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126
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Complications of burns contracture itself like hypertrophic
scar, keloid formation.
It is a life-threatening exotoxin medi-
ated disease caused by Staphylococcus aureus. It is common
in children, presents with rashes, myalgia, diarrhoea, vomiting,
and multi
B
x Hypovolaemia (refractory and uncontrolled) and shock
x Renal failure
x Pulmonary oedema and ARDS
x Septicaemia
SRB's Manual of Surgery
x Multiorgan failure
x Acute airway block in head and neck burns
organ failure with high mortality.
Deep burns face with eyelid involvement.
A
B
Burns hand both palmar and dorsal aspect.
Stop the burning process and shift the patient away from
the burning area.
Cool the area with tap water by continuous irrigation for 20
minutes (not cold water as it can cause hypothermia).
B
x Any moderate and severe burns
x Airway burns of any type
x Burns in extremes of age
x All electrical/deep chemical burns
B
x Clothing should be removed
x Cooling of the part by running water for 20 minutes
x Cleaning the part to remove dust, mud, etc
x Chemoprophylaxis—tetanus toxoid; antitetanus globulin (ATG—
500 units, IM); antibiotics; local antiseptics
x Covering with dressings by different methods
x Comforting with sedation and pain killer
Deep burn in the scalp involving extensively.
Admit the patient.
Maintain airway, breathing, circulation (ABC). Emergency
endotracheal intubation may be required in early period itself;
in such situation succinylcholine should not be used.
Assess the percentage, degree, and type of burn.
Keep the patient in a clean environment.
Sedation and proper analgesia.
Patient should be placed in burns unit (ideally air-condi-
tioned) with barrier nursing, sterile clothes, bed sheets with
all aseptic methods.
Extensive burn patient of fluid therapy
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with CVP line.
Formulas to calculate the fluid replacement:
4 m
L/% burn/kg body weight/24 hours.
Maximum percentage considered is 50%.
Half the volume is given in first 8 hours, rest given in 16
hours.
For colloid after 12–24 hours.
% Burns × Body weight in kg
2
3 Rations given in first 12 hours.
2 Rations in second 12 hours.
1 Ration in third 12 hours.
B
x
5000 mL/m
x
First 24 hours: RL: 4 mL/kg/% burns in 24 hours (first half in first
8 hours) Colloid—none.
Second 24 hours: Crystalloids—to maintain urine output;
Colloids—0.3 mL to 0.5 mL/kg/burns in 24 hours; (Albumin in
RL solution) (Albumin alone should be given with care if really
indicated only).
x
In first 24 hours: Normal saline 1 mL/kg/% burns; Colloids 1 mL/
kg/% burns; 5% dextrose in water, 2000 mL in adult.
In second 24 hours: Half of the volume used in first 24 hours.
2
burned + 1500 mL/m2 total
Fluids used are Ringer lactate, Hartmann fluid, plasma. Ringer
lactate is the fluid of choice. Blood is transfused in later period
(after 48 hours).
First 24 hours only crystalloids should be given (Crystalloids
are one which can pass through capillary wall like saline either
hypo, iso or hypertonic, dextrose saline, Ringer lactate).
= 1 Ration
Sodium is assessed by formula: 0.52 mmol × kg body weight ×
% body burns, given at a rate of 4.0 to 4.4 m
L/kg/hour.
After 24 hours up to 30–48 hours, colloids should be given to
compensate plasma loss (colloids are one which are retained
in intravascular compartment). Plasma, hae
maccel (gelatin),
dextrans, hetastarch are used. Usually at a rate of 0.35–0.5
m
L/kg/% burns is used in 24 hours. Human albumin is ideal
colloid.
Urinary catheterization to monitor output; 30–50 mL/hour
should be the urine output.
Tetanus toxoid.
Monitoring the patient: Hourly pulse, BP, PO
, PCO2, elec-
2
trolyte analysis, blood urea, nasal oxygen, often intubation
is required.
IV ranitidine 50 mg 8th hourly.
