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