PROTOCOL FOR BLUNT ABDOMINAL TRAUMA

Definition

1. FAST Exam (Focused (Focused Abdominal Sonography in Trauma): an ultrasound examination of

the abdomen that utilizes a 4-view approach for the diagnosis of blood or fluid in the abdominal
cavity and pericardial fluid.
2. E-FAST Exam: is an extended exam that includes transverse view of the chest to look for
pneumothorax.

Guidelines:

1. Treat ABC’s first. The diagnosis of abdominal trauma is done during secondary survey.
2. Perform physical examination of the abdomen, including the rectal exam and flank exam. Do
logroll.
3. Possibility of abdominal injury.
a. Obvious abdominal pain with or without peritoneal findings on PE.
b. Significant external findings on the abdominal wall (deformity, contusion, bleeding,
laceration).
c. Fractures above and below the diaphragm.
d. Lower rib fractures.
e. Lumbar of Thoracic spine fractures.
f. Unexplained hemorrhage, shock, or blood loss.
g. History of abdominal impact in a patient with altered sensorium
i. Drugs and alcohol impairment.
ii. Tetraplegia, paraplegia.
iii. Traumatic brain injury with coma.
iv. Prolonged non-abdominal surgery requiring anesthesia.
4. Direct to Operating Room for Laparotomy:
a. Diffuse peritoneal irritation.
b. Hemorrhagic shock with an indication that there is blood loss in the abdomen.
c. Ruptured diaphragm on chest xray.
d. Obvious peritoneal penetration.
5. If the patient has possible abdominal injury and is hemodynamically unstable, E-FAST is
performed:
a. If positive, direct the patient to the Operating Room for Exploratory Laparotomy.
b. If negative, consider other causes of massive hemorrhage resulting in hemodynamic
instability (long bone fractures, pelvic fractures, hemothorax).
i. If no other source of bleeding is rapidly found, consider doing exploratory
laparotomy as a negative E-FAST may yield false negative results.
6. If the patient has possible abdominal injury or with equivocal abdominal findings with no gross
need for exploration and is hemodynamically stable:
a. Perform E-FAST.
b. If Positive, do Diagnostic Peritoneal Lavage
i. If DPL is positive, do exploratory laparotomy
ii. If DPL is negative, do Non-operative Management
7. Consider Abdominal CT scan with contrast if solid organ injury is suspected
8. If Non-Operative Management is chosen, patients should have regular interval examination and
laboratory studies. If the patient develops peritoneal signs, significant fever, or increasing pain
away from the site of injury, consider laparotomy
a. Serial Hematocrit monitoring every 6 hours for the first 24 hours
b. Serial abdominal examination every 2 hours
c. Monitor hemodynamic stability every hour
 PROTOCOL FOR PENETRATING ABDOMINAL TRAUMA

Definition:

1. Penetrating Abdominal Injury: any penetrating injury that could have penetrated through the
peritoneal cavity or retroperitoneum, inflicting damage on the abdominal contents. The entry
wounds for abdominal injury extends from the 5 th intercostal space to the perineum.
2. Anterior penetrating abdominal injury: an entry wound on the anterior abdomen or chest.
Usually occurs anterior to the posterior axillary line.
3. Posterior or Flank penetrating abdominal injury: an entry wound posterior to the posterior
axillary line. Wounds in this area are different in that the most likely organ to be injured will be
in the retroperitoneum. Additionally, the large mass of flank and back muscle will make the
diagnosis of organ injury more difficult and the possibility of organ injury less frequent.
4. Thoraco-abdominal penetrating abdominal injury: an entry wound below the 5 th ICS and above
the costal margin. These are wounds that could have initially entered the chest and then
penetrated the diaphragm to enter the abdomen. These injuries are always associated with
chest pathology.

