Trauma ITE Review
Michelle Slezak
Henry Ford Hospital
Department of Emergency Medicine
Basic Principles of Trauma
Three peaks for trauma deaths
• First (immediate death)
• Massive head injury, high C-spine injury, cardiac laceration, aortic rupture,
laceration of other great vessels, airway obstruction
• Second (minutes to few hours) “Golden hour”
• Subdural/epidural hematoma, ruptured spleen, lacerated liver, multiple
injuries with hypovolemic shock, fracture of pelvis or multiple long bones,
hemopneumothorax, tension pneumothorax, cardiac tamponade, massive
hemothorax, aortic dissection/rupture
• Third (days to weeks)
• Multisystem organ failure, systemic inflammatory response syndrome
Primary Survey (ABCDE)
• Airway (and C-spine)
•
•
•
•
If patient can speak, airway is intact
Noisy respirations– partial obstruction
Gag reflex depressed/absent or secretions pooling– airway poorly protected
Intubate with collar loosened and inline precautions; collar restricts mouth
opening to 20 mm or less
• Breathing
• Rate, depth, pattern of respiration; supplemental O2, pulse ox
• Tension pneumo– needle thoracostomy followed by tube
• Sucking chest wound– sterile occlusive dressing taped on three sides
Primary Survey (ABCDE)
• Circulation and hemorrhage control
•
•
•
•
•
•
Pulse quality, rate, regularity; skin color, capillary refill, LOC
Large bore IVs, warmed crystalloid, cardiac monitor
Direct pressure for external bleeding
Wrap unstable pelvic fractures with sheet
Pericardiocentesis for tamponade
ED thoracotomy
Primary Survey (ABCDE)
• Disability
• Pupil size, reactivity, symmetry
• Level of consciousness
• AVPU (qualitative)– Alert, responds to vocal stimuli, responds to painful
stimuli, unresponsive
• GCS (quantitative)– eye opening, verbal response, motor response
• Intubate for GCS <=8
• Exposure
• Undress, warm blankets
Hemorrhagic Shock
Head Injuries
Head injury
• Leading cause of death and disability in trauma patients
• Assume cervical spine injury exists
• Suspect in intoxicated, headache, sensory changes, LOC, persistent
amnesia, skull fx, lateralized weakness, abnormal pupillary function
• Classification based on GCS
• Mild (14-15)
• Moderate (9-13)
• Severe (3-8)
Head injury
• Concussion
• Brief loss of neurologic function,
headache, +/- vomiting, amnesia,
no focal findings
• CT negative
• Post-concussive syndrome
• Headache, irritability, dizziness,
depression, loss of memory,
inability to concentrate
• Outpatient workup
• Diffuse axonal injury
• Prolonged coma, +/- posturing, +/autonomic dysfunction
• No mass lesion on CT (may see
punctate hemorrhages)
• Mortality 33%
Head injury
• Cerebral contusion
• Confusion, obtundation, coma, +/focal deficits
• Visible on CT (frontal and temporal
lobes)
• Coup vs contrecoup
• Delayed complications– cerebral
edema, intracerebral hematoma
• Skull fractures
•
•
•
•
Linear, non-depressed– no tx
Depressed– may be operative
Open skull fx– operative
“egg shell”– evaluate for child
abuse
Epidural hematoma
• InjuryLOClucid interval (30%)coma (fixed,
dilated ipsilateral pupil, contra hemiparesis)
• Transtentorial herniation compresses CN III and
corticospinal tract
• Arterial bleed (middle meningeal artery)
• Lens-like, biconvex lesion does not cross cranial
sutures
• Associated parietal or temporal fx (80%)
• Mortality 0-20%
Subdural hematoma
• More common than epidural
• Significant intrinsic brain damage
• Mild headache, confusion, lethargy, coma
• Bleeding from bridging veins
• Pts with brain atrophy more susceptible
• Crescent shaped lesion can extend beyond
cranial sutures
• Mortality for acute 30-60%
Basilar skull fracture
• Battle’s sign
• Raccoon eyes
• Hemotympanum
• CSF rhinorrhea
• “ring sign”
• Can compress CN (esp VII)
Increased intracranial pressure
• Headache, N/V, decreasing LOC,
progressive deficit, Cushing
reflex (hypertension,
bradycardia), sixth nerve
paresis, papilledema, herniation
• Most rapid mechanism for
