS 189 table 10-2 pediatric trauma score ASSESSMENT +2 SCORE -1 COMPONENT +1 Weight >20 kg (>44 lb) 10–20 kg (22–44 lb) <10 kg (<22 lb) Airway Normal Oral or nasal airway, oxygen Intubated, cricothyroido- tomy, or tracheostomy Systolic Blood Pressure >90 mm Hg; good periph- 50–90 mm Hg; carotid/ <50 mm Hg; weak or no pulses eral pulses and perfusion femoral pulses palpable Level of Consciousness Awake Obtunded or any loss of Coma, unresponsive consciousness Fracture None seen or suspected Single, closed Open or multiple Cutaneous None visible Contusion, abrasion, lacer- Tissue loss, any gunshot wound ation <7 cm not through fascia or stab wound through fascia Totals: Source: Adapted with permission from Tepas JJ, Mollitt DL, Talbert JL, et al. The pediatric trauma score as a predictor of injury severity in the injured child. Journal of Pediatric Surgery 1987; 22(1)15. size, shape, and surface area to occur in children, even when they have sustained internal organ damage. For example, rib fractures in Because children have smaller body mass than adults, children are uncommon, whereas pulmonary contu- the energy imparted from objects such as fenders and sion is not. Other soft tissues of the thorax and medias- bumpers, or from falls, results in greater force being tinum also can sustain significant damage without applied per unit of body area. This concentrated energy evidence of bony injury or external trauma. The is transmitted to a body that has less fat, less connective presence of skull and/or rib fractures in a child sug- tissue, and a closer proximity of multiple organs than gests the transfer of a massive amount of energy; in in adults. These factors result in the high frequency of this case, underlying organ injuries, such as traumatic multiple injuries seen in the pediatric population. In brain injury and pulmonary contusion, should addition, a child’s head is proportionately larger than be suspected. an adult’s, which results in a higher frequency of blunt brain injuries in this age group. psychological status The ratio of a child’s body surface area to body mass The potential for significant psychological ramifications is highest at birth and decreases as the child matures. should be considered in children who sustain trauma. As a result, thermal energy loss is a significant stress In young children, emotional instability frequently factor in children. Hypothermia may develop quickly leads to a regressive psychological behavior when and complicate the treatment of pediatric patients stress, pain, and other perceived threats intervene in with hypotension. the child’s environment. Children have a limited ability to interact with unfamiliar individuals in strange and skeleton difficult situations, which can make history taking and cooperative manipulation, especially if it is painful, A child’s skeleton is incompletely calcified, contains extremely difficult. Clinicians who understand these multiple active growth centers, and is more pliable characteristics and are willing to soothe an injured than an adult’s. Therefore, bone fractures are less likely ■ BACK TO TABLE OF CONTENTS
190 CHAPTER 10 ■ Pediatric Trauma child are more likely to establish a good rapport, which and studies are obtained using the lowest possible facilitates a comprehensive assessment of the child’s radiation doses. psychological and physical injuries. Nevertheless, the long-term quality of life for The presence of parents or other caregivers during children who have sustained trauma is surprisingly evaluation and treatment, including resuscitation, positive, even though in many cases they will expe- may assist clinicians by minimizing the injured child’s rience lifelong physical challenges. Most patients natural fears and anxieties. report a good to excellent quality of life and find gainful employment as adults, an outcome justifying long-term effects of injury aggressive resuscitation attempts even for pediatric patients whose initial physiologic status might A major consideration in treating injured children is suggest otherwise. the effect of that injury on their subsequent growth and development. Unlike adults, children must recover equipment from the traumatic event and then continue the normal process of growth and development. The potential Successful assessment and treatment of