Guidelines:

1. Follow the ABC’s, and resuscitate patient according to findings of the primary survey.
2. Assess the abdomen looking for entry wounds, bleeding, and peritoneal findings. Make sure that
a good chest exam is performed, since chest injuries can be associated with penetrating
abdominal injuries.
3. Determine if there are symptoms or signs suggestive of immediate need for operative
intervention:
a. Herniated abdominal contents.
b. Massive bleeding from the wound.
c. Obvious peritoneal signs consistent with hollow viscous injury or hemoperitoneum.
d. Signs of hemodynamic instability associated with abdominal injury.
e. Signs of lower extremity ischemia suggestive of vascular injury.
f. ALL gunshot wounds with path or other evidence of intraperitoneal penetration or
retroperitoneal organ injury.
4. If any of the above signs are present, then take the patient to the operating room immediately
for exploratory laparotomy.
5. For stab wounds and low velocity gunshot wounds (.22 and .25 calber) in the Right Upper
Quadrant of the abdomen (in the area of the liver), consider using the “Right Upper Quadrant
Penetrating Injury Guidelines”
6. If stab wound is anterior:
a. Determine if there is penetration into the peritoneal cavity by exploring the wound. This
is done by infiltrating the wound with local anesthesia, after which the wound is
prepped and draped. The wound is extended if necessary to allow visual inspection and
determine its depth.
b. If the wound does not penetrate the anterior fascia, it can be debrided, irrigated, and
closed. The patient may be discharged after 24 hours if no other injuries exist. If the
anterior fascia has been violated, determine if there is peritoneal penetration.
c. If the wound does penetrate into the peritoneum, then laparotomy should be
considered. If the patient has no evidence of peritoneal irritation, then DPL may be
 performed. Prior to DPL, a foley catheter and an NG tube should be placed. Laparotomy
is indicated with gross hematuria or blood from NG tube. The threshold for a DPL in
these circumstances is gross fecal spillage or blood on aspiration or an RBC of
1000/mm3 and WBC of 500/mm3. Lavage fluid from foley catheter, NG tube or chest
tube also mandates exploration. All patients with anterior fascia penetration who are
not taken to the OR should be admitted for 24 hours of observation.
7. If the wound is thoraco-abdominal:
a. Obtain chest x-ray with wound markers to determine the presence of chest injury and
determine the relationship of the entry wound to the diaphragm.
b. If wound could possibly have penetrated through the diaphragm, consider:
i. CT scan of the abdomen. This will be positive if any fluid or air is in the
abdominal cavity.
ii. DPL with a threshold of RBC count of 1000/mm3.
iii. Diagnostic Laparoscopy. If performed, should be prepared to insert a chest tube,
as insufflation may cause tension pneumothorax through the rent in the
diaphragm.
8. If the wound is posterior or flank:
a. Insert a foley catheter to determine the presence of hematuria.
b. Obtain a triple contrast CT scan to determine injury by retroperitoneal organs.
9. For pelvic wounds that may have traversed the rectum:
a. Perform anoscopy and sigmoidoscopy to determine the presence of mucosal defect.
b. Consider diversion and rectal washout if injury is found. Pre-sacral drainage should be
used when contamination levels are high or there has been significant tissue destruction
around the anus.
10. For “tangential” gunshot wound of the abdomen:
a. Missile tract through the subcutaneous tissue with no abdominal cavity entry.
i. Entry and exit wound clearly identified.
ii. No diffuse abdominal tenderness.
b. Obtain CT scan, mark entry and exit wounds
c. If no evidence of abdominal cavity involvement, then may observe for 24 hours. May
discharge after observation period if without signs of developing peritonitis or
hemodynamic instability.
11. For all patients brought to the OR for exploratory laparotomy:
a. Once decision to go to the OR is made, do not delay!!!
b. Make sure of blood availability.
c. Administer prophylactic antibiotics for bowel flora.
d. Prep widely for all contingencies (chin to knees, table to table).
e. Obtain IVP to determine presence of bilateral kidneys if hematuria is present.
Alternatively, an abdominal CT scan with contrast may be performed.
f. After appropriate debridement and irrigation, consider primary closure of standard
gunshot wounds.
 PROTOCOL FOR RIGHT UPPER QUADRANT PENETRATING ABDOMINAL TRAUMA

Definition:

1. Right upper quadrant penetrating injury: a penetrating injury at the right upper quadrant of the
abdomen in which the trajectory of the penetration appears to have involved the liver as the
only injured abdominal organ.