(Enteral feeding). For burns >15%.
Antibiotics: Penicillins, aminoglycosides, cephalo sporins,
metronidazole.
Culture of the discharge; total white cell count and platelet
count at regular intervals are essential to identify the sepsis
along with fever, tachycardia and tachypnoea.
In burns of oral cavity tracheostomy may be required to
maintain the airway.
is required for faster
recovery, using carbohydrates, lipids, vitamins (through a
CVP line).
Tracheostomy/intubation tube may be required in impending
respiratory failure or upper airway block.
Intensive nursing care.
Dressing at regular intervals under general anaesthesia
using paraffin gauze, hydrocolloids, plastic films, vaseline
impregnated gauze or fenestrated silicone sheet or biological
dressings like amniotic membrane or synthetic biobrane.
with application of silver sulfa diazine without any
dressings, used commonly in burns of face, head and neck.
is with dressings done to soothen and to
protect the wound, to reduce the pain, as an absorbent.
of burn wound with skin grafting can be
done within 48 hours in patients with less than 25% burns.
It is usually done in deep dermal burn wherein dead dermis
is removed layer by layer until fresh bleeding occurs. Later
skin grafting is done.
Advantages of tangential excision: It reduces—the chance
of secondary infection, the hospital stay, and formation of
hypertrophic scar or contracture, the cost.
In burns of head and neck region, exposure treatment is
advised.
Slough excision is done regularly.
s -
ointment is used. It is an antiseptic and soothening
agent. It causes neutropenia.
127
CHAPTER 1I General Surgery: Burns
Life’s disappointments are opportunity’s hidden appointment.
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Topical agent Advantages Problems
Silver sulfadiazine (1%) • Antiseptic (G +ve and G –ve) • Neutropenia, pseudoeschar
• It diffuses poorly through the eschar
• Soothening, good penetration,
• Hydration and softening of eschar occurs
• It does not cause pain • Causes wound maceration
Sulfamylon (5%/11%) • Antipseudomonal, anticlostridial • Very irritant, painful
(Mafenide acetate) • Penetrates very well into tissues
• It is water soluble
SRB's Manual of Surgery
Silver nitrate (0.5%) • Antiseptic, antipseudomonal • Stains burnt area
Povidone iodine (5%) • Antiseptic (G +ve, G –ve) • Irritant and painful
Silver sulphadiazine and
cerium nitrate
• It is good antipseudomonal agent
• Used on granulation tissue after eschar
separation
• Used in perineum and buttocks to prevent
maceration
• Boosts cell-mediated immunity and forms
sterile eschar
• Causes hypertrophic granulation and so not used once
wound is clean and eschar is separated
• It should be avoided in pregnancy, nursing mother and
infants below 2 years of age
• Causes acidosis, by inhibiting the carbonic anhydrase
• Not used in partial burns
Other agents used are Sulfamylon (Mafenide acetate) and
Silver nitrate.
¾
Sulfamylon is antipseudomonal and anticlostridial agent.
It penetrates well into the tissues but it is very irritant. It
causes acidosis.
¾
Silver nitrate causes staining of burnt area.
¾
0.025% sodium hypochlorite (Dakin’s solution) is effective against Gram +ve organisms; 0.25% acetic acid is
effective against Gram –ve organisms, but both mildly
inhibit epithelialisation.
Regular culture and sensitivity for bacteria is required, to see
for streptococcal growth which should be less than 1,00,000
5
) per gram of tissues.
(10
C
Once the area granulates well, in 3 weeks usually, split skin
grafting is done (SSG, Thiersch graft).
For wider area MESH split skin graft is used.
If there is eschar, escharotomy is required to prevent
compression of vessels.
In certain areas like face and ear, full thickness graft (Wolfe
graft) or flap is required.
Full thickness skin biopsy of patient’s skin
is done immediately after admission. By specialized culture
technology sheets of skin can be manufactured in 3 weeks
as cultured epithelial grafts. It can cover skin of almost
entire body. It is usually useful in burns of >80%. Take up
of cultured graft is 60–75%. Limitations are—time taken to
develop cultured graft; more vulnerability for mechanical
trauma; costly; time taken to manufacture; scarring.
