Advanced Trauma Life Support ATLS Student Course Manual 2018
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170<br />
CHAPTER 9 n Thermal Injuries<br />
Thermal injuries are major causes of morbidity<br />
and mortality, but adherence to the basic<br />
principles of initial trauma resuscitation and<br />
the timely application of simple emergency measures<br />
can help minimize their impact. The major principles<br />
of thermal injury management include maintaining<br />
a high index of suspicion for the presence of airway<br />
compromise following smoke inhalation and secondary<br />
to burn edema; identifying and managing associated<br />
mechanical injuries; maintaining hemodynamic<br />
normality with volume resuscitation; controlling<br />
temperature; and removing the patient from the injurious<br />
environment. Clinicians also must take<br />
measures to prevent and treat the potential complications<br />
of specific burn injuries. Examples include<br />
rhabdomyolysis and cardiac dysrhythmias, which can<br />
be associated with electrical burns; extremity or truncal<br />
compartment syndrome, which can occur with large<br />
burn resuscitations; and ocular injuries due to flames<br />
or explosions.<br />
The most significant difference between burns and<br />
other injuries is that the consequences of burn injury<br />
are directly linked to the extent of the inflammatory<br />
response to the injury. The larger and deeper the burn,<br />
the worse the inflammation. Depending on the cause,<br />
the energy transfer and resultant edema may not be<br />
evident immediately; for example, flame injury is<br />
more rapidly evident than most chemical injuries—<br />
an important factor in burn injury management.<br />
Monitor intravenous lines closely to ensure they do<br />
not become dislodged as the patient becomes more<br />
edematous. Regularly check ties securing endotracheal<br />
and nasogastric tubes to ensure they are not too tight,<br />
and check that identification bands are loose or not<br />
circumferentially affixed.<br />
Note: Heat injuries, including heat exhaustion and<br />
heat stroke, are discussed in Appendix B: Hypothermia<br />
and Heat Injuries.<br />
clothing. Synthetic fabrics can ignite, burn rapidly<br />
at high temperatures, and melt into hot residue that<br />
continues to burn the patient. At the same time, take care<br />
to prevent overexposure and hypothermia. Recognize<br />
that attempts made at the scene to extinguish the fire<br />
(e.g., “stop, drop, and roll”), although appropriate,<br />
can lead to contamination of the burn with debris or<br />
contaminated water.<br />
Exercise care when removing any clothing that was<br />
contaminated by chemicals. Brush any dry chemical<br />
powders from the wound. Caregivers also can be injured<br />
and should avoid direct contact with the chemical. After<br />
removing the powder, decontaminate the burn areas by<br />
rinsing with copious amounts of warm saline irrigation<br />
or rinsing in a warm shower when the facilities are<br />
available and the patient is able.<br />
Once the burning process has been stopped, cover<br />
the patient with warm, clean, dry linens to prevent<br />
hypothermia.<br />
Establish Airway Control<br />
The airway can become obstructed not only from<br />
direct injury (e.g., inhalation injury) but also from<br />
the massive edema resulting from the burn injury.<br />
Edema is typically not present immediately, and signs<br />
of obstruction may initially be subtle until the patient<br />
is in crisis. Early evaluation to determine the need for<br />
endotracheal intubation is essential.<br />
Factors that increase the risk for upper airway<br />
obstruction are increasing burn size and depth, burns<br />
to the head and face, inhalation injury, associated<br />
trauma, and burns inside the mouth (n FIGURE 9-1). Burns<br />
localized to the face and mouth cause more localized<br />
Primary Survey and<br />
Resuscitation of Patients<br />
with BuRNs<br />
<strong>Life</strong>saving measures for patients with burn injuries<br />
include stopping the burning process, ensuring that<br />
airway and ventilation are adequate, and managing<br />
circulation by gaining intravenous access.<br />
Stop the Burning Process<br />
Completely remove the patient’s clothing to stop the<br />
burning process; however, do not peel off adherent<br />
n FIGURE 9-1 Factors that increase the risk for upper airway<br />
obstruction are increasing burn size and depth, burns to the head<br />
and face, inhalation injury, associated trauma, and burns inside<br />
the mouth.<br />
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