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Trauma surgery 75

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Special investigations

While the primary survey is conducted, adjuncts are utilized to improve the understanding of the patient’s condition:

•

A Focused Assessment with Sonography for

Trauma (FAST scan): a rapid targeted ultrasound scan giving reallung, pericardial and abdominal injuries.

X- rays: Chest, pelvic and occasionally lateral

• C-

spine X- rays may be performed at the bedside in the resuscitation department, although these have been largely replaced by rapid access to cross-

• Trauma CT scan from the head to the knees: a contrast enhanced scan providing arterial and portal phase images of the chest and abdomen, and noncontrast images of the head and neck.

• Arterial blood gas: critical to providing a snapshot of the underlying physiology of the patient. Evidence of significant acidosis (low pH) or a raised lactate level indicates the urgency of definitive interventions.

time information on potential

Monitoring

Depending on the severity of injuries and time available before transfer to the operating room, additional lines, such as a central and arterial, may be placed. Consideration should be given to urinary catheter insertion, especially if the patient is to be transferred to a major trauma centre.

Relative contraindications to urinary catheterization in trauma patients include findings that might suggest urethral disruption, such as:

•

blood at the urethral meatus;

•

scrotal haematoma; high riding prostate;

•

frank haematuria.

Head andneck

• Basal skull fracture assessment: any signs that might indicate a basal skull fracture should be recorded:

– periorbital bruising (raccoon eyes); – cerebrospinal fluid (CSF) rhinorrhoea; – CSF otorrhoea; – Battle’s sign (bruising over the mastoid

process);

– haemotympanum (blood behind the tympanic

membrane);

– cranial nerve palsy.

• Scalp lacerations: These can lead to significant blood loss. They should be addressed with direct pressure (bandages) or skin stapling devices as a temporizing measure if definitive management is not possible.

• Assessment of the cervical spine: This can also be performed in patients without distracting injuries. Any pain and/or neurological signs should be carefully recorded to determine if further assessments are required before removing the cervical spine protection.

Chest

• Rib fractures: These in isolation are a significant cause of pain, and patients often require admission for adequate analgesia. Without adequate analgesia, atelectasis is not uncommon, and if left untreated, progression to pneumonia may occur. In more severe trauma, a flail segment may be present (Chapter 14). This will compromise ventilation to a greater or lesser extent depending on the number and distribution of ribs involved. The vast majority of rib fractures are managed conservatively.

• Contusions: If significant force has been transmitted through the chest or thorax, pulmonary or cardiac contusions may exist, impairing oxygenation of the bloodstream or contributing to cardiovascular instability.

Secondary survey

Time permitting, a secondary survey is conducted by examining the patient head to toe. Important signs to consider and record include any bruising or disruption of the skin, previous surgical scars/injuries and areas of pain that may require further imaging. Specific signs/symptoms are considered below.

Transfer tothe next phase ofcare

Once the primary survey has been completed, the team should understand how critically ill the patient is. The trauma team leader and surgical teams will need to consider the next step in the patient’s journey. There will typically be options ranging from crosssectional imaging, intensive care or moving directly to

76 Trauma surgery

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the operating theatre or interventional radiology suite. If in a small hospital or trauma unit, consideration will need to be given to transferring the patient for definitive care at a major trauma centre.

Indications for the immediate transfer to the oper-

ating theatre include:

evisceration;

•

non- responders to resuscitation with hypovolaemic

shock;

impalement patients who are unstable.

•

For patients not meeting the aboveteria, a judgement needs to be made about the patient’s overall stability. Generally, patients who are either responders or transient responders to resuscitation are safe to be transferred to the cross- sectional imaging suite.

mentioned cri-

Damage control ethos

A damage control ethos is adopted for critically ill trauma patients and is included within the resuscitation phase of the patient’s journey. The philosophy consists of different elements of care, including permissive hypotension and damage control surgery with balanced resuscitation (with appropriate blood products).