injured physiologic and psychological effects of injury on children depends on immediately available equipment this process can be significant, particularly in cases of the appropriate size (■ TABLE 10-3; also see Pediatric involving long-term function, growth deformity, or Equipment on MyATLS mobile app). A length-based subsequent abnormal development. Children who resuscitation tape, such as the Broselow® Pediatric sustain even a minor injury may have prolonged Emergency Tape, is an ideal adjunct for rapidly disability in cerebral function, psychological adjust- determining weight based on length for appropriate ment, or organ system function. fluid volumes, drug doses, and equipment size. By measuring the child’s height, clinicians can readily Some evidence suggests that as many as 60% of determine his or her ’estimated weight. One side of the children who sustain severe multisystem trauma have tape provides drugs and their recommended doses for residual personality changes at one year after hospital pediatric patients based on weight, and the other side discharge, and 50% show cognitive and physical identifies equipment needs for pediatric patients based handicaps. Social, affective, and learning disabilities on length (■ FIGURE 10-1). Clinicians should be familiar are present in one-half of seriously injured children. with length-based resuscitation tapes and their uses. In addition, childhood injuries have a significant impact on the family—personality and emotional pitfall prevention disturbances are found in two-thirds of uninjured siblings. Frequently, a child’s injuries impose a strain on Incorrect doses of • Recognize the need for the parents’ personal relationship, including possible fluids or medications weight-based dosing, and financial and employment hardships. Trauma may are administered use a resuscitation tape to affect not only the child’s survival but also the quality estimate weight from length. of the child’s life for years to come. Hypothermia rapidly develops • Recognize the significance Bony and solid visceral injuries are cases in point: of a high body surface area Injuries through growth centers can cause growth in children, and keep the abnormalities of the injured bone. If the injured bone environment warm and the is a femur, a leg length discrepancy may result, causing child covered. a lifelong disability in running and walking. If the fracture is through the growth center of one or more airway thoracic vertebra, the result may be scoliosis, kyphosis, or even gibbus deformity. Another example is massive The “A” of the ABCDEs of initial assessment is the disruption of a child’s spleen, which may require a same in the child as for adults. Establishing a patent splenectomy and predisposes the child to a lifelong risk airway to provide adequate tissue oxygenation is of overwhelming postsplenectomy sepsis and death. the first objective. The inability to establish and/or maintain a patent airway with the associated lack Ionizing radiation, used commonly in evaluation of oxygenation and ventilation is the most common of injured patients may increase the risk of certain malignancies and should be used if the information needed cannot obtained by other means, the information gained will change the clinical management of the patient, obtaining the studies will not delay the transfer of patients who require higher levels of care, ■ BACK TO TABLE OF CONTENTS
AIRWAY 191 table 10-3 pediatric equipmenta AIRWAY AND BREATHING AGE O2 ORAL BAG- LARYNGO- ET TUBE STYLET SUCTION AND MASK AIRWAY VALVE SCOPE WEIGHT Premie Premie, Infant Infant 0 straight 2.5–3.0 6 Fr 6–8 Fr 3 kg newborn no cuff 0–6 mos Newborn Infant, Infant 1 straight 3.0–3.5 6 Fr 8 Fr 3.5 kg small no cuff 6–12 mos Pediatric Small Pediatric 1 straight 3.5–4.0 6 Fr 8-10 Fr 7 kg cuffed or uncuffed 1–3 yrs Pediatric Small Pediatric 1 straight 4.0–4.5 6 Fr 10 Fr 10–12 kg cuffed or uncuffed 4–7 yrs Pediatric Medium Pediatric 2 straight or 5.0–5.5 14 Fr 14 Fr 16–18 kg curved no cuff 8–10 yrs Adult Medium, Pediatric, 2-3 straight 5.5–6.5 14 Fr 14 Fr 24–30 kg large adult or curved cuffed CIRCULATION SUPPLEMENTAL EQUIPMENT AGE BP CUFF IV OG/NG CHEST URINARY CERVICAL AND CATHETERb TUBE TUBE CATHETER COLLAR WEIGHT Premie Premie, newborn 22–24 ga 8 Fr 10-14 Fr 5 Fr feeding — 3 kg 0–6 mos Newborn, infant 22 ga 10 Fr 12-18 Fr 6 Fr or 5–8 Fr — 3.5 kg feeding 6–12 mos Infant, child 22 ga 12 Fr 14-20 Fr 8 Fr Small 7 kg 1–3 yrs Child 20-22 ga 12 Fr 14-24 Fr 10 Fr Small 10–12 kg 4–7 yrs Child 20 ga 12 Fr 20-28 Fr 10-12 Fr Small 16–18 kg 8–10 yrs Child, adult 18-20 ga 14 Fr 28-32 Fr 12 Fr Medium 24–30 kg aUse of a length-based resuscitation tape, such as a BroselowTM Pediatric Emergency Tape, is preferred. bUse of the largest IV catheter that can readily be inserted with reasonable certainty of success is preferred. ■ BACK TO TABLE OF CONTENTS
