Trauma Bullets - February 2020

July 11, 2020

Case: Level 2 trauma 18 y/o M with facial and hand burns secondary to an exploded aerosol can thrown into a bonfire.

Airway compromise

- Beware the evolving airway in the burn patient; when in doubt secure the airway

- Classic findings for airway compromise include singed nasal hairs and soot in the oropharynx however nasal and facial hairs may not be present in an explosive injury and tracheal burns may not be evident on external exam.

- Other indications for intubation include hoarseness, stridor, AMS, full thickness burns to the face or perioral region, supraglottic edema or inflammation on bronchoscopy.

- Inhalation/explosive injuries have high incidences of airway compromise and will frequently have concomitant injuries and traumatic sequelae.

- Avoid succinylcholine in burns, classic teaching is to not use >72h after a burn or crush injury, if a non-depolarizing agent such as rocuronium is available it should be considered.

Indications for transfer to a burn center

- Partial thickness burns >10% TBSA

- Involvement of face, hands, feet, genitals, perineum, major joints

- Any 3rd degree burns

- Electrical burns, including lightning injury

- Chemical burns

- Inhalation injury

Total Body Surface Area (TBSA) Rule of 9’s

- Adults: 9% for each arm, 9% for the head, 18% each leg, 18% front of torso, 18% back of torso

- Children: 9% for each arm, 14% each leg, 18% for the head, 18% front torso, 18% back torso

- Size of patient’s fist: approximately 1% TBSA

Fluid resuscitation

The Parkland formula

- Fluid Requirement = TBSA(%) x Wt(kg) x 4mL

- Give first ½ in the first 8h, then give second ½ over the next 16h

- Typically used in TBSA burns of 20% or greater

Modified Brooke formula

- Initial 24h

- Adults: TBSA(%) x Wt(kg) x 2mL

- Children: TBSA(%) x Wt(kg) x 3mL

-Burn centers are moving toward the use of the Modified Brooke formula, however for boards and classical teaching purposes the Parkland formula is by far the most common resuscitation modality.

-More recent studies have shown that the Modified Brooke formula results in significantly less resuscitation volumes without resulting in higher morbidity or mortality. J Trauma. 2009 Aug;67(2):231-7

-Isotonic crystalloids (LR, Hartmann solution) are recommended in large-volume resuscitations to prevent the hyperchloremic acidosis associated with large-volume NS use.

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