THE MANAGEMENT OF MAJOR INJURIES

Aetiology of major trauma

• Injury is one of the top three causes of death for people between the ages of 5 and 44
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worldwide, so it has a particular impact on young people.

• Nearly a third of the global 5.8 million deaths from injuries are the result of violence and
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nearly a quarter the result of road traffic crashes.

Mode of death
Deaths as a result of trauma have classically been shown to follow a trimodal pattern, described
by Trunkey in 1983, with three waves following the injury.
• Some 50% of fatally injured casualties died from non-survivable injuries immediately, or
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within minutes after the accident;

•​ 30% survived the initial trauma, but died within 1–3 hours;
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•​ 20% died from complications at a late stage during the 6 weeks after injury
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The initial mortality peak is usually due to nonsurvivable, central nervous system injury or
cardiovascular disruption. The second peak of deaths during the first few hours after injury is
most often due to hypoxia and hypovolaemic shock. A significant proportion of these deaths can
be avoided with an effective emergency medical service (EMS), as has been demonstrated in the
UK since 2012; hence, this period has been called ‘the golden hour’. The third peak in the
cumulative mortality rate within the 6 weeks following injury was largely due to multisystem
failure and sepsis.
Sequence of management
• In developed healthcare systems, an effective EMS is available to initiate management at the
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scene of the injury and transfer the casualty rapidly to hospital.

• Immediate first-aid manoeuvres, such as opening the airway and controlling external
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haemorrhage with direct pressure, are life-saving interventions that require minimal
equipment and training.
• Treatment is centred on evaluation, resuscitation and stabilization. This phase merges into
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definitive care in the operating theatre, with control of airway, ventilation and surgical
management of haemorrhage.
PRE-HOSPITAL MANAGEMENT
ORGANIZATION
• Provision of prehospital EMS depends on economic resources and varies from no provision
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in rural, low-income countries to sophisticated services related to hospital care in developed

countries.
•​ EMS in each country varies.
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• For large cases in UK, interventions were provided by the Mobile Services team d'Urgence
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et de Reanimation (SMUR) - a hospital-based medical team with advanced equipment and

access to various transportation including helicopters. This service is very expensive and
demands a lot of experienced medical staff
SAFETY ON SCENE
• medical team must be equipped with personal protective equipment (PPE), PPE must protect
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the head, eyes, hands, feet, limbs and body to a level that is appropriate for physical,
chemical, thermal and acoustic risks.
IMMEDIATE ACTIONS AND TRIAGE
• The initial action of a doctor who arrived at the scene was to build safety - personal safety,
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safety at the scene and safety of the victim.

•​ Triage has two stages that apply in a prehospital environment: triage sieve and triage sort.
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Triage filters are fast and uncomplicated systems based on simple clinical observations of the
victim's ability to walk, breathe, and maintain peripheral perfusion. This type of triage requires a
level of clinical training and uses physiological measurements to assess victims and place them
in priority groups. Both triage systems place victims into four priority categories with color
codes, as shown in Box 22.1.

Awareness
Awareness of the environment, patterns of damage to vehicles and the nature of events can help
caring doctors predict the possibility of injury and facilitate their early recognition.
Recognition
Immediate assessment of the airway, breathing and circulation - 'ABC' from trauma assessment.
Management
• Injury management is prioritized to treat the most life-threatening injuries first, traditionally
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following the ABCDE sequence.

• When a victim with airway obstruction dies within a few minutes, securing a patent airway is
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always a priority. After the airway is open, the victim must be given oxygen and given
ventilation if breathing is inadequate.
• Circulatory compromise is then dealt with primarily by control of external bleeding;
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Intravenous cannula should be placed

• Stability of the cervical spine must be protected at all times until the neck can be cleaned
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from the risk of injury. Long spinal boards should be used

AIRWAY
•​ The airway is opened initially with a 'bare-handed' hand lift and jaw maneuver.
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•​ If blood, saliva or vomiting is in the airway, suction should be used.