lowering ICP– hyperventilation
(to 30-35 mm Hg)
• Causes vasoconstriction of
cerebral vasculature
ENT Trauma
ENT trauma
• Auricular hematoma
• Drain; compressive dressing to
prevent “cauliflower ear”
• Reassess in 24 hours
• TM perforation
• Penetrating object, loud noise,
infection, lightning strike, rapid
changes in pressure
• Exam shows tear; immobility of
TM on bulb insufflation
• Tx– heal spontaneously, keep dry
• Can have hearing loss, N/V,
vertigo, facial palsy (suggests
injury to ossicles, labyrinth,
temporal bone)
ENT trauma
• Nasal bone fractures
• Most common facial fx
• Imaging not necessary
• ENT for reduction once swelling
improves
• Gross angulation reduced in ED
• Nasal septal hematoma
• Bluish-purple, grapelike swelling of
septum
• Need vertical I&D to prevent
“saddle nose” deformity due to
avascular necrosis
• Pack, anti-staph abx, ENT
LeFort fractures
• Usually occur in combination
• Beware of cervical spine and
airway
• Diagnose by grasping upper
alveolar ridge and note which
part of the midface moves
• Avoid NG tube
LeFort fractures
• I– horizontal fx of maxilla at level of nasal
floor
• Allows movement of alveolar ridge and hard
palate
• II– pyramidal fx with apex just above
bridge of nose and extends laterally and
inferiorly through infraorbital rims
• Allows movement of maxilla, nose, infraorbital
rims
• III– complete craniofacial disruption
• Involves zygoma, infraorbital rims, maxilla;
dishpan face
Mandible fracture
• Second most common facial fracture
• Ringlike structure– two or more fractures in 50%
• Most common fracture sites– condyle, body, angle
• Tenderness, deformity, sublingual hematoma, asymmetry, deviation
TOWARD side of fx
• Tongue blade test
• Panorex (most useful), CT
Mandible dislocation
• Trauma, yawning, laughing
• Bilateral– anterior open bite
• Unilateral– jaw displaced AWAY
from side of dislocation
• Reduction– thumbs on posterior
molars and push mandible
downward and posterior
Tripod fracture
• Fracture of zygomatic arch,
zygomaticofrontal suture, and infraorbital
foramen
• Also, lateral wall of maxillary sinus and
orbital floor
• Flattening of cheek, periorbital swelling,
ecchymosis, diplopia, palpable step-off of
inferior orbital rim, anesthesia of
cheek/upper teeth/lip/gum
Dental fractures
• Ellis I– enamel fx; no pain, no hot/cold
sensitivity; elective followup
• Ellis II- enamel fx and dentin exposed;
hot/cold sensitivity; followup within 24 hrs
• Ellis III– enamel fx, both dentin and pulp
exposed; pink dot; severe pain; immediate
dental referral
• Alveolar fracture– considered open fx; need
antibiotics
Avulsed teeth
• Permanent tooth
•
•
•
•
Rinse with saline and replace ASAP
Do not brush; will remove periodontal ligament
Viability decreased 1% for every minute out of socket
Can also transport in Hank’s solution or milk
• Primary tooth
• 6 months to 5 years
• Do not replace
Ocular Trauma
UV keratitis
• Prolonged UV exposure– arc welding, reflected sunlight
(snow blindness), artificial sunlight (tanning bed)
• Symptoms 6-12 hours after exposure
• Severe pain, photophobia, FB sensation, tearing, blepharospasm,
decreased visual acuity
• Multiple pinpoint epithelial surface irregularities on fluorescein
staining
• Treat with topical cycloplegic, ointment, oral pain meds
• No topical anesthetic b/c increases risk of corneal ulceration
Traumatic iritis
• Symptoms 1-4 days post trauma
• Tearing, photophobia, decreased visual
acuity
• Consensual photophobia, ciliary flush,
miotic pupil, cells and flare
• Treat with topical cycloplegic (paralyzes
ciliary body, dilates pupil, prevents
formation of posterior synechiae), topical
steroid
Orbital floor fracture (blow-out fracture)
• Pain and diplopia on upward gaze (entrapment of inferior rectus and
inferior oblique), enophthalmos, hypesthesia of infraorbital nerve,
subcutaneous orbital emphysema
• Best seen on Water’s view
• Air-fluid level in maxillary sinus, “tear-drop” sign (prolapse of orbital