Vaseline impregnated gauze dressing prevents stiffness of
eschar.
Hydrocolloid dressing (duoderm) helps moist environment,
proper epithelialisation. It is useful in mixed deep burns. It
is changed once in 3 days.
Opsite is less expensive, with less pain, creates moist barrier.
But it does not have antimicrobial effect and it causes accumulation of exudates.
Biobrane is collagen coated silicone sheet which gets
adherent to wound acting as barrier without any pain. But it
does not have antimicrobial effect and it causes accumulation
of exudates. It is used for 2nd degree burns.
Transcyte has similar features of biobrane. It contains growth
factor derived from cultured fibroblasts which promotes
wound healing.
Integra contains deeper collagen matrix as dermal substitute;
outer silicone sheet as epidermal substitute. Inner collagen
matrix acts as dermis whereas outer silicone sheet is removed
2 weeks after dressing and additional autograft should be
placed. It provides complete wound cover. Scarring after
healing is reduced significantly.
It is used to cover the wound temporarily as a barrier and
also to have some immunologic function. Eventually graft will
slough. Later wound is covered with auto-skin graft. It is used
for massive burn injuries more than 50%. Possible problem is
transmission of viral diseases.
Xenograft is of pig skin. Allograft is of cadaver skin (homograft)—it gives all existing normal skin function for temporary
period. It may leave a dermal equivalent in the wound later.
It is charred, denatured, full thickness, deep burns with
contracted dermis.
It is insensitive, with thrombosed superficial veins.
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in the upper limb, lower limb,
neck, thorax can cause more oedema which initially causes
venous compression and later arterial compres sion causing
ischaemia, gangrene of the distal part. So distal area should
be monitored for circulation.
If required deep longitudinal full thickness incisions are
made in different areas so as to prevent collection of oedema
fluid and also to prevent compression over the vessels.
This is called as . Escharotomy causes large
quantity of blood loss and so blood transfusion is needed
while doing escharotomy. Incision should be of adequate
length and depth during escharotomy. It should be placed
in such a way so as to avoid injury to major neurovascular
system. Release of muscle compartment is needed often
in these patients.
B
Ifeanyichukwu has classified neck contracture into: Type 1—mild
anterior with narrow contracting band less than fingerbreadth (1a) or
broad band (1b); type 2—moderate anterior with narrow band (2a) or
broad band (2b); type 3—severe anterior mentosternal adhesion with
supple neck skin (3a) or without supple skin (3b); type 4—posterior
with narrow band (4a) or multiple or broad band (4b).
x Mild (less than 1/3rd)—inability to see ceiling.
x Moderate (1/3rd to 2/3rd)—flexion is possible but not extension.
x Severe (more than 2/3rd)—fully contracted in flexed position
with pull on lower lip.
x Extensive—contraction is extensive with mentosternal adhesions.
Reconstruction territories in neck in burn contracture based
on functional benefits are—central above; central below;
central above and below; lateral.
Ectropion of eyelid causing keratitis and corneal ulcer.
Disfigurement in face.
Narrowing of mouth
Contracture in the neck causing restricted neck movements.
Disability and nonfunctioning of joints due to contracture.
Hypertrophic scar and keloid formation.
Repeated breaking of scar and infection, ulcer, cellulitis.
Pain and tenderness in the scar contracture.
Marjolin’s ulcer: Refer Chapter 1B.
129
CHAPTER 1I General Surgery: Burns
Extensive eschar involving both thighs.
Multiple incisions or incisions over the joints may be needed.
Early rapid separation of eschar indicates severe sepsis
underneath.
Eventually eschar should be excised and the area is allowed
to granulate and skin grafting should be done.
is thickened burnt skin due to repeated silver
sulphadiazine application.