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• If the 'empty hand' technique is inadequate, the oropharyngeal (OP) or nasopharyngeal (NP)
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airway must be placed carefully to prevent the posterior aspect of the tongue from blocking
the pharynx.
•​ Supraglottic airway devices is now routinely
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• Intubation or cricothyroidotomy is very difficult for trapped victims. Rapid sequence

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induction of anesthesia (RSI) remains the gold standard for securing the airway in trauma
victims, recommends 45 minutes from the start call to emergency services to intubation.
BREATHING
• If breathing clearly adequate, oxygen is given from high flow, mask reservoir not
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non-rebreathing. With flow the rate of 15 L / minute.

• If there are doubts adequate breathing, ventilation must be supported with bag-valve-mask
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(BVM) assesslip color to detect cyanosis, or use pulse oximeter. Adequate ventilation can
 assessed by clinical assessment of chest expansion and breath sounds, or the use of chemical
or electronic deposits monitoring of carbon dioxide (EtCO2) (capnography) if the
supraglottic airway device or tracheal tube in place.
• Tension pneumothorax occurs immediately life-threatening injuries, treated with
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decompression with a large drill (14-gauge) intravenous cannula through the second
intercostal space (ICS) at the midclavicular line or 4/5 ICS in the anterior axillary line
CIRCULATION
• Severe, external bleeding must be aggressive controlled by packing wounds with hemostatics
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gauze (eg Celox ™), applying pressure with compression replace (eg Olaes® modular
bandages), and use of tourniquet like C-A-T ™ (Combat Tourniquet Application).
• If specialist equipment is not available, use simple pads and direct pressure, Tranexamic acid
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(1 g) must be given .
• Vascular access must be secured with a wide hole the cannula is located in a large vein, or
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intraosseous cannula located at the head of the humerus or tibia

• Severe and unresponsive shock is likely to be the result external uncontrolled bleeding or
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into the chest, stomach, pelvis and many long bones

DISABILITY
Victims are quickly assessed for neurological disability use the Glasgow Coma Scale (GCS) and
assessment of pupil size and asymmetry.
EXTRICATION AND IMMOBILIZATION
• carefully and attention is given to the protection of the spine, usually using spinal board or
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other rigid immobilization tool.

•​ Broken limbs must be dissected anatomically position to preserve neurovascular function.
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• Analgesia may need to release injured victims, and this can be achieved by inhalation or
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intravenously agent.
• Reducing traction fracture, and compression fracture fracture the hematoma reduces further
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bleeding.

TRANSFER TO HOSPITAL
• The right transportation method must be chosen, with helicopters offering several advantages
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to long distance or rough and long distance transfers field.

• Oxygen saturation must be maintained above 95% if possible, and ventilated victims have
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their EtCO2 maintained at a low normal level (4.0-4.5 kPa).

•​ Bleeding is controlled by direct and specialist dressing and crystalloid solution
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HOSPITAL MANAGEMENT
ORGANIZATION
·​ Receiving Hospitals –​ hospitals not able to take any trauma
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· Trauma Units (TUs) ​– hospitals able to manage single system trauma which is not
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immediately life-threatening (Level 2)

· Major Trauma Centres (MTCs) ​– large, regional hospitals able to manage all levels of
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polytrauma (Level 1), with all relevant specialties on site.

TRAUMA TEAMS
·​ Emergency Department physician
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·​ physician anaesthetist and anaesthetic technician

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·​ Emergency Department nurses

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·​ radiographer
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·​ surgeon from appropriate specialties, usually general surgery and orthopaedics

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·​ intensive care specialists

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· appropriate specialists – e.g. paediatric, obstetric, ear, nose and throat (ENT), maxillofacial,
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neurosurgical, plastic surgery, cardiothoracics can be called in as required once a specialist

problem is identified.
THE ATLS CONCEPT
• Primary survey and simultanous resuscitation – rapid assessment and treatment of life
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threatening injury
•​ Secondary survey – head to toe evaluation
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•​ Definitive care
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INITIAL ASSESSMENT AND MANAGEMENT

The ABCs
·​ A Airway with cervical spine protection
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·​ B Breathing
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·​ C Circulation with control haemorrhage control

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·​ D Disability or neurological status

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·​ E Exposure and Environment-remove clothing, keep warm

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Triage
·​ Airway: Actual or future Obstruction Priority 1
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·​ Breathing: Hypoxia or failure of ventilation Priority 2

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·​ Circulation: External bleeding or shock. Priority 3

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Primary survey and resuscitation

During the main survey, conditions were life threatening identified and resuscitation starts
simultaneously, again following the ABCDE sequence.
· Awareness - Head injuries are the most likely cause unconscious and airway blocked in
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trauma victim.
·​ Recognition - Obstructed airway is recognized by search, listen and feel the diagnostic signs.
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· Management - Airway established with 'empty hand' simple maneuvers, additional airways,
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advanced airway intervention or surgical airway technique.