tissue into maxillary antrum), clouding of maxillary sinus, orbital
emphysema
Medial orbital wall fracture
• Epistaxis, emphysema of lids/conjunctiva, limited lateral gaze
(entrapment of medial rectus)
• Clouding of ethmoid sinus, orbital emphysema
• Treatment of orbital fractures
• Exclude associated ocular injuries (globe rupture)
• Decongestants, antibiotics, avoid Valsalva, ophtho
Ocular chemical burns
• Alkali (liquefaction necrosis)-- worse
• Acid (coagulation necrosis)
• Immediate, copious irrigation until pH neutral
• Topical cycloplegic, antibiotic ointment, oral analgesics, ophtho
Lid lacerations
• Superficial can be repaired with 6-0 or 7-0 nonabsorbable
• Refer to ophtho
•
•
•
•
•
Lacrimal canaliculi
Levator muscle/tendon (ptosis)
Canthal tendons
Orbital septum (fat protrusion)
Lid margins
Corneal abrasion
• Pain, FB sensation, tearing, photophobia, conjunctival injection
• Evert lids to look for FB
• Treat with cycloplegic, topical antibiotic, oral analgesics
• Avoid eye patch (esp if vegetable matter or contacts)
Corneal rust ring
• Can remove FB after topical anesthetic
• Use 25 g needle
• Refer for removal of rust ring the next day
Globe perforation
• Bell’s phenomenon– eyeball rolls upward and
outward in response to eye closure
• Perforations often located in inferior aspect of globe
• Teardrop/irregular pupil, flattening of anterior
chamber, black iris pigment at wound edges,
decreased visual acuity
• Seidel test– fluorescein stain flows from lac in
“riverlike” pattern b/c aqueous humor leakage
• DO NOT check IOP!
• Metal eye shield, NPO, tetanus, IV abx, analgesics
Hyphema
• Bleeding into anterior chamber from blood vessels of ciliary body or
iris
• Eye pain, photophobia, blurred vision
• Examine in sitting position so blood layers in anterior chamber
• Keep HOB 45⁰, metal eye shield, avoid eye movement, no ASA or
NSAIDs
• B-blockers, alpha-agonists, carbonic anhydrase inhibitors (avoid in
sickle cell)
• Complications– rebleeding 2-5 days later, secondary glaucoma,
corneal staining
Retrobulbar hematoma
• Extreme blunt or deep penetrating trauma
• Proptosis, decreased vision, pain, limited mobility, increased IOP,
afferent pupillary defect
• Lateral canthotomy
Neck Injuries
Neck injuries
• Most common cause of death is
exsanguination
• Vascular injury occurs in 25% of
penetrating neck wounds (IJ, carotid)
• Historically, all injuries that penetrate
platysma explored surgically
Zones of the neck
• Zone I: base of neck to cricoid cartilage
• Structures– subclavian vessels, brachiocephalic
veins, common carotid arteries, aortic arch, jugular
veins, trachea, esophagus, lung apices, cervical
spine, spinal cord, cervical nerve roots
• Angiography needed to determine integrity of
thoracic outlet vessels
• Positive angio may necessitate thoracotomy
Zones of the neck
• Zone II: cricoid cartilage to angle of mandible
• Structures– carotid and vertebral arteries, jugular
veins, pharynx, larynx, trachea, esophagus,
cervical spine, spinal cord
• Most common location for penetrating trauma
• Easily accessible surgically
• Some recommend CT angio or carotid duplex
Zones of the neck
• Zone III: angle of mandible to base of skull
• Structures– salivary and parotid glands,
esophagus, trachea, vertebral bodies, carotid
arteries, jugular veins, major nerves (CN IX-XII)
• Difficult to expos surgically
• Angio to assess internal carotid and intracerebral
circulation
Spine Injuries
Spine injuries
• Spinal cord ends at L2
• Cross-table lateral must visualize all 7 cervical
vertebrae and C7-T1 interspace
• NEXUS criteria
•
•
•
•
•
No midline tenderness
No focal neurologic deficit
Normal alertness
No intoxication
No painful distracting injury
Jefferson fracture
• C1 ring blowout
• Axial load injury
• Seen on open-mouth odontoid view
Odontoid fractures
• Swelling anterior to C2 on lateral film
• Abnormalities on open-mouth odontoid
• Type I– tip of the dens
