Problem 2

Emergency medicine block

Lo 1 : Burns

Etiology
Burns can be classified into six
categories:
Scald hot liquids, grease, or steam
Contact hot or cold surfaces
Thermal fire or flames
Radiation burns
Chemical burns
Electrical burns

Signs and Symptoms

Most burns will have external signs of
integumentary damage.
Inhalation injury:
Facial burns
Carbonaceous sputum
Pharyngeal injection
Wheezing
Hoarseness
Singed nasal hair

Electrical burns may have minimal external

findings.

History
Information from emergency medical services
(EMS), family, friends, or witnesses may be
required.
Medical history, surgical history, medications,
allergies, social history, tetanus immunization
status
Carbon monoxide poisoning with exposure to
combustion
Cyanide poisoning from burning wool, silk,
nylon, and polyurethane found in furniture and
paper

Physical Exam
Focus on airway, breathing first, then head-totoe secondary survey for concurrent injuries.
Evaluate face and oropharynx for signs of
inhalation injury.
Assess need for immobilization of cervical
spine.
Eye examination for corneal burns
Determine severity of partial- and fullthickness burns by assessing size and depth of
burn:
Estimate surface area involved

Size
Reported as percent involvement of total
body surface area (TBSA) in one of three
ways:
1. Rule of nines:
TBSA of body parts is estimated by multiples of
9%; applies to adults only.
Adult estimates of percentage of TBSA:

Head and neck: 9

Arms: right, 9; left, 9
Legs: right, 18; left, 18
Trunk: front, 18; back, 18
Perineum, palms: 1

Size
In infants and children, the head
contributes more to the percentage of
TBSA and legs contribute less.
Infants/children:

Head and neck: 18

Arms: right, 9; left, 9
Legs: right, 14; left, 14
Trunk: front, 18; back, 18

Size
2. Lund and Browder chart divides
body into areas and assigns
percentage of BSA based on age
3. Palm surface area patient's palm
is approximately 1% of TBSA:
2. Estimate size in terms of number of
patient's palms that cover burn.
3. Helpful in assessing smaller, scattered
burns

Depth
Superficial or first-degree burns (epidermis only):
local erythema and pain only, no blisters; healing
occurs in several days
Partial-thickness or second-degree burns
(epidermis and dermis): divided into superficial
partial-thickness and deep partial-thickness burns:
Superficial partial-thickness: epidermis and superficial
dermis:
Skin is red, moist, painful, good capillary refill, develop blisters
Heals in 14 - 21 days

Deep partial-thickness: epidermis and deep dermis:

Skin may be blistered, with dermis white to yellow; absent
capillary refill, and pain sensation
Heals via epithelialization within 3 - 12 weeks

 Full-thickness or third-degree burns

(epidermis and dermis, extends into
subcutaneous tissue):
Skin is charred, leathery and pale, no blisters.
Sensation absent
Lesions will not heal spontaneously; needs
surgical repair and skin grafting.
Full-thickness burns with damage to
underlying muscle or fourth-degree burns:
Full-thickness plus involvement of underlying
fascia, muscle, bone, and other tissues
Requires extensive debridement
Resultant disability

Lab
For severe burns, obtain CBC, serum
electrolytes, glucose, BUN,
creatinine, and PT/PTT, type and
cross-match, pregnancy test (female)
Blood gas with carbon monoxide
level for closed space or inhalation
exposures
Cyanide level if suspected

Imaging
Chest radiograph
Fiber optic bronchoscopy to assess
inhalation injury

Differential Diagnosis
Electrical injury
Chemical injury
Associated trauma or intoxication

Treatment Pre Hospital

Stop the burning process, remove smoldering
clothes/jewelry.
Establish patent airway; frequent reassessment:
Intubate early for signs of respiratory distress.

Initiate early IV fluid therapy.

Relieve pain.
Protect the wound with clean sheets.
Transport to burn center (for major burns) if
transport time shorter than 30 minutes.
Immobilize spine if decreased sensorium or
trauma.

Initial Stabilization
Airway control paramount:
Early intubation for patients with signs
of upper airway injury, significant
nasolabial burns, or circumferential neck
burns

IV access, supplemental 100%

oxygen, monitor, pulse oximetry
Evaluation for concurrent injuries
Provide adequate analgesia.

ED Treatment
Fluid Resuscitation: Partial and Full-thickness
Burns (>20% TBSA)
Parkland formula: 4 mL of lactated Ringer
solution or normal saline (NS) per kilogram per
percentage of BSA burned IV; one half of this
total is given in the first 8 hours and the
remaining half over the next 16 hours:
For large burns, >20% TBSA, IV fluid therapy
should be guided by invasive hemodynamic
monitoring or urine output; maintain urine output
of 0.5 to 1.0 mL/kg/h for adults and 1.0 - 1.5
mL/kg/h for children.

