8 MUSCULOSKELETAL TRAUMA
Injuries to the musculoskeletal system are common in trauma patients. The delayed recogni-
tion and treatment of these injuries can result in life-threatening hemorrhage or limb loss.
CHAPTER 8 Outline Other Extremity Injuries
• Contusions and Lacerations
Objectives • Joint and Ligament Injuries
• Fractures
Introduction
Principles of Immobilization
Primary Survey and Resuscitation of Patients • Femoral Fractures
with Potentially Life-Threatening Extremity • Knee Injuries
Injuries • Tibial Fractures
• Ankle Fractures
• Major Arterial Hemorrhage and Traumatic Amputation • Upper Extremity and Hand Injuries
• Bilateral Femur Fractures
• Crush Syndrome Pain Control
Adjuncts to the Primary Survey Associated Injuries
• Fracture Immobilization
• X-ray Examination Occult Skeletal Injuries
Secondary Survey Teamwork
• History
• Physical Examination chapter Summary
Limb-Threatening Injuries Bibliography
• Open Fractures and Open Joint Injuries
• Vascular Injuries
• Compartment Syndrome
• Neurologic Injury Secondary to Fracture Dislocation
OBJECTIVES
After reading this chapter and comprehending the knowledge 4. Describe key elements of the secondary survey of
components of the ATLS provider course, you will be able to: patients with musculoskeletal trauma, including the
history and physical examination.
1. Explain the significance of musculoskeletal injuries in
patients with multiple injuries. 5. Explain the principles of the initial management of
limb-threatening musculoskeletal injuries.
2. Outline the priorities of the primary survey and
resuscitation of patients with extremity injuries, quickly 6. Describe the appropriate assessment and initial
separating the potentially life-threatening injuries from management of patients with contusions, lacerations,
those that are less urgent. joint and ligament injuries, and fractures.
3. Identify the adjuncts needed in the immediate 7. Describe the principles of proper immobilization of
treatment of life-threatening extremity hemorrhage. patients with musculoskeletal injuries.
nnBBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 149
150 CHAPTER 8 n Musculoskeletal Trauma
M any patients who sustain blunt trauma fractures and soft tissue injuries may not be initially
also incur injuries to the musculoskeletal recognized in patients with multiple injuries.
system. These injuries often appear dramatic,
but only infrequently cause immediate threat to life Continued reevaluation of the patient is necessary
or limb. However, musculoskeletal injuries have to identify all injuries.
the potential to distract team members from more
urgent resuscitation priorities. First, clinicians Pr im ary Surv e y and
need to recognize the presence of life-threatening Resuscitation of
extremity injuries during the primary survey and Patients w ith P otenti a lly
understand their association with severe thoracic L i f e-T h r e at e n i n g
and abdominal injuries. The provider must also be E x tr emit y In jur ie s
familiar with extremity anatomy to be able to protect
the patient from further disability, and anticipate and During the primary survey, it is imperative to recognize
prevent complications. and control hemorrhage from musculoskeletal injuries.
Major musculoskeletal injuries indicate that the Potentially life-threatening extremity injuries include
body sustained significant forces (n FIGURE 8-1). For major arterial hemorrhage, bilateral femoral fractures,
example, a patient with long-bone fractures above and crush syndrome. (Pelvic disruption is described in
and below the diaphragm is at increased risk for Chapter 5: Abdominal and Pelvic Trauma.)
associated internal torso injuries. Unstable pelvic
fractures and open femur fractures can be accompanied Deep soft-tissue lacerations may involve major
by brisk bleeding. Severe crush injuries cause the vessels and lead to exsanguinating hemorrhage.
release of myoglobin from the muscle, which can Hemorrhage control is best achieved with direct
precipitate in the renal tubules and result in renal pressure. Hemorrhage from long-bone fractures can
failure. Swelling into an intact musculofascial space be significant, and femoral fractures in particular
can cause an acute compartment syndrome that, often result in significant blood loss into the thigh.
if not diagnosed and treated, may lead to lasting Appropriate splinting of fractures can significantly
impairment and loss of the extremity. Fat embolism, an decrease bleeding by reducing motion and enhancing
uncommon but highly lethal complication of long-bone the tamponade effect of the muscle and fascia. If the
fractures, can lead to pulmonary failure and impaired fracture is open, application of a sterile pressure
cerebral function. dressing typically controls hemorrhage. Appropriate
fluid resuscitation is an important supplement to these
Musculoskeletal trauma does not warrant a re- mechanical measures.
ordering of the ABCDE priorities of resuscitation,
but its presence does pose a challenge to clinicians. Pitfall prevention
Musculoskeletal injuries cannot be ignored and treated
at a later time; rather, clinicians must treat the whole Blood loss from • Recognize that femur
patient, including musculoskeletal injuries, to ensure musculoskeletal fractures and any open
an optimal outcome. Despite careful assessment, injuries is not long-bone fractures
immediately with major soft-tissue
recognized. involvement are potential
sites of significant
hemorrhage.
n FIGURE 8-1 Major injuries indicate that the patient sustained Major Arterial Hemorrhage and
significant forces, and significant blood loss is possible. Traumatic Amputation
n BACK TO TABLE OF CONTENTS Penetrating extremity wounds can result in major
arterial vascular injury. Blunt trauma resulting in
an extremity fracture or joint dislocation in close
proximity to an artery can also disrupt the artery. These
injuries may lead to significant hemorrhage through
the open wound or into the soft tissues. Patients with
PRIMARY SURVEY AND RESUSCITATION 151
traumatic amputation are at particularly high risk of life- as 250 mm Hg in an upper extremity and 400 mm Hg
threatening hemorrhage and may require application in a lower extremity. Ensure that the time of tourniquet
of a tourniquet. application is documented. In these cases, immediate
Assessment surgical consultation is essential, and early transfer to
Assess injured extremities for external bleeding, loss a trauma center should be considered.
of a previously palpable pulse, and changes in pulse
quality, Doppler tone, and ankle/brachial index. The If time to operative intervention is longer than 1
ankle/brachial index is determined by taking the hour, a single attempt to deflate the tourniquet may
systolic blood pressure value at the ankle of the injured be considered in an otherwise stable patient. The risks
leg and dividing it by the systolic blood pressure of of tourniquet use increase with time; if a tourniquet
the uninjured arm. A cold, pale, pulseless extremity must remain in place for a prolonged period to save a
indicates an interruption in arterial blood supply. A life, the choice of life over limb must be made.
rapidly expanding hematoma suggests a significant
vascular injury. The use of arteriography and other diagnostic tools
Management is indicated only in resuscitated patients who have no
A stepwise approach to controlling arterial bleed- hemodynamic abnormalities; other patients with clear
ing begins with manual pressure to the wound. vascular injuries require urgent operation. If a major
(Bleedingcontrol.org provides lay public training in arterial injury exists or is suspected, immediately consult
hemorrhage control.) A pressure dressing is then a surgeon skilled in vascular and extremity trauma.
applied, using a stack of gauze held in place by a
circumferential elastic bandage to concentrate pres- Application of vascular clamps into bleeding open
sure over the injury. If bleeding persists, apply manual wounds while the patient is in the ED is not advised,
pressure to the artery proximal to the injury. If bleed- unless a superficial vessel is clearly identified. If a
ing continues, consider applying a manual tourniquet fracture is associated with an open hemorrhaging
(such as a windlass device) or a pneumatic tourniquet wound, realign and splint it while a second person
applied directly to the skin (n FIGURE 8-2). applies direct pressure to the open wound. Joint
dislocations should be reduced, if possible; if the joint
Tighten the tourniquet until bleeding stops. A prop- cannot be reduced, emergency orthopedic intervention
erly applied tourniquet must occlude arterial inflow, may be required.
as occluding only the venous system can increase
hemorrhage and result in a swollen, cyanotic extremity. Amputation, a severe form of open fracture that results
A pneumatic tourniquet may require a pressure as high in loss of an extremity, is a traumatic event for the
patient, both physically and emotionally. Patients with
n FIGURE 8-2 The judicious use of a tourniquet can be lifesaving traumatic amputation may benefit from tourniquet
and/or limb-saving in the presence of ongoing hemorrhage. application. They require consultation with and
intervention by a surgeon. Certain mangled extremity
injuries with prolonged ischemia, nerve injury, and
muscle damage may require amputation. Amputation
can be lifesaving in a patient with hemodynamic
abnormalities resulting from the injured extremity.
Although the potential for replantation should
be considered in an upper extremity, it must be
considered in conjunction with the patient’s other
injuries. A patient with multiple injuries who requires
intensive resuscitation and/or emergency surgery
for extremity or other injuries is not a candidate for
replantation. Replantation is usually performed on
patients with an isolated extremity injury. For the
required decision making and management, transport
patients with traumatic amputation of an upper
extremity to an appropriate surgical team skilled in
replantation procedures.
In such cases, thoroughly wash the amputated part
in isotonic solution (e.g., Ringer’s lactate) and wrap it
in moist sterile gauze. Then wrap the part in a similarly
moistened sterile towel, place in a plastic bag, and
transport with the patient in an insulated cooling
chest with crushed ice. Be careful not to freeze the
amputated part.
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152 CHAPTER 8 n Musculoskeletal Trauma
Bilateral Femur Fractures Management
Initiating early and aggressive intravenous fluid
Patients who have sustained bilateral femur fractures therapy during resuscitation is critical to protecting
are at significantly greater risk of complications the kidneys and preventing renal failure in patients
and death. Such fractures indicate the patient has with rhabdomyolysis. Myoglobin-induced renal
been subjected to significant force and should alert failure can be prevented with intravascular fluid
clinicians to the possibility of associated injuries. expansion, alkalinization of the urine by intravenous
Compared with patients with unilateral femur administration of bicarbonate, and osmotic diuresis.
fractures, patients with bilateral femur fractures
are at higher risk for significant blood loss, severe A djunc ts to the Pr im ary
associated injuries, pulmonary complications, multiple Survey
organ failure, and death. These patients should be
assessed and managed in the same way as those with Adjuncts to the primary survey of patients with
unilateral femur fractures. Consider early transfer to a musculoskeletal trauma include fracture immo-
trauma center. bilization and x-ray examination, when fracture is
suspected as a cause of shock.