Permissive hypotension

Permissive hypotension (also known as hypovolaemic resuscitation) is a concept of accepting a lowerthan- normal blood pressure (systolic 80–90mmHg, mean arterial pressure around 50 mmHg), by avoiding aggressive resuscitation to ‘normalize’ blood pressure readings. This approach reduces blood loss by allowing vessels that have undergone vasospasm to continue to function in this manner rather than ‘opening’ them up with higher perfusion pressures.

Permissive hypertension is contraindicated in those with traumatic brain injuries where higher cerebral perfusion pressures (CPP) may be needed to maintain cerebral perfusion to prevent secondary brain injuries (Chapter 17). In trauma, the normal autoregulation of cerebral perfusion may be disrupted and, therefore, active management by maintaining a mean pressure of 80mmHg may be required, or even higher in the elderly.

Damage control surgery

Research has shown that initial, short surgical procedures (typically 60 minutes or less) to ‘control damage’ were more successful than undertaking prolonged major surgery at the time of presentation. This surgical approach aims to control haemorrhage and contamination, and making specific organ interventions. The two main operative procedures are resuscitative/emergent thoracotomy and trauma laparotomy.

Resuscitative or emergent thoracotomy

A resuscitative or emergent thoracotomy may be required in the event of a loss of cardiac output in trauma patients or if intrathoracic pathology is suspected as the underlying cause for deterioration. This is generally performed by performing a left thoracotomy entering the chest typically in the fifth left intercostal space. Better exposure can be achieved by converting the incision into a ‘clamshell’ thoracotomy with the division of the sternum and right fifth intercostal space, facilitating excellent exposure of both left and right lungs as well as the heart itself. If this procedure is performed either in the preting or emergency department, thoracotomies are generally only performed as a clamshell.

Once in the adult thoracic cavity, a pericardial tamponade can be quickly evacuated through a vertical incision to avoid damage to the phrenic nerve as it runs over the anterolateral aspect of the pericardium. Once the pericardium has been evacuated, open direct current (DC) cardioversion shock can be administered if required.

Significant bleeding from lung parenchymal injuries can be controlled either temporarily using a clamp or more definitively using linear staplers and over- sewing the area of trauma. There may be a need to perform an emergent pneumonectomy, although this is quite rare.

Entering into the thoracic cavity gives the opportunity to control the descending thoracic aorta, with either manual manipulation or instrumentation. In order to avoid damage to the oesophagus, typically located immediately anterior to the descending thoracic aorta, many surgeons advocate manual compression rather than instrumentation.

Outcomes vary depending on the type of trauma (penetrating versus blunt) and indication for

hospital set-

Trauma surgery 77

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thoracotomy. Success rates for patients with penetrating traumatic injuries, leaving the hospital neurologically intact, range between 3% and 25%. This is only the case if the resuscitative thoracotomy is performed within 15min of loss of signs of life. For blunt trauma, outcomes are significantly worse, with at best

1.5% of patients leaving the hospital alive and neurologically intact.

Indications for thoracotomy in the context of blunt trauma need to be considered carefully. The outcome in blunt trauma also depends on the location of the intervention (preand the skill set of the team performing the procedure. Unless definitive treatment for the underlying cause of the blunt traumatic cardiac arrest is addressed rapidly, the outcome is unlikely to be successful.

hospital versus operative theatre)

Emergency laparotomy

There has been a significant fall in the number of patients undergoing emergency laparotomy for trauma due to improvements in crossing and changes in the management of specific organs. For example, splenectomy once was relatively commonly performed for traumatic indications; however, it is now much rarer with advancements in interventional radiology.

