Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 9 Outline Objectives iNtroduction pRimARy Survey and Resuscitation of Patients with BuRNs • Stop the Burning Process • Establish Airway Control • Ensure Adequate Ventilation • Manage Circulation with Burn Shock Resuscitation Patient Assessment • History • Body Surface Area • Depth of Burn Secondary Survey and Related Adjuncts • Documentation • Baseline Determinations for Patients with Major Burns • Peripheral Circulation in Circumferential Extremity Burns • Gastric Tube Insertion • Narcotics, Analgesics, and Sedatives • Wound Care • Antibiotics • Tetanus Unique Burn Injuries • Chemical Burns • Electrical Burns • Tar Burns • Burn Patterns Indicating Abuse Patient Transfer • Criteria for Transfer • Transfer Procedures Cold Injury: Local Tissue Effects • Types of Cold Injury • Management of Frostbite and Nonfreezing Cold Injuries Cold Injury: Systemic Hypothermia Teamwork Chapter Summary BibliogRAphy OBJECTIVES After reading this chapter and comprehending the knowledge components of the <strong>ATLS</strong> provider course, you will be able to: 1. Explain how the unique pathophysiology of burn injury affects the approach to patient management when compared with other traumatic injuries. 2. Identify the unique problems that can be encountered in the initial assessment of patients with burn injuries. 3. Describe how to manage the unique problems that can be encountered in the initial assessment of patients with burn injuries. 4. Estimate the extent of the patient’s burn injury, including the size and depth of the burn(s), and develop a prioritized plan for emergency management of the patient’s injuries. 5. Describe the unique characteristics of burn injury that affect the secondary survey. 6. Describe common mechanisms of burn injuries, and explain the impact of specific mechanisms on management of the injured patients. 7. List the criteria for transferring patients with burn injuries to burn centers. 8. Describe the tissue effects of cold injury and the initial treatment of patients with tissue injury from cold exposure. 9. Describe the management of patients with hypothermia, including rewarming risks. n BACK TO TABLE OF CONTENTS 169
170 CHAPTER 9 n Thermal Injuries Thermal injuries are major causes of morbidity and mortality, but adherence to the basic principles of initial trauma resuscitation and the timely application of simple emergency measures can help minimize their impact. The major principles of thermal injury management include maintaining a high index of suspicion for the presence of airway compromise following smoke inhalation and secondary to burn edema; identifying and managing associated mechanical injuries; maintaining hemodynamic normality with volume resuscitation; controlling temperature; and removing the patient from the injurious environment. Clinicians also must take measures to prevent and treat the potential complications of specific burn injuries. Examples include rhabdomyolysis and cardiac dysrhythmias, which can be associated with electrical burns; extremity or truncal compartment syndrome, which can occur with large burn resuscitations; and ocular injuries due to flames or explosions. The most significant difference between burns and other injuries is that the consequences of burn injury are directly linked to the extent of the inflammatory response to the injury. The larger and deeper the burn, the worse the inflammation. Depending on the cause, the energy transfer and resultant edema may not be evident immediately; for example, flame injury is more rapidly evident than most chemical injuries— an important factor in burn injury management. Monitor intravenous lines closely to ensure they do not become dislodged as the patient becomes more edematous. Regularly check ties securing endotracheal and nasogastric tubes to ensure they are not too tight, and check that identification bands are loose or not circumferentially affixed. Note: Heat injuries, including heat exhaustion and heat stroke, are discussed in Appendix B: Hypothermia and Heat Injuries. clothing. Synthetic fabrics can ignite, burn rapidly at high temperatures, and melt into hot residue that continues to burn the patient. At the same time, take care to prevent overexposure and hypothermia. Recognize that attempts made at the scene to extinguish the fire (e.g., “stop, drop, and roll”), although appropriate, can lead to contamination of the burn with debris or contaminated water. Exercise care when removing any clothing that was contaminated by chemicals. Brush any dry chemical powders from the wound. Caregivers also can be injured and should avoid direct contact with the chemical. After removing the powder, decontaminate the burn areas by rinsing with copious amounts of warm saline irrigation or rinsing in a warm shower when the facilities are available and the patient is able. Once the burning process has been stopped, cover the patient with warm, clean, dry linens to prevent hypothermia. Establish Airway Control The airway can become obstructed not only from direct injury (e.g., inhalation injury) but also from the massive edema resulting from the burn injury. Edema is typically not present immediately, and signs of obstruction may initially be subtle until the patient is in crisis. Early evaluation to determine the need for endotracheal intubation is essential. Factors that increase the risk for upper airway obstruction are increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth (n FIGURE 9-1). Burns localized to the face and mouth cause more localized Primary Survey and Resuscitation of Patients with BuRNs <strong>Life</strong>saving measures for patients with burn injuries include stopping the burning process, ensuring that airway and ventilation are adequate, and managing circulation by gaining intravenous access. Stop the Burning Process Completely remove the patient’s clothing to stop the burning process; however, do not peel off adherent n FIGURE 9-1 Factors that increase the risk for upper airway obstruction are increasing burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth. n BACK TO TABLE OF CONTENTS