When each stage in ABC is complete, the victim re-evaluated for damage or repair; in After
completing the assessment of breathing, the airway rechecked and the airway and breathing are
reassessed before moving to circulation, etc.
A - AIRWAY CONTROL AND CERVICAL SPINE
The cervical spine is stabilized immediately the basis that unstable injuries at first cannot be
overcome outside. There are two techniques for this:
•​ manual in-line immobilization
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•​ cervical collar, head support and binder.

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Simultaneously, the airway is examined for obstruction by looking, listening and feeling signs
like respiratory disorders, use of respiratory accessory muscles, level of consciousness decreases
and lack is detected breath in the hand or cheek. Airway supported at first by lifting the chin or
pushing the jaw forward from below the mandibular angle. Secretion and carefully aspirated
blood, and OP or NP airways used to hold the tongue forward.
B - BREATHING
A clear airway does not mean the victim is breathing sufficient to allow oxygenation of
peripheral tissue. Once the airway is secured, the chest must be exposed and checked by looking,
listening and feeling. Adequate and symmetrical outings, bruises, open wounds and tachypnea
sought, and auscultation chest for abnormal or absent breath sounds, which indicate
pneumothorax or haemothorax.
C - CIRCULATE WITH HAEMORRHAGE CONTROL
Circulation is assessed by looking for an external bleeding and shock signs that look like pale,
prolonged capillary refill and decreased consciousness level. Heart auscultation to detect
muffled, bad sound of heart tampons perfusion is assessed by feeling sweating and cold skin.
Peripheral and central pulses are palpable to detect tachycardia and decrease or absent pulse
pressure.
External bleeding is controlled by pressure, and two 14 size cannula placed for administration IV
fluid and blood. Use of tranexamic acid and tourniquets feature in the 10th edition of ATLS®.
Blood Samples can be taken from cannula for baseline diagnostic testing and cross matching of
transfusions.
D - DISABILITY
Key element in assessing a patient's neurology the status is the Glasgow Coma Score (GCS)
E - EXPOSURE AND ENVIRONMENT
The patient must remove all clothing allows full examination of all body surfaces the area to be
held. Victims must be guarded warm to keep body temperature as close as possible 37 ° C is
possible, and all liquids and gases are ventilated must be warmed.
Adjuncts to primary surveys
A number of additional controls and diagnostics are used to complete the main survey and
resuscitation, besides monitoring vital and hematological signs testing:
• Electrocardiographic monitoring (ECG) – used to monitor heart rate and detect arrhythmias
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and ischemic changes.

• Pulse oximetry - measures arterial oxygen saturation (SaO2) and monitor peripheral tissue
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perfusion.
• Monitoring of final tidal carbon dioxide (EtCO2; capnography) - gives an estimate of arteries
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partial carbon dioxide pressure in and ventilated patient, allowing optimization lung
ventilation.
•​ Arterial blood gas (ABGs)
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•​ Urethral catheter
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•​ Nasogastric tube - decompressing the stomach and help prevent aspiration

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• Chest radiograph - important for diagnosis Life-threatening chest injuries such as

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pneumothorax, which will require early treatment.

• Pelvic X-rays - allowing a broken pelvis to be diagnosed, which will remind of the
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possibility of retroperitoneal bloody.