Preparation for an emergency laparotomy (if possible) includes a thorough team brief of the theatre staff before starting the case (Chapter 2). This ensures that all the required equipment is readily available and that potential unexpected steps have been planned for, such as an emergent thoracotomy or the need for particular stapling devices/energy devices. If the patient has not already been catheterized in the emergency room, this should be performed as soon they enter the operating theatre. Ongoing resuscitation will occur as the surgeons start the operation to try and correct the abnormal physiology. For critically ill patients, the theatre is often prepared similarly to that of a ruptured abdominal aortic aneurysm, with the patient often conscious while the skin preparation and draping is applied. Once the surgical team is ready to make the first incision, the anaesthetist will often induce the patient at that stage. The operation starts as soon as the anaesthetic team is prepared. Depending on the situation’s urgency, a knife/scissors may be used rather than monopolar diathermy to expedite entry into the abdominal cavity.

sectional imag-

Once the abdominal cavity has been opened, there is an immediate evacuation of any blood and the small bowel is delivered into the wound to enable packing of the abdomen. Using multiple large abdominal swabs, the abdominal cavity is then packed in quadrants, taking note of where most of the blood has originated from or where most of the injuries are suspected. Any damage or bleeding from the small bowel mesentery is addressed using sutures, but this is not the time to do anastomoses or other timeinterventions. In coordination with the anaesthetic team (dependant on the patient’s stability), a systematic examination of the abdominal cavity is performed. This typically starts in the quadrant furthest away from suspected pathology. For example, if a shattered spleen has been the cause of the haemoperitoneum and the need for emergency laparotomy, packs will typically be removed from the right lower quadrant first and then removing swabs from successive quadrants until the final quadrant can be addressed safely.

Once all packs have been removed, and haemorrhage controlled, a more thorough assessment of the intra-

abdominal organs can be performed. The primary objective is to control bleeding and any contamination from a hollow viscus.

consuming

Individual organ management

Spleen (see also Chapter35)

Many splenic injuries are now managed conservatively or with interventional radiological techniques rather than splenectomy at open surgery. Splenic trauma can occur either as an isolated event or as part of a more complex multiple injury pattern in a trauma patient. Some predisposing pathological conditions of the spleen, such as splenomegaly, may result in splenic rupture with relatively minor force. Most assessments of potential splenic injury are performed using CT rather than ultrasound.

It is important to salvage the spleen if at all possible due to its role in protection against infection particularly from capsulated organisms. Most early stage splenic injuries can be treated conservatively (without intervention). More severe injuries may require radiological embolization if they result in cardiovascular instability. Severe splenic injury, such as a shattered spleen, often require a splenectomy to control the bleeding.

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Liver (see also Chapter32)

Most bleeding from liver injuries is a result of venous bleeding rather than arterial. As such, packing the liver by placing large abdominal swabs around the liver to reusually sufficient to arrest the bleeding. Any further bleeding can be controlled using interventional radiological techniques with embolization.

approximate the tear in the liver capsule is

Extrahepatic biliary tree

Injuries to the gall bladder are rare outside of the context of penetrating trauma. The treatment for most injuries is to perform a cholecystectomy with careful inspection of the porta hepatis.

Stomach, small bowel andcolon

Primary repair of any isolated hollow viscus injury is usually performed in stable patients. In the context of damage control surgery, the mainstay of treatment is to control contamination and haemorrhage rather than definitive management of the injuries. This approach may include leaving the abdomen open (a laparostomy) and transferring the patient to the intensive care unit to normalize the abnormal physiology. In the context of damage control surgery, performing anastomoses or stomas would not be appropriate at this first laparotomy. Instead, stapling devices are typically used to close any defects in the hollow viscus to enable a rapid transfer to the intensive care unit. Consideration for anastomosis or a stoma can be made at a subsequent second look laparotomy 24–48 hours later.

Pancreas

Most pancreatic injuries are treated conservatively, especially when it is an isolated injury. Even in patients with multiple intra- abdominal pathologies, the pancreas often does not require surgical intervention

outside of haemorrhage issues. Disruption of ducts, for example, can often be treated using stents and endoscopic retrograde cholangiopancreatography (ERCP) rather than open operative surgical techniques.