Guidelines:

1. For all penetrating injuries of the abdomen, follow ATLS guidelines.

a. Two large bore IV lines. Use Lactated Ringer’s solution.
2. Patient must be hemodynamically stable. If there is a drop in blood pressure, tachycardia, or
acidosis, then the patient must be directed to the Operating room.
3. Do Non-Operative Management on the following:
a. Hemodynamically stable.
b. Stab wound or low velocity gunshot wound.
c. Entry and exit (if present) wound suggests a trajectory that transverses the liver as the
only abdominal organ injured.
d. Entry wound and x-ray showing the bullet suggests that the liver is the only abdominal
organ injured.
e. No other associated injuries or morbidity that would preclude non-operative
management.
f. Associated hemopneumothorax is OK as long as hemothorax is small (<500 mL).
4. Place Fr 36 chest tube if needed.
5. Obtain a CT of the abdomen with Oral and IV contrast.
6. Determine the trajectory of the bullet or knife into or through the liver. Consider Non-Operative
Management if:
a. The liver is the only injured organ.
b. The amount of blood around the liver and in the abdomen is
c. There is no active swirl sign suggesting active bleeding.
d. Go for laparotomy unless all of the above conditions are fulfilled.
7. If Non-Operative approach is used:
a. Admit to ICU/SICU.
b. NPO. Do serial examinations.
c. Do serial Hematocrit every 6 hours until stable, then every 24 hours.
d. Bedrest for three days.
e. Do liver function studies on 2nd day Post-Injury.
8. If hemodynamically stable with unchanging hematocrit after 24-48 hours:
a. Transfer to Surgical Ward.
b. Advance diet.
c. Mobilize on the 4th day.
d. Repeat CT scan of whole abdomen with contrast on the 2 nd day Post-Injury.
i. If there is minimal increase in fluid and bilirubin is normal, continue
management and discharge when patient is able to tolerate DAT, afebrile, and
with bowel movement.
ii. If there is an increase in fluid and bilirubin is elevated:
⮚ Percutaneous drainage of biloma.
⮚ Consider ERCP with placement of stents.
 PROTOCOL FOR NON-OPERATIVE MANAGEMENT OF SPLENIC INJURIES

Definition:

Splenic Injury:

Grade I Hematoma Subcapsular, <10% surface area

Laceration Capsular tear, <1 cm in parenchymal tear
Grade II Hematoma Subcapsular, 10-50% surface area, <5 cm in diameter
Laceration 1-3 cm in parenchymal depth that does not involve a trabecular
vessel
Grade III Hematoma Subcapsular, >50% surface area or expanding; ruptured
subcapsularorparenchymal hematoma; intrapareanchymal
hematoma>5 cm or expanding
Laceration >3 cm parenchymal depth or involving trabecular vessels
Grade IV Laceration Involving segmental or hilar vessels producing major
Devascularisation (>25% of spleen)
Grade V Laceration Shattered spleen
Vascular Hilar vascular injury that devascularizes the spleen

Guidelines:

1. Indications (when ALL of the following conditions have been met):

a. Diagnosis of splenic injury on CT scan.
b. Hemodynamically stable.
c. Grade I-III splenic injury. Consider for Grade IV or V injury in children or adults if no
significant hemoperitoneum is present.
d. No other major intra-abdominal injury.
e. Available facility for monitoring abdominal status and blood counts.
f. No other sources of major blood loss.
g. No other pre-morbid illness that suggest the patient could not tolerate blood loss.
h. No contraindications for blood transfusion.
i. Active bleeding (swirl sign) if successful embolization.
2. Protocol:
a. Admit all Grade II or higher splenic injuries to Telemetry unit or SICU. Consider admitting
all Grade IV or V splenic injuries to and ICU.
i. Monitor vital signs.
ii. Bed rest.
iii. NPO.
iv. Serial CBC every 6 hours until stable on 2 consecutive draws.
b. When haematocrit is stable and without any adverse hemodynamic events:
i. Transfer to a regular room.
ii. Advance diet.
iii. CBC daily.
iv. Bed rest for the number of days corresponding to the grade of the injury.
v. If stable and diet is tolerated, may discharge 1 day after patient starts
ambulating.
c. After discharge:
 i. No school or work for 1 week.
ii. No physical education classes or heavy labor for approximately six weeks.
iii. No major contact sports for approximately 3 months.
iv. Follow-up at the OPD one week after discharge.
v. Instruct to return to the ED if with developing or worsening LUQ pain, dizziness,
syncope, or hypotension.
d. Failures (requires laparotomy):
i. Children: requires >40 mL/kg of blood transfusion to maintain Hct>26%.
ii. Adults: requires 2 units blood transfusion to maintain Hct>26% in the absence of
other injuries.
iii. Any patient:
⮚ New onset diffuse peritoneal irritation suggestive of perforated viscus.
⮚ Sudden hypotension not associated with other bleeding sites.
iv. If splenectomy is required, administer vaccines prior to discharge:
⮚ Pneumococcus vaccine
⮚ Meningococcus vaccine
⮚ Hemophilusinfluenzae vaccine
 PROTOCOL FOR MANAGEMENT OF LIVER INJURIES