Pitfall prevention
Fracture Immobilization
Delayed transfer to a • Transfer patients with
trauma center vascular injury and The goal of initial fracture immobilization is to
concomitant fracture realign the injured extremity in as close to anatomic
to a trauma center with position as possible and prevent excessive motion at
vascular and orthopedic the fracture site. This is accomplished by applying
surgical capabilities. inline traction to realign the extremity and maintain-
ing traction with an immobilization device (n FIGURE 8-3).
• Bilateral femur fractures Proper application of a splint helps control blood
result in a significantly loss, reduces pain, and prevents further neurova-
increased risk of compli- scular compromise and soft-tissue injury. If an open
cations and death; these fracture is present, pull the exposed bone back into
patients benefit from early the wound, because open fractures require surgical
transfer to a trauma center.
Crush Syndrome
Crush syndrome, or traumatic rhabdomyolysis, refers
to the clinical effects of injured muscle that, if left
untreated, can lead to acute renal failure and shock.
This condition is seen in individuals who have sustained
a compression injury to significant muscle mass,
most often to a thigh or calf. The muscular insult is a
combination of direct muscle injury, muscle ischemia,
and cell death with release of myoglobin.
Assessment AB
Myoglobin produces dark amber urine that tests
positive for hemoglobin. A myoglobin assay may be n FIGURE 8-3 The goal of initial fracture immobilization is to realign
requested to confirm its presence. Amber-colored urine the injured extremity in as close to anatomic position as possible
in the presence of serum creatine kinase of 10,000 U/L and prevent excessive fracture-site motion. A. Shortening and
or more is indicative of rhabdomyolysis when urine external rotation of right leg due to a mid-shaft femur fracture B.
myoglobin levels are not available. Rhabdomyolysis can Application of in-line traction with stabilization of the leg in normal
lead to metabolic acidosis, hyperkalemia, hypocalcemia, anatomic position.
and disseminated intravascular coagulation.
n BACK TO TABLE OF CONTENTS
SECONDARY SURVEY 153
debridement. Remove gross contamination and The clinician should mentally reconstruct the injury
particulate matter from the wound, and administer scene, consider other potential injuries the patient
weight-based dosing of antibiotics as early as possible may have sustained, and determine as much of the
in patients with open fractures. (See Appendix G: following information as possible:
Circulation Skills.)
1. Where was the patient located before the crash?
Qualified clinicians may attempt reduction of joint In a motor vehicle crash, the patient’s precrash
dislocations. If a closed reduction successfully relocates location (i.e., driver or passenger) can suggest
the joint, immobilize it in the anatomic position with the type of fracture—for example, a lateral
prefabricated splints, pillows, or plaster to maintain compression fracture of the pelvis may result
the extremity in its reduced position. from a side impact collision.
If reduction is unsuccessful, splint the joint in the 2. Where was the patient located after the crash—
position in which it was found. Apply splints as soon as inside the vehicle or ejected? Was a seat belt or
possible, because they can control hemorrhage and pain. airbag in use? This information may indicate
certain patterns of injury. If the patient was
However, resuscitation efforts must take priority ejected, determine the distance the patient
over splint application. Assess the neurovascular was thrown, as well as the landing conditions.
status of the extremity before and after manipulation Ejection generally results in unpredictable
and splinting. patterns of injury and more severe injuries.
X-ray Examination 3. Was the vehicle’s exterior damaged, such as
having its front end deformed by a head-on
Although x-ray examination of most skeletal injuries collision? This information raises the suspicion
is appropriate during the secondary survey, it may be of a hip dislocation.
undertaken during the primary survey when fracture is
suspected as a cause of shock. The decisions regarding 4. Was the vehicle’s interior damaged, such as a
which x-ray films to obtain and when to obtain them deformed dashboard? This finding indicates a
are based on the patient’s initial and obvious clinical greater likelihood of lower-extremity injuries.
findings, the patient’s hemodynamic status, and the
mechanism of injury. 5. Did the patient fall? If so, what was the distance
of the fall, and how did the patient land? This
Secondary Surv e y information helps identify the spectrum
of injuries.
Important elements of the secondary survey of patients
with musculoskeletal injuries are the history and 6. Was the patient crushed by an object? If so,
physical examination. identify the weight of the crushing object,
the site of the injury, and duration of weight
History applied to the site. Depending on whether a
subcutaneous bony surface or a muscular area
Key aspects of the patient history are mechanism of was crushed, different degrees of soft-tissue
injury, environment, preinjury status and predisposing damage may occur, ranging from a simple
factors, and prehospital observations and care. contusion to a severe degloving extremity
injury with compartment syndrome and
Mechanism of Injury tissue loss.
Information obtained from the patient, relatives,
prehospital and transport personnel, and bystanders 7. Did an explosion occur? If so, what was the
at the scene of the injury should be documented magnitude of the blast, and what was the
and included as a part of the patient’s history. It is patient’s distance from the blast? An individual
particularly important to determine the mechanism close to the explosion may sustain primary
of injury, which can help identify injuries that may not blast injury from the force of the blast wave. A
be immediately apparent. (See Biomechanics of Injury.) secondary blast injury may occur from debris
and other objects accelerated by the blast (e.g.,
fragments), leading to penetrating wounds,
lacerations, and contusions. The patient may
also be violently thrown to the ground or against
other objects by the blast effect, leading to
blunt musculoskeletal and other injuries (i.e., a
tertiary blast injury).
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154 CHAPTER 8 n Musculoskeletal Trauma
n FIGURE 8-4 Impact points vary based
on vehicle and individual, i.e., height of
bumper and patient's age and size.
8. Was the patient involved in a vehicle-pedestrian Prehospital Observations and Care
collision? Musculoskeletal injuries follow
predictable patterns based on the patient’s size All prehospital observations and care must be reported
and age (n FIGURE 8-4). and documented. Findings at the incident site that may
help to identify potential injuries include
Environment
When applicable, ask prehospital care personnel •• The time of injury, especially if there is ongoing
for the following information about the post- bleeding, an open fracture, and a delay in
crash environment: reaching the hospital
1. Did the patient sustain an open fracture in a •• Position in which the patient was found
contaminated environment?
•• Bleeding or pooling of blood at the scene,
2. Was the patient exposed to temperature extremes? including the estimated amount
3. Were broken glass fragments, which can also
•• Bone or fracture ends that may have been exposed
injure the examiner, at the scene?
4. Were there any sources of bacterial •• Open wounds in proximity to obvious or
suspected fractures
contamination, such as dirt, animal feces, and
fresh or salt water? •• Obvious deformity or dislocation
This information can help the clinician anti-
cipate potential problems and determine the initial •• Any crushing mechanism that can result in a
antibiotic treatment. crush syndrome
Preinjury Status and Predisposing Factors •• Presence or absence of motor and/or sensory
When possible, determine the patient’s baseline function in each extremity
condition before injury. This information can enhance
understanding of the patient’s condition, help •• Any delays in extrication procedures or transport
determine treatment regimen, and affect outcome.
An AMPLE history should be obtained, including •• Changes in limb function, perfusion, or neuro-
information about the patient’s exercise tolerance logic state, especially after immobilization or
and activity level, ingestion of alcohol and/or other during transfer to the hospital
drugs, emotional problems or illnesses, and previous
musculoskeletal injuries. •• Reduction of fractures or dislocations during
extrication or splinting at the scene
•• Dressings and splints applied, with special
attention to excessive pressure over bony
prominences that can result in peripheral nerve
compression or compartment syndrome
•• Time of tourniquet placement, if applicable
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SECONDARY SURVEY 155
Physical Examination table 8-1 common joint dislocation
deformities
For a complete examination, completely undress the
patient, taking care to prevent hypothermia. Obvious JOINT DIRECTION DEFORMITY
extremity injuries are often splinted before the patient
arrives at the ED. The three goals for assessing the Shoulder Anterior Squared off
extremities are:
Posterior Locked in internal
1. Identify life-threatening injuries (primary survey). rotation
2. Identify limb-threatening injuries (secondary survey).
3. Conduct a systematic review to avoid missing Elbow Posterior Olecranon
prominent
any other musculoskeletal injury (i.e., posteriorly
continuous reevaluation).
Hip Anterior Extended, abducted,
Assessment of musculoskeletal trauma includes externally rotated
looking at and talking to the patient, palpating the
patient’s extremities, and performing a logical, system- Posterior Flexed, adducted,
atic review of each extremity. Extremity assessment internally rotated
must include the following four components to avoid
missing an injury: skin, which protects the patient Knee Anteroposterior Loss of normal
from excessive fluid loss and infection; neuromuscular contour, extended
function; circulatory status; and skeletal and ligament-
ous integrity. (See Appendix G: Secondary Survey.) *May spontaneously
reduce prior to
Look and Ask evaluation
Visually assess the extremities for color and perfusion,
wounds, deformity (e.g., angulation or shortening), Ankle Lateral is most Externally rotated,
swelling, and bruising. common prominent medial
malleolus
A rapid visual inspection of the entire patient will
help identify sites of major external bleeding. A pale Subtalar Lateral is most Laterally displaced
or white distal extremity is indicative of a lack of joint common os calcis (calcaneus)
arterial inflow. Extremities that are swollen in the
region of major muscle groups may indicate a crush patient, trauma team members can assess active
injury with an impending compartment syndrome. voluntary muscle and peripheral nerve function by
Swelling or ecchymosis in or around a joint and/or asking the patient to contract major muscle groups.
over the subcutaneous surface of a bone is a sign of The ability to move all major joints through a full range
a musculoskeletal injury. Extremity deformity is an of motion usually indicates that the nerve-muscle unit
obvious sign of major extremity injury. n TABLE 8-1 is intact and the joint is stable.
outlines common joint dislocation deformities.