Diaphragmatic injuries

Diaphragmatic injuries are rare on the right side because of the bare area of the liver providing protection. The left diaphragm is more prone to injury from blunt force trauma or penetrating injuries. A surgical repair of such injuries is indicated. Typically, a strong non-

absorbable suture is used to close such defects. Occasionally, small diagrammatic hernias can present late, some months or even years after the initial injury.

Abdominal closure

Temporary closure of the midline wound, or leaving it open as a laparostomy may be performed, with definitive closure some days later. Muscles left unopposed will contract over a period of days, making the eventual closure technically more challenging. For laparotomies in physiologically stable patients, definitive closure can be undertaken as part of the primary procedure.

Phases 3 to5

After damage control surgery, the patients are taken to the intensive care unit where normalization of clotting and other physiological parameters are the main goals of therapy. Typically, patients with laparostomies will be reassessed in the operating theatre every 48 hours, although this is also dictated by the patient’s response to treatment in the intensive care unit. Second look laparotomies can be used to definitively manage any hollow viscus injuries, with anastomoses being performed or stomas created at subsequent operations (Phase 4). Consideration is also given to the timing of abdominal wall closure (Phase 5), either with primary or secondary intention.

Burns

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Ian Grant

Learning objectives

✓ To know the dierent types of burn. ✓ To be able to determine the extent of a burn injury as a percentage of the

total body surface area and to understand how this aects treatment.

✓ To be able to assess the depth of a thermal burn. ✓ To know the principles of the initial management of the patient with

burns.

Causes

• Thermal burn: the most common cause of a burn, due either to direct contact with a hot surface, flame or scalding liquid, or to hot vapour such as steam. The severity of the burn is related to the temperature of the surface, and the duration of exposure. The thermal burn from steam is due to both temperature of steam and latent heat released as it changes phase from vapour to liquid.

Electrical burn: contact with a source of electricity. A

• voltage of more than 500 V is considered high voltage and likely to cause greater injury. The patient will often have burns at the site of entry and at the site of exit of the electricity, and internal organs, including muscle and nerve, can be injured.

• Chemical burn: inadvertent exposure to a strong acid or base (alkali). Most commonly, this is a commercially available product such as acid from a battery or alkali drain cleaner. Initial management of the wound includes prolonged irrigation for more than 10minutes or until a neutral pH is achieved.

Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition. Edited by Christopher Watson and Justin Davies. © 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd. Companion website: www.wiley.com/go/Watson/GeneralSurgery14

• Radiation burn: exposure to radiation, such as radiotherapy treatment for cancer.

Severity

The severity of a burn is assessed based on the depth of burn and the amount of skin involved, together with other associated clinical features.

Depth ofburn

Thermal burns can be subdivided according to the depth of thermal injury to the sequential layers of the skin (Figure 10.1). Burns of different depths exhibit different pathophysiology and require different treatment (Table10.1).

Burns can be subdivided into:

superficial/erythema;

•

• superficial partial thickness;

• deep partial thickness;

• full thickness burns.

Partial-

thickness burns heal spontaneously, superficial partial- thickness wounds heal within 2–3weeks without scarring, and deep partial- thickness wounds take longer than 3weeks to heal and do so with scarring.

80 Burns

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(a) First-degree burns

(b) Second-degree burns

Epidermis

Dermis

Subcutaneous tissues

(defined as a major burn injury) are associated with a systemic physiological change referred to as burns shock. A patient with a burn of this size requires immediate fluid resuscitation. The amount of fluid required by the patient can be calculated with knowledge of the weight of the patient, the burn area as a percentage of their total body surface area and the time of the injury.

Patients who have sustained major burn injuries and are best managed with the support of a specialist burns unit. Clinicians starting the initial management of these patients in peripheral locations are encouraged to liaise as quickly as possible with the local specialist burns unit in order to plan further care and urgent transfer of the patient.

