Advanced Trauma Life Support ATLS Student Course Manual 2018

176
CHAPTER 9 n Thermal Injuries
that represent multiples of 9%. BSA distribution differs
considerably for children, because a young child’s head
represents a larger proportion of the surface area, and
the lower extremities represent a smaller proportion
than an adult’s. The palmar surface (including the
fingers) of the patient’s hand represents approximately
1% of the patient’s body surface. The rule of nines helps
estimate the extent of burns with irregular outlines or
distribution and is the preferred tool for calculating
and documenting the extent of a burn injury.
Pitfall
Overestimating or
underestimating
burn size
prevention
• Do not include superficial burns
in size estimation.
• Use the rule of nines, recognizing
that children have a proportionately
larger head than
adults do.
• For irregular or oddly sized
burns, use the patient’s palm
and fingers to represent 1% BSA.
• Remember to logroll the patient
to assess their posterior aspect.
pliable and elastic it becomes; therefore these areas
may appear to be less swollen.
Secondary Survey and
Related Adjuncts
Key aspects of the secondary survey and its related
adjuncts include documentation, baseline trauma
bloodwork, including carboxyhemoglobin levels,
and x-rays, maintenance of peripheral circulation in
circumferential extremity burns, gastric tube insertion,
narcotic analgesics and sedatives, wound care, and
tetanus immunization.
Documentation
A flow sheet or other report that outlines the patient’s
treatment, including the amount of fluid given and a
pictorial diagram of the burn area and depth, should
be initiated when the patient is admitted to the ED.
This flow sheet should accompany the patient when
transferred to the burn unit.
Depth of Burn
The depth of burn is important in evaluating the severity
of a burn, planning for wound care, and predicting
functional and cosmetic results.
Superficial (first-degree) burns (e.g., sunburn) are
characterized by erythema and pain, and they do
not blister. These burns are not life threatening and
generally do not require intravenous fluid replacement,
because the epidermis remains intact. This type of
burn is not discussed further in this chapter and is not
included in the assessment of burn size.
Partial-thickness burns are characterized as either
superficial partial thickness or deep partial thickness.
Superficial partial-thickness burns are moist, painfully
hypersensitive (even to air current), potentially
blistered, homogenously pink, and blanch to touch
(n FIGURE 9-5 A and B). Deep partial-thickness burns
are drier, less painful, potentially blistered, red or
mottled in appearance, and do not blanch to touch
(n FIGURE 9-5 C).
Full-thickness burns usually appear leathery (n FIGURE
9-5 D). The skin may appear translucent or waxy white.
The surface is painless to light touch or pinprick and
generally dry. Once the epidermis is removed, the
underlying dermis may be red initially, but it does
not blanch with pressure. This dermis is also usually
dry and does not weep. The deeper the burn, the less
Baseline Determinations for Patients
with Major Burns
Obtain blood samples for a complete blood count
(CBC), type and crossmatch/screen, an arterial blood
gas with HbCO (carboxyhemoglobin), serum glucose,
electrolytes, and pregnancy test in all females of
childbearing age. Obtain a chest x-ray in patients
who are intubated or suspected of having smoke
inhalation injury, and repeat films as necessary.
Other x-rays may be indicated for appraisal of
associated injuries.
Peripheral Circulation in
Circumferential Extremity Burns
The goal of assessing peripheral circulation in a patient
with burns is to rule out compartment syndrome.
Compartment syndrome results from an increase in
pressure inside a compartment that interferes with
perfusion to the structures within that compartment.
In burns, this condition results from the combination
of decreased skin elasticity and increased edema in
the soft tissue. In extremities, the main concern is
perfusion to the muscle within the compartment. Although
a compartment pressure greater than systolic
blood pressure is required to lose a pulse distal
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