Feel
Inspect the patient’s entire body for lacerations Palpate the extremities to determine sensation to
and abrasions. Open wounds may not be obvious on the skin (i.e., neurologic function) and identify areas
the dorsum of the body; therefore, carefully logroll of tenderness, which may indicate fracture. Loss
patients to assess for possible hidden injuries. (See of sensation to pain and touch demonstrates the
Logroll video on MyATLS mobile app.) Any open wound presence of a spinal or peripheral nerve injury. Areas
to a limb with an associated fracture is considered of tenderness or pain over muscles may indicate a
to be an open fracture until proven otherwise by muscle contusion or fracture. If pain, tenderness, and
a surgeon. swelling are associated with deformity or abnormal
motion through the bone, fracture should be suspected
Observe the patient’s spontaneous extremity motor
function to help identify any neurologic and/or
muscular impairment. If the patient is unconscious,
absent spontaneous extremity movement may be the
only sign of impaired function. With a cooperative
n BACK TO TABLE OF CONTENTS
156 CHAPTER 8 n Musculoskeletal Trauma
Do not attempt to elicit crepitus or demonstrate
abnormal motion.
Joint stability can be determined only by clinical
examination. Abnormal motion through a joint
segment is indicative of a tendon or ligamentous
rupture. Palpate the joint to identify any swelling and
tenderness of the ligaments as well as intraarticular
fluid. Following this, cautious stressing of the specific
ligaments can be performed. Excessive pain can mask
abnormal ligament motion due to guarding of the joint
by muscular contraction or spasm; this condition may
need to be reassessed later.
Circulatory Evaluation n FIGURE 8-5 Blanched skin associated with fractures and
Palpate the distal pulses in each extremity, and assess dislocations will quickly lead to soft tissue necrosis. The purpose of
capillary refill of the digits. If hypotension limits digital promptly reducing this injury is to prevent pressure necrosis on the
examination of the pulse, the use of a Doppler probe lateral ankle soft tissue.
may detect blood flow to an extremity. The Doppler the arterial blood supply and reduce the pressure on
signal must have a triphasic quality to ensure no the skin. Alignment can be maintained by appropriate
proximal lesion. Loss of sensation in a stocking or glove immobilization techniques.
distribution is an early sign of vascular impairment.
Limb -Thr e atening In jur ie s
In patients with normal blood pressure, an arterial
injury can be indicated by pulse discrepancies, Extremity injuries that are considered potentially
coolness, pallor, paresthesia, and even motor function limb-threatening include open fractures and joint
abnormalities. Open wounds and fractures close injuries, ischemic vascular injuries, compartment
to arteries can be clues to an arterial injury. Knee syndrome, and neurologic injury secondary to fracture
dislocations can reduce spontaneously and may or dislocation.
not present with any gross external or radiographic
anomalies until a physical exam of the joint is Open Fractures and Open Joint
performed and instability is detected clinically. Injuries
An ankle/brachial index of less than 0.9 indicates
abnormal arterial flow secondary to injury or Open fractures and open joint injuries result from
peripheral vascular disease. Expanding hematomas communication between the external environment
and pulsatile hemorrhage from an open wound also and the bone or joint (n FIGURE 8-6). Muscle and
indicate arterial injury. skin must be injured for this to occur, and the
degree of soft-tissue injury is proportional to the
X-ray Examination energy applied. This damage, along with bacterial
The clinical examination of patients with musculo- contamination, makes open fractures and joint
skeletal injuries often suggests the need for x-ray injuries prone to problems with infection, healing,
examination. Tenderness with associated bony and function.
deformity likely represents a fracture. Obtain x-ray
films in patients who are hemodynamically normal. Assessment
Joint effusion, abnormal joint tenderness, and joint The presence of an open fracture or an open joint injury
deformity indicate a joint injury or dislocation that should be promptly determined. The diagnosis of an
must also be x-rayed. The only reason to forgo x-ray open fracture is based on a physical examination of
examination before treating a dislocation or a fracture the extremity that demonstrates an open wound on
is the presence of vascular compromise or impending
skin breakdown. This condition is commonly seen
with fracture-dislocations of the ankle (n FIGURE 8-5).
If a delay in obtaining x-rays is unavoidable, imme-
diately reduce or realign the extremity to reestablish
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LIMB-THREATENING INJURIES 157
necessary. The patient should be adequately
resuscitated and, if possible, hemodynamically
normal. Wounds may then be operatively debrided,
fractures stabilized, and distal pulses confirmed.
Tetanus prophylaxis should be administered. (See
Tetanus Immunization.)
Pitfall prevention
Failure to give timely • Recognize that infection is
antibiotics to patients a significant risk in patients
with open fractures with open fractures.
n FIGURE 8-6 Example of an open fracture. Open fractures and joint • Administer weight-based
injuries are prone to problems with infection, healing, and function. doses of appropriate
antibiotics as soon as an
open fracture is suspected.
the same limb segment as an associated fracture. At Vascular Injuries
no time should the wound be probed.
In patients who manifest vascular insufficiency
Documentation of the open wound begins during associated with a history of blunt, crushing, twisting,
the prehospital phase with the initial description of or penetrating injury or dislocation to an extremity,
the injury and any treatment rendered at the scene. clinicians should strongly suspect a vascular injury.
If an open wound exists over or near a joint, it should
be assumed that the injury connects with or enters Assessment
the joint. The presence of an open joint injury may be The limb may initially appear viable because extremities
identified using CT. The presence of intraarticular gas often have some collateral circulation that provides
on a CT of the affected extremity is highly sensitive adequate flow. Non-occlusive vascular injury, such
and specific for identifying open joint injury. If CT as an intimal tear, can cause coolness and prolonged
is not available, consider insertion of saline or dye capillary refill in the distal part of the extremity, as
into the joint to determine whether the joint cavity well as diminished peripheral pulses and an abnormal
communicates with the wound. If an open joint is ankle/brachial index. Alternatively, the distal extremity
suspected, request consultation by an orthopedic may have complete disruption of flow and be cold, pale,
surgeon, as surgical exploration and debridement may and pulseless.
be indicated.
Management
Management It is crucial to promptly recognize and emergently
Management decisions should be based on a com- treat an acutely avascular extremity.
plete history of the incident and assessment of the
injury. Treat all patients with open fractures as Early operative revascularization is required to
soon as possible with intravenous antibiotics using restore arterial flow to an ischemic extremity. Muscle
weight-based dosing. First-generation cephalosporins necrosis begins when there is a lack of arterial blood
are necessary for all patients with open fractures flow for more than 6 hours. Nerves may be even
(n TABLE 8-2). Delay of antibiotic administration more sensitive to an anoxic environment. If there is
beyond three hours is related to an increased risk an associated fracture deformity, correct it by gently
of infection. pulling the limb out to length, realigning the fracture,
and splinting the injured extremity. This maneuver
Remove gross contamination and particulates from often restores blood flow to an ischemic extremity when
the wound as soon as possible, and cover it with a moist the artery is kinked by shortening and deformity at the
sterile dressing. Apply appropriate immobilization fracture site.
after accurately describing the wound and determining
any associated soft-tissue, circulatory, and neurologic
involvement. Prompt surgical consultation is
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158 CHAPTER 8 n Musculoskeletal Trauma
table 8-2 intravenous antibiotic weight-based dosing guidelines
OPEN FRACTURES FIRST-GENERATION IF ANAPHYLACTIC AMINOGLYCOCIDE PIPERACILLIN/
CEPHALOSPORINS PENICILLIN (GRAM-NEGATIVE TAZOBACTAM
Wound <1 cm; (GRAM-POSITIVE ALLERGY (BROAD-SPECTRUM
minimal con- (INSTEAD OF COVERAGE) GRAM-POSITIVE
tamination or soft COVERAGE) GENTAMICIN AND NEGATIVE
tissue damage FIRST- GENERATION COVERAGE)
CEFAZOLIN CEPHALOSPORIN) Loading dose in ER:
Wound 1–10 cm; 2.5 mg/kg for child 3.375 gm Q 6 hr
moderate soft <50 kg: 1 gm Q 8 hr CLINDAMYCIN (or <50 kg) (<100 kg)
tissue damage; 50–100 kg: 2 gm Q 8 hr 5 mg/kg for adult 4.5 gm Q 6 hr (>100
comminution of >100 kg: 3 gm Q 8 hr <80 kg: 600 mg Q 8 hr (i.e., 150-lb pt = 340 mg) kg)
fracture >80 kg: 900 mg Q 8 hr
<50 kg: 1 gm Q 8 hr
Severe soft- 50–100 kg: 2 gm Q 8 hr <80 kg: 600 mg Q 8 hr
tissue damage >100 kg: 3 gm Q 8 hr >80 kg: 900 mg Q 8 hr
and substantial
contamination with <50 kg: 1 gm Q 8 hr <80 kg: 600 mg Q 8 hr
associated vascular 50–100 kg: 2 gm Q 8 hr >80 kg: 900 mg Q 8 hr
injury >100 kg: 3 gm Q 8 hr
Farmyard, soil or
standing water,
irrespective of
wound size or
severity
**If anaphylactic
penicillin allergy
consult Infectious
Disease Department
or Pharmacy
Data from: Schmitt SK, Sexton DJ, Baron EL. Treatment and Prevention of Osteomyelitis Following Trauma in Adults. UpToDate. http://www.
uptodate.com/contents/treatment-and-prevention-of-osteomyelitis-following-trauma-in-adults. October 29, 2015; O’Brien CL, Menon M, Jomha NM.
Controversies in the management of open fractures. Open Orthop J 2014;8:178–184.