Contracture in burns can occur anywhere. It is more common
wherein flexibility and mobility is present like along the joint,
eyelids, cheeks, lips, neck, elbow, knee, etc. Contracture can
be intrinsic by loss of tissue or extrinsic by pull during healing
phase contraction. Contracture proceeds towards position of
comfort until it meets or closely reaches opposite surface. There
is clearly wound shortening. Disorganised over formation of
compact collagen (3 times normal) causes hypertrophic scar
leading further contracture.
Deficit of neck extension is graded, normal >110°; E
E2 is 85–95°; E3 is <85° with mentosternal synechia.
95–110°;
1
Release of contracture surgically and use of skin graft or “Z”
plasty or different flaps. Different flaps used are—transposi-
tion flaps, vertical or transverse; laterally based flap; bilobed
flap; bipedicled flap; advancement flap; regional flap; random
cutaneous flap (Epaulette flap, Charretera flap); fasciocu-
taneous/myocutaneous flap; tube flap; expanded skin flap;
combined skin graft and flap; microvascular free flap.
Proper physiotherapy and rehabilitation is essential.
Pressure garments to prevent hypertrophic scars.
Management of itching in the scar using aloe vera, antihis-
tamines and moisturizing creams.
BC
Giving proper anaesthesia is challenging.
Scar excision can cause significant bleeding.
Ectropion of upper eyelid due to burns.
A picture is a poem without words and is worth a thousand words
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A B C
SRB's Manual of Surgery
Contracture at different parts of the body—chest, face and neck.
A
(A) Marjolin’s ulcer developed over burns scar; (B) Severe contracture at knee joint causing deformity
(C) Same patient with knee contracture undergoing release surgery.
A B C
(A) Infant had burns in head and neck region causing severe contracture; (B) Elbow contracture due to burns;
Identifying major structures in the area and safeguarding
vascular and other structures is often worrisome.
Need for repeated surgeries as staged one.
Maintaining the position with skeletal traction, fixation, collar,
POP cast, etc.
Psychological problems and needs counseling.
Prolonged hospital stay, cost factors.
B C
(C) Keloid in the hand after burn injury.
B
x Joint exercise in full range during recovery period of burns
x Pressure garments for a long period
x Topical silicon sheeting; Saline expanders for scars
A
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B
High voltage electric burn wound of entry in the
hand with extensive destruction. Some patient showing wound of exit
in the buttock which is extensive and deep.
Low tension injury: Less than 1000 volts.
High tension injury: More than 1000 volts—may be due to
current itself causing intense damage on the tissues up to
2000°C; flash injury due to electrical arc up to 4000°C; flame
injury by catching of fire to the clothing and body; traumatic
injury like fractures and internal organ injuries.
It is always a deep burn (always a major burn).
There is a wound of entry and wound of exit.
Patient may also have major internal organ injuries. GIT,
thoracic injuries.
Often convulsions can develop.
Death may occur due to cardiac arrhythmias (instant death
due to ventricular fibrillation).
Gas gangrene is common after electric injury.
Release of myoglobin can cause renal tubular damage and renal
failure.
Acidosis is common and so often bicarbonate infusion is
needed.
Patient should always be admitted and should be assessed by
ECG, cardiac monitor, ultrasound (US) abdomen, chest X-ray,
sometimes even CT scan head, cardiac enzyme analysis.
Depending on the injury it is managed accordingly.
Fractures and dislocations are common in electrical injuries
which is treated accordingly.
Mafenide acetate is better agent as it penetrates well and it
is useful against clostridial infection.
Mannitol is used to prevent myoglobin induced renal failure.
Wound excision, amputation, surgery for internal organ
injury, cardiac monitoring are essential part of the surgical
management.
131
CHAPTER 1I General Surgery: Burns
It occurs after major fire burns, burns in vehicle/aeroplane/
Wound of entry in an electric burn.
T
Types Treatment Complications Monitoring and prevention
High voltage—can
cause ventricular
fibrillation, cardiac
arrest, death.
Extensive organ and
surface injuries with
fractures.