192 CHAPTER 10 ■ Pediatric Trauma AB n FIGURE 10-1 Resuscitation Tape. A. A length-based resuscitation tape, such as the Broselow® Pediatric Emergency Tape, is an ideal adjunct to rapidly determine weight based on length for appropriate fluid volumes, drug doses, and equipment size. B. Detail, showing recommended drug doses and equipment needs for pediatric patients based on length. cause of cardiac arrest in children. Therefore, the Plane of face is not child’s airway is the first priority. (Also see Chapter 2: parallel to spine board Airway and Ventilatory Management, and Appendix G: Airway Skills.) anatomy A The smaller the child, the greater is the disproportion Plane of face is between the size of the cranium and the midface. The parallel to spine board large occiput results in passive flexion of the cervical spine, leading to a propensity for the posterior pharynx B to buckle anteriorly. To avoid passive flexion of the cervical spine, ensure that the plane of the midface n FIGURE 10-2 Positioning for Airway Maintenance. A. Improper is maintained parallel to the spine board in a neutral positioning of a child to maintain a patent airway. The disproportion position, rather than in the “sniffing position” (■ FIGURE between the size of the child’s cranium and midface leads to a 10-2A). Placement of a 1-inch layer of padding beneath propensity for the posterior pharynx to buckle anteriorly. The the infant or toddler’s entire torso will preserve neutral large occiput causes passive flexion of the cervical spine. B. Proper alignment of the spinal column (■ FIGURE 10-2B). positioning of a child to maintain a patent airway. Avoid passive flexion of the cervical spine by keeping the plane of the midface Several anatomical features of children affect airway parallel to the spine board in a neutral position, rather than in the assessment and management. The soft tissues of an “sniffing position.” Placement of a 1-inch layer of padding beneath infant’s oropharynx (i.e., the tongue and tonsils) are the infant’s or toddler’s entire torso will preserve neutral alignment relatively large compared with the tissues in the oral of the spinal column. cavity, which may compromise visualization of the larynx. A child’s larynx is funnel shaped, allowing mainstem bronchus, inadequate ventilation, accidental secretions to accumulate in the retropharyngeal area. tube dislodgment, and/or mechanical barotrauma. The The larynx and vocal cords are more cephalad and optimal endotracheal tube (ETT) depth (in centimeters) anterior in the neck. The vocal cords are frequently can be calculated as three times the appropriate more difficult to visualize when the child’s head is in the normal, supine, anatomical position during intubation than when it is in the neutral position required for optimal cervical spine protection. An infant’s trachea is approximately 5 cm long and grows to 7 cm by about 18 months. Failure to appreciate this short length can result in intubation of the right ■ BACK TO TABLE OF CONTENTS
AIRWAY 193 tube size. For example, a 4.0 ETT would be properly (See Infant Endotracheal Intubation video on MyATLS positioned at 12 cm from the gums. mobile app.) However, the use of cuffed ETTs, even in toddlers and small children, provides the benefit of management improving ventilation abnlodoCdOf2lomwa.nPargeevmioeunst, resulting in improved cerebral concerns In a spontaneously breathing child with a partially about cuffed endotracheal tubes causing tracheal obstructed airway, optimize the airway by keeping the necrosis are no longer relevant due to improvements plane of the face parallel to the plane of the stretcher in the design of the cuffs. Ideally, cuff pressure should or gurney while restricting motion of the cervical be measured as soon as is feasible, and <30 mm Hg is spine. Use the jaw-thrust maneuver combined with considered safe. bimanual inline spinal motion restriction to open the A simple technique to gauge the ETT size needed for airway. After the mouth and oropharynx are cleared of a specific patient is to approximate the diameter of the secretions and debris, administer supplemental oxygen. child’s external nares or the tip of the child’s smallest If the patient is unconscious, mechanical methods finger and use a tube with a similar diameter. Length- of maintaining the airway may be necessary. Before based pediatric resuscitation tapes also list appropriate attempting to mechanically establish an airway, fully tube sizes. Ensure the ready availability of tubes that preoxygenate the child. are one size larger and one size smaller than the predicted size. If using a stylet to facilitate intubation, Oral Airway ensure that the tip does not extend beyond the end of An oral airway should be inserted only if a child is the tube. unconscious, because vomiting is likely to occur Most trauma centers use a protocol for emergency if the gag reflex is intact. The practice of inserting intubation, referred to as drug-assisted or drug- the airway backward and rotating it 180 degrees facilitated intubation, also known as rapid sequence is not recommended for children, since trauma intubation. Clinicians must pay careful attention to the and hemorrhage into soft-tissue structures of the child’s weight, vital signs (pulse and blood pressure), oropharynx may occur. Insert the oral airway gently and level of consciousness to determine which branch and directly into the oropharynx. Using a tongue blade of the Algorithm for Drug-Assisted Intubation (■ FIGURE to depress the tongue may be helpful. 10-3) to use. (Also see Drug-Assisted Intubation in Pediatric Patients on MyATLS mobile app.) Orotracheal Intubation Preoxygenate children who require an endotracheal Orotracheal intubation is indicated for injured children tube for airway control. Infants have a more pro- in a variety of situations, including nounced vagal response to endotracheal intubation than do children and adults, and they may experience • a child with severe brain injury who requires controlled ventilation • a child in whom an airway cannot be maintained • a child who exhibits signs of ventilatory failure • a child who has suffered significant hypovolemia and has a depressed sensorium or requires operative intervention Orotracheal intubation is the most reliable means of n FIGURE 10-3 Algorithm for Drug-Assisted Intubation/Rapid establishing an airway and administering ventilation Sequence Intubation in Pediatric Patients. to a child. The smallest area of a young child’s airway is at the cricoid ring, which forms a natural seal around an uncuffed ETT, a device that is commonly used in infants because of their anatomic features. ■ BACK TO TABLE OF CONTENTS
194 CHAPTER 10 ■ Pediatric Trauma bradycardia with direct laryngeal stimulation. Brad- Cricothyroidotomy ycardia in infants is much more likely to be due to When airway maintenance and control cannot be hypoxia. Atropine sulfate pretreatment should be accomplished by bag-mask ventilation or orotracheal considered for infants requiring drug-assisted intu- intubation, a rescue airway with either laryngeal bation, but it is not required for children. Atropine mask airway (LMA), intubating LMA, or needle also dries oral secretions, enabling visualization of cricothyroidotomy is necessary. Needle-jet insufflation landmarks for intubation. via the cricothyroid membrane is an appropriate, temporizing technique for oxygenation, but it does After inserting the endotracheal tube, ensure that not provide adequate ventilation, and progressive its position is assessed clinically (see below) and, if hypercarbia will occur. LMAs are appropriate adjunct correct, the tube carefully secured. If it is not possible to airways for infants and children, but their placement place the ETT after the patient is chemically paralyzed, requires experience, and ventilation may distend the ventilate the child with 100% oxygen administered patient’s stomach if it is overly vigorous. with a self-inflating bag-mask device until a definitive airway is secured. Surgical cricothyroidotomy is rarely indicated for infants or small children. It can