When an arterial injury is associated with dislocation The potential for vascular compromise also exists
of a joint, a clinician may attempt gentle reduction whenever an injured extremity is splinted. It is
maneuvers. Otherwise, the clinician must splint therefore important to perform and document a careful
the dislocated joint and obtain emergency surgical neurovascular examination of the injured extremity
consultation. CT angiography may be used to evaluate before and after reduction and application of a splint.
extremity vascular injuries, but it must not delay Vascular compromise can be identified by loss of or
reestablishing arterial blood flow and is indicated only change in the distal pulse, but excessive pain after
after consultation with a surgeon. splint application must be investigated. Patients in
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LIMB-THREATENING INJURIES 159
casts can also have vascular compromise Promptly •• Injuries immobilized in tight dressings or casts
release splints, casts, and any other circumferential •• Severe crush injury to muscle
dressings upon any sign of vascular compromise, and •• Localized, prolonged external pressure to
then reassess vascular supply.
an extremity
Compartment Syndrome •• Increased capillary permeability secondary to
Compartment syndrome develops when increased reperfusion of ischemic muscle
pressure within a musculofascial compartment causes •• Burns
ischemia and subsequent necrosis. This increased •• Excessive exercise
pressure may be caused by an increase in compartment
content (e.g., bleeding into the compartment or swelling n BOX 8-1 details the signs and symptoms of compart-
after revascularization of an ischemic extremity) or a ment syndrome. Early diagnosis is the key to successful
decrease in the compartment size (e.g., a constrictive treatment of acute compartment syndrome. A high
dressing). Compartment syndrome can occur wherever degree of awareness is important, especially if the
muscle is contained within a closed fascial space. patient has an altered sensorium and is unable to
Remember, the skin acts as a restricting layer in certain respond appropriately to pain. The absence of a
circumstances. Common areas for compartment palpable distal pulse is an uncommon or late finding
syndrome include the lower leg, forearm, foot, hand, and is not necessary to diagnose compartment
gluteal region, and thigh (n FIGURE 8-7). syndrome. Capillary refill times are also unreliable
for diagnosing compartment syndrome. Weakness or
Delayed recognition and treatment of compartment paralysis of the involved muscles in the affected limb
syndrome is catastrophic and can result in neurologic is a late sign and indicates nerve or muscle damage.
deficit, muscle necrosis, ischemic contracture, infection, Clinical diagnosis is based on the history of injury and
delayed healing of fractures, and possible amputation. physical signs, coupled with a high index of suspicion.
If pulse abnormalities are present, the possibility of a
Assessment proximal vascular injury must be considered.
Any injury to an extremity can cause compartment
syndrome. However, certain injuries or activities are Measurement of intracompartmental pressure can
considered high risk, including be helpful in diagnosing suspected compartment
syndrome. Tissue pressures of greater than 30 mm
•• Tibia and forearm fractures Hg suggest decreased capillary blood flow, which can
result in muscle and nerve damage from anoxia. Blood
Anterior Tibia pressure is also important: The lower the systemic
compartment pressure, the lower the compartment pressure that
Lateral Deep posterior causes a compartment syndrome.
compartment compartment
Compartment syndrome is a clinical diagnosis.
Fibula Nerves and Pressure measurements are only an adjunct to aid
blood vessels in its diagnosis.
Superficial posterior box 8-1 signs and symptoms of
compartment compartment syndrome
• Pain greater than expected and out of proportion to
the stimulus or injury
• Pain on passive stretch of the affected muscle
• Tense swelling of the affected compartment
• Paresthesias or altered sensation distal to the
affected compartment
n FIGURE 8-7 Compartment Syndrome. This condition develops Management
when increased pressure within a compartment causes ischemia and Compartment syndrome is a time- and pressure-
subsequent necrosis. The illustration of a cross section of the lower dependent condition. The higher the compartment
leg shows the anatomy and relations of the four musculofasical
compartments.
n BACK TO TABLE OF CONTENTS
160 CHAPTER 8 n Musculoskeletal Trauma
pressure and the longer it remains elevated, the greater Assessment
the degree of resulting neuromuscular damage and A thorough examination of the neurologic system
resulting functional deficit. If compartment syndrome is essential in patients with musculoskeletal injury.
is suspected, promptly release all constrictive dressings, Determination of neurologic impairment is important,
casts, and splints applied over the affected extremity and progressive changes must be documented.
and immediately obtain a surgical consultation.
The only treatment for a compartment syndrome is Assessment usually demonstrates a deformity of
a fasciotomy (n FIGURE 8-8). A delay in performing a the extremity. Assessment of nerve function typi-
fasciotomy may result in myoglobinuria, which may cally requires a cooperative patient. For each signi-
cause decreased renal function. Immediately obtain ficant peripheral nerve, voluntary motor function
surgical consultation for suspected or diagnosed and sensation must be confirmed systematically.
compartment syndrome. n TABLE 8-3 and n TABLE 8-4 outline peripheral nerve
assessment of the upper extremities and lower
Neurological Injury Secondary to extremities, respectively. (Also see Peripheral Nerve
Fracture or Dislocation Assessment of Upper Extremities and Peripheral Nerve
Assessment of Lower Extremities on MyATLS mobile
Fractures and particularly dislocations can cause sig- app.) Muscle testing must include palpation of the
nificant neurologic injury due to the anatomic rela- contracting muscle.
tionship and proximity of nerves to bones and joints
(e.g., sciatic nerve compression from posterior hip In most patients with multiple injuries, it is diffi-
dislocation and axillary nerve injury from anterior shoul- cult to initially assess nerve function.However,
der dislocation). Optimal functional outcome depends assessment must be continually repeated, especially
on prompt recognition and treatment of the injury. after the patient is stabilized. Progression of neurologic
findings is indicative of continued nerve compression.
Pitfall prevention The most important aspect of any neurologic assess-
ment is to document the progression of neurologic
Delayed • Maintain a high index of suspicion findings. It is also an important aspect of surgical
diagnosis of for compartment syndrome in decision making.
compartment any patient with a significant
syndrome. musculoskeletal injury. Management
Reduce and splint fracture deformities. Qualified
• Be aware that compartment syn- clinicians may attempt to carefully reduce dis-
drome can be difficult to recognize in locations, after which neurologic function should
patients with altered mental status. be reevaluated and the limb splinted. If reduction
is successful, the subsequent treating doctor
• Frequently reevaluate patients with must be notified that the joint was dislocated and
altered mental status for signs of successfully reduced.
compartment syndrome.
AB
n FIGURE 8-8 Fasciotomy to Treat Compartment Syndrome. A. Intraoperative photo showing fasciotomy of upper extremity compartment
syndrome secondary to crush injury. B. Postsurgical decompression of compartment syndrome of the lower leg, showing medial incision.
n BACK TO TABLE OF CONTENTS
OTHER EXTREMITY INJURIES 161
Other E x tr emit y In jur ie s neral, lacerations require debridement and closure. If a
laceration extends below the fascial level, it may require
Other significant extremity injuries include contusions operative intervention to more completely debride the
and lacerations, joint injuries, and fractures. wound and assess for damage to underlying structures.
Contusions and Lacerations Contusions are usually recognized by pain, localized
swelling, and tenderness. If the patient is seen early,
Assess simple contusions and/or lacerations to rule contusions are treated by limiting function of the
out possible vascular and/or neurologic injuries. In ge- injured part and applying cold packs.
Crushing and internal degloving injuries can be
subtle and must be suspected based on the mechanism
of injury. With crush injury, devascularization and
table 8-3 peripheral nerve assessment of upper extremities
NERVE MOTOR SENSATION INJURY
Ulnar Index and little finger abduction Little finger Elbow injury
Median distal Thenar contraction with opposition Distal tip of index finger Wrist fracture or dislocation
Median, anterior Index tip flexion None Supracondylar fracture of
interosseous humerus (children)
Musculocutaneous Elbow flexion Radial forearm Anterior shoulder dislocation
Radial Thumb, finger metocarpo- First dorsal web space Distal humeral shaft, anterior
phalangeal extension shoulder dislocation
Axillary Deltoid Lateral shoulder Anterior shoulder dislocation,
proximal humerus fracture
table 8-4 peripheral nerve assessment of lower extremities
NERVE MOTOR SENSATION INJURY
Femoral Knee extension Anterior knee Pubic rami fractures
Obturator Hip adduction Medial thigh Obturator ring fractures
Posterior tibial Toe flexion Sole of foot Knee dislocation
Superficial peroneal Ankle eversion Lateral dorsum of foot Fibular neck fracture,
knee dislocation
Deep peroneal Ankle/toe dorsiflexion Dorsal first to second Fibular neck fracture,
web space compartment syndrome
Sciatic nerve Ankle dorsiflexion or plantar flexion Foot Posterior hip dislocation
Superior gluteal Hip abduction Upper buttocks Acetabular fracture
Inferior gluteal Gluteus maximus hip extension Lower buttocks Acetabular fracture
n BACK TO TABLE OF CONTENTS
162 CHAPTER 8 n Musculoskeletal Trauma
necrosis of muscle can occur. Soft-tissue avulsion can curred and placed the limb at risk for neurovascular
shear the skin from the deep fascia, allowing for the injury. Surgical consultation is usually required for
significant accumulation of blood in the resulting cavity joint stabilization.