Secondary Survey
Secondary surveys are detailed and head-to-toe evaluations to identify all injuries that are not
recognized within primary survey. That happened after the main survey has been completed, if
the patient is stable enough and does not need immediate care; maybe, actually, occurs after
surgery, or intensively care unit (ICU).
HISTORY
• Patient accounts about their trauma and past medical history must be recorded. Helpful
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mnemonic is AMPLE: allergy; drugs; past diseases; last meal; event and environment.
EXAMINATION
• Examination follows a logical sequence from the head down to the extremities, including
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log-roll to make sure that all body surfaces are examined. That guide the command is to look,
listen, feel
• Head is examined for bruises, lacerations and clinically detected fractures. GCS must be
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repeated. Facial faces are examined for signs of fractures with the risk of airway obstruction -
contusions, laceration, deformity, and dental malocclusion crepitus.
• Chest are examined for deformities, bruises like the classic 'seat belt' and open sign, maybe
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penetrate, wound. Stethoscope is used for auscultation of the lungs, compare the left and
right apices and bases to identify loss of breath sounds, indicate a pneumothorax.
• Abdomen is checked for bruising and wounds and auscultation because there is no intestine
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sound indication of visceral damage. Early use of specialist imaging such as ultrasound and
computed tomography (CT) is indicated.
• The main indicator of pelvic fracture is uneven leg length and pain or crepitus during
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palpation.
• Limbs are examined for bruising, deformity and pallor. Pain and crepitus during palpation is
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an indication of the underlying fracture or dislocation,

• Neurology Rapid neurological assessment is carried out to detect signs of lateralization, loss
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of sensation and motor power, and reflex abnormalities.

IMAGING
• Chest X-rays and pelvic X-rays may still be performed in the main survey, but the cervical
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spine radiography has a high false-negative incidence results that limit their use.
• The spiral CT scanner is fast and, if located close together Emergency Department, whole
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body trauma CT can be completed in a few minutes. CT scans allow accurate diagnosis, and
this Engineering becomes the gold standard.
• Magnetic resonance imaging available as an emergency procedure and not safe with unstable
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victims. Ultrasound scanning often helps, in particular to diagnose intra-abdominal bleeding.

• Extended focused assessment with sonography at trauma (eFAST) has supplanted diagnostic
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peritoneal lavage and is also used to detect cardiac tamponade and pneumothorax.
PAIN MANAGEMENT
INTRAVENOUS ANALGESIA
• Ketamine is beneficial in patients preservation breathing drives are the most important and
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deep patients where opioid analgesia has not been controlled pain. The analgesic dose is
0.1-0.5 mg / kg.
INHALATIONAL ANALGESIA
• Methoxifluran inhalers can be used once used at Entonox premises and can be used safely on
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the presence of a suspected pneumothorax.

NERVE BLOCKS
• Risk of covering up compartment syndrome. The femoral nerve block is technically easy and
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can be used for the midshaft femur, anterior thigh and knee injuries.

SYSTEMIC MANAGEMENT
AIRWAY
Awareness
•​ Head Injury
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•​ Maxillofacial trauma
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•​ Neck trauma
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•​ Laryngeal trauma
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•​ Inhalation burns
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Recognition
Look
•​ Agitation, aggression, anxiety - suggest hypoxia.
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•​ Chaotic level of consciousness - shows hypercarbia.

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•​ Cyanosis - blue discoloration on the nail bed and lips are caused by inadequate hypoxemia.
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•​ Sweating - increases autonomic activity.

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• Use of ventilation accessory muscles; victim sit in front classically and use splints neck and
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shoulder muscles to help with breathing.

•​ Tracheal tug and intercostal retraction - caused by excessive intrathoracic pressure swings.
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Listen
• Noisy breathing - breaking down the pharyngeal muscles blocking the airway which causes
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snoring sounds.
• Stridor - air flow through the upper airway that blocks change from laminar to turbulent,
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produce in typical stridor whites – spooky sign, due to a minimal reduction further in the
airway lumen can cause critical airway obstruction.
•​ Hoarseness (dysphonia) - functional damage to larynx.
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•​ Absence of sound - can indicate a complete airway obstruction or apnea.