be performed in older Orotracheal intubation under direct vision with children in whom the cricothyroid membrane is easily restriction of cervical motion is the preferred method palpable (usually by the age of 12 years). of obtaining definitive airway control. Do not perform nasotracheal intubation in children, as it requires pitfall prevention blind passage around a relatively acute angle in the nasopharynx toward the anterosuperiorly located Patient’s oxygen Use the “Don’t be a DOPE” glottis, making intubation by this route difficult. saturation mnemonic as a reminder of the The potential for penetrating the child’s cranial vault decreases common causes of deterioration in or damaging the more prominent nasopharyngeal intubated patients: (adenoidal) soft tissues and causing hemorrhage also • D—Dislodgment can easily occur, discourages the use of the nasotracheal route for airway control. as the trachea of an infant or child is short. Secure the tube well and Once the ETT is past the glottic opening, position it 2 recognize the situation early if it to 3 cm below the level of the vocal cords and carefully occurs. Use monitoring equipment, secure in place. Next, conduct primary confirmation especially during transport, to help techniques, such as auscultation of both hemithoraces alert the provider of this problem. in the axillae, to ensure that right mainstem bronchial • O—Obstruction with secretions or intubation has not occurred and that both sides of secondary to kinking can occur, as the chest are being adequately ventilated. Then use the diameter of the tubes is small. a secondary confirmation device, such as a real-time Suctioning can clear secretions, waveform capnograph, a colorimetric end-tidal carbon but tube replacement may dioxide detector, or an esophageal detector device, to be necessary. document tracheal intubation, and obtain a chest x-ray • P—Pneumothorax. Tension to accurately identify ETT position. pneumothorax can develop with positive pressure in patients with Because young children have short tracheas, any underlying pneumothorax from movement of the head can result in displacement of the traumatic injury or barotrauma ETT, inadvertent extubation, right mainstem bronchial related to mechanical ventilation. intubation, or vigorous coughing due to irritation of the This conditions warrants carina by the tip of the tube. These conditions may not decompression. be recognized clinically until significant deterioration • E—Equipment failure. Ventila- has occurred. Thus, clinicians should evaluate breath tors, pulse oximeters, and oxygen sounds periodically to ensure that the tube remains in delivery devices can malfunction. the appropriate position and identify the possibility of Ensure that equipment is evolving ventilatory dysfunction. well maintained and properly functioning, and use backup If there is any doubt about correct placement of the equipment when necessary. ETT that cannot be resolved expeditiously, remove the tube and replace it immediately. The mnemonic, “Don’t be a DOPE” (D for dislodgment, O for obstruction, P for pneumothorax, E for equipment failure) may be a useful reminder of the common causes of deterioration in intubated patients. ■ BACK TO TABLE OF CONTENTS
CIRCULATION AND SHOCK 195 breathing over-the-needle catheters in infants and small children, as the longer needle length may cause rather than cure A key factor in evaluating and managing breathing a tension pneumothorax. and ventilation in injured pediatric trauma patients is the recognition of impaired gas exchange. This Chest tubes need to be proportionally smaller (see includes oxygenation and elimination of carbon ■ TABLE 10-3) and are placed into the thoracic cavity by dioxide resulting from alterations of breathing caused tunneling the tube over the rib above the skin incision by mechanical issues such as pneumothorax and lung site and then directing it superiorly and posteriorly injury from contusion or aspiration. In such cases, along the inside of the chest wall. Tunneling is especially apply appropriate countermeasures such as tube important in children because of their thinner chest thoracostomy and assisted ventilation. wall. The site of chest tube insertion is the same in children as in adults: the fifth intercostal space, just breathing and ventilation anterior