(i.e., Morel-Lavallée lesion). Alternatively, the skin may
be sheared from its blood supply and undergo necrosis Fractures
over a few days. This area may have overlying abrasions
or bruised skin, which are clues to a more severe degree Fractures are defined as a break in the continuity of the
of muscle damage and potential compartment or crush bone cortex. They may be associated with abnormal
syndromes. These soft-tissue injuries are best evaluated motion, soft-tissue injury, bony crepitus, and pain. A
by knowing the mechanism of injury and by palpating fracture can be open or closed.
the specific component involved. Consider obtaining
surgical consultation, as drainage or debridement may Assessment
be indicated. Examination of the extremity typically demonstrates
pain, swelling, deformity, tenderness, crepitus, and
The risk of tetanus is increased with wounds that are abnormal motion at the fracture site. Evaluation for
more than 6 hours old, contused or abraded, more than crepitus and abnormal motion is painful and may
1 cm in depth, from high-velocity missiles, due to burns increase soft-tissue damage. These maneuvers are
or cold, and significantly contaminated, particularly seldom necessary to make the diagnosis and must not
wounds with denervated or ischemic tissue (See be done routinely or repetitively. Be sure to periodically
Tetanus Immunization.) reassess the neurovascular status of a fractured limb,
particularly if a splint is in place.
Joint and Ligament Injuries
X-ray films taken at right angles to one another
When a joint has sustained significant ligamentous confirm the history and physical examination findings
injury but is not dislocated, the injury is not usually of fracture (n FIGURE 8-9). Depending on the patient’s
limb-threatening. However, prompt diagnosis and hemodynamic status, x-ray examination may need to
treatment are important to optimize limb function. be delayed until the patient is stabilized. To exclude
occult dislocation and concomitant injury, x-ray films
Assessment must include the joints above and below the suspected
With joint injuries, the patient usually reports ab- fracture site.
normal stress to the joint, for example, impact to the
anterior tibia that subluxed the knee posteriorly, impact
to the lateral aspect of the leg that resulted in a valgus
strain to the knee, or a fall onto an outstretched arm
that caused hyperextension of the elbow.
Physical examination reveals tenderness throughout
the affected joint. A hemarthrosis is usually present
unless the joint capsule is disrupted and the bleeding
diffuses into the soft tissues. Passive ligamentous
testing of the affected joint reveals instability. X-ray
examination is usually negative, although some small
avulsion fractures from ligamentous insertions or
origins may be present radiographically.
Management AB
Immobilize joint injuries, and serially reassess the
vascular and neurologic status of the limb distal n FIGURE 8-9 X-ray films taken at right angles to one another
to the injury. Knee dislocations frequently return confirm the history and physical examination findings of fracture.
to near anatomic position and may not be ob- A. AP view of the distal femur. B. Lateral view of the distal femur.
vious at presentation. In a patient with a multi- Satisfactory x-rays of an injured long bone should include two
ligament knee injury, a dislocation may have oc- orthogonal views, and the entire bone should be visualized. Thus
the images alone would be inadequate.
n BACK TO TABLE OF CONTENTS
PAIN CONTROL 163
Management compartment syndrome. If readily available, plaster
Immobilization must include the joint above and splints immobilizing the lower thigh, knee, and ankle
below the fracture. After splinting, be sure to reassess are preferred.
the neurologic and vascular status of the extremity.
Surgical consultation is required for further treatment. Ankle Fractures
Principles of Immobilization Ankle fractures may be immobilized with a well-padded
splint, thereby decreasing pain while avoiding pressure
Unless associated with life-threatening injuries, over bony prominences (n FIGURE 8-10).
splinting of extremity injuries can typically be
accomplished during the secondary survey. However, Pitfall prevention
all such injuries must be splinted before a patient is
transported. Assess the limb’s neurovascular status Application of traction to • Avoid use of traction
before and after applying splints or realigning an extremity with a tibia/ in extremities with
a fracture. fibula fracture can result in combined femur and
a neurovascular injury. tibia/fibula fractures.
Femoral Fractures
• Use a long-leg posterior
Femoral fractures are immobilized temporarily with splint with an additional
traction splints (see n FIGURE 8-3; also see Traction Splint sugar-tong splint for the
video on MyATLS mobile app). The traction splint’s force lower leg.
is applied distally at the ankle. Proximally, the post is
pushed into the gluteal crease to apply pressure to the Upper Extremity and Hand Injuries
buttocks, perineum, and groin. Excessive traction can
cause skin damage to the foot, ankle, and perineum. The hand may be temporarily splinted in an ana-
Because neurovascular compromise can also result tomic, functional position with the wrist slightly
from application of a traction splint, clinicians must dorsiflexed and the fingers gently flexed 45 degrees
assess the neurovascular status of the limb before at the metacarpophalangeal joints. This position
and after applying the splint. Do not apply traction typically is accomplished by gently immobilizing
in patients with an ipsilateral tibia shaft fracture. Hip the hand over a large roll of gauze and using a
fractures can be similarly immobilized with a traction short-arm splint.
splint but are more suitably immobilized with skin
traction or foam boot traction with the knee in slight The forearm and wrist are immobilized flat on padded
flexion. A simple method of splinting is to bind the or pillow splints. The elbow is typically immobilized
injured leg to the opposite leg. in a flexed position, either by using padded splints
or by direct immobilization with respect to the body
Knee Injuries using a sling-and-swath device. The upper arm
may be immobilized by splinting it to the body or
Application of a commercially available knee immo- applying a sling or swath, which can be augmented
bilizer or a posterior long-leg plaster splint is effect- by a thoracobrachial bandage. Shoulder injuries are
ive in maintaining comfort and stability. Do not managed by a sling-and-swath device or a hook- and-
immobilize the knee in complete extension, but with loop type of dressing.
approximately 10 degrees of flexion to reduce tension
on the neurovascular structures. PAIN CONTROL
Tibial Fractures The appropriate use of splints significantly decreases
a patient’s discomfort by controlling the amount
Immobilize tibial fractures to minimize pain and of motion that occurs at the injured site. If pain is
further soft-tissue injury and decrease the risk of not relieved or recurs, the splint should be removed
and the limb further investigated. Analgesics are
indicated for patients with joint injuries and fractures.
Patients who do not appear to have significant pain
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164 CHAPTER 8 n Musculoskeletal Trauma
AB
n FIGURE 8-10 Splinting of an ankle fracture. Note extensive use of padding with posterior and sugartong splints. A. Posterior and sugartong
plaster splints being secured in place with an elastic bandage wrap. B. Completed splint.
or discomfort from a major fracture may have other table 8-5 musculoskeletal injuries:
associated injuries which interfere with sensory common missed or associated injuries
perception (e.g., intracranial or spinal cord lesions)
or be under the influence of alcohol and/or drugs. INJURY MISSED/ASSOCIATED
INJURY
Effective pain relief usually requires the admin-
istration of narcotics, which should be given in • Clavicular fracture • Major thoracic injury,
small doses intravenously and repeated as needed. • Scapular fracture especially pulmonary
Administer sedatives cautiously in patients with • Fracture and/or contusion and rib
isolated extremity injuries, such as when reducing fractures
a dislocation. Whenever analgesics or sedatives are dislocation of shoulder
administered to an injured patient, the potential exists • Scapulothoracic
for respiratory arrest. Consequently, appropriate dissociation
resuscitative equipment and naloxone (Narcan) must
be immediately available. • Fracture/dislocation • Brachial artery injury
of elbow • Median, ulnar, and radial
Regional nerve blocks play a role in pain relief and
the reduction of appropriate fractures. It is essential to nerve injury
assess and document any peripheral nerve injury before
administering a nerve block. Always keep the risk of • Femur fracture • Femoral neck fracture
compartment syndrome in mind, as this condition • Ligamentous knee injury
may be masked in a patient who has undergone a • Posterior hip dislocation
nerve block.
• Posterior knee • Femoral fracture
Associated Injuries dislocation • Posterior hip dislocation
Because of their common mechanism, certain • Knee dislocation • Popliteal artery and
musculoskeletal injuries are often associated with • Displaced tibial plateau nerve injuries
other injuries that are not immediately apparent or
may be missed (n TABLE 8-5). • Calcaneal fracture • Spine injury or fracture
• Fracture-dislocation of
Steps to ensure recognition and management of these
injuries include: talus and calcaneus
• Tibial plateau fracture
1. Review the injury history, especially the
mechanism of injury, to determine whether • Open fracture • 70% incidence of
another injury is present. associated nonskeletal
injury
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CHAPTER SUMMARY 165
2. Thoroughly reexamine all extremities, with •• Because potentially life-threatening
special emphasis on the hands, wrists, feet, and musculoskeletal injuries can be detected during
the joints above and below fractures the assessment of circulation, the team leader
and dislocations. must rapidly direct the team to control external
hemorrhage using sterile pressure dressings,
3. Visually examine the patient’s back, including splints, or tourniquets as appropriate. The
the spine and pelvis. trauma team’s ability to work on different tasks
simultaneously is particularly relevant in
4. Document open injuries and closed soft-tissue this scenario.
injuries that may indicate an unstable injury.
•• More than one team member may be required
5. Review the x-rays obtained in the secondary to apply a traction splint, and the team leader
survey to identify subtle injuries that may be may direct other assistants or specialist team
associated with more obvious trauma. members (e.g., vascular and orthopedic
surgeons) to assist the team.
Occult Skeletal Injuries
•• The team must be able to recognize limb-
Not all injuries can be diagnosed during the initial threatening injuries and report these accurately
assessment. Joints and bones that are covered or well- to the team leader so decisions can be made for
padded within muscular areas may contain occult managing these injuries in conjunction with
injuries. It can be difficult to identify nondisplaced life-threatening problems involving airway,
fractures or joint ligamentous injuries, especially if the breathing, and circulation.
patient is unresponsive or has other severe injuries. In
fact, injuries are commonly discovered days after the •• Ensure that the trauma team performs a
injury incident—for example, when the patient is being complete secondary survey, so injuries are not
mobilized. Therefore, it is crucial to reassess the patient overlooked. Occult injuries are particularly
repeatedly and to communicate with other members common in patients with a depressed level of
of the trauma team and the patient’s family about the consciousness, and the team leader should
possibility of occult skeletal injuries. ensure timely reevaluation of the limbs to
minimize missed injuries.