Definitions:

Liver Injury:

Grade I Hematoma Subcapsular, non-expanding <10 cm surface area

Laceration Capsular tear, nonbleeding ≤1 cm parenchymal depth
Grade II Hematoma Subcapsular, non-expanding, 10-15% surface area;
Intraparenchymal, non-expanding ≤10 cm in diameter
Laceration Capsular tear, active bleeding; 1-3 cm parenchymal depth
<10 cm in length
Grade III Hematoma Subcapsular, >50% surface area or expanding; ruptured
Subcapsular hematoma with active bleeding;
Intraparenchymal hematoma >10 cm or expanding
Laceration >3 cm in parenchymal depth
Grade IV Hematoma Ruptured intraparenchymal hematoma with active bleeding
Laceration Parenchymal disruption involving 25-75% of hepatic lobe or
1-3 Couinaud’s segment within a single lobe
Grade V Laceration Parenchymal disruption involving >75% of hepatic lobe or
>3 Couinaud’s segment within a single lobe
Vascular Juxtahepatic venous injuries (ie, retrohepatic vena cava/central
major hepatic veins
Grade VI Vascular hepatic Avulsion

Guidelines:

1. Indications for operative and non-operative management of liver injuries:

a. Operative management should be considered when there is ongoing bleeding from the
liver injury resulting in hemodynamic instability or if there is a possibility of other
injuries.
i. Hemodynamic instability with rapidly expanding abdomen or increasing rigidity.
ii. Grossly positive peritoneal lavage.
iii. Grade V liver injury on CT scan.
iv. “Swirl” pattern on CT Scan suggestive of ongoing bleeding when angiography is
not available in a timely fashion.
v. High velocity gunshot wound to the abdomen at the RUQ.
b. Non-operative management of active bleeding may be selected if:
i. Angiography for embolization is readily available.
ii. Vital signs respond appropriately to fluid resuscitation.
iii. There are no other obvious injuries in the abdomen.
iv. The trauma team is available to monitor the patient.
c. Non-operative management can be undertaken in the otherwise stable patient.
i. Grade I-IV liver injury is diagnosed on CT Scan and patient is hemodynamically
stable:
⮚ No hilar injury
⮚ Rim of blood is localized around the liver
 ii. E-FAST positive for intraperitoneal fluid and liver injury is diagnosed on CT scan
in a stable patient.
2. Operative Management:
a. Direct patient to OR
b. Prep patient from chin to mid-thigh, table to table.
c. Generous midline incision from xiphoid to below the umbilicus.
d. Perihepatic packing. If bleeding is brisk or patient is in hypotension, consider doing
Aortic Cross Clamping.
e. Check the mesentery for bleeding.
f. Assess the bleeding from the liver.
i. If the bleeding is brisk, do Pringle maneuver (clamp portahepatis with your
finger or a non-crushing clamp).
⮚ If bleeding persists, consider hepatic vein injury or retrohepaticcaval
injury.
a. Consider resectional debridement to get to the vena cava and
branches of the hepatic veins.
b. Consider median sternotomy for better control.
c. Consider packing.
⮚ If bleeding subsides:
a. Control bleeding with suture ligatures.
b. Release Pringle maneuver and control major bleeding with
suture ligatures.
c. Consider omental pack.
⮚ If bleeding subsides but worsens because of coagulopathy, consider
packing as definitive interim procedure.
ii. If bleeding is moderate but controllable with packs:
⮚ Mobilize the liver:
a. Divide falciform ligaments.
b. Divide lateral triangular ligaments.
c. Rotate the liver medially into wound.
⮚ Explore the injury (but do not worsen it)
⮚ Control bleeding with suture ligatures.
⮚ Consider liver edge approximation with large absorbable sutures.
⮚ Consider omental pack.
g. When hepatic hemorrhage is controlled, explore the rest of the abdomen with particular
attention to the portahepatis, duodenum, pancreas, and right colon.
h. Drain liver if lacerations are deep and there is a possibility of bile leak and fluid
collection.
i. If packs are placed, they should be removed in 24-48 hours. Prepare for this procedure
with availability of blood products.
j. If packs are placed, treat with Cefazolin 1 gm every 8 hours while packs are in place.
3. Non-Operative Management:
a. Admit all Grade III-IV Liver Lacerations or those with significant blood around the liver
and are hemodynamically stable to the SICU or Telemetry Unit. Admit those with large
amounts of blood around the liver with haematocrit <32% to the ICU. All others can be
admitted to the Surgical Ward.
i. Monitor hourly vital signs.
ii. Bed Rest.
 iii. NPO.
iv. Serial Hematocrit and Hemoglobin every 6 hours until stable (within 2%) x2.
b. When Hematocrit is stable and there have been no adverse hemodynamic events:
i. Transfer to Regular Room.
ii. Advance Diet.
iii. CBC daily.
iv. Liver enzymes and Bilirubin on Day 2 to help rule out biloma. If Bilirubin is
elevated consider HIDA scan to rule out bile leak.
v. Bed rest 2 days. Grade I and Grade II liver fractures may ambulate immediately.
vi. If stable and tolerating diet:
⮚ Grade I and II injuries: discharge on day 1-2.
⮚ Grade III and IV injuries: discharge on day 4.
vii. After discharge:
⮚ No school for a week.
⮚ No physical education for six weeks.
⮚ No major contact sport:
a. Grade I and II: for six weeks
b. Grade III and IV: for three months
⮚ Follow-up at the OPD after 1 week
⮚ Avoid alcoholic beverages.
⮚ Instruct to return to the ED if:
a. Worsening RUQ pain
b. Fever
c. Jaundice
d. Hematemesis
 PROTOCOL FOR PENETRATING NECK INJURIES