Escharotomy
Circumferential burn eschar may lead to
neurovascular compromise:
Monitor pulses; may need Doppler flow
probe.
Elevate burned extremity.
If circulation is compromised, escharotomy
incisions on extremities should be made
medially and laterally along the long axis of
the limb just to the subcutaneous layer
through the entire length of the burn eschar.

 A circumferential burn of the chest

wall may prevent adequate
ventilation unless escharotomy is
performed:
Make longitudinal incisions at anterior
axillary line from the second rib to the
level of the twelfth rib; connect with two
transverse incisions across the chest.

Wound Care
Cover the wounds with sterile moist saline
dressings.
If disposition is delayed, cleanse with sterile
saline or poloxamer 188 product (e.g., ShurClens), debride blisters except those on palms
or soles, and apply topical antibacterial agent
(e.g., silver sulfadiazine, bacitracin, or mafenide
acetate).
Do not delay transfer to burn unit for wound
care.
Prophylactic antibiotics not indicated

Outpatient Management of Minor

Burns
Sterile technique for cleansing and
debridement
Remove loose, necrotic skin; debride
broken, tense, or infected blisters.
Topical antibacterial agents: (e.g.,
silver sulfadiazine, bacitracin,
mafenide acetate) recommended in
deep partial-thickness or fullthickness burns only

 Three-layer burn dressings should keep the

wound moist and absorb exudate:
Inner layer should be nonadherent porous mesh
gauze saturated with a non-petroleum-based
lubricant, or use a mild ointment (e.g., bacitracin
or Polysporin) under a nonadherent porous gauze.
The next layer should be fluffed coarse-mesh
gauze.
The outer wrap should keep the dressing in place
without constricting.
Dressings should be changed at least daily.

 Silver wound dressings (Silverlon and

Acticoat):
Thin coating of metallic silver applied to
knitted fabric backing
Requires dressing to remain moist
May leave on for up to 3 days

Pediatric Considerations
Parkland formula underestimates fluid requirements in
children; the Galveston formula may be used instead:
5,000 mL/m2 BSA burned plus 2,000 mL/m2.
TBSA of 5% dextrose in lactated Ringer solution IV
over the first 24 hours, half in the first 8 hours and the
other half over the next 16 hours
Consider nonaccidental trauma, particularly with burns
on the back of hands or feet, buttocks, the perineum,
and the legs.
Avoid hypothermia:
Children have greater BSA/mass ratio and lose heat
more rapidly.
Avoid hypoglycemia:
Children are more prone to hypoglycemia owing to

Pregnancy Considerations
Significant morbidity to mother and
child
Fluid requirements may exceed
estimations.
Fetal monitoring and early obstetric
consultation recommended

Medication (Drugs)
Bacitracin ointment: Apply to wound onefour
times per day.
Mafenide (Sulfamylon) acetate cream: Apply to
wound one or two times per day.
Morphine: 0.1 - 0.2 mg/kg titrated to effect for pain
control after shock
Silverlon and Acticoat: Cut sheet to size of burn;
moisten with sterile water.
Silver sulfadiazine cream: Apply to wound one or two
times per day.
Tetanus toxoid or immunoglobulin: 0.5 mL IM; 250 U
IM once along with toxoid

Follow-Up
Injuries Requiring Admission
Partial-thickness burns of noncritical areas (not
the eyes, ears, face, hands, feet, or perineum)
involving 10 - 20% of BSA in adults (older than 10
years and younger than 50 years)
Partial-thickness burns of noncritical areas
involving 5 - 10% of BSA in children younger than
10 years
Suspicion of nonaccidental trauma
Patients unable to care for wounds in outpatient
setting (e.g., homeless patients)

Injuries Requiring Transfer and Admission to a Burn

Center
Partial-thickness and full-thickness burns involving 10% of
BSA in patients younger than 10 years or older than 50
years
Partial-thickness and full-thickness burns over >20% of
BSA in any patient
Full-thickness burns involving >5% of BSA
Partial-thickness and full-thickness of face, hands, feet,
genitalia, perineum, or major joints
Electrical burns, including lightning injury
Significant chemical injury
Inhalation injury
Burn injury in patients with pre-existing illness that could
complicate management
Burn injury in patients with a concomitant trauma or social
barrier

Discharge Criteria
Partial-thickness burns of <15% of
BSA in adults (<10% in children)
involving noncritical areas only and
in patients able to manage wounds
as outpatients and follow up reliably