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TENTH EDITION ATLS ® Advanced Trau
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Chair of Committee on Trauma: Ronal
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FOREWORD My first exposure to Advan
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viii PREFACE MyATLS Mobile Applicat
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x PREFACE Gary A. Vercruysse, MD, F
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xii PREFACE Jacqueline Bustraan, MS
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ACKNOWLEDGMENTS It is clear that ma
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xvii ACKNOWLEDGMENTS Bertil Bouillo
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xix ACKNOWLEDGMENTS Oscar Guillamon
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xxi ACKNOWLEDGMENTS Mahesh Misra, M
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xxiii ACKNOWLEDGMENTS James Vosswin
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xxv ACKNOWLEDGMENTS James A. Geilin
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xxvii ACKNOWLEDGMENTS Tone Slåke R
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xxx COURSE OVERVIEW m. Protection o
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xxxii COURSE OVERVIEW Atls and Trau
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xxxiv COURSE OVERVIEW a systematize
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xxxvi COURSE OVERVIEW 69. Switzerla
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xxxviii COURSE OVERVIEW United Stat
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xl COURSE OVERVIEW 67. Hendrickson
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xlii COURSE OVERVIEW 122. Palusci V
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BRIEF CONTENTS Foreword Preface Ack
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xlviii DETAILED CONTENTS Teamwork 5
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l DETAILED CONTENTS Introduction 21
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1 INITIAL ASSESSMENT AND MANAGEMENT
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4 CHAPTER 1 n Initial Assessment an
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10 CHAPTER 1 n Initial Assessment a
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2 AIRWAY AND VENTILATORY MANAGEMENT
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24 CHAPTER 2 n Airway and Ventilato
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3 SHOCK The first step in the initi
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44 CHAPTER 3 n Shock The first step
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46 CHAPTER 3 n Shock Recognition of
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48 CHAPTER 3 n Shock However, the a
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50 CHAPTER 3 n Shock Class II Hemor
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52 CHAPTER 3 n Shock hypothermia, a
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54 CHAPTER 3 n Shock replacement du
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56 CHAPTER 3 n Shock aggregation an
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58 CHAPTER 3 n Shock Presence of Pa
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60 CHAPTER 3 n Shock rate can be ac
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4 THORACIC TRAUMA Thoracic injury i
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64 CHAPTER 4 n Thoracic Trauma Thor
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66 CHAPTER 4 n Thoracic Trauma shoc
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68 CHAPTER 4 n Thoracic Trauma comp
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70 CHAPTER 4 n Thoracic Trauma Norm
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72 CHAPTER 4 n Thoracic Trauma Seco
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74 CHAPTER 4 n Thoracic Trauma A B
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76 CHAPTER 4 n Thoracic Trauma Spec
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78 CHAPTER 4 n Thoracic Trauma temp
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80 CHAPTER 4 n Thoracic Trauma 18.
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ABDOMINAL AND 5 PELVIC TRAUMA When
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84 CHAPTER 5 n Abdominal and Pelvic
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100 CHAPTER 5 n Abdominal and Pelvi
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6 HEAD TRAUMA The primary goal of t
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104 CHAPTER 6 n Head Trauma Head in
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106 CHAPTER 6 n Head Trauma fibrous
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108 CHAPTER 6 n Head Trauma n FIGUR
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110 CHAPTER 6 n Head Trauma table 6
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112 CHAPTER 6 n Head Trauma covery.