DEFINITIONS:
Penetrating Injury: Any inflicted injury that penetrates the skin. This could be a gunshot
wound, stab wound or foreign body penetration of any nature.

Neck: The circumferential region of the body bounded by the clavicles and the base of
the skull.

Penetrating Neck Injury – penetrating neck injury with violation of the platysma

Zones of the Neck:

a. Zone I – below cricoid cartilage.
b. Zone II – between cricoid and angle of the mandible.
c. Zone III – above the angle of the mandible.

Hard Signs: uncontrolled hemorrhage, massive hemoptysis, rapidly expanding

hematoma

Soft Signs: Dysphagia, venous bleeding, subcutaneous emphysema, hematoma,

hoarseness, stridor, odynophagia

GUIDELINES:
1. For all penetrating injuries of the neck, first apply all of the principals of ATLS.
NOTE: EARLY intubation is key. Emergency cricothyrotomy or tracheostomy
may be complicated by release of contained hematoma with potentially
disastrous consequences. Proceed only with caution.

2. If the neck injury is associated with hemodynamic instability, uncontrolled

hemorrhage and/or presenting with hard signs, then the patient should be taken
immediately to the operating room for operative exploration.

3. For STABLE Zone I injuries:

a. Obtain a chest X-ray to rule out the presence of a chest injury.
i. Obtain an angiogram or CTA, including the aortic arch and the
great vessels.
ii. Obtain an esophagogram
iii. Obtain or perform bronchoscopy
b. Obtain CT scan to determine track of bullet
c. If track approaches vessels or airway, then will need an angiogram and
bronchoscopy
d. Treat on the basis of the findings

4. For a hemodynamically stable Zone II injury and asymptomatic , obtain a CTA

scan and look for injuries to vital structures. If found and obvious then explore,
otherwise:
 i. Obtain esophagogram.
ii. Perform laryngoscopy and bronchoscopy if indicated (e.g., air in tissues or
subcutaneous emphysema).
iii. Treat based on the findings.
iv. Prophylaxis with antibiotics.

5. For asymptomatic Zone II Injury (except for transcervical gunshot wounds),

observation may done except for 24 hrs.

6. For Stable Zone III injuries with soft signs:

a. Obtain angiogram.
b. Obtain or perform direct pharyngoscopy and laryngoscopy.
c. Treat based on findings.