to the midaxillary line. (See Chapter 4: Thoracic Trauma, and Appendix G: Breathing Skills.) The respiratory rate in children decreases with age. An infant breathes 30 to 40 times per minute, whereas an circulation and shock older child breathes 15 to 20 times per minute. Normal, spontaneous tidal volumes vary from 4 to 6 mL/kg Key factors in evaluating and managing circulation for infants and children, although slightly larger tidal in pediatric trauma patients include recognizing volumes of 6 to 8 mL/kg and occasionally as high as circulatory compromise, accurately determining the 10 mL/kg may be required during assisted ventilation. patient’s weight and circulatory volume, obtaining Although most bag-mask devices used with pediatric venous access, administering resuscitation fluids patients are designed to limit the pressure exerted and/or blood replacement, assessing the adequacy of manually on the child’s airway, excessive volume resuscitation, and achieving thermoregulation. or pressure during assisted ventilation substantially increases the potential for iatrogenic barotrauma due recognition of circulatory to the fragile nature of the immature tracheobronchial compromise tree and alveoli. When an adult bag-mask device is used to ventilate a pediatric patient, the risk of barotrauma Injuries in children can result in significant blood is significantly increased. Use of a pediatric bag-mask loss. A child’s increased physiologic reserve allows for is recommended for children under 30 kg. maintenance of systolic blood pressure in the normal range, even in the presence of shock (■ FIGURE 10-4). Up Hypoxia is the most common cause of pediatric to a 30% decrease in circulating blood volume may be cardiac arrest. However, before cardiac arrest occurs, required to manifest a decrease in the child’s systolic hypoventilation causes respiratory acidosis, which is the most common acid-base abnormality encountered during the resuscitation of injured children. With adequate ventilation and perfusion, a child should be able to maintain relatively normal pH. In the absence of adequate ventilation and perfusion, attempting to correct an acidosis with sodium bicarbonate can result in further hypercarbia and worsened acidosis. needle and tube thoracostomy n FIGURE 10-4 Physiological Impact of Hemodynamic Changes on Pediatric Patients. Injuries that disrupt pleural apposition—for example, hemothorax, pneumothorax, and hemopneumothorax, have similar physiologic consequences in children and adults. These injuries are managed with pleural decompression, preceded in the case of tension pneumothorax by needle decompression just over the top of the third rib in the midclavicular line. Take care during this procedure when using 14- to 18-gauge ■ BACK TO TABLE OF CONTENTS
196 CHAPTER 10 ■ Pediatric Trauma blood pressure. This can mislead clinicians who are not diastolic pressure should be about two-thirds of the familiar with the subtle physiologic changes manifested systolic blood pressure. (Normal vital functions by by children in hypovolemic shock. Tachycardia and age group are listed in ■ TABLE 10-5.) Hypotension in poor skin perfusion often are the only keys to early a child represents a state of decompensated shock recognition of hypovolemia and the early initiation of and indicates severe blood loss of greater than 45% of appropriate fluid resuscitation. When possible, early the circulating blood volume. Tachycardia changing assessment by a surgeon is essential to the appropriate to bradycardia often accompanies this hypotension, treatment of injured children. and this change may occur suddenly in infants. These physiologic changes must be treated by a rapid infusion Although a child’s primary response to hypovolemia of both isotonic crystalloid and blood. is tachycardia, this sign also can be caused by pain, fear, and psychological stress. Other more subtle pitfall prevention signs of blood loss in children include progressive weakening of peripheral pulses, a narrowing of pulse Failure to recognize and • Recognize that tachy- pressure to less than 20 mm Hg, skin mottling (which treat shock in a child cardia may be the only substitutes for clammy skin in infants and young physiologic abnormality. children), cool extremities compared with the torso skin, and a decrease in level of