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BURN AND BLAST INJURIES Capt Regan Miller CSTARS

BURN AND BLAST INJURIES Capt Regan Miller CSTARS

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BURN AND BLAST INJURIES Capt Regan Miller CSTARS

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  1. BURN AND BLAST INJURIESCapt Regan MillerCSTARS American Association of Critical Care Nurses Unclassified INTEGRITY—SERVICE—EXCELLENCE Reviewed 22 Jan 2010 Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  2. BURN AND BLAST INJURIES OBJECTIVES • - Go over trauma principles in the Primary survey • - Summarize Primary Survey adjunctive tests • - Briefly discuss the secondary survey • - Discuss burn principles and how they apply to the primary survey/fluid resuscitation • - Go over blast principles/management specifically primary, secondary, and tertiary Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  3. BURN AND BLAST INJURIESPrimary Survey • AIRWAY w/C-Spine protection • BREATHING • CIRCULATION • DISABILITY • EXPOSURE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  4. BURN AND BLAST INJURIESPrimary Survey Vertical vs. Horizontal resuscitation of a trauma patient Vertical = ATLS model (more time) Horizontal = Team Leader with assigned tasks (less time) Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  5. BURN AND BLAST INJIRESPrimary Survey Airway = establish patency; decide if patient needs definitive or not. Everyone gets O2 Breathing = absent or decrease breath sounds Circulation = stop obvious bleeds and check pulses Disability = GCS and pupils Exposure = completely expose, log roll, rectal exam, and burn calculations Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  6. BURN AND BLAST INJURIESPrimary Survey Adjuncts • EKG Monitoring • Urinary and gastric catheters • Contraindications • X-rays and diagnostic studies • Chest, and Pelvic X-Rays • FAST (Focused Abdominal Sonogram for Trauma) • Bedside procedure of choice for free intraperitoneal/pericardial fluid • Operator dependent • Consider need for transfer Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  7. BURN AND BLAST INJURIESSecondary Survey - Head to toe examination - Fingers and tubes in every orifice (if needed) - AMPLE history (allergies, meds, past med, last meal, events leading up to) Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  8. BURN AND BLAST INJURIES Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  9. BURN AND BLAST INJURIESBURN ASSESSMENT • All burn patients are trauma patients • Do not be distracted by the burn • Rarely immediately life threatening Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  10. BURN AND BLAST INJURIESASSESSMENT • Stop the burning process! • Airway/C-spine: soot, sloughed tissue, edema • Anticipate need for early intubation • C-spine precautions esp with electrical burns • Breathing: restrictive circumferential chest burns • Circulation: extremity perfusion, compartment syndrome, I.V. access • Disability: neurologic (GCS) prior to RSI • Expose: calculate burn size %TBSA, remove clothing and jewelry, elevate burned extremity • Fluids: Parkland formula, two 16 ga I.V.s Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  11. BURN AND BLAST INJURIESBURNS - AIRWAY • Inhalation injury is the most frequent cause of death in thermal injuries • Anticipate need for early intubation • Severe facial burns, smoke inhalation- confined space, stridor, hoarseness, cough, carbonaceous sputum, cinged facial hair • Use large (8mm) ETT to facilitate bronchoscopy • Prophylacticallyintubate prior to transport • Closed vs open space Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  12. BURN AND BLAST INJURIESBURNS - AIRWAY Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  13. BURN AND BLAST INJURIESBURNS - AIRWAY 13 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  14. BURN AND BLAST INJURIESBURNS BREATHING • Physiologic tourniquet • ↑ airway pressures • ↑ pCO2 • ↓ SaO2 • Escharotomy • Bilateral anterior axillary lines • Subcostal margin 14 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  15. BURN AND BLAST INJURIESBURNS CIRCULATION • Control hemorrhage • Establish two 16 ga I.V.s • Through burned tissue if necessary • Fluid resuscitation with LR • Monitor for compartment syndromes • Extremity and abdomen • Absent distal pulses, etc.. • Usually happens in first few hours of admission 15 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  16. BURN AND BLAST INJURIESBURNS • % TBSA x wt (kg) x 2-4 cc • LR over first 24 hours • ½ Volume in first 8 hrs • ½ Volume in next 16 hrs • TBSA • Based on the Rule of Nines for adults • Doesn’t apply for infants, children • Patient’s hand = 1% TBSA • Adjust fluid • Based on urine output/MAPs 16 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  17. BURN AND BLAST INJURIESBURNS – TBSA ESTIMATION • “Rule of Nines”- good for adults • Each upper ext 9% • Head, neck 9% • Lower ext 18% • Ant and post trunk 18% • Perineum, genitalia 1% • Palm of hand 1% Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  18. BURN AND BLAST INJURIESBURNS – TBSA ESTIMATION, INFANTS & CHILDREN 18 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  19. BURN AND BLAST INJURIESBURNS – EXTREMITY CARE • Circumferential burn • Assess for distal perfusion • If decreasing, escharotomy • Exercise burned extremities hourly • Sulfamylon solution soaked dressings 19 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  20. BURN AND BLAST INJURIESBURNS – WOUND CARE • IV pain management • Remove foreign bodies • Debridement / unroof blisters • Clean with surgical soap • Topical antimicrobials • Scalp, trunk, neck, and • extremities in sulfamylon • solution soaked dressings (painful) • Silvadene cream first choice for awake pt, no eschar penetration • Sulfamylon cream to burns on ears, nose • Bacitracin to face burns • Tetanus 20 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  21. BURN AND BLAST INJURIESBURNS – WOUND CARE • Prevent hypothermia • Patch