The surface area of the burn area can be rapidly assessed using a ‘Lund–Browder’ chart (Figure10.2). The chart takes into account differences in the body surface area with age. For example, an infant’s head has a proportionately greater surface area than an adult’s head. These charts are readily available in Emergency Departments. Areas of partial and full thickness burns are drawn on the chart to allow calculation of the burn area.

In the adult, a rough approximation of burn size can also be achieved using the rule of nines. The body is divided into zones of percentage of surface area (Figure10.3). Alternatively, as a rough rule, the patient’s hand is approximately 1% of the body surface area.

Figure10.1 A partial- thickness burn (a) leaves part or

the whole of the germinal epithelium intact; complete healing takes place (b). A full thickness burn (c) destroys the germinal layer and, unless very small, can heal only by dense scar tissue.

Full thickness burns have no potential for sponta-

neous healing.

Area ofthe burn

Estimation of the area of a burn is critical. Burns of more than 20% of the patient’s total body surface area

Percentage surface area

Head and neck 9

Each arm 9

Each leg 2 × 9 = 18

Front of the trunk 2 × 9 = 18

Back of the trunk 2 × 9 = 18

Perineum 1

The initial management ofthe severe burn injury patient

Urgent assessment, resuscitation and transfer to a specialist unit is likely to give the patient the best chance of recovery. Well- established protocols for the best management of these patients are documented in the Emergency Management of Severe Burns (EMSB) and Advanced Burns Life Support (ABLS) courses.

Table10.1 Burn comparison

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Burns 81

Thickness

Superficial/ erythema (historically called a

degree burn)

first-

Superficial partial thickness (historically, this would be called a secondburn)

Deep partial thickness (historically, this would also be called a seconddegree burn)

Full thickness (historically called a ‘third-

degree

degree burn’)

Depth of thermal necrosis Appearance Pain/sensibility

Epidermis Dry, blanching with

Upper (papillary) dermis, with preservation of the epidermal ridges of the dermojunction

Deep (reticular dermis) with necrosis of the dermo- epidermal junction but preservation of the hair follicles lined with epidermis

The necrosis extends through the entire thickness of the skin

epidermal

pressure

Blisters, wet, swollen, blanching with pressure

Blisters, does not blanch, colour can vary in patches from pale yellow to red

White, or brown, inelastic, dry

Painful, and sensate to light touch

Painful, sensate to pressure but not to light touch

Painless, sensate only to deep pressure

Prognosis if untreated

Heals without scars in 5–10days

Heals without scars in 14–21days

Heals with scarring in over 21days, often requires tangential excision and then split skin grafting to accelerate healing and minimize scarring

Heals only by contraction. With the exception of small burns of less than 2% total body surface area; the burn requires excision and the application of a split skin graft

Airway management

A thermal injury to the upper airway should be suspected if the patient was in an enclosed space breathing in hot smoke. Examination of the patient might also reveal that he or she has a hoarse voice, stridor, burnt facial hair and soot around his/her mouth or nose. Dangerous narrowing of the airway can occur quickly due to oedema. The clinician with the greatest experience of airway management (most commonly an anaesthetist or emergency physician) should protect the patient’s airway, possibly by urgent endotracheal intubation.

Breathing andventilation

In rare circumstances, a patient may have circumferential full thickness burns of his/her chest, preventing normal respiratory movements. These patients require urgent bedside incision of the burn (termed an escharotomy) to allow the chest to expand.

Fluid resuscitation

A burn of >20% total body surface area initiates a dramatic release of pro- inflammatory cytokines, causing systemic changes that include an increase in capillary permeability with loss of proteins and fluid into the interstitial space. This starts at the time of injury and peaks at around 24 hours. It continues for approximately 72 hours. The effect of this loss of intravascular fluid is compounded by the toxic effect of the systemic response of the body to a major burn, which can reduce myocardial contractility, and the local response to the burn causing fluid loss from blistering and oedema.

Pain

Pain is severe in partial- thickness burns due to stimulation of numerous nerve endings in damaged skin; full thickness burns can be painless.