Low voltage—deep
burn at the site of
wound of entry.
Emergency resuscitation
Assessment of burn
Prevention of renal failure by
hydration, dialysis, alkalisation
of urine to clear myoglobin,
mannitol therapy, IV sodium
bicarbonate.
Extensive fasciotomy,
debridement.
Infection control.
Reconstruction.
• Neurological like epilepsy, haemiplegia,
aphasia, memory loss, headache, transverse
myelitis.
• Cardiac—arrhythmias.
• Vascular injuries—major vessels, bleeding.
• Compartment syndromes.
• Ischaemia, gangrene of limbs.
• Contracture development.
• Bronchopneumonia, pleural effusion.
• Abdominal—ileus, erosive gastritis, Curling
ulcer, injury to liver, pancreas, spleen, GIT,
ARF.
• Bone and joint injuries.
• Cataract can occur in high voltage burn.
• Severe potassium deficiency is common.
Complete and lasting freedom from disease is but a dream remembered from imaginings of garden of Eden.—
train accidents.
ECG, echocardiography
Relevant investigations
like X-ray, ultrasound, CT,
electrolytes, urine analysis,
LFT, renal function tests.
Care during electrical work and
with electrical system.
Unused outlets should be
sealed with plastic.
Electrical system should be
away from water source.
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It is due to:
¾
Inhalation of heat.
¾
Noxious gases and incomplete products of combustion.
¾
At the site of fire, oxygen concentration is less than 2%
which can cause death in 45 seconds due to hypoxia.
¾
Inhaled carbon monoxide binds with Hb immediately to
form carboxyhaemoglobin causing severe anoxia and death.
¾
Carbon monoxide (CO) has got 240 times more affinity
for haemoglobin than oxygen. Carboxyhaemoglobin in
blood more than 10% is dangerous; more than 60% is
life-threatening.
¾
Symptoms of carbon monoxide intoxication—headache,
disorientation, visual changes, fatigue, vomiting, halluci-
SRB's Manual of Surgery
nations, shock and cardiac arrest.
¾
Smoke contains hydrocyanide which causes tissue
hypoxia and profound acidosis.
¾
Laryngeal oedema and laryngospasm.
¾
Bronchial oedema and bronchospasm.
¾
Formation of bronchial cast is typical which is due
to oedema, lymph exudation, separation of ciliated
epithelial cells from basement membrane. Inhaled gas
causes supraglottic airway burn, laryngeal oedema,
loss of respiratory epithelium, acute respiratory distress
syndrome (ARDS), CO poisoning, mechanical restriction
of chest wall movement.
Later problems: ARDS, pneumonia; Atelectasis, pulmonary
embolism; Pulmonary oedema, pneumothorax.
Features:
¾
They have low oxygen saturation.
¾
Charring of mouth, oropharynx with facial burns.
¾
Carbon sputum.
¾
Change in the voice, singed facial and nasal hair.
¾
Decreased level of consciousness with stridor or
dyspnoea.
¾
Acute pulmonary insufficiency with asphyxia, CO
poisoning, upper airway obstruction. After 3 to 5 days,
ARDS and hypoxia develops. Bronchopneumonia with
septicaemia occurs after 5 days.
Management:
¾
Replacing the patient from the site earliest.
¾
Ventilator support for several weeks.
¾
Antibiotics.
¾
Bronchoscopy, at regular intervals to remove bronchial
cast.
¾
Tracheostomy whenever required.
¾
Hyperbaric oxygen.
¾
IV heparin to reduce bronchial cast. Heparin nebulisation
(10,000 units in 3 mL saline 4th hourly) is also useful.
N-acetylcysteine nebulisation—20% in 3 mL saline 4th
hourly, bronchodilators like albuterol 2nd hourly is very
useful. Hypertonic saline inhalation induces the effective
coughing to remove casts. Racemic epinephrine is used
to reduce mucosal oedema.
¾
Monitoring the patient with arterial blood gas analysis
regularly.