7. For asymptomatic Zone III injury, observe for 24 hours.

8. For all penetrating neck injuries that have violated oral mucosa, treat with
antibiotics (usually penicillin, penicillin/aminoglycoside or clindamycin).
 THERMAL INJURIES

The major principles of thermal injury management include maintaining a high index of suspicion for the presence
of airway compromise following smoke inhalation and secondary to burn edema; identifying and managing
associated mechanical injuries; maintaining hemodynamic normality with volume resuscitation; controlling
temperature; and removing the patient from the injurious environment

PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS:

❖ Stop the burning process

⮚ Completely remove the patient’s clothing to stop the burning process; however, do not peel off adherent
clothing. At the same time, take care to prevent overexposure and hypothermia. Once the burning
process has been stopped, cover the patient with warm, clean, dry linens to pre- vent hypothermia.
❖ Establish Airway Control
⮚ Factors that increase the risk for upper airway obstruction are increasing burn size and depth, burns to
the head and face, inhalation injury, associated trauma, and burns inside the mouth
⮚ American Burn Life Support (ABLS) indications for early intubation include:
▪ Signs of airway obstruction (hoarseness, stridor, accessory respiratory muscle use, sternal retraction)
▪ Extent of the burn (total body surface area burn > 40%–50%)
▪ Extensive and deep facial burns
▪ Burns inside the mouth
▪ Significant edema or risk for edema
▪ Difficulty swallowing
▪ Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor oxygenation or
ventilation
▪ Decreased level of consciousness where airway protective reflexes are impaired
▪ Anticipated patient transfer of large burn with airway issue without qualified personnel to intubate
en route
❖ Ensure Adequate Ventilation
⮚ Breathing concerns arise from three general causes: hypoxia, carbon monoxide poisoning, and smoke
inhalation injury.
⮚ Administer supplemental oxygen with or without intubation.
⮚ Arterial blood gas determinations should be obtained as a baseline for evaluating a patient’s pulmonary
status.
⮚ As a baseline for evaluating the pulmonary status of a patient with smoke inhalation injury, clinicians
should obtain a chest x-ray and arterial blood gas determination.
❖ Manage circulation with burn shock resuscitation
⮚ resuscitation is required to replace the ongoing losses from capillary leak due to inflammation. Therefore,
clinicians should provide burn resuscitation fluids for deep partial and full-thickness burns larger than 20%
TBSA, taking care not to over-resuscitate.
⮚ immediately establish intravenous access with two large-caliber (at least 18-gauge) intravenous lines in a
peripheral vein. If the extent of the burn precludes placing the catheter through unburned skin, place the
IV through the burned skin into an accessible vein. The upper extremities are preferable to the lower
extremities as a site for venous access because of the increased risk of phlebitis and septic phlebitis when
the saphenous veins are used for venous access.
⮚ If peripheral IVs cannot be obtained, consider central venous access or intraosseous infusion.
⮚ Begin infusion with a warmed isotonic crystalloid solution, preferably lactated Ringer’s solution
⮚ Insert an indwelling urinary catheter in all patients receiving burn resuscitation fluids, and monitor urine
output to assess perfusion.
⮚ Fluid boluses should be avoided unless the patient is hypotensive. Low urine output is best treated with
titration of the fluid rate.
⮚ The initial fluid rate used for burn resuscitation has been updated by the American Burn Association to
reflect concerns about over-resuscitation when using the traditional Parkland formula.
PATIENT ASSESSMENT

❖ Body Surface Area

⮚ The rule of nines is a practical guide for determining the extent of a burn using calculations based on areas
of partial- and full-thickness burns
⮚ Lund and Browder chart for pediatric patients
⮚ The palmar surface (including the fingers) of the patient’s hand represents approximately 1% of the
patient’s body surface. Used for irregularly sized burns.
❖ Baseline determinations for patients with major burns