82 Burns

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Lund and Browder chart

Ignore simple erythema

Deep Supercial

Region %

Head

Neck

Ant.trunk

Post.trunk

Right arm

Left arm

Buttocks

Genitalia

Right leg

Left leg

Total burn

Relative percentage of body surface area affected by growth surface

Area Age 0 1 5 10 15 Adult

A =

of head 9.5 8.5 6.5 5.5 4.5 3.5

of one thigh 2.75 3.25 4.0 4.5 4.5 4.75

B =

of one leg 2.5 2.5 2.75 3.25 3.25 3.5

C =

Figure10.2 The Lund and

Browder chart allows more accurate estimation of burn surface area and is particularly useful in children. The extent of the burn is marked on the chart. The areas of burns on the head, thighs and lower legs (A, B and C on the chart) are calculated and multiplied by the age factor in the table.

Anaemia

Anaemia results partly from destruction of red blood cells within involved skin capillaries and partly from toxic inhibition of the bone marrow if infection of the burnt area occurs.

Stress reaction

Peptic ulceration (Curling’s ulcers1)can be seen in patients with major burns.

omas Blizzard Curling (1811–1888), surgeon to the London Hospital; also wrote the rst accurate description of cretinism in adults (myxoedema) in 1850.

Treatment

1 Immediate first aid treatment. The immediate

treatment of any burn is to safely stop the process straight away. This can be achieved by removing the patient from the source of the burn and applying cold running water to cool the area to prevent continued damage. A temporary dressing such as ‘cling film’ can be applied to the wound during the transfer of the patient to an appropriate centre.

2 Resuscitation. The airway is checked for evidence

of burns. If there is any suspicion of an inhalation injury urgent review and assessment of the patient by a clinician skilled in airway management is needed. Blood should be taken to assess the level

Head

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and neck = 9%

Each arm = 9%

Front of trunk = (9×2)%

Back of trunk = (9×2)%

Perineum = 1%

Each leg = (9×2)%

Burns 83

Subsequent treatment.Thereafter, the principles of

the treatment of burns are as follows:

local treatment of the burn wound– minimiz-

ing fluid loss, prevention of infection, provision of an optimal environment for moist wound healing, avoidance of contracture.

systemic treatment – mitigating the systemic

effects of severe burns.

reconstruction and rehabilitation of the

patient.

Local treatment

Supercial partial- thickness burns

Superficial partial- thickness burns and very small deep partial- thickness burns are managed with simple non- adherent dressings such as paraffinimpregnated gauze under several layers of absorbent gauze; dressings are changed every 2–3days. When the patient presents late, a topical antibiotic such as silver sulfadiazine cream (Flamazine) may be applied to the burn below the non- adherent dressings. When the hands are involved, the burn may be covered by sulfadiazine cream and placed in a sealed polythene bag. The wounds should heal with minimal scarring within approximately 2weeks.

Figure10.3 The ‘rule of nines’– a useful guide to the

estimation of the area of a burned surface. (Note also that a patient’s hand represents 1% of the body surface area.)

of carboxyhaemoglobin (carbon monoxide has an affinity for haemoglobin over 200× that of oxygen). Patients suspected of having been exposed to carbon monoxide should be given oxygen through a re- breathing mask at a rate of 8–15 L/min for > 6hours.

If the burn area is over 15% (or 10% if a child), admission and intravenous resuscitation are warranted; intravenous access with a large- bore cannula should be gained at a site remote from the burn, and fluid resuscitation started. Less extensive burns can be managed by oral replacement. Advice should be sought from a specialist burns unit.

3 Assessment of burn severity. The depth, extent and

location of burn are assessed and documented using the Lund–Browder chart (Figure10.2).

Full thickness burns

Full thickness burns, and more extensive deep partialthickness burns, require excision of the burn wound. Early excision (within the first 2–7days after injury) has been shown to produce better outcomes than delayed excision of the burn wound.

