Advanced Trauma Life Support ATLS Student Course Manual 2018

178
CHAPTER 9 n Thermal Injuries
junction of the thorax and abdomen usually relieve
the problem.
To maintain peripheral circulation in patients with
circumferential extremity burns, the clinician should:
••
Remove all jewelry and identification or allergy
bands on the patient’s extremities.
••
Assess the status of distal circulation, checking
for cyanosis, impaired capillary refill, and
progressive neurologic signs such as paresthesia
and deep-tissue pain. Assessment of peripheral
pulses in patients with burns is best performed
with a Doppler ultrasonic flow meter.
••
Relieve circulatory compromise in a circumferentially
burned limb by escharotomy, always with
surgical consultation. Escharotomies usually are
not needed within the first 6 hours of a burn injury.
••
Although fasciotomy is seldom required, it may
be necessary to restore circulation in patients
with associated skeletal trauma, crush injury,
or high-voltage electrical injury.
••
Although standard escharotomy diagrams are
generally followed, always attempt to incise
the skin through the burned, not the unburned
skin (if unburned skin is present), as the burned
skin will likely be debrided by the burn center.
Gastric Tube Insertion
Insert a gastric tube and attach it to a suction setup if
the patient experiences nausea, vomiting, or abdominal
distention, or when a patient’s burns involve more
than 20% total BSA. To prevent vomiting and possible
aspiration in patients with nausea, vomiting, or
abdominal distention, or when a patient’s burns involve
more than 20% total BSA, insert a gastric tube and
ensure it is functioning before transferring the patient.
Narcotics, Analgesics, and Sedatives
Severely burned patients may be restless and anxious
from hypoxemia or hypovolemia rather than pain.
Consequently, manage hypoxemia and inadequate
fluid resuscitation before administering narcotic
analgesics or sedatives, which can mask the signs of
hypoxemia and hypovolemia. Narcotic analgesics
and sedatives should be administered in small, frequent
doses by the intravenous route only. Remember that
simply covering the wound will decrease the pain.
Wound Care
Partial-thickness burns are painful when air currents
pass over the burned surface, so gently covering the
burn with clean sheets decreases the pain and deflects
air currents. Do not break blisters or apply an antiseptic
agent. Remove any previously applied medication
before using antibacterial topical agents. Application
of cold compresses can cause hypothermia. Do not
apply cold water to a patient with extensive burns (i.e.,
> 10% TBSA). A fresh burn is a clean area that must
be protected from contamination. When necessary,
clean a dirty wound with sterile saline. Ensure that
all individuals who come into contact with the wound
wear gloves and a gown, and minimize the number of
caregivers within the patient’s environment without
protective gear.
Pitfall
Patient develops deeptissue
injury from
constricting dressings
and ties.
Patient develops deeptissue
injury from
constricting burn eschar.
Antibiotics
There is no indication for prophylactic antibiotics in
the early postburn period. Reserve use of antibiotics
for the treatment of infection.
Tetanus
prevention
• Remember that edema
takes time to develop.
• Reassess or avoid
circumferential ties
and dressings.
• Remove constricting
rings and clothing early.
• Recognize that burned
skin is not elastic.
Circumferential
burns may require
escharotomies.
Determination of the patient’s tetanus immunization
status and initiation of appropriate management
is very important. (See Tetanus Immunization.)
Unique buRN injuries
Although the majority of burn injuries are thermal,
there are other causes of burn injury that warrant special
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