Pitfall prevention
C h a p ter Summ ary
Occult injuries may not • Logroll the patient and
be identified during the remove all clothing 1. Musculoskeletal injuries can pose threats to both
primary assessment or to ensure complete life and limb.
secondary survey. evaluation and avoid
missing injuries. 2. The initial assessment of musculoskeletal trauma
is intended to identify those injuries that pose a
• Repeat the head-to- threat to life and/or limb. Although uncommon,
toe examination once life-threatening musculoskeletal injuries must
the patient has been be promptly assessed and managed. A staged
stabilized to identify approach to hemorrhage control is utilized by
occult injuries. applying direct pressure, splints, and tourniquets.
TeamWORK 3. Most extremity injuries are appropriately diagnosed
and managed during the secondary survey. A
•• Musculoskeletal injuries, especially open thorough history and careful physical examination,
fractures, often appear dramatic and can including completely undressing the patient, is
potentially distract team members from more essential to identify musculoskeletal injuries.
urgent resuscitation priorities. The team leader
must ensure that team members focus on life- 4. It is essential to recognize and manage arterial
threatening injuries first injuries, compartment syndrome, open fractures,
crush injuries, and dislocations in a timely manner.
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166 CHAPTER 8 n Musculoskeletal Trauma
5. Knowledge of the mechanism of injury and history 10. Kobbe P, Micansky F, Lichte P, et al. Increased
of the injury-producing event can guide clinicians morbidity and mortality after bilateral femoral
to suspect potential associated injuries. shaft fractures: myth or reality in the era of
damage control? Injury 2013Feb;44(2):221–225.
6. Early splinting of fractures and dislocations can
prevent serious complications and late sequelae. 11. Konda SR, Davidovich RI, Egol KA. Computed
Careful neurovascular examination must be tomography scan to detect traumatic arthrotomies
performed both prior to and after application of and identify periarticular wounds not requiring
a splint or traction device. surgical intervention: an improvement over the
saline load test. J Trauma 2013;27(9):498–504.
Special thanks to Julie Gebhart, PA-C, Lead Orthopedic
Physician Assistant, and Renn Crichlow, MD, Orthopedic 12. Kostler W, Strohm PC, Sudkamp NP. Acute
Trauma Surgeon, OrthoIndy and St. Vincent Trauma compartment syndrome of the limb. Injury
Center, for all their help and collaboration with this project, 2004;35(12):1221–1227.
as well as provision of many of the photographs used in
the chapter. 13. Lakstein D, Blumenfeld A, Sokolov T, et al.
Tourniquets for hemorrhage control on the
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renal failure in patients with rhabdomyolysis: Vascular and nerve injury after knee dislocation:
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J Trauma 2004;56:1191. 2014Oct;472(1):2984–2990.
3. Bulger EM, Snyder D, Schoelles C, et al. An 16. Mills WJ, Barei DP, McNair P. The value of the
evidence-based prehospital guideline for ankle-brachial index for diagnosing arterial
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17. Natsuhara KM. Yeranosian MG, Cohen JR, et
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5. Elliot GB, Johnstone AJ. Diagnosing acute 18. Ododeh M. The role of reperfusion-induced injury
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2003;85:625–630. Engl J Med 1991;324:1417–1421.
6. German Trauma Society. Prehospital (section 19. Okike K, Bhattacharyya T. Trends in the
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with Severe and Multiple Injuries. (English version
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fractures: a new classification of type III open in the management of open fractures. Open
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24. Steinhausen E, Lefering R, Tjardes T, et al. A
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BIBLIOGRAPHY 167
in multiple trauma patients: an analysis based 28. Walters TJ, Wenke JC, Kauvar DS, et al. Effectiv-
on the trauma registry of the German Trauma eness of self-applied tourniquets in human
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9 THERMAL INJURIES
The most significant difference between burns and other injuries is that the consequences of
burn injury are directly linked to the extent of the inflammatory response to the injury.
CHAPTER 9 Outline Unique Burn Injuries
• Chemical Burns
Objectives • Electrical Burns
• Tar Burns
Introduction • Burn Patterns Indicating Abuse
Primary Survey and Resuscitation of Patients Patient Transfer
with Burns • Criteria for Transfer
• Transfer Procedures
• Stop the Burning Process
• Establish Airway Control Cold Injury: Local Tissue Effects
• Ensure Adequate Ventilation • Types of Cold Injury
• Manage Circulation with Burn Shock Resuscitation • Management of Frostbite and Nonfreezing Cold Injuries
Patient Assessment Cold Injury: Systemic Hypothermia
• History
• Body Surface Area Teamwork
• Depth of Burn
Chapter Summary
Secondary Survey and Related Adjuncts
• Documentation Bibliography
• Baseline Determinations for Patients with Major Burns
• Peripheral Circulation in Circumferential Extremity Burns
• Gastric Tube Insertion
• Narcotics, Analgesics, and Sedatives
• Wound Care
• Antibiotics
• Tetanus
OBJECTIVES
After reading this chapter and comprehending the knowledge management of the patient’s injuries.
components of the ATLS provider course, you will be able to:
5. Describe the unique characteristics of burn injury
1. Explain how the unique pathophysiology of burn that affect the secondary survey.
injury affects the approach to patient management
when compared with other traumatic injuries. 6. Describe common mechanisms of burn injuries,
and explain the impact of specific mechanisms on
2. Identify the unique problems that can be management of the injured patients.
encountered in the initial assessment of patients
with burn injuries. 7. List the criteria for transferring patients with burn
injuries to burn centers.
3. Describe how to manage the unique problems that
can be encountered in the initial assessment of 8. Describe the tissue effects of cold injury and the
patients with burn injuries. initial treatment of patients with tissue injury from
cold exposure.
4. Estimate the extent of the patient’s burn injury,
including the size and depth of the burn(s), 9. Describe the management of patients with hypothermia,
and develop a prioritized plan for emergency including rewarming risks.
nnBBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 169
170 CHAPTER 9 n Thermal Injuries
T hermal injuries are major causes of morbidity clothing. Synthetic fabrics can ignite, burn rapidly
and mortality, but adherence to the basic at high temperatures, and melt into hot residue that
principles of initial trauma resuscitation and continues to burn the patient. At the same time, take care
the timely application of simple emergency measures to prevent overexposure and hypothermia. Recognize
can help minimize their impact. The major principles that attempts made at the scene to extinguish the fire
of thermal injury management include maintaining (e.g., “stop, drop, and roll”), although appropriate,
a high index of suspicion for the presence of airway can lead to contamination of the burn with debris or
compromise following smoke inhalation and secondary contaminated water.
to burn edema; identifying and managing associated
mechanical injuries; maintaining hemodynamic Exercise care when removing any clothing that was
normality with volume resuscitation; controlling contaminated by chemicals. Brush any dry chemical
temperature; and removing the patient from the in- powders from the wound. Caregivers also can be injured
jurious environment. Clinicians also must take and should avoid direct contact with the chemical. After
measures to prevent and treat the potential com- removing the powder, decontaminate the burn areas by
plications of specific burn injuries. Examples include rinsing with copious amounts of warm saline irrigation
rhabdomyolysis and cardiac dysrhythmias, which can or rinsing in a warm shower when the facilities are
be associated with electrical burns; extremity or truncal available and the patient is able.
compartment syndrome, which can occur with large
burn resuscitations; and ocular injuries due to flames Once the burning process has been stopped, cover
or explosions. the patient with warm, clean, dry linens to pre-
vent hypothermia.
The most significant difference between burns and
other injuries is that the consequences of burn injury Establish Airway Control
are directly linked to the extent of the inflammatory
response to the injury. The larger and deeper the burn, The airway can become obstructed not only from
the worse the inflammation. Depending on the cause, direct injury (e.g., inhalation injury) but also from
the energy transfer and resultant edema may not be the massive edema resulting from the burn injury.
evident immediately; for example, flame injury is Edema is typically not present immediately, and signs
more rapidly evident than most chemical injuries— of obstruction may initially be subtle until the patient
an important factor in burn injury management. is in crisis. Early evaluation to determine the need for
Monitor intravenous lines closely to ensure they do endotracheal intubation is essential.
not become dislodged as the patient becomes more
edematous. Regularly check ties securing endotracheal Factors that increase the risk for upper airway
and nasogastric tubes to ensure they are not too tight, obstruction are increasing burn size and depth, burns
and check that identification bands are loose or not to the head and face, inhalation injury, associated
circumferentially affixed. trauma, and burns inside the mouth (n FIGURE 9-1). Burns
localized to the face and mouth cause more localized
Note: Heat injuries, including heat exhaustion and
heat stroke, are discussed in Appendix B: Hypothermia
and Heat Injuries.
Pr im ary Surv e y and
R e sus c itation of Patients
w ith Burns
Lifesaving measures for patients with burn injuries
include stopping the burning process, ensuring that
airway and ventilation are adequate, and managing
circulation by gaining intravenous access.
Stop the Burning Process n FIGURE 9-1 Factors that increase the risk for upper airway
obstruction are increasing burn size and depth, burns to the head
Completely remove the patient’s clothing to stop the and face, inhalation injury, associated trauma, and burns inside
burning process; however, do not peel off adherent the mouth.
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PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 171
edema and pose a greater risk for airway compromise. can lead to swelling of the tissues around the airway;
Because their airways are smaller, children with burn therefore, early intubation is also indicated for full-
injuries are at higher risk for airway problems than thickness circumferential neck burns.
their adult counterparts.