Complications
1. For major thermal injuries (>20% BSA)
and significant burns (>10% BSA) in
patients with other medical conditions, the
possibility of multiorgan failure needs to be
anticipated.
2. All burn patients should be evaluated
for carbon monoxide poisoning.
3. Significant electrical burns to the mouth
may be followed (usually in 7 to 10 days) by
delayed bleeding from the labial artery

Lo 2 : Sepsis

Description
Systemic inflammatory response triggered by an
infection in the host and mediated by chemical
messengers:
Decreased peripheral vascular resistance
Elevated cardiac output in response to vasodilatation
Later in septic shock, myocardial depression, and
reduced cardiac output (due to injury at the cellular
level or mediators acting on the heart)
Multiple organ dysfunction syndrome (MODS) if sepsis is
ineffectively treated

Adult respiratory distress syndrome (ARDS)

Acute tubular necrosis and kidney failure
Hepatic injury and failure
Disseminated intravascular coagulation

 Sepsis is classified by the systemic inflammatory

response syndrome (SIRS):
Temperature >38C or <36C
Heart rate >90 beats/minute
Respiratory rate >20/minute or PaCO2 <32 mm Hg
WBC >12,000/mm3, <4,000/mm3, or >10% band forms

Sepsis: two or more of the SIRS criteria with an

underlying infection
Severe sepsis:
Sepsis with organ dysfunction as manifested by one of the
following:

Acidosis
Renal dysfunction
Acute change in mental status
Pulmonary dysfunction
Hypotension
Thrombocytopenia or coagulopathy
Liver dysfunction

 Severe sepsis:
Sepsis with organ dysfunction as
manifested by one of the following:

Acidosis
Renal dysfunction
Acute change in mental status
Pulmonary dysfunction
Hypotension
Thrombocytopenia or coagulopathy
Liver dysfunction

Etiology
Gram-negative bacteria most common:
Escherichia coli
Pseudomonas aeruginosa
Rickettsiae
Legionella species

Gram-positive bacteria:
Enterococcus species
Staphylococcus aureus
Streptococcus pneumoniae

Fungi (Candida species)

Viruses

Pediatric Considerations
Children with a minor infection may
have many of the findings of SIRS.
Major causes of pediatric bacterial
sepsis
Neisseria meningitis
Streptococcal pneumoniae
Haemophilus influenzae

Signs and Symptoms

Physical Exam
General:
Fever
Tachycardia
Tachypnea
Hypothermia (poor prognosis)
Hypoxemia
Diaphoresis

Cardiovascular:
BP
Normal early in sepsis
Hypotension when septic shock occurs
Poor perfusion with septic shock:
Prolonged capillary refill
Cool and clammy extremities

 Gastrointestinal/Genitourinary:
Abdominal pain
Nausea, vomiting
Diarrhea
Dysuria/Frequency
Reduced urine output
Abdominal tenderness:
Diffuse
Localized to right upper quadrant (liver or gallbladder
source)
Right lower quadrant (appendicitis with or without abscess)
Suprapubic area or lower quadrants (urinary tract or pelvic
source or diverticulitis)

Flank pain:
With pyelonephritis or retroperitoneal abscess

 Dermatologic:
Any rash is important.
Localized erythema with lymphangitis (streptococcal or
staphylococcal cellulitis)
Rash involving palms of hands and soles of feet
(rickettsial infection)
Petechiae scattered on the torso and extremities
(meningococcemia)
Ecthyma gangrenosum (pseudomonas septicemia)
Round, indurated, painless lesion with surrounding
erythema and central necrotic black eschar
Decubitus ulcers
Indwelling catheter:
Surrounding skin erythematous with or without purulent
drainage

 Pulmonary:
Shortness of breath
Tachypnea:
Present even when the lungs are not the source of
sepsis

Productive cough

CNS:
Change in mental status
Confusion
Delirium
Coma
Neck stiffness (meningitis)

Lab
Serum lactate:
>4 mmol/L defines severe sepsis

CBC with differential:

Leukocytosis is insensitive and nonspecific.
Neutrophil count <500 cells/mm3 should prompt isolation
and empiric IV antibiotics in chemotherapy patients.
>5% bands on a peripheral smear is an imperfect
indicator of infection.
Hematocrit:
Needed to determine whether adequate oxygen delivery can be
achieved
Patients should be maintained with a hematocrit >30% and
hemoglobin >10 g/dl.

 Platelets:
May be elevated in the presence of infection or sepsis-induced
volume depletion
Low platelet count is a significant predictor of bacteremia and
death.

Electrolytes, blood urea nitrogen, creatinine, glucose:

Low bicarbonate suggests inadequate perfusion.
Renal dysfunction or failure indicates a worse prognosis.