Note:
Steroids are not beneficial in inhalation burns.
In chemical burns, tissue destruction is more and progres-
sive. It is always a deep burn.
burn occurs in skin, soft tissues and gastrointestinal tract
(GIT). In GIT, it is common in either due to nitric acid
or sulphuric acid which may lead to severe gastritis or pyloric
stenosis. Other acids are formic acid, hydro fluoric acid. They
cause metabolic aci dosis, renal failure, ARDS, haemo lysis.
Acidaemia should be corrected by IV sodium bicarbonate.
Hydrofluoric acid is commonly used in industrial areas. It is
strongest inorganic acid that can produce corrosion and dehydration. It chelates blood calcium causing hypocalcaemia and
arrhythmias. It is managed with water irrigation, application
of 2.5% calcium gluconate gel at 15 minutes interval, local
intradermal and intra-arterial injection of 10% calcium gluconate. Continuous cardiac monitoring, IV calcium gluconate or
calcium chloride administration is needed.
burns occur in oral cavity and which
leads to multiple oesophageal strictures. Sodium hydroxide,
lime, potassium hydroxide and bleach are common alkalis
involved. They cause saponification of fat, fluid loss, release
of alkali proteinates and hydroxide ions which are toxic.
External chemical burns are always deep and cause extensive
disfigurement with cosmetic problems.
Initial treatment is dilution with water (Hydro therapy). It is
done using 15–20 litres of running tap water.
Neutralisation with antidote should never be done at initial phase
of treatment as it creates exothermic reaction which aggravates
the tissue damage. Late neutralisation is done, if required by
0.2% acetic acid in alkali burns; sodium bicarbonate, calcium
gluconate 10% gel, topical ziphrin solution in acid burns.
Treatment should always be with hospitalisation.
Mannitol diuresis, haemodialysis, calcium glu co nate IV, pain
relief, serum electrolyte management, total parenteral nutrition
(TPN), ventilator support are systemic management required.
Late treatment is reconstruction of the face.
Oesophageal dilatation or colonic transposition is done for
oesophageal stricture due to alkali burn.
Gastrojejunostomy is done for acid induced pyloric stenosis.
Tar burns are treated additionally with neosprin which
contains Tween-80 emulsifier of tar.
Cement is calcium oxide alkali. Its burn is due to hydroxyl ion
which is often deep. Treatment is removal of cloth, irrigation
with water, keeping pH below 8. Often it may form eschar.
B
x Police should be informed whenever a female, pregnant patient
arrives with burns
x Consent for high-risk should be taken especially in burns
>30%
x Burns should be assessed whether it is accidental or homicidal
x Relatives should be informed about the duration of stay, prob-
lems, repeated surgeries
x In patients with severe burns who is likely to die, when suspected,
dying declaration should be arranged
x Cost of therapy, long duration of stay and cosmetic problems
should be informed to the relatives
J. Trauma
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C hapter Outline
·
Triage
·
Concepts in Trauma
Management
·
Spinal Injury
·
Neck Injuries
·
Bullet Injuries
·
Blast Injuries
·
Penetrating Injuries
·
Abdominal Trauma
Trauma is a major public health problem in all countries. It
causes death disability and both. 50% die immediately at the
time of accident. 25% die in golden hour of trauma, i.e. first 4–6
hours of trauma. 25% may die late during treatment period due
to sepsis and complications. Injuries may be penetrating, blunt,
blast, chemical, electrical and other injuries.
Fig. 1.235: Trauma causing large tissue defect
exposing the bone.