• Type II– traverses dens at junction of body of C2
• Type III– involves vertebral body of C2
Cervical spine fractures
• Hangman’s fracture
• Bipeduncular fx of C2
• Extension injury
• Clay shoveler’s fracture
• Flexion avulsion fx of spinous
process of C6-T3 (C7 most
common)
• Flexion injury
• Direct blow to spinous process
Vertebral injuries
• Facet dislocation
• Unilateral (flexion-rotation)
• Bilateral (flexion)
• Anterior displacement of superior
vertebral body relative to
adjoining inferior vertebral body
• Flexion teardrop fracture
• Significant disruption of posterior
ligaments
• Anterior cord syndrome
Vertebral fractures
• Chance fracture
• Transverse fx through vertebral
body from flexion about axis
anterior to vertebral column
• MVC when only lap belt worn
• Associated with retroperitoneal
and abdominal visceral injuries
• Fracture-dislocations
• Extreme flexion or severe blunt
trauma
• Disruption of posterior elements
(pedicles, facets, laminae)
• Often complete neuro deficit
Spinal Cord Syndromes
Anterior cord syndrome
• Flexion injury
• Loss of function of anterior 2/3 of
cord
• Complete loss of motor, pain,
temperature below level
• Preservation of posterior column
functions of vibration and position
Central cord syndrome
• Hyperextension injury in patients with
degenerative spurring or congenital
narrowing
• Weakness greater in arms than legs
• Good prognosis
Brown-Sequard syndrome
• Penetrating injury hemisects cord
• Ipsi motor paralysis, loss of proprioception
and vibration
• Contra loss of pain and temperature
• Good prognosis
Cauda equina syndrome
• Injury to lumbar, sacral, coccygeal nerve roots
causing peripheral nerve injury
• Motor/sensory loss in lower extremities
• Bladder dysfunction (most consistent)
• Bowel dysfunction
• Saddle anesthesia
• Decreased rectal tone
• Weakness in dorsiflexion of great toe
Neurogenic shock
• Loss of neurologic function and accompanying
autonomic tone
• Flaccid paralysis
• Loss of reflexes
• Loss of urinary and rectal tone
• Bradycardia (may need atropine, pacemaker)
• Hypotension (IVF, +/- dopamine or
phenylephrine)
• Hypothermia
• Ileus
SCIWORA
• Spinal Cord Injury Without Radiographic Abnormalities
• Kids more susceptible b/c greater elasticity of cervical structures
• Brief episode of upper extremity weakness or paresthesias
• Delayed development of neuro deficits
• Must obtain MRI
Thoracic Trauma
Tension pneumothorax
• Respiratory distress
• Hypotension
• Tachycardia
• PEA
• Tracheal deviation away
• Absent breath sounds
• Hyperresonance
• Needle thoracostomy followed by tube
thoracostomy
Simple pneumothorax
• Decreased breath sounds
• Hyperresonance
• Dyspnea
• Diagnosed best on expiratory CXR
• May observe up to 25%
• Always chest tube if transport by
air
Flail chest
• Contiguous rib fx in multiple places
• Paradoxical movement of chest
wall
• Do not wrap chest
Pulmonary contusion
• Most common potentially lethal chest injury
• Direct chest wall trauma
• Dyspnea, tachypnea, tachycardia, chest wall
tenderness/ecchymosis, rib fractures
• CXR findings localized to site of injury
• Usually present on arrival and always within 6 hours
• Treat with O2, pulmonary hygiene, pain control
• May need intubation and ventilation with good lung
down
• Pneumonia is most common complication
Hemothorax
•
•
•
•
•
•
•
CXR requires 200-300 ml
Blunting of costophrenic angle on upright
Diminished breath sounds
Dullness to percussion
Decreased tactile fremitus
Most need chest tube
Thoracotomy
•
•
•
•
•
Blood loss >1500 initial drainage
Persistent bleeding requiring continuous transfusion
Hypotension or decompensation
Blood loss >200 ml/hr for 2-4 hours
50% hemorrhage
Myocardial contusion
• High-speed deceleration
• Heart (usually RV) strikes sternum
• ECG neither sensitive or specific
• Sinus tachycardia, multiple PVCs, atrial fib, bundle
branch block (RBBB), ST-T wave changes
• Echo
• Impaired regional systolic function, increased enddiastolic wall thickness