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Page 182 and 183: CHAPTER 7 Outline Objectives iNtrod
Page 184 and 185: ANATOMY AND PHYSIOLOGY 131 B A n FI
Page 186 and 187: RIGHT INTERNATIONAL STANDARDS FOR N
Page 188 and 189: DOCUMENTATION OF SPINAL CORD INJURI
Page 190 and 191: SPECIFIC TYPES OF SPINAL INJURIES 1
Page 192 and 193: RADIOGRAPHIC EVALUATION 139 Penetra
Page 194 and 195: GENERAL MANAGEMENT 141 When the low
Page 196 and 197: GENERAL MANAGEMENT 143 them to the
Page 198 and 199: BIBLIOGRAPHY 145 Bibliography 1. Bi
Page 201 and 202: 8 MUSCULOSKELETAL TRAUMA Injuries t
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Page 221: 9 THERMAL INJURIES The most signifi
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Page 239 and 240: 10 PEDIATRIC TRAUMA Injury remains
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Page 270 and 271: PRIMARY SURVEY WITH RESUSCITATION 2
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PRIMARY SURVEY WITH RESUSCITATION 2
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SPECIFIC INJURIES 221 table 11-6 ph
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BIBLIOGRAPHY 223 comprise only 12%
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12 TRAUMA IN PREGNANCY AND INTIMATE
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228 CHAPTER 12 n Trauma in Pregnanc
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240 CHAPTER 13 n Transfer to Defini
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Appendix A OCULAR TRAUMA OBJECTIVES
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259 APPENDIX A n Ocular Trauma In c
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261 APPENDIX A n Ocular Trauma to t
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Appendix B HYPOTHERMIA AND HEAT INJ
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267 APPENDIX B n Hypothermia and He
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Appendix C TRAUMA CARE IN MASS-CASU
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277 APPENDIX C n Trauma Care in Mas
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Appendix D DISASTER PREPAREDNESS AN
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291 APPENDIX D n Disaster Preparedn
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Pitfall Inadequate security Failed
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Appendix E ATLS AND TRAUMA TEAM RES
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305 APPENDIX E n ATLS and Trauma Te
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Appendix F TRIAGE SCENARIOS OBJECTI
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319 APPENDIX F n Triage Scenarios T
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333 APPENDIX F n Triage Scenarios 4
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Skill Station A AIRWAY Part 1: Basi
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339 APPENDIX G n Skills One-Person
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341 APPENDIX G n Skills STEP 5. Con
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343 APPENDIX G n Skills STEP 13. Co
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346 APPENDIX G n Skills STEP 1. D
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Skill Station C CIRCULATION LEARNIN
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351 APPENDIX G n Skills manual trac
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353 APPENDIX G n Skills STEP 3. Aft
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355 APPENDIX G n Skills STEP 2. If
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358 APPENDIX G n Skills A. Note fac
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360 APPENDIX G n Skills •• Flex
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362 APPENDIX G n Skills Utilization
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366 APPENDIX G n Skills n FIGURE G-
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368 APPENDIX G n Skills less than 1
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372 APPENDIX G n Skills G. Inspect
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374 APPENDIX G n Skills in the inju
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378 INDEX LTA for, 31-32, 32f Malla
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380 INDEX atlanto-occipital disloca
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382 INDEX Frostbite, 181-183, 182f
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384 INDEX Kussmaul’s sign, 69 Lac
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386 INDEX PEA. See Pulseless electr
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388 INDEX for musculoskeletal traum
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390 INDEX Tibial fractures, 163 Tou
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TRAUMA SCORES Correct triage is ess
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394 TRAUMA SCORES on Field Triage,
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396 INJURY PREVENTION Safety Admini
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398 INJURY PREVENTION providers to
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BIOMECHANICS OF INJURY Injuries occ
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402 BIOMECHANICS OF INJURY Ejection
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404 BIOMECHANICS OF INJURY •• A
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406 BIOMECHANICS OF INJURY in a 30-
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408 TETANUS IMMUNIZATION •• Wou
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410 TETANUS IMMUNIZATION Summary Gu
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SAMPLE TRAUMA FLOW SHEET Page 1 of
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414 SAMPLE TRAUMA FLOW SHEET Page 3
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420 SAMPLE TRAUMA FLOW SHEET Some h
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