❖ LaboratoryWork-up
⮚ Initial labs for flame burns upon arrival at the ER
▪ CBC with platelet count
▪ Bun, Crea, Na, K , Cl, alb
▪ PT/PTT
▪ CXR
▪ Typing
▪ ABG (for consideration of inhalational injury)
⮚ Initial labs for electrical burns
▪ CBC with platelet count
▪ Bun, Crea, Na, K , Cl, alb
▪ PT/PTT
▪ CXR
▪ Typing
 ▪ ABG (for consideration of inhalational injury)
▪ 12-L ECG
▪ Urine myoglobin
⮚  For acutely injured (48 hrs post burn) and critically ill patients the ff should be done daily
▪ CBC
▪ Serum electrolytes
▪ ABG
⮚ For chronic patients, the ff should be done every four to five days:
▪ CBC
▪ Serum electrolytes
▪ Albumin
⮚ For intubated patients (to monitor tube position)
▪ Daily CXR
⮚ Weighingofpatientsshouldbedoneattheemergencyroom.Adultsshouldbe weighed once a week and
pediatric patients twice a week.
❖ Gastric tube insertion
⮚ Insert a gastric tube and attach it to a suction setup if the patient experiences nausea, vomiting, or
abdomin- al distention, or when a patient’s burns involve more than 20% total BSA.
❖ Wound Care
⮚ Do not break blisters or apply an antiseptic agent.
⮚ A fresh burn is a clean area that must be protected from contamination. When necessary, clean a dirty
wound with sterile saline. Ensure that all individuals who come into contact with the wound wear gloves
and a gown, and minimize the number of caregivers within the patient’s environment without protective
gear.
⮚ Silver sulfadiazine is the topical antibiotic of choice. Sandwich type dressing is the technique of choice.
❖ Narcotics, analgesics, and sedatives
⮚ Narcotic analgesics and sedatives should be administered in small, frequent doses by the
intravenousroute only. Remember that simply covering the wound will decrease the pain.
❖ Tetanus

⮚ Determination of the patient’s tetanus immunization status and initiation of appropriate management
is very important.

❖ Antibiotics

⮚ There is no indication for prophylactic antibiotics in the early postburn period. Reserve use of antibiotics
for the treatment of infection.

❖ Nutrition

⮚ Early enteral feeding for patients with burns >20% TBSA is safe and may reduce loss of lean body
mass,slow the hypermetabolic response, and result in more efficient protein metabolism.
⮚ A commonly used formula in non- burned patients is the Harris-Benedict equation, which calculates
caloric needs using factors such as gender, age, height, and weight. This formula uses an activity factor for
specific injuries, and for burns, the basal energy expenditure is multiplied by two.

⮚ The Harris-Benedict equation may be inaccurate in burns of <40% TBSA, and in these patients, the Curreri
formula may be more appropriate. This formula estimates caloric needs to be 25 kcal/kg per d plus 40
kcal/%TBSA per d.

OTHER UNIQUE BURN INJURIES

CHEMICAL BURNS
❖ Acidic burns cause a coagulation necrosis of the surrounding tissue, which impedes the penetration of the acid
to some extent.

❖ Alkali burns are generally more serious than acid burns, as the alkali penetrates more deeply by liquefaction
necrosis of the tissue.

❖ Rapid removal of the chemical and immediate attention to wound care are essential.

❖ If dry powder is still present on the skin, brush it away before irrigating with water. Otherwise, immediately
flush away the chemical with large amounts of warmed water, for at least 20 to 30 minutes, using a shower or
hose .

❖ Alkali burns require longer irrigation.

❖ Neutralizing agents offer no advantage over water lavage, because reaction with the neutralizing agent can
itself produce heat and cause further tissue damage.

❖ Alkali burns to the eye require continuous irrigation during the first 8 hours after the burn.

ELECTRICAL BURNS

❖ Immediate treatment of a patient with a significant electrical burn includes establishing an airway and
ensuring adequate oxygenation and ventilation, placing an intravenous line in an uninvolved extremity, ECG
monitoring, and placing an indwelling bladder catheter. Electricity can cause cardiac arrhythmias that may
produce cardiac arrest.

❖ Prolonged monitoring is reserved for patients who demonstrate injury from the burn, loss of consciousness,
exposure to high voltage (>1,000 volts) or cardiac rhythm abnormalities or arrhythmias on early evaluation.

❖ Do not wait for laboratory confirmation before instituting therapy for myoglobinuria.

❖ If the patient’s urine is dark red, assume that hemochromogens are in the urine.

❖ ABA consensus formula guidelines are to start resuscitation for electrical burn injury at 4 mL/kg/%TBSA to
ensure a urinary output of 100 mL/hr in adults and 1–1.5 mL/kg/hr in children weighing less than 30 kg.

❖ Once the urine is clear of pigmentation, titrate the IV fluid down to ensure a standard urine output of
0.5cc/kg/hr.
REFERENCES

1. ATLS: Advanced Trauma Life Support Student Course Manual. 10 th Edition. 2018. American College of
Surgeons pp.170-180.

2. Dr. Alfredo T. Ramirez Burn Center Department Of Surgery Philippine General Hospital Service Manual.

3. F. Charles Brunicardi, MD, FACS. Schwartz’s Principles of Surgery. 11 th Edition. 2019