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Feel
• Feel the flow of air through the mouth and nose with your palm; very sensitive to detect air
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flowing.
• Palpate the trachea at the suprasternal notch will detect deviations related to tension
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pneumothorax.
AIRWAY - MANAGEMENT
• The chin lift is lifted forward with the practitioner positioned on the head or side of the
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victim, use one hand. This attracts the jaw and pharynx advanced structure of the posterior
pharyngeal wall and glottis, and opens the airway.
• Jaw thrust is a more assertive manoeuvre that is effective in patient with small jaws or thick
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necks, or who are edentulous, jaw thrust can be combined with the application from the
BVM assembly for lung ventilation
• Oropharyngeal airway is a curved and flat, hard, proximal plastic tube flange, which is
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shaped and sized to hold the tongue and pharynx of the posterior pharyngeal wall
• Nasopharyngeal airway is soft plastic tube with smooth and distal and bevel proximal
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flanges. The NP airway is lubricated with water jelly, and put along the floor nasal cavity
into the nasopharynx.
• Supraglottic airway devices Function between OP airway and trachea tube; Contemporary
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use is largely confined to the larynx mask airway (LMA) or second generation devices like
i-gel.
• Tracheal Intubation is preferred method for securing and protecting airway disturbed in
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trauma patients.
• Needle Cricothyroidotomy is insertion of needles through cricothyroid membrane to the
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trachea to allow jet swelling of the lungs with oxygen. Used on emergency 'cannot be
intubated, cannot ventilate' situation to buy time while expert help is sought or definitive
surgical airway is prepared.
• Surgical airway Surgical airway is an installation tracheal tube or tracheostomy, through a
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incision in the cricothyroid membrane, inside windpipe.

Breathing and chest injuries
Look
•​ Respiratory rate - tachypnea is an indication hypoxia.
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•​ Shallow breathing, gasping or tightness – suggests respiratory failure.

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•​ Cyanosis - shows hypoxia.

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•​ mostly and petechiae - suggest asphyxia and break the chest.

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• paradoxical respiration; 'Pendulum' breathes with synchronization between the chest and
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abdomen, produce a look around - showing breathing failure or structural damage.

•​ Uneven chest inflation - shows a pneumothorax or pounding on the chest.
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• Bruising and bruising - indicates significant transfer of energy and lungs that underlie the
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consequences bruising and potential hypoxia (eg 'seat belt' sign).

•​ Penetrating chest injury - potential for pneumothorax and open, suck on the pneumothorax.
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• distended neck veins - increased venous pressure secondary to pneumothorax or tense heart
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tamponade.
Listen
•​ Absence of breath sounds - showing apnea or tension pneumothorax.
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• Breath noise / crepitation / stridor / wheezing - shows airway, blood and partially obstructed
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secretions in the airways, trachea or bronchial damage.

• Reducing air entries unilaterally - showing pneumothorax, haemothorax or
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haemopneumothorax, and pounding on the chest.

Feel
• Tracheal aberration - an indication of tension pneumothorax, shift the mediastinum. (Note:
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the trachea is felt inferior in the suprasternal notch; do not confuse the larynx, which is
extrathoracic and therefore does not shift.)
•​ Softness - shows significant chest wall contusions and / or broken ribs.
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•​ Crepitus / instability - shows the underlying fracture Ribs.

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• Surgical emphysema (crackling and rupture, bubble opping wrap, crepitation feels on
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subcutaneous tissue palpation, because of the air that is forced into the network under
pressure) - tension pneumothorax, rupture bronchi or trachea and larynx rupture.
Breathing Management
•​ Open pneumothorax
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2016 NICE Guidelines recommend open thoracostomy use rather than needle decompression, if
expertise is available.
•​ Massive haemothorax
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Management is by open thoracostomy followed by insertion of a chest drain, correction of

hypovolaemia, tranexamid acid and blood transfusion.
•​ Cardiac Tamponade
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Management has two components: eliminate pressure in the pericardium by draining

accumulation blood, and stop the source of bleeding to prevent re-accumulation.
•​ Flail Chest
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Management initially supported the administration oxygen and analgesia. Reduces advanced
pain epidural methods may be needed. Deep hypoxia may require that the patient be intubated
and ventilated until the content is sufficiently resolved and pain can be controlled.
•​ Disruption of tracheobronchial tree
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•​ Simple Pneumothorax
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Intubation and ventilation in the presence of a pneumothorax predisposes to the development of a

tension pneumothorax and so chest drains should immediately be placed
•​ Haemothorax
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Treatment is with a large calibre, intercostal drain, if more than 1500 ml of blood are drained,
thoracoscopy should be consudered
•​ Pulmonary Contusion
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Treatment with supportive measures and oxygen administration

•​ Tracheobroncial tree
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Treatment is initially with one or more large chest drains

•​ Blunt Cardiac Injury
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Patient should be monitored closely for a minimum of 24 hours, following which the risk of
sudden dysrhytmias diminished substantially
•​ Mediastinal Traversing Woound
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ABC Resuscitation with bilateral chest drains, prior to definitive surgical management
CIRCULATION AND SHOCK
• Results of hypovolemic shock from loss of volume in circulation; it may be because of loss
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of all blood due to bleeding, or plasma and loss of fluid due to burns or severe medical
conditions.
• Cardiogenic shock is a result of decreased myocardial contractility, and hence reduction in
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stroke volume and cardiac output.