Traumatic myocardial infarction
• Coronary artery occlusion by arterial spasm, intimal tear, thrombosis,
compression from adjacent hemorrhage/edema
• Pre-existing CAD at greatest risk
• Thrombolytics contraindicated
Pericardial tamponade
• Penetrating trauma most common
• Rapid deceleration of blood filled ventricles
during early systole or late
diastolerents/tears/lacs of rigid myocardial
wallimpending myocardial rupture
• 60-100 ml in pericardium
• Beck’s triad– hypotension, JVD, muffled heart
tones
• Decreased pulse pressure, rising CVP, Kussmaul’s
sign, pulsus paradoxus
• Electrical alternans, PEA, pericardial fluid on US
• Pericardiocentesis, open thoracotomy
Traumatic aortic rupture
• Sudden deceleration
• Most occur at ligamentum arteriosum (point of
greatest aortic fixation) just distal to left subclavian
• Retrosternal pain
• Dyspnea
• Harsh systolic murmur
• Upper extremity hypertension
• Decreased/absent femoral pulses
• Ischemic pain of extremities
• paraplegia
Traumatic aortic rupture findings
•
•
•
•
•
•
•
•
•
•
Widening of superior mediastinum
Obliterated/indistinct aortic knob (most reliable)
Deviation of trachea and/or esophagus to right
Depression of left mainstem bronchus >40⁰ below
horizontal
Obliteration of space between pulmonary artery and aorta
Left apical pleural cap
Multiple rib fractures
Widening and/or displacement of paratracheal stripe to
right
Widening of left or right paraspinous stripe
Fractures of first or second ribs or scapula
Abdominal Trauma
Abdominal trauma
• Blunt trauma-- spleen most commonly injured organ; followed by liver
• Penetrating trauma– liver most commonly injured organ; followed by small
bowel
• GSW– high incidence of peritoneal cavity penetration and intraperitoneal
injury
• Most require laparotomy
• Stab wounds– low incidence of intraperitoneal injuries
• Exploration, diagnostic laparoscopy
• Most common location is LUQ
• Solitary lap belt– jejunal injuries and mesenteric lacerations
Ultrasound
• Initial diagnostic modality for hemodynamically stable
and unstable patients with blunt trauma
• Advantages
•
•
•
•
•
Noninvasive
Detects intraabdominal/pericardial/pleural fluid
Rapid, safe, portable, doesn’t interfere with resuscitation
No contrast
Sensitive
• Disadvantages
•
•
•
•
Can miss bowel and retroperitoneal injuries
Cannot differentiate fluids
Impaired in obese
Operator dependent
Ultrasound
• Unstable patient + positive US laparotomy
• Stable patient + positive US CT
• Unstable patient + negative US repeat US or DPL
• Stable patient + negative US observation
CT
• Study of choice for hemodynamically stable patients with blunt trauma, GU
trauma, suspected retroperitoneal injuries
• Advantages
• Noninvasive
• Gives information on specific organ injury
• Diagnoses retroperitoneal and pelvic injuries
• Disadvantages
•
•
•
•
Contrast
More time than DPL
Expert interpretation
Can miss diaphragm, pancreas, bladder, bowel injuries
• Normal VS + normal US CT can be deferred
• Normal VS + positive US CT
DPL
• Identify intraabdominal bleeding or bowel injury that requires immediate
laparotomy in unstable patient if FAST not available or inconclusive
• Advantages
• Rapid
• Readily available
• Sensitive
• Disadvantages
• Invasive
• Misses retroperitoneal/diaphragm/isolated hollow viscus injuries
• Less specific
• Only contraindication to DPL is an existing indication for laparotomy
Genitourinary Trauma
Renal injury
• Flank ecchymosis
• Lateral abdominal tenderness/mass
• Hematuria
• Fracture of lower posterior ribs or lumbar vertebrae
• Deceleration injury can cause pedicle
injuryuncontrolled hemorrhage, renal ischemia,
exsanguination
• Diagnose with IVP, CT
Urethral injury
• Most common mechanism is straddle
injury
• Perineal pain
• Inability to void
• Gross hematuria
• Blood at urethral meatus
• Perineal swelling/ecchymosis
• Absent/high-riding/boggy prostate
• Diagnose with retrograde urethrogram
• Do not place foley catheter!