consciousness with a • Recognize that children dulled response to pain. A decrease in blood pressure have increased physio- and other indices of inadequate organ perfusion, logic reserve. such as urinary output, should be monitored closely, but generally develop later. Changes in vital organ • Recognize that normal function by degree of volume loss are outlined vital signs vary with the in ■ TABLE 10-4. age of the child. The mean normal systolic blood pressure for children • Carefully reassess the is 90 mm Hg plus twice the child’s age in years. The patient for mottled skin lower limit of normal systolic blood pressure in children and a subtle decrease in is 70 mm Hg plus twice the child’s age in years. The mentation. table 10-4 systemic responses to blood loss in pediatric patients SYSTEM MILD BLOOD MODERATE BLOOD SEVERE BLOOD VOLUME LOSS VOLUME LOSS VOLUME LOSS (30%–45%) (<30%) (>45%) Cardiovascular Increased heart rate; weak, Markedly increased heart rate; Tachycardia followed by thready peripheral pulses; weak, thready central pulses; bradycardia; very weak or normal systolic blood absent peripheral pulses; low absent central pulses; absent pressure (80 − 90 + 2 × age in normal systolic blood pressure peripheral pulses; hypotension years); normal pulse pressure (70 − 80 + 2 × age in years); (<70 + 2 × age in years); narrowed narrowed pulse pressure pulse pressure (or undetectable diastolic blood pressure) Central Nervous Anxious; irritable; Lethargic; dulled Comatose System confused response to paina Skin Cool, mottled; prolonged Cyanotic; markedly prolonged Pale and cold capillary refill capillary refill Urine Outputb Low to very low Minimal None aA child’s dulled response to pain with moderate blood volume loss may indicate a decreased response to IV catheter insertion. bMonitor urine output after initial decompression by urinary catheter. Low normal is 2 ml/kg/hr (infant), 1.5 ml/kg/hr (younger child), 1 ml/kg/hr (older child), and 0.5 ml/hg/hr (adolescent). IV contrast can falsely elevate urinary output. ■ BACK TO TABLE OF CONTENTS
CIRCULATION AND SHOCK 197 table 10-5 normal vital functions by age group AGE GROUP WEIGHT HEART RATE BLOOD RESPIRATORY URINARY RANGE (beats/min) PRESSURE RATE OUTPUT (in kg) (mL/kg/hr) (mm Hg) (breaths/min) 2.0 Infant 0–10 <160 >60 <60 0–12 months Toddler 10-14 <150 >70 <40 1.5 1–2 years Preschool 14-18 <140 >75 <35 1.0 3–5 years School age 18-36 <120 >80 <30 1.0 6–12 years Adolescent 36-70 <100 >90 <30 0.5 ≥13 years determination of weight and in young children (■ FIGURE 10-5; also see Intraosseous circulating blood volume Puncture video on MyATLS mobile app.) or insertion of a femoral venous line of appropriate size using It is often difficult for emergency department (ED) personnel to estimate a child’s weight, particularly A when they do not often treat children. The simplest and quickest method of determining a child’s weight in order to accurately calculate fluid volumes and drug dosages is to ask a caregiver. If a caregiver is unavail- able, a length-based resuscitation tape is extremely helpful. This tool rapidly provides the child’s approx- imate weight, respiratory rate, fluid resuscitation volume, and a variety of drug dosages. A final method for estimating weight in kilograms is the formula ([2 × age in years] + 10). The goal of fluid resuscitation is to rapidly replace the circulating volume. An infant’s blood volume can be estimated at 80 mL/kg, and a child age 1-3 years at 75 mL/kg, and children over age 3 years at 70 mL/kg. venous access B Intravenous access in young children with hypovo- n FIGURE 10-5 Intraosseous Infusion, A. Distal femur, B. Proximal lemia can be a challenging skill, even in the most tibia. If percutaneous access is unsuccessful after two attempts, experienced hands. Severe hypovolemic shock is consider starting intraosseous infusion via a bone-marrow needle (18 typically caused by the disruption of intrathoracic or gauge in infants, 15 gauge in young children). intra-abdominal organs or blood vessels. A peripheral percutaneous route is preferable to establish venous access. If percutaneous access is unsuccessful after two attempts, consider intraosseous infusion via a bone-marrow needle: 18-gauge in infants, 15-gauge ■ BACK TO TABLE OF CONTENTS
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