• Septic shock is caused by the entry of toxins into the circulation, which poison the
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vasoconstrictive mechanism in blood vessels.

• Neurogenic shock Neurogenic shock is produced by a high spinal cord injury, which is
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sympathetic nerves that control vasoconstriction. That peripheral blood vessels relax and
become very deep widen, reduce pre-load and afterload. Even with increased cardiac output,
patients cannot maintain adequate blood pressure and shock occur later.
• Anaphylactic shock This is a type of allergic reaction. Antigen exposure where an individual
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previously sensitive trigger cascade reaction. Mast cells degenerate and release large the
amount of histamine in the bloodstream. Other vasoactive substances are released, and deep
vasodilation caused.

Management
•​ Control Haemmorhage
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Tourniquets have been developed for controlling peripheral limb haemorrhage

•​ Peripheral venous cannulation
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•​ Central venous cannulation

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•​ Intraosseous cannulation
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•​ Fluid administration
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Two large bore intravenous cannulae and administer an initial bolus of 2L of warmed Ringer
lactate and Hartmann solution. Haemorrhagic shock should be treated with blood and fresh
frozen plasma 1:1
DISABILITY
Head Injury
·​ Brain injury can blunt or translucent.
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· Primary brain injury occurs during trauma, and results from sudden distortion and cutting of
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brain tissue in a rigid skull. Damage suffered as possible be focused, usually resulting from a
local punch or penetrating, or diffuse injury, usually occurs from the impact of high
momentum.
· Sudden acceleration or a slowdown can cause a counter coup injury, because the brain
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affects the side of the skull far from impact. High-speed missile penetrator the injury will
also cause diffuse and severe brain injury when the pressure wave produced moves cross the
brain. Secondary brain injury is pressure related, and caused by internal swelling brain,
causing an increase in ICP as described earlier. This is compounded by hypoxia, hypercarbia
and hypotension.
·​ The injuries can be classified into three groups based on the GCS
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Mild (80%) GCS 13-15

Moderate (10%) GCS 9-12
Severe (10%) GCS 3-8
· The Royal College of Surgeons of England advises that specific indications for a head CT
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are:
1. GCS <13 on first Emergency Department assessment
2. GCS <15 2 hours after initial assessment
3. suspected open or depressed skull fracture
4. clinical basal skull fracture
5. post-traumatic seizure
6. focal neurological deficit
7. >1 episode of vomiting
 8. amnesia of events >30 minutes before impact
9. post-injury amnesia if:
-​ age >65 years
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-​ associated with coagulopathy

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- due to a dangerous mechanism of injury (pedestrian versus motor

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vehicle, ejection from motor vehicle, fall from height >1 m).
-
Abdominal Injury
Penetrating injury between the nipple and the perineum can cause intra-abdominal injury, with
unexpected and extensive damage resulting from falling and breaking shrapnel. High speed
rounds transfer significant kinetic energy to abdominal viscera, causing cavitation and tissue
damage.

Most gunshot wounds involve:

•​ small intestine (50%)
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•​ large intestine (40%)

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•​ liver (30%)
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•​ abdominal blood vessels (25%).

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Stab wounds injure adjacent abdominal structures. Small wounds can occur due to the thin
bladed knife has broken through some deep and damaged structures, with the most frequently
injured are:
•​ liver (40%)
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•​ small intestine (30%)

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•​ diaphragm (20%)
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•​ large intestine (15%).

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Laparatomy is the definitive management and the province of the surgeon, the general principles
at initial operation is to perform damage control surgery
·​ control haemorrhage with ligation of vessels and packing
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·​ remove dead tissue

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·​ control contamination with clamps, suturing and stapling devices
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·​ lavage the abdominal cavity

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·​ close the abdomen without tension.