Full thickness burns can be excised by fascial excision (removal of the skin and fat to expose the fascia). Extensive (>2% TBSA) deep partialare likely to heal quicker and with less scarring if the burnt tissue is excised by tangential excision (the burnt skin is subject to progressively deeper tangential excision until healthy bleeding tissue is exposed).

The wounds are closed using meshed split skin grafts (usually from the patient’s thighs or buttocks). The grafts take about 10–14days to produce new skin. For burns that involve >50% of the total body surface area with limited donor sites, temporary closure of the burn wound can be achieved using cadaveric skin or commercial skin substitutes. These products are removed and replaced at approximately 2- week intervals with the patient’s own skin (through repeated ‘cropping’ of the donor sites).

thickness burns

84 Burns

Fluid replacement mL in first h after injury

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Facial burns

The deep sweat and sebaceous glands of the face facilitate the healing of most partialwith only supportive topical dressings. Skin grafting is carried out if the eyelids are involved in order to prevent ectropion with the risk of corneal ulceration; an opaque cornea suggests a deep corneal burn requiring ophthalmic assessment.

thickness burns

Burns tohands

Burns to hands require careful management, as oedema and scarring can produce contractures across the joints. The palm skin will usually recover from most scalds, and deep partialburns and deeper injuries requiring burn excision and skin grafting are rare and are usually caused by prolonged contact burns. The skin on the back of the hand is thinner and more commonly requires surgery. Patients with hand burns often require hand therapy to maintain movement and splinting (usually with the metacarpophalangeal joints flexed and the interphalangeal joints extended as soon as the dressing requirements allow the application of a splint).

thickness

General treatment

24hours. Half the volume should be given in the first 8 hours, and the remainder over the next 16hours.

would, using this formula, require a figure of 4×70×40=11,200mL. Half of this (5,600mL) is given in the first 8hours, and the other half in the next 16hours. In addition, the fluid regime should also include the daily maintenance fluid requirement (3L in an adult).

ment of the patient should include monitoring the hourly urinary output, pulse, blood pressure, central venous pressure and core temperature. Fluid replacement may need to be adjusted according to these observations.

2 Type of fluid used for replacement.There is now

consensus that a crystalloid solution is most appropriate for the first 24 hours after injury (most commonly this is Hartmann’s solution). At the end of 24hours, the fluid regimen can be augmented with colloids such albumin, fresh frozen plasma and blood.

mL weight k

2 4– gg burn area%

For example, a 70kg patient with a 40% burn

During the resuscitation phase, clinical assess-

Pain

Provide adequate pain relief; this may include intravenous opiates (e.g. morphine).

Hypovolaemic shock

Rapid fluid loss occurs, the rate of loss being quickest in the first 12hours. Aggressive replacement of this fluid as soon as possible is essential. There are two underlying principles in this replacement: first, the correct amount of fluid should be replaced, and second, the correct type of fluid is important.

Amount of fluid replacement.This depends upon

the extent of the burn as calculated from the Lund–Browder chart (Figure10.2). The Parkland

formula ing the volume of fluid to be given in the first

e Parkland Hospital, Southwestern University Medical

Center, Dallas, TX, USA.

is now the most accepted way of estimat-

Antimicrobial therapy

Burn wounds left untreated rapidly become colonized by bacteria. Burns presenting late are usually dressed with topical antimicrobial agents, with silver sulfadiazine most commonly used. Invasive infection requires the use of broadtreatment covering streptococcal and staphylococcal infection (including methicillin- resistant species, e.g. with vancomycin) as well as Pseudomonas; prophylaxis against fungal infection may also be appropriate in cases of extensive burns.

spectrum antimicrobial

Nutrition

The patient’s nutrition should be maintained, especially when burns are extensive. For major burns requiring resuscitation, enteral feeding should be started as soon as possible. The daily calorific requirement has been estimated at a minimum of 25kcal/kg weight plus 40kcal per percentage area burned.

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