Bladder injury
• Extraperitoneal
• Full bladder poked by pelvic fx
• Nonsurgical tx
• Foley for 1-2 weeks
• Intraperitoneal
• Full bladder ruptures with urine spillage into
peritoneum
• Surgical tx
• Diagnose with CT cystography, retrograde
cystography
Other GU injuries
• Asymptomatic microscopic hematuria
• Not good predictor of GU injury
• Amount of blood does not correlate with severity of injury
• Close follow-up and repeat UA
• Penile fracture
• Sudden tear in tunica albuginea with rupture of corpora
cavernosum
• Snapping noise and immediate detumescence
• Testicular disruption
• Fall or kick to scrotum
• Swollen, ecchymotic scrotum
• Absent testis
Trauma in Pregnancy
Trauma in pregnancy
• Most common cause of non-obstetric maternal death during
pregnancy
• MVC, interpersonal violence, falls
• Fetal survival depends on maternal survival
• Management directed at resuscitation of mother
• Review normal physiologic changes of pregnancy
• Increased HR, decreased BP, increased plasma volume, physiologic anemia,
increased wbc, hyperventilation, uterine flow comprises 20% cardiac output
• LR better than NS for resuscitation
Trauma in pregnancy
• Position patients tilted to left to relieve compression of IVC from
gravid uterus
• >20 weeks should undergo continuous cardiotocographic monitoring
• Chest tubes– never below 4th ICS
• DPL– open, supraumbilical technique
• Rhogam
• Mini dose (50 mcg) if <12 weeks
• Standard dose (300 mcg) if >12 weeks
Trauma in pregnancy
• Uterine rupture
• Free intraperitoneal air
• Extended fetal extremities
• Abnormal fetal position
• Placental abruption
•
•
•
•
•
•
•
•
Vaginal bleeding
Abdominal pain
Uterine tenderness
Expanding fundal height
Maternal shock
Fetal distress
DIC
Only 50% detected by US
Perimortem C-section
• Fetal prognosis improves with advanced gestational age
• Maternal improvement may be from relief of aortocaval compression
by fetus
• Best if done within 5 minutes of maternal loss of vitals
Miscellaneous Traumatic
Conditions
Compartment syndrome
• Six Ps
•
•
•
•
•
•
•
•
•
•
Pain out of proportion to injury (earliest)
Paresthesias
Paralysis
Pallor
Palpable tenseness/tenderness
Pulselessness (latest)
Most consistent exam finding– loss of two-point discrimination
∆P <30 is indication for fasciotomy (∆P=DBP-CP)
Keep extremity level or slightly elevated
Most commonly seen with tibial fractures
Drowning
• 10-15% are dry
• No aspiration
• Laryngospasm with closed glottis
• Co-morbidities– hypothermia, hypotension, C-spine injuries
• Death usually due to hypoxia
• CXR normal, generalized pulmonary edema, perihilar pulmonary
edema
• Most common cause of dysrhythmia is hypoxia
• Most reliable prognostic indicators– duration of submersion and
resuscitation
Electrical shock
• Conduction system changes
• Cardiac– asystole, Vfib (most common cause of death in acute phase)
• CNS– respiratory, apnea, seizures (nerves have highest conductive capacity
• Thermal tissue damage
• Cutaneous burns and muscle injury
• Muscle injuryrhabdomyolysisrenal failure
• Blunt trauma
• Shock can throw victim
• Tetanic contractions– scapular fx, shoulder dislocations
Electrical shock
•
•
•
•
•
Most common entrance sites are hand and skull
Most common exit site is heel
Cleanse, tetanus, check for compartment syndrome, don’t debride
Beware of traumatic cataracts
Hospitalize
• High-voltage (>1000 V) burns
• Low-voltage (<1000 V) burns with sx (dysrhythmias, chest pain, cutaneous findings,
abnormal urine)
• Discharge
• Asx patients with low-voltage injuries after period of obs and cardiac monitoring
• Extent of cutaneous injury in no way correlates with amount of underlying
tissue damage
Lip burns
• Can have delayed bleeding from labial
artery 3-14 days later when eschar
separates
Rhabdomyolysis
• Muscle pain, weakness, tenderness, hypotension, AKI, shock
• Elevated CPK
• Hypocalcemia (63%)
• Hyperkalemia (40%); get an EKG
• Myoglobinuria (+blood but no rbc on microscopy)
• Maintain urine output 1.5-2.0 ml/kg/hr
• IVF, Lasix, mannitol, alkalinization of urine with sodium bicarbonate
Thermal burns
• Inhalation injury
•
•
•
•
•
•
•
•
Facial burns
Singed facial and nasal hair
Oropharyngeal inflammation
Carbon deposits in oropharynx
Carbonaceous sputum
Fire exposure in confined space
Circumferential burns of neck
Early intubation!!
Thermal burns
• Rule of Nines; Rule of Palms
• Parkland formula
• Fluid in 24 hours = 4 x weight (kg) x % BSA
• First half in 8 hours; second half next 16 hours
• Guide resuscitation based on urine output
• Adults 0.5-1.0 ml/kg/hr
• Kids 1-2 ml/kg/hr