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·​ Second-look laparotomy at 24–48 hours may

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Spinal Injuries
Spinal injuries can be stable or unstable, Unstable injuries are a significant injury risk of fracture
displacement and neurological sequelae. The mechanism of injury is traction (avulsion), directly
indirect injury and injury. Injuries directly penetrate wounds are usually associated with firearms
and knives. Indirect injuries are the most common and usually the result of falling from a height
or a vehicle accident where there are violent movements or neck luggage. Regional events spinal
cord injury approximately:
•​ cervix (55%)
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•​ thorax (15%)
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•​ thoracolumbar junction (15%)

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•​ lumbosacral (15%).
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Spinal fractures with transection of the spinal cord also interfere supply of sympathetic nerves
and distal causes vasodilation.
Burn (thermal,chemical, electrical, cold injury)
Thermal Burn - Awareness
·​ Major burns can present a threat to life through compromise of the airway, breathing and
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circulation
·​ Circumferential burns around the neck can cause tissue swelling and airway obstruction, and
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burns round the chest may cause restrictive respiratory failure

·​ Large burns cause in significant fluid shifts, and resultant shock
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·​ Massive thermal injury results in an increase in haematocrit with increased blood viscosity
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during the early phase, followed by anaemia from erythrocyte extravasation and destruction

Inhalational burns
·​ Inhalational injury is now the main cause of mortality in the burns patient, and half of all
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fire-related deaths are due to smoke inhalation

·​ Direct thermal injury is usually limited to the upper airway above the vocal cords and it can
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result in rapid development of airway obstruction due to mucosal oedema

·​ Toxic inhalants are divided into three main groups: (1) tissue asphyxiants; (2) pulmonary
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irritants; (3) systemic toxins.

·​ The two major tissue asphyxiants are carbon monoxide and hydrogen cyanide
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·​ Severe carbon monoxide poisoning will produce brain hypoxia and coma, with loss of
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airway protective mechanisms

Diagnosis of carbon monoxide poisoning

Carbon monoxide level Physical symptoms

<20% No physical symptoms

20–30% Headache and nausea

30–40% Confusion

40–60% Coma

>60% Death

Depth of burns:
1. Epidermal burns
2. Partial-thickness burns
·​ In superficial partial thickness
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 ·​ Deep partial thickness
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3. Full thickness burns (third degree)

4. Full thickness burns (fourth degree)
Management
·​ Airway
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Inhalation burns can cause pharyngeal oedema and swelling, which can make tracheal intubation
difficult if not impossible. This may leave a surgical airway as the only recourse
·​ Breathing
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Should be supported with high-flow oxygen administrated via a non-rebreathing, reservoir mask
that delivers 85% at a fow rate of 15 L/min
·​ Circulation
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Adults Children

Hartmann’s or Ringer’s lactate: Hartmann’s or Ringer’s lactate:

4 mL × weight (kg) × per cent BSA over 3 mL × weight (kg) × per cent BSA over initial 24
initial 24 hours Half over first 8 hours hours plus maintenance Half over first 8 hours from
from the time of burn (other the time of burn (other half over
half over subsequent 16 hours) subsequent 16 hours)

Example: ​An adult weighing 70 kg with 40% second- and third-degree burns would require
4 mL × 70 kg × 40 = 11200 mL over 24 hours.

Cold Injury Burns

Depends on the degree of freezing, cold injury can be systemic or localized. Hypothermia
is defined as a core body temperature below 35 °C (95 °F), where the systemic effects depend on
the severity of the drop in core temperature:
·​ Mild
​ 35–32 °C (95–89.6 °F)
·​ Moderate
​ 32–30 °C (89.6–86 °F)
·​ Severe
​ <30 °C (<86 °F)
Localized cold injury is seen in three forms:
1. Frostnip – mildest form, reversible with warming
2. Frostbite – freezing of tissue, intracellular ice crystals and microvascular occlusion,
can be classified as two types and four degrees: superficial frostbite (first and second
degree), deep frost bite (third and fourth degree)
3. Non-freezing injury – trench foot or immersion foot, with microvascular endothelial
damage, stasis and vascular occlusion

