Advanced Trauma Life Support ATLS Student Course Manual 2018

COLD INJURY: LOCAL TISSUE EFFECTS 181
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical
disorders that could complicate management,
prolong recovery, or affect mortality (e.g.,
diabetes, renal failure)
8. Any patient with burns and concomitant trauma
(e.g., fractures) in which the burn injury poses
the greatest risk of morbidity or mortality.
In such cases, if the trauma poses the greater
immediate risk, the patient may be initially
stabilized in a trauma center before being
transferred to a burn unit. Physician judgment
is necessary in such situations and should be
considered in concert with the regional medical
control plan and triage protocols.
9. Burned children in hospitals without qualified
personnel or equipment for the care of children
10. Burn injury in patients who will require special
social, emotional, or rehabilitative intervention
Because these criteria are so comprehensive, clinicians
may elect to consult with a burn center
and determine a mutually agreeable plan other
than transfer. For example, in the case of a partialthickness
hand or face burn, if adequate wound care
can be taught and oral pain control tolerated, followup
at an outpatient burn clinic can avoid the costs of
immediate transfer to a burn center.
Pitfall
Patient loses airway
during transfer.
Patient experiences
severe pain with
dressing change.
The receiving hospital
is unable to discern the
burn wound size from
the documentation.
The receiving hospital is
unable to discern the
amount of fluid resuscitation
provided from
the documentation.
prevention
• Reassess airway frequently
before transfer.
• When the patient has risk
factors for inhalation injury
or has received significant
amounts of resuscitation
fluid, contact the receiving
facility to discuss intubation
before transfer.
• Provide adequate
analgesia before
manipulating burns.
• Use non-adherent
dressings or burn sheets
to protect burn from contamination
before transfer.
• Ensure that appropriate
information is relayed
by using transfer forms
or checklist.
• Ensure that the flow
sheets documenting IV
fluids and urinary output
are sent with the patient.
Transfer Procedures
Transfer of any patient must be coordinated with the
burn center staff. All pertinent information regarding
test results, vital signs, fluids administered, and urinary
output should be documented on the burn/trauma
flow sheet that is sent with the patient, along with any
other information deemed important by the referring
and receiving doctors.
Cold Injury: Local Tissue
Effects
The severity of cold injury depends on temperature,
duration of exposure, environmental conditions,
amount of protective clothing, and the patient’s general
state of health. Lower temperatures, immobilization,
prolonged exposure, moisture, the presence of
peripheral vascular disease, and open wounds all
increase the severity of the injury.
Types of Cold Injury
Two types of cold injury are seen in trauma patients:
frostbite and nonfreezing injury.
Frostbite
Damage from frostbite can be due to freezing of tissue,
ice crystal formation causing cell membrane injury,
microvascular occlusion, and subsequent tissue anoxia
(n FIGURE 9-8). Some of the tissue damage also can result
from reperfusion injury that occurs on rewarming.
Frostbite is classified into first-degree, second-degree,
third-degree, and fourth-degree according to depth
of involvement.
1. First-degree frostbite: Hyperemia and edema are
present without skin necrosis.
2. Second-degree frostbite: Large, clear vesicle
formation accompanies the hyperemia and
edema with partial-thickness skin necrosis.
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