·
Blunt Trauma of
Abdomen
·
Duodenal Injury
·
Small Bowel Injury
·
Colonic Injury
·
Abdominal
Compartment Syndrome
·
Seat-belt Injuries
ASSESSMENT OF FOUR COMPONENTS
B
i. Physiologic response
ii. Anatomical injury
iii. Biomechanical injury
iv. Comorbid factors
TRIAGE ALGORITHM
B
Step One (Assess physiological impact)
Measure vital signs and level of consciousness
x By Glasgow coma scale
x Systolic blood pressure
x Respiratory rate
x Revised trauma score. It is based on airway, laryngeal injury,
spine injury, maxillofacial injury
Step Two (Assess anatomical impact)
All penetrating injuries to head, neck, thorax, major burns, fracture
bones, pelvic fractures, paralysis
Step Three (Assess mechanism)
Automobile accidents, crash or blast injuries, high energy injuries,
fall from more than 20 feet. Bullet injury
Step Four (Assess history)
x Patient’s age below 5 years or age more than 55 years
x Cardiac diseases, respiratory and metabolic diseases
x Pregnancy
x Patients with bleeding disorders
x Immunosuppressed individuals
BASED ON THESE STEPS CONSIDER TO SHIFT THE PATIENT TO
TRAUMA CENTER and TRAUMA TEAM SHOULD BE KEPT ALERT.
It is important in multiple and mass casualities (fire, blasts, automobile accidents, train accidents).
TRIAGE
Triage means “To sort” in French.
Triage is a system to attend trauma patients, formu lated by
Committee of Trauma of the American College of Surgeons.
Advanced trauma life support (ATLS) is essential for first
hour care of an injured patient.
Pre-hospital trauma life support (PHTLS) is to prevent
deaths while injured patients are transported to the hospital.
Types of Triage System
Multiple casualties: Staff and facilities are sufficient but
priority is given to life-threatening injuries.
Mass casualties: Staff and facilities are not sufficient to
manage. Here those who are likely to have highest chance
of survival are given priority.
Management
Initial evaluation of the patient.
Physiologic stabilisation.
Control of haemorrhage.
Management of thoracic and abdominal injury.
Management of cranial injury.
I. Primary Management
Airway management (blocked by food, vomitus, clot, fallen
tongue).
Breathing.
Circulation.
Disability and level of consciousness assessment by Glasgow
coma scale.
Exposure of the patient from head to toe for final assessment.
Fingers and tubes: Finger evaluation, Foley’s catheterisation.
There is no right way to do something wrong.
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Goals
Identify life-threatening conditions.
Decide and implement appropriate treatment to the area of
trauma.
First think to salvage the life, then think to salvage the limb.
Rapid assessment, rapid resuscitation, rapid stabilisation.
Optimum, complete care.
Transport efficiently to higher trauma centre.
III. Secondary Survey
Re-evaluate the patient completely again.
IV. Denitive Care
(All discussed under individual topics.)
Mechanism of Trauma
Blunt trauma—direct or indirect blunt injury can occur. Seat-
belt reduces the blunt injury in vehicles.
CATEGORISE THE PATIENT
B
I: Deceased
SRB's Manual of Surgery
II: Walking wounded
III: Immobile wounded
IV: Trapped wounded
Tag the patient accordingly
Red colour
Yellow colour
Green colour
Blue colour
Black colour
: Immediate treatment is required
: Urgent treatment is required
: Delayed treatment is required
: Expectant treatment is required
: Deceased
Penetrating injury—severity depends on the extent of deeper
injury.
Blast injury.
Crush injury—earthquake, industrial accidents, and train acci-
dents—causes crush syndrome; compartment syndrome.
Burn injury.
Injury in alcohol patients.
AIRWAY
Chin lift 100% oxygen, 15 litres/minute
Jaw thrust
Nasal airway
Oral airway
Endotracheal intubation
Tracheostomy
(assess airway patency)
CIRCULATION DISABILITY EVALUATION
Monitor vitals Neurological examination
Heart sounds
ECG
IV fluids blood transfusion
Treatment of shock
Control of external bleed
Use two IV lines—14G/16G
EXPOSE THE PATIENT
FULLY
Undress the patient Use required tubes like catheter,
Hypothermia assessment
Assess injuries
Examine joints, bones,
abdomen, other systems
Look for identification marks
BREATHING
Assess bilateral chest raise
Assess breath sounds
Use pulse oximetry
Treat flail chest, pneumothorax
Intercostal tube drainage
Glasgow coma scale
Pupillary reaction
FINGERS AND TUBES
Examine all orifices like P/R, P/V,
etc.