Systematic cold injury assessed in the primary survey, a low-reading rectal or

oesophageal temperature probe will be needed to accurately gauge the degree of hypothermia.
Local injuries are assessed during the secondary survey. Hypothermia is treated by securing the
airway, oxygenating and ventilating, gaining intravenous access and treating shock with warmed
intravenous fluids. Mild and moderate hypothermia are treated by active external rewarming,
while severe hypothermia and hypotermic cardiac arrest require active internal (core) rewarming
such as:
·​ Extracorporeal blood rewarming
​

· Left-sided thoracotomy followed by pleural cavity irrigation with warmed

​

saline
·​ Thoracic lavage or haemodialysis
​

· Repeated peritoneal dialysis with 2 L of warm (43 °C) potassium-free

​

dialysate solution every 10-12 minutes

·​ Warm parenteral fluid (43 °C)
​

·​ Humidified air heated to 42 °C through a face mask or tracheal tube

​

Localized cold injury is initially managed in the field. Wet and constrictive clothing
should be removed, involved extremities should be elevated and wrapped carefully in dry sterile
gauze, and affected fingers and toes should be separated. Rapid rewarming is the single most
effective therapy for frostbite. The current consensus is that clear blister are aspirated or debrided
and dressed whereas early surgical intervention such as tissue debridement and amputation is not
indicated; full demarcation of dead tissue can take 3-4 weeks to occur.
Burns – Take-home Message
· Thermal burns are assessed by depth and extend, and managed by addressing the airway,
​

breathing, and circulation.

·​ Huge volumes of intravenous fluid may be required to maintain homeostasis.
​

·​ Chemical burns are treated primarily by copious irrigation with water.

​

· Electrical burns may be associated with severe tissue damage and systemic disturbance, and
​

treatment is needed for local burns and systemic cardiac, respiratory and renal complications.
· Cold injury can be systemic hypothermia, which is treated by active external and internal
​

rewarming, depending on severity, or localized soft tissue damage. Localized tissue damage
is treated by rapid rewarming and delayed surgical debridement.
Multiple Organ Failure
Multiple organ failure or dysfunction syndrome (MODS) is the clinical appearance of a
seemingly poorly controlled severe systemic inflammatory reaction, following a triggering event
such as infection, inflammation or trauma.
·​ The classical form of MODS appears to progress through four clinical phases:
​

1. Shock
2. Period of active resuscitation
3. Stable hypermetabolism
4. Organ failure

Management of MODS
·​ The best treatment for MODS remains prevention.
​

·​ This entails early aggressive resuscitation following the original insult, avoidance of
​

hypotensive episodes and removal of risk factors, for example by early excision of necrotic
tissue, early fracture stabilization and ambulation, and appropriate antibiotic usage following
drainage of sources of sepsis.
·​ Early circulatory resuscitation is of paramount importance and this should be guided by
​

invasive monitoring.
·​ Oxygen delivery should be maximized to a point where oxygen consumption no longer rises
​

or to the level where markers of anaerobic metabolism such as serum lactate fall.
·​ It appears that the use of less invasive clinical markers for the adequacy of the circulation,
​

such as mean arterial pressure, temperature gradients and urine output, may not entirely
reflect the success of microcirculatory resuscitation.
·​ Once the sequence of MODS is established, early appropriate institution of organ support
​

(e.g. endotracheal intubation and ventilation) is essential. The treatment of ALI/ARDS

remains mainly supportive and includes the management of precipitating causes.

Tetanus
With established tetanus, intravenous antitoxin (human for choice) is advisable. Heavy sedation
and muscle-relaxant drugs may help; tracheal intubation and ventilation are the only options to
treat respiratory muscle involvement. Prophylaxis against tetanus by active immunization with
tetanus toxoid vaccine is a valuable goal. If the patient has been immunized, booster doses of
toxoid are given after all but trivial skin wounds. In the non-immunized patient prompt and
thorough wound toilet together with antibiotics may be adequate but, if the wound is
contaminated, and particularly with a delay before operation, antitoxin is advisable.

Crush Syndrome
If compartement syndrome develops, and is confirmed, then fasiotomy is indicated.

INTENSIVE CARE UNIT SCORING SYSTEM

Scoring systems are often classified into three subsets:
(1) anatomical (e.g. the injury severity score); (2) physiological (e.g. the GCS) and therapeutic
(e.g. therapeutic intervention scoring systems). Most intensive care scoring systems are based on
physiological variables; however, other data are also included in the score, making simple
classification very difficult.