corneal abrasions • Bacitracin to eyelids • E-mycinoint to eyes • Inspect daily: • Chemical cellulitis • Burn-wound infection • Avoid definitive burn surgery in combat zone Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  22. BURN AND BLAST INJURIESBURNS – FURTHER CARE • Stress ulcer prophylaxis • Early enteral nutrition • Monitor for abdominal compartment syndrome • Anticipate persistent hypermetabolic state • Assess airway prior to extubation 22 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  23. BURN AND BLAST INJURIESBURNS – ELECTRICAL • High-voltage injury (>1,000 Volts) • Deep muscle injury • Rhabdomyolysiswith myoglobinuria • Hyperkalemia • Acute renal failure • Compartment syndrome • Treat for rhabdomyolysis • At risk for spine fracture 20 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  24. BURN AND BLAST INJURIESBURNS – CHEMICAL • Remove offending agent immediately • Brush-off dry material • Copious lavage • Alkali burns require several hours water lavage • Resuscitate and manage as thermal burn 24 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  25. BURN AND BLAST INJURIESBURNS – TRIAGE CONSIDERATIONS • Immediate • Inhalation, chemical or electrical, trauma • Delayed • 15-20% TBSA • Minimal • <15% TBSA (1° or 2°) • Not face, hands, genitalia • Expectant • >80% 25 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  26. BURN AND BLAST INJURIESBLAST INJURIES • Blasts occur from multiple causes • Military weapons • Terrorist bombings • Natural disasters • Man-made disasters 26 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  27. BURN AND BLAST INJURIESBLAST INJURIES • http://www.youtube.com/watch?v=PVG_WftW73E Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  28. BURN AND BLAST INJURIESBLAST INJURIES Civilian, as well as military http://www.youtube.com/watch?v=jtde8GOCbtI Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  29. BURN AND BLAST INJURIESBLAST INJURIES Explosion • Primary • Secondary • Tertiary • Burns 29 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  30. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Primary Blast Injuries • Caused by the direct effect of the blast wave upon the body through energy transfer (barotrauma) • Injury is seen almost exclusively in gas containing structures • Ear: most sensitive • Respiratory system: most common cause of early morbidity and mortality • Gastrointestinal tract: most common cause of delayed morbidity and mortality 30 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  31. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Ear Injuries • Tympanic membrane rupture • Foreign material in ear • Inner ear damage • Hearing loss • Care: varies by injuries from observation to specialist consultation 31 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  32. BURN AND BLAST INJURIESBLAST - PRIMARY INJURIES • Lung Injuries • Pulmonary contusions • Pneumothorax • Traumatic lung cyst • Pneumomediastinum • Interstitial emphysema • Subcutaneous emphysema • Air emboli Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  33. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Lung Treatment • ABC’s • Chest tube for pneumothorax • Supportive care • Oxygen • Respiratory care • Mechanical ventilation • Watch for tension pneumothorax or air emboli 33 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  34. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Air Emboli • Symptoms / severity depend on which vascular bed has been compromised • Retinal vessels • Coronary arteries • Cerebral circulation • Most common cause sudden death • Treatment • Supportive by system involved • Hyperbaric O2 34 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  35. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Gastrointestinal Tract Injuries • Hematomas and perforations of the bowel • Hematomas and tears of the mesentery • Rupture of the hollow abdominal viscera • Presentation delayed • Underwater blast can cause pure primary blast injury to gastrointestinal tract 33 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  36. BURN AND BLAST INJURIESBLAST – PRIMARY INJURIES • Gastrointestinal Tract • Examination • Serial exams (presentation can be delayed) • Diagnostic peritoneal lavagevs FAST exam • Treatment • Abdominal exploration and definitive repair 34 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  37. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES • Secondary Blast Injuries • From fragments or secondary missiles propelled by the blast • Treat the same as other penetrating injuries 37 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  38. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES 38 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  39. BURN AND BLAST INJURIESBLAST – SECONDARY INJURIES 37 INTEGRITY—SERVICE—EXCELLENCE Unclassified Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  40. BURN AND BLAST INJURIESBLAST – TERTIARY INJURIES • Tertiary Blast Injuries • Occurs when the victim is thrown against the ground or solid objects • Injuries are similar to blunt trauma or falls • Care follows blunt trauma guidelines • Multiple mechanism, multiple trauma • Common to see all three components of blast injury in varying degrees at once • Plus -- can get thermal, chemical, and biological injuries 40 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  41. BURN AND BLAST INJURIES SUMMARY • A, B, C, D, E, Fs of burn care • TBSA calculation • Wound care • Electrical and chemical • Transfer criteria • Burn triage • Burn record Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  42. BURN AND BLAST INJURIES SUMMARY • IDENTIFIED THE GENERAL PRINCIPLES OF BURN MANAGEMENT • DISCUSSED THE PRINCIPLES OF TRAUMA MANAGEMENT FOR BLAST INJURIES 40 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10

  43. BURN AND BLAST INJURIES QUESTIONS ?????? 41 Unclassified INTEGRITY—SERVICE—EXCELLENCE Distribution A: Approved for public release; distribution is unlimited. 311 ABG/PA No. 10-109, 7 APR 10