trauma

Clinical toc =Trauma = This page will cover traumatic conditions, with a wilderness focus. It will follow the sequence of the secondary survey.

[|Trauma moulages] [|Anesthesia and perioperative care of the combat casualty]

Ottawa Rules
These are well developed and validated clinical decision rules for imaging after blunt trauma. They were developed and validated in the hospital rather than the pre-hospital environment but still may be of value. [|Ankle rule] [|Knee rule] [|Cervical spine rule] [|Head injury & CT rule]

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[|UK ambulance guidance on pelvic fractures]

Burns
Management of a casualty with burns should follow the standard structured approach.

The following are key steps in the first aid of burn patients:
 * Point-of-Injury Care**
 * Stop the burning process.** Extinguish and remove burning clothing, and remove the patient from a burning vehicle or building. In an electrical injury, remove the patient from the power source, while avoiding rescuer injury. Wash chemical agents from the skin surface with copious water lavage.
 * Ensure airway patency, control hemorrhage, and splint fractures.**
 * Remove all constricting articles**, such as rings, bracelets, wristwatches, belts, and boots. However, do not undress the patient unless the injury has been caused by a chemical agent, in which case remove all contaminated clothing.
 * Cover the patient** with a clean sheet and a blanket, if appropriate, to maintain body temperature and to prevent gross contamination during transport to a treatment facility; special burn dressings are not required. Hypothermia is a complication of large surface area burns.
 * Establish intravenous access** through unburned skin if possible, and through burned skin if necessary. Intraosseous access is also acceptable.
 * Begin resuscitation** with lactated Ringer’s solution (LR) or similar solution, and continue during evacuation.

Do not be distracted by the burn! The priorities of management for burn casualties are the same as those for other injured patients, with the addition of burn pathophysiology. The airway may be compromised by facial or upper airway burns. Breathing may be affected by inhalation or by circumferential burn around the chest. If a casualty with burns is shocked in the early stages an additional problem should be sought; shock occurs later after burns.
 * Primary Survey**

Fluid replacement and evacuation decisions dpend upon the depth of the burn, the part(s) of the body affected, and the extent of the burn. Simple erythema (e.g. sunburn) does not require evacuation but can impair performance and do increase the risk of heat illness as thermoregulation is affected. Partial and full thickness burns will require specific treatment; in partial thickness burns some of the skin epithelium remains (and sensation is preserved) but in full thickness burns no epithelium remains and sensation is lost.

Extent of the burn, in adults, is assessed using the "[|rule of nines]". In younger children the rule o fnines is not accurate so age-specific charts are used.

IV fluids are given to patients with significant partial or full thickness burns. Enough should be given to maintain a urine output of at least 0.5ml/hr in adults (more in children) but as a rule of thumb give 2ml x body weight (kg) x % body surface area affected by burn in the first 8 hours after the burn (NOT after the time at which the infusion is started) and the same amount in the next 16 hours. This formula is for crystalloids.

Dry sterile dressing use //pieces// of Clingfilm – **only wind Clingfilm round a burn if you are willing to remove it yourself later.**
 * Extremity Care**

Carefully monitor the extremities throughout the resuscitation period. The management of the burned extremity can be summarized as follows: Elevate; Exercise burned extremities hourly; Evaluate pulses and neurologic status hourly; and Perform escharotomy as indicated.


 * In extremities with full thickness, circumferential burns, edema formation beneath the inelastic eschar may gradually constrict the venous outflow and, ultimately, arterial inflow.**

Indications for evacuation (when available) Superficial burn involves more than 20% of the body surface area and the victim suffers from fever, chills, or vomiting. Partial thicknburn involves a significant portion of the face, eyes, hands, feet, genitals, or an area greater than 5% of the total body surface area, a physician evaluation is required. All third-degree burns are serious and should be seen by a physician.

Consider escharotomy. • Circumferential burns cause the skin to loose its elasticity. · If burns surround the chest, inhalation may be inhibited. If around an extremity may cause compartment syndrome.

Adequate perfusion must be assessed hourly during resuscitation. Pulses may be difficult to palpate in edematous, burned extremities. However, **in the absence of a Doppler flowmeter, and in the appropriate clinical setting, loss of palpable pulses may indicate a need for escharotomy. ** Patients requiring escharotomy often present with a tight and edematous extremity. They may have progressive neurologic dysfunction such as unrelenting deep tissue pain or paresthesias, and/or distal cyanosis.

The dashed lines indicate the preferred sites for escharotomy incisions. The bold lines in the figure indicate the importance of extending the incision over involved major joints. Incisions are made through the burned skin into the underlying subcutaneous fat. For a thoracic escharotomy, begin incision in the midclavicular lines. Continue the incision along the anterior axillary lines down to the level of the costal margin. Extend the incision across the epigastrium as needed

RTC casualties
[|Helmet removal]

Blast injuries
[|CDC material]