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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 andneck
• 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 tothe next phase ofcare
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
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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 80–90mmHg,
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 80mmHg 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-
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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 15min 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 Chapter35)
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 Chapter32)
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 andcolon
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 to5
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 dierent 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 aects 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 10minutes 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
10
• 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 ofburn
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 (Table10.1).
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 2–3weeks without
scarring, and deep partial- thickness wounds take longer
than 3weeks to heal and do so with scarring.
80 Burns
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(a) First-degree burns
(b) Second-degree burns
(c) Third-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 (Figure10.2). 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
(Figure10.3). Alternatively, as a rough rule, the patient’s
hand is approximately 1% of the body surface area.
Figure10.1 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 ofthe 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
ofthe 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.
Table10.1 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, 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
5–10days
Heals without scars in
14–21days
Heals with scarring in
over 21days, 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 andventilation
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
A
Ignore simple erythema
1
A
1
22
/
2
1
2
BB
13
1
1
/
/
2
2
2
13
1
/
2
1
1
/
1
2
1
1
/
2
1
1
/
1
2
1
1
1
/
1
2
BB
Deep
Supercial
Region %
CC
Head
Neck
Ant.trunk
3
/
4
1
1
Post.trunk
3
/
4
Right arm
Left arm
Buttocks
Genitalia
Right leg
Left leg
Total burn
CC
3
3
/
/
4
4
1
1
Relative percentage of body surface area affected by growth surface
Area Age 0 1 5 10 15 Adult
1
/
2
A =
of head 9.5 8.5 6.5 5.5 4.5 3.5
1
/
2
of one thigh 2.75 3.25 4.0 4.5 4.5 4.75
B =
1
/
of one leg 2.5 2.5 2.75 3.25 3.25 3.5
2
C =
1
/
2
1
/
1
2
Figure10.2 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.
1
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
4
the treatment of burns are as follows:
a
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
b
effects of severe burns.
reconstruction and rehabilitation of the
c
patient.
Local treatment
Supercial 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 2–3days.
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
2weeks.
Figure10.3 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 >
6hours.
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 (Figure10.2).
Full thickness burns
Full thickness burns, and more extensive deep partialthickness burns, require excision of the burn wound.
Early excision (within the first 2–7days 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 10–14days 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 tohands
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
24hours. Half the volume should be given in the
first 8 hours, and the remainder over the next
16hours.
would, using this formula, require a figure of
4×70×40=11,200mL. Half of this (5,600mL) is
given in the first 8hours, and the other half in the
next 16hours. In addition, the fluid regime should
also include the daily maintenance fluid requirement (3L 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 24hours, 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 70kg 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 12hours. 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.
1
Amount of fluid replacement.This depends upon
the extent of the burn as calculated from the
Lund–Browder chart (Figure10.2). The Parkland
2
formula
ing the volume of fluid to be given in the first
2
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
25kcal/kg weight plus 40kcal per percentage area
burned.
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