Ca, Mg, Ph
C-reactive protein
Cortisol level
International normalized ratio/prothrombin
time/partial thromboplastin time
Liver function tests

 Arterial blood gas:

Mixed acidbase abnormalities:
respiratory alkalosis with metabolic
acidosis

Blood cultures:
From two different sites
One may be drawn through an
indwelling central line (i.e., Broviac).

Urine analysis and culture

Imaging
Chest radiograph:
Determine whether pneumonia is the infectious
source.
Fluffy, bilateral infiltrates may indicate that ARDS is
already present.
Free air under the diaphragm indicates the source of
the infection in intraperitoneal and a surgical
intervention.

Soft tissue plain films:

Indicated if extremity erythema or severe pain
Air in the soft tissues associated with necrotizing or
gas-forming infection

 CT scan of the abdomen and pelvis

Suspicion of abdominal source of infection:
Diverticulitis, appendicitis, necrotizing pancreatitis,
microperforation of the stomach or bowel, or formation of
an intra-abdominal abscess

Abdominal ultrasound:
Indicated for suspected cholecystitis

Pelvic ultrasound:
Tubo-ovarian abscess or endometritis

Transesophageal echo:
When endocarditis is suspected to detect the
presence of any valvular vegetations

MRI:
May be useful to identify soft tissue infections or
epidural abscess

Diagnostic Procedures/Surgery
Lumbar puncture:
Indicated when meningeal signs are present or altered
mental status without a source of infection
Cerebrospinal fluid analysis:

Cell count and differential, tube 1

Total protein and glucose, tube 2
Culture and gram stain, tube 3
Cell count and differential, tube 4
Depending on the clinical situation: cytology, venereal disease
research laboratory, AFB stain/culture, fungal stain

Central venous access:

Central venous pressure (CVP) and ongoing measurement of
central venous oximetry catheter may be helpful in guiding
resuscitation.

Differential Diagnosis

Pancreatitis
Trauma
Toxic shock syndrome
Anaphylaxis
Adrenal insufficiency
Drug or toxin reactions
Heavy metal poisoning
Hepatic insufficiency
Neurogenic shock

Treatment
Pre Hospital
Aggressive fluid resuscitation for hypotension
Initial Stabilization
ABCs
Supplemental oxygen to maintain PaO 2 >60
mm Hg
Intubation and mechanical ventilation if shock
or hypoxia are present
Administer 0.9% NS IV

ED Treatment
Early goal-directed therapy:
500 cc boluses of 0.9% saline up to 12 liters
empirically
Place central line
Continue 500 cc saline boluses until CVP >8 cm H2O
If the mean arterial pressure <65 mm Hg and CVP
>8, then initiate pressors:
Dopamine or norepinephrine to raise blood pressure
Norepinephrine is preferred if tachycardia or dysrhythmias
are present.
Phenyl epinephrine for cases where shock is refractory to
other pressors

 If the ScvO2 <70 and HCT <30, transfuse 2

units PRBCs.
If ScvO2 >70 and HCT >30, then add
dobutamine.
Administer antibiotics early based on the most
likely organisms or site of infection.
If no source identified after initial assessment:
Normal immune function:
Second- or third-generation cephalosporin and gentamicin
Nafcillin and gentamicin
Add vancomycin if there is a history of methicillin resistant
staphylococcus aureous or the patient resides in a nursing
facility or there is a history of recent hospitalizations.

 Immunocompromised host:
Piperacillin and gentamicin
Ceftazidime and either nafcillin or vancomycin and
gentamicin

If source identified, or highly suspected, treat

the most likely organisms:
Pulmonary source:
Second- or third-generation cephalosporin and
gentamicin, and possibly erythromycin

Intra-abdominal source:
Ampicillin and metronidazole and gentamicin
Cefoxitin and gentamicin

Urinary tract source:

Ampicillin or piperacillin and gentamicin

Pediatric Considerations
Antibiotic therapy based on age:
<3 months (2 drugs): ampicillin and gentamicin
or cefotaxime
>3 months: cefotaxime or ceftriaxone

Initiate vasopressors after no response to

60 mL/kg IV fluid.
Avoid hyponatremia and hypoglycemia.
Dexamethasone for children with bacterial
meningitis:
0.15 mg/kg q6h for 4 days

Medication (Drugs)

Ampicillin
Cefoxitin
Ceftazidime
Dopamine
Gentamicin
Metronidazole
Nafcillin
Norepinephrine
Piperacillin
Vancomycin

Complication
Septic shock
Multiple organ disfunction
Adult respiratory distress syndrome
(ARDs)
Sisseminated intravascular
coagulation (DIC)

Prognosis
Most people recover from mild
sepsis, but the mortality rate for
severe sepsiss or septick shock is
close to 50%