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Immediate resuscitation: follow the primary and secondary surveys of Advanced Trauma Life Support (ATLS).


  • Airway:
    • Intubate early: airway edema can progress rapidly
    • Use ETT with ID ≥8 mm to allow subsequent bronchoscopy
    • Unconscious patient ⇒ full stomach and unstable neck
    • Succinylcholine safe during the first 24–48 hours, and then contraindicated up to 18 months after major burn
  • Breathing:
    • Inhalation injury is the leading cause of death during the acute phase
    • Three components:
      • Thermal: hot smoke burns mucous membranes ⇒ edema ⇒obstruction (more in upper airway since smoke cools as it moves distally)
      • Chemical: smoke components toxic by themselves ⇒ alveolar damage
      • Systemic: carbon monoxide (CO) and cyanide (CN) can displace oxygen (O2) from hemoglobin (Hb), leading to tissue hypoxia
    • Face mask 100% O2; consider hyperbaric O2 for patients with neurologic symptoms and carboxyhemoglobin (HbCO) levels >25%
    • Suspect CN poisoning in comatose patients with HbCO <30%, particularly if high (>80%) Sv̅O2 and metabolic acidosis:
      • 100% O2
      • Full and prolonged CPR as needed
      • Sodium thiosulfate (150 mg/kg over 15 minutes IV infusion)
    • Circumferential chest wall injury: consider escharotomy
  • Circulation:
    • During the first 24 hours, use one of the common formulas for fluid resuscitation
    • Estimate adequacy of resuscitation by U/O:
      • Adults: ≥0.5 mL/kg/h
      • Children: ≥1 mL/kg/h
      • Myoglobinuria: ≥2 mL/kg/h (consider adding NaHCO3 to IV fluids)
    • Also Hct ≤50%, serum Na ≤150 mEq/L, serum albumin ≥2 g/dL, urine Na ≥40 mEq/L, SBP ≥100 mm Hg, HR ≥120
    • After 24 hours, use 5% or 25% albumin to keep albumin ≥2 g/dL
    • Monitor for abdominal compartment syndrome (IAP ≥25 mm Hg) whenever IV fluid volumes ≥20 L
  • Disability:
    • GCS score in all trauma patients
    • Assess for spinal cord injury (SCI)
    • Consider CO and CN poisoning as causes of coma
  • Exposure:
    • Perform head-to-toe examination on a fully exposed patient while protecting from hypothermia
    • Assess for any associated injury
    • Assess burn injury taking into consideration burn size and depth as well as patient age (see Figure 218-1)
    • For thermal injury, follow the 6 C's approach:
      • Clothing: remove nonsticking clothing
      • Cooling: with clean water
      • Cleaning: with nonalcoholic solution such as chlorhexidine
      • Chemoprophylaxis: with topical antibiotic cream
      • Covering: with gauze impregnated with petroleum jelly and wrapped with absorbent gauze
      • Comforting (pain relief): with analgesics
    • For chemical burns, brush off dry chemical powder, rinse with water for 30 minutes (irrigate eye for 8 hours), and then treat according to causative agent
    • For electrical burns:
      • Internal injury (eye, heart, nerve, muscle) can far exceed external skin injury
      • CPK and K+ levels
      • Monitor EKG for arrhythmias
      • Myoglobinuria: maintain UO ≥2 mL/kg/h and add 50 mEq NaHCO3 plus 12.5 g mannitol to each 1 L IV fluids
      • High-voltage injury, measure compartmental intramuscular pressure (IMP) and perform fasciotomy if >30 mm Hg or neurovascular compromise

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Fluid Resuscitation for the First 24 Hours
Adults (Parkland formula)Children (Evans formula)
  • LR at 4 mL × %TBSA ...

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