Ryle’s tube
Fig. 1.236: Crush injury leg due to road traffic accident.
II. Investigations
X-ray spine, chest, pelvis, extremities.
CT scan—whole body CT scan is useful as it identifies all
injuries. But still its concept in trauma to achieve effective
survival is under debate.
Blood group and cross-matching.
Arterial blood gas analysis.
Serum electrolytes.
Ultrasoud abdomen.
Fig. 1.237: Ankle injury with open wound.
Abbreviated Injury Scale (AIS)
https://t.me/medicina_free
It is an anatomical scoring system. Injuries are ranked on a scale
of 1 to 6, with 1 being minor, 5 severe and 6 a nonsurvivable
injury. This assesses the 'threat to life' of an injury and is not a
measure of severity.
Injury 1 2 3 4 5 6
AIS
score
Minor Moderate Serious Severe Critical Unsurvivable
Injury Severity Score (ISS)
It is an anatomical scoring system that provides an overall
score for patients with multiple injuries. Each injury is assigned
with AIS with one of the six body regions—Head, Face, Chest,
Abdomen, Extremities including pelvis, External. The highest AIS
score in each body region is used. The 3 most severely injured
body regions have their score squared and added together to
produce the ISS score. A major trauma is defined as the Injury
Severity Score being greater than 15; it is associated with
mortality of 10% or more. ISS ranges from 1 to 75.
Other Scoring Systems
New injury severity score (NISS): It is the sum of the squares
of the top three scores regardless of the body region. The NISS
is said to be better than ISS score.
Trauma and Injury Severity Score (TRISS) system is done using
anatomical and physiological scores; it indicates the probability
of survival.
CRAMS score (Circulation; Respiration; Abdomen; Motor;
Speech) is used often; score <8 suggests major trauma.
Note:
• Valuesindicativeofcriticalphysiologicderangementinclude:
Temperature <35°C; pH <7.2; base excess > –6; lactate >4 mmol/L;
ionised calcium <1.1 mmol/L; platelet count <50,000/; PT – INR >1.5;
APTT >1.5 × normal; fibrinogen level <1.0 g/L.
• Major trauma is ISS >15; 15% of injured patients will have major trauma.
135
CHAPTER 1J General Surgery: Trauma
Fig. 1.2 38: Degloving injury involving entire left lower limb, perineum,
and left groin. Patient has lost scrotum and both testes. There were no
internal injuries and vessels and nerves were intact. Patient underwent
wound excision extensively and colostomy was done to promote healing
of perineal wound and prevent contamination.
Fig. 1.239: Class III dog bite on face in a boy.
Revised Trauma Score (RTS)
It is a reliable physiological scoring system in trauma. Here
Glasgow coma scale, systolic blood pressure, respiratory rate
are used as parameters.
RTS = 0.9368 × GCS + 0.7326 × systolic BP + 0.2908 × Resp-
ratory. RTS will come between 0–7.8. Value <4 needs critical care.
Glasgow
scale
coma
13–15 >89 10–19 4
9–12 76–89 >29 3
6–8 50–75 6–9 2
4–5 1–49 1–5 1
3 0 0 0
Blood
pressure
systolic
Surgeons are Chromophobic—They don't like Red (blood); Green (bile); Blue (organ ischaemia);
Respiratory
rate
Fig. 1.240: Degloving of scalp with bone periosteum exposing the
skull bone. Outer table was actually dead and required bone removal
and graft after healthy granulation tissue was formed.
Value
CONCEPTS IN TRAUMA MANAGEMENT
Concept of ‘golden hour’ to treat the trauma patient is
important.
Multidisciplinary approach.
Planning, setting up, organizing, team work.
Assess respiratory system; circulation; bleeding areas—as
priority.
Assess also whether patient is haemodynamically stable or
unstable.
Yellow (Pus, fecal matter).
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