Pitfall prevention
A history of confinement in a burning environment or
early signs of airway injury on arrival in the emergency Airway obstruction • Recognize smoke inhalation
department (ED) warrants evaluation of the patient’s in a patient with burn as a potential cause of airway
airway and definitive management. Pharyngeal thermal injury may not be obstruction from particulate
injuries can produce marked upper airway edema, and present immediately. and chemical injury.
early protection of the airway is critical. The clinical
manifestations of inhalation injury may be subtle and • Evaluate the patient for
frequently do not appear in the first 24 hours. If the circumferential burns of
provider waits for x-ray evidence of pulmonary injury the neck and chest, which
or changes in blood gas determinations, airway edema can compromise the airway
can preclude intubation, and a surgical airway may and gas exchange.
be required. When in doubt, examine the patient’s
oropharynx for signs of inflammation, mucosal injury, • Patients with inhalation
soot in the pharynx, and edema, taking care not to injure injury are at risk for
the area further. bronchial obstruction
from secretions and
Although the larynx protects the subglottic airway debris, and they may
from direct thermal injury, the airway is extremely sus- require bronchoscopy.
ceptible to obstruction resulting from exposure to heat. Place an adequately sized
airway—preferably a size 8
American Burn Life Support (ABLS) indications for mm internal diameter (ID)
early intubation include: endotracheal tube (min-
imum 7.5 mm ID in adults).
•• Signs of airway obstruction (hoarseness, stridor,
accessory respiratory muscle use, sternal Ensure Adequate Ventilation
retraction)
Direct thermal injury to the lower airway is very
•• Extent of the burn (total body surface area rare and essentially occurs only after exposure to
burn > 40%–50%) superheated steam or ignition of inhaled flammable
gases. Breathing concerns arise from three general
•• Extensive and deep facial burns causes: hypoxia, carbon monoxide poisoning, and
smoke inhalation injury.
•• Burns inside the mouth
Hypoxia may be related to inhalation injury, poor
•• Significant edema or risk for edema compliance due to circumferential chest burns, or
thoracic trauma unrelated to the thermal injury. In
•• Difficulty swallowing these situations, administer supplemental oxygen
with or without intubation.
•• Signs of respiratory compromise: inability
to clear secretions, respiratory fatigue, poor Always assume carbon monoxide (CO) exposure
oxygenation or ventilation in patients who were burned in enclosed areas. The
diagnosis of CO poisoning is made primarily from
•• Decreased level of consciousness where airway a history of exposure and direct measurement of
protective reflexes are impaired carboxyhemoglobin (HbCO). Patients with CO levels
of less than 20% usually have no physical symptoms.
•• Anticipated patient transfer of large burn with Higher CO levels can result in:
airway issue without qualified personnel to
intubate en route •• headache and nausea (20%–30%)
•• confusion (30%–40%)
A carboxyhemoglobin level greater than 10% in •• coma (40%–60%)
a patient who was involved in a fire also suggests •• death (>60%)
inhalation injury. Transfer to a burn center is indicated
for patients suspected of experiencing inhalation injury;
however, if the transport time is prolonged, intubate
the patient before transport. Stridor may occur late
and indicates the need for immediate endotrach-
eal intubation. Circumferential burns of the neck
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172 CHAPTER 9 n Thermal Injuries
Cherry-red skin color in patients with CO exposure is Products of combustion, including carbon parti-
rare, and may only be seen in moribund patients. Due cles and toxic fumes, are important causes of inha-
to the increased affinity of hemoglobin for CO—240 lation injury. Smoke particles settle into the distal
times that of oxygen—it displaces oxygen from the bronchioles, leading to damage and death of the
hemoglobin molecule and shifts the oxyhemoglobin mucosal cells. Damage to the airways then leads to
dissociation curve to the left. CO dissociates very slowly, an increased inflammatory response, which in turn
and its half-life is approximately 4 hours when the leads to an increase in capillary leakage, resulting in
patient is breathing room air. Because the half-life increased fluid requirements and an oxygen diffusion
of HbCO can be reduced to 40 minutes by breathing defect. Furthermore, necrotic cells tend to slough
100% oxygen, any patient in whom CO exposure could and obstruct the airways. Diminished clearance of
have occurred should receive high-flow (100%) oxygen the airway produces plugging, which results in an
via a non-rebreathing mask. increased risk of pneumonia. Not only is the care of
It is important to place an appropriately sized patients with inhalation injury more complex, but
endotracheal tube (ETT), as placing a tube that is too their mortality is doubled compared with other burn
small will make ventilation, clearing of secretions, and injured individuals.
bronchoscopy difficult or impossible. Efforts should
be made to use endotracheal tubes at least 7.5 mm ID The American Burn Association has identified two
or larger in an adult and size 4.5 mm ID ETT in a child. requirements for the diagnosis of smoke inhalation
Arterial blood gas determinations should be obtained injury: exposure to a combustible agent and signs
as a baseline for evaluating a patient’s pulmonary of exposure to smoke in the lower airway, below the
status. However, measurements of arterial PaaCOO2 vocal cords, seen on bronchoscopy. The likelihood
do not reliably predict CO poisoning, because of smoke inhalation injury is much higher when the
partial pressure of only 1 mm Hg results in an HbCO injury occurs within an enclosed place and in cases of
level of 40% or greater. Therefore, baseline HbCO prolonged exposure.
levels should be obtained, and 100% oxygen should
be administered. If a carboxyhemoglobin level is As a baseline for evaluating the pulmonary status
not available and the patient has been involved in a of a patient with smoke inhalation injury, clinicians
closed-space fire, empiric treatment with 100% oxygen should obtain a chest x-ray and arterial blood gas
for 4 to 6 hours is reasonable as an effective treatment determination. These values may deteriorate over time;
for CO poisoning and has few disadvantages. An normal values on admission do not exclude inhalation
exception is a patient with chronic obstructive lung injury. The treatment of smoke inhalation injury is
disease, who should be monitored very closely when supportive. A patient with a high likelihood of smoke
100% oxygen is administered. inhalation injury associated with a significant burn (i.e.,
Pulse oximetry cannot be relied on to rule out carbon greater than 20% total body surface area [TBSA] in an
monoxide poisoning, as most oximeters cannot adult, or greater than 10% TBSA in patients less than
distinguish oxyhemoglobin from carboxyhemoglo- 10 or greater than 50 years of age) should be intubated.
bin. In a patient with CO poisoning, the oximeter If the patient’s hemodynamic condition permits and
may read 98% to 100% saturation and not reflect the spinal injury has been excluded, elevate the patient’s
true oxygen saturation of the patient, which must be head and chest by 30 degrees to help reduce neck and
obtained from the arterial blood gas. A discrepancy chest wall edema. If a full-thickness burn of the anterior
between the arterial blood gas and the oximeter may and lateral chest wall leads to severe restriction of chest
be explained by the presence of carboxyhemoglobin wall motion, even in the absence of a circumferential
or an inadvertent venous sample. burn, chest wall escharotomy may be required.
Cyanide inhalation from the products of combustion
is possible in burns occurring in confined spaces, Manage Circulation with Burn
in which case the clinician should consult with a Shock Resuscitation
burn or poison control center. A sign of potential
cyanide toxicity is persistent profound unexplained Evaluation of circulating blood volume is often difficult
metabolic acidosis. in severely burned patients, who also may have
There is no role for hyperbaric oxygen therapy in the accompanying injuries that contribute to hypovole-
primary resuscitation of a patient with critical burn mic shock and further complicate the clinical pic-
injury. Once the principles of ATLS are followed to ture. Treat shock according to the resuscitation princi-
stabilize the patient, consult with the local burn center ples outlined in Chapter 3: Shock, with the goal of
for further guidance regarding whether hyperbaric maintaining end organ perfusion. In contrast to resus-
oxygen would benefit the patient. citation for other types of trauma in which fluid deficit
is typically secondary to hemorrhagic losses, burn
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PRIMARY SURVEY AND RESUSCITATION OF PATIENTS WITH BURNS 173
resuscitation is required to replace the ongoing losses Pitfall prevention
from capillary leak due to inflammation. Therefore,
clinicians should provide burn resuscitation fluids for Intravenous catheters • Remember that edema takes
deep partial and full-thickness burns larger than 20% and endotracheal time to develop.
TBSA, taking care not to over-resuscitate (n FIGURE 9-2). tubes can become
dislodged after • Use long IV catheters to
After establishing airway patency and identifying resuscitation. account for the inevitable
and treating life-threatening injuries, immediately swelling that will occur.
establish intravenous access with two large-caliber
(at least 18-gauge) intravenous lines in a peripheral • Do not cut endotracheal
vein. If the extent of the burn precludes placing the tubes, and regularly assess
catheter through unburned skin, place the IV through their positioning.
the burned skin into an accessible vein. The upper
extremities are preferable to the lower extremities as using the traditional Parkland formula. The current
a site for venous access because of the increased risk consensus guidelines state that fluid resuscitation
of phlebitis and septic phlebitis when the saphenous should begin at 2 ml of lactated Ringer’s x patient’s body
veins are used for venous access. If peripheral IVs weight in kg x % TBSA for second- and third-degree burns.
cannot be obtained, consider central venous access
or intraosseous infusion. The calculated fluid volume is initiated in the
following manner: one-half of the total fluid is provided
Begin infusion with a warmed isotonic crystalloid in the first 8 hours after the burn injury (for example,
solution, preferably lactated Ringer’s solution. Be a 100-kg man with 80% TBSA burns requires 2 × 80 ×
aware that resulting edema can dislodge peripheral 100 = 16,000 mL in 24 hours). One-half of that volume
intravenous lines. Consider placing longer catheters (8,000 mL) should be provided in the first 8 hours, so
in larger burns. the patient should be started at a rate of 1000 mL/hr.
The remaining one-half of the total fluid is administered
Blood pressure measurements can be difficult to during the subsequent 16 hours.
obtain and may be unreliable in patients with severe
burn injuries. Insert an indwelling urinary catheter It is important to understand that formulas provide a
in all patients receiving burn resuscitation fluids, and starting target rate; subsequently, the amount of fluids
monitor urine output to assess perfusion. Osmotic provided should be adjusted based on a urine output
diuresis (e.g., glycosuria or use of mannitol) can target of 0.5 mL/kg/hr for adults and 1 mL/kg/hr for
interfere with the accuracy of urine output as a marker children weighing less than 30 kg. In adults, urine
of perfusion by overestimating perfusion. output should be maintained between 30 and 50 cc/
hr to minimize potential over-resuscitation.
The initial fluid rate used for burn resuscitation
has been updated by the American Burn Association The actual fluid rate that a patient requires depends
to reflect concerns about over-resuscitation when on the severity of injury, because larger and deeper
burns require proportionately more fluid. Inhalation
n FIGURE 9-2 Patients with burns require resuscitation with injury also increases the amount of burn resuscitation
Ringer's lactate solution starting at 2 mL per kilogram of body required. If the initial resuscitation rate fails to produce
weight per percentage BSA of partial-thickness and full-thickness the target urine output, increase the fluid rate until the
burns during the first 24 hours to maintain adequate perfusion, urine output goal is met. However, do not precipitously
titrated hourly. decrease the IV rate by one-half at 8 hours; rather, base
the reduction in IV fluid rate on urine output and titrate
to the lower urine output rate. Fluid boluses should be
avoided unless the patient is hypotensive. Low urine
output is best treated with titration of the fluid rate.
Resuscitation of pediatric burn patients (n FIGURE 9-3)
should begin at 3 mL/kg/% TBSA; this balances a higher
resuscitation volume requirement due to larger surface
area per unit body mass with the smaller pediatric
intravascular volume, increasing risk for volume
overload. Very small children (i.e., < 30 kg), should
receive maintenance fluids of D5LR (5% dextrose in
Lactated Ringers), in addition to the burn resuscitation
fluid. n TABLE 9-1 outlines the adjusted fluid rates and
target urine output by burn type.
n BACK TO TABLE OF CONTENTS
174 CHAPTER 9 n Thermal Injuries
Pitfall prevention
Under- or over- • Titrate fluid resuscitation
resuscitation of burn to the patient’s physiologic
patients. response, adjusting the
fluid rate up or down based
n FIGURE 9-3 Resuscitation of pediatric burn patients must balance on urine output.
a higher resuscitation volume requirement due to larger surface
area per unit body mass with the smaller pediatric intravascular • Recognize factors that
volume, which increases the risk for volume overload. affect the volume of
resuscitation and urine
It is important to understand that under-resuscitation output, such as inhalation
results in hypoperfusion and end organ injury. Over- injury, age of patient,
resuscitation results in increased edema, which can renal failure, diuretics,
lead to complications, such as burn depth progression and alcohol.
or abdominal and extremity compartment syndrome.
The goal of resuscitation is to maintain the fine balance • Tachycardia is a poor
of adequate perfusion as indicated by urine output. marker for resuscitation
in the burn patient. Use
Cardiac dysrhythmias may be the first sign of hypoxia other parameters to discern
and electrolyte or acid-base abnormalities; therefore, physiologic response.
electrocardiography (ECG) should be performed for
cardiac rhythm disturbances. Persistent acidemia in including under-resuscitation or infusion of large
patients with burn injuries may be multifactorial, volumes of saline for resuscitation.
Patient A s se s sment
In addition to a detailed AMPLE history, it is important
to estimate the size of the body surface area burned
and the depth of the burn injury.
table 9-1 burn resuscitation fluid rates and target urine output by burn
type and age
CATEGORY OF BURN AGE AND WEIGHT ADJUSTED FLUID RATES URINE OUTPUT
Flame or Scald Adults and older 2 ml LR x kg x % TBSA 0.5 ml/kg/hr
children (≥14 years old) 30–50 ml/hr
Children (<14 years old) 3 ml LR x kg x % TBSA 1 ml/kg/hr
Infants and young 3 ml LR x kg x % TBSA 1 ml/kg/hr
children (≤30kg)
Plus a sugar-containing solution at
maintenance rate
Electrical Injury All ages 4 ml LR x kg x % TBSA until urine clears 1-1.5 ml/kg/hr until urine
clears
LR, lactated Ringer’s solution; TBSA, total body surface area
n BACK TO TABLE OF CONTENTS
PATIENT ASSESSMENT 175
History known allergies and/or drug sensitivities. Check the
status of the patient’s tetanus immunization. Be aware
The injury history is extremely valuable when treating that some individuals attempt suicide through self-
patients with burns. Burn survivors can sustain immolation. Match the patient history to the burn
associated injuries while attempting to escape a fire, pattern; if the account of the injury is suspicious,
and explosions can result in internal injuries (e.g., consider the possibility of abuse in both children
central nervous system, myocardial, pulmonary, and and adults.
abdominal injuries) and fractures. It is essential to
establish the time of the burn injury. Burns sustained Body Surface Area
within an enclosed space suggest the potential for
inhalation injury and anoxic brain injury when there The rule of nines is a practical guide for determining the
is an associated loss of consciousness. extent of a burn using calculations based on areas of
partial- and full-thickness burns (n FIGURE 9-4). The adult
The history, whether obtained from the patient or body configuration is divided into anatomic regions
other individuals, should include a brief survey of
preexisting illnesses and drug therapy, as well as any
Pediatric
9% 9%
4.5% 4.5% 4.5%
18%
4.5%
13%
2.5% 2.5% 7% 7%
7%
7%
Adult 4.5% 4.5%
n FIGURE 9-4 Rule of Nines. This practical guide
is used to evaluate the severity of burns and
determine fluid management. The adult body is
generally divided into surface areas of 9% each
and/or fractions or multiples of 9%.
18%
18%
4.5% 4.5% 4.5% 4.5%
1%
9% 9% 9% 9%
n BACKASdtuTvdaOenncteTCdAoTuBrrasLuemEMaOaLniFufeaClS, u8OpepNortTfoErNDoTcStors
American College of Surgeons
Figure# 09.01
176 CHAPTER 9 n Thermal Injuries
that represent multiples of 9%. BSA distribution differs pliable and elastic it becomes; therefore these areas
considerably for children, because a young child’s head may appear to be less swollen.
represents a larger proportion of the surface area, and
the lower extremities represent a smaller proportion Secondary Surv e y and
than an adult’s. The palmar surface (including the Related Adjuncts
fingers) of the patient’s hand represents approximately
1% of the patient’s body surface. The rule of nines helps Key aspects of the secondary survey and its related
estimate the extent of burns with irregular outlines or adjuncts include documentation, baseline trauma
distribution and is the preferred tool for calculating bloodwork, including carboxyhemoglobin levels,
and documenting the extent of a burn injury. and x-rays, maintenance of peripheral circulation in
circumferential extremity burns, gastric tube insertion,
Pitfall prevention narcotic analgesics and sedatives, wound care, and
tetanus immunization.
Overestimating or • Do not include superficial burns
underestimating in size estimation. Documentation
burn size
• Use the rule of nines, recogniz- A flow sheet or other report that outlines the patient’s
ing that children have a pro- treatment, including the amount of fluid given and a
portionately larger head than pictorial diagram of the burn area and depth, should
adults do. be initiated when the patient is admitted to the ED.
This flow sheet should accompany the patient when
• For irregular or oddly sized transferred to the burn unit.
burns, use the patient’s palm
and fingers to represent 1% BSA.
• Remember to logroll the patient
to assess their posterior aspect.
Depth of Burn Baseline Determinations for Patients
with Major Burns
The depth of burn is important in evaluating the severity
of a burn, planning for wound care, and predicting Obtain blood samples for a complete blood count
functional and cosmetic results. (CBC), type and crossmatch/screen, an arterial blood
gas with HbCO (carboxyhemoglobin), serum glucose,
Superficial (first-degree) burns (e.g., sunburn) are electrolytes, and pregnancy test in all females of
characterized by erythema and pain, and they do childbearing age. Obtain a chest x-ray in patients
not blister. These burns are not life threatening and who are intubated or suspected of having smoke
generally do not require intravenous fluid replacement, inhalation injury, and repeat films as necessary.
because the epidermis remains intact. This type of Other x-rays may be indicated for appraisal of
burn is not discussed further in this chapter and is not associated injuries.
included in the assessment of burn size.
Peripheral Circulation in
Partial-thickness burns are characterized as either Circumferential Extremity Burns
superficial partial thickness or deep partial thickness.
Superficial partial-thickness burns are moist, painful- The goal of assessing peripheral circulation in a patient
ly hypersensitive (even to air current), potentially with burns is to rule out compartment syndrome.
blistered, homogenously pink, and blanch to touch Compartment syndrome results from an increase in
(n FIGURE 9-5 A and B). Deep partial-thickness burns pressure inside a compartment that interferes with
are drier, less painful, potentially blistered, red or perfusion to the structures within that compartment.
mottled in appearance, and do not blanch to touch In burns, this condition results from the combination
(n FIGURE 9-5 C). of decreased skin elasticity and increased edema in
the soft tissue. In extremities, the main concern is
Full-thickness burns usually appear leathery (n FIGURE perfusion to the muscle within the compartment. Al-
9-5 D). The skin may appear translucent or waxy white. though a compartment pressure greater than systolic
The surface is painless to light touch or pinprick and blood pressure is required to lose a pulse distal
generally dry. Once the epidermis is removed, the
underlying dermis may be red initially, but it does
not blanch with pressure. This dermis is also usually
dry and does not weep. The deeper the burn, the less
n BACK TO TABLE OF CONTENTS
SECONDARY SURVEY AND RELATED ADJUNCTS 177
A
C
BD
n FIGURE 9-5 Depth of Burns. A. Schematic of superficial partial-thickness burn injury. B. Schematic of deep partial-thickness burn.
C. Photograph of deep partial-thickness burn. D. Photograph of full-thickness burn.
to the burn, a pressure of > 30 mm Hg within the •• Paresthesias or altered sensation distal to the
compartment can lead to muscle necrosis. Once the affected compartment
pulse is gone, it may be too late to save the muscle. Thus,
clinicians must be aware of the signs and symptoms of A high index of suspicion is necessary when patients
compartment syndrome: are unable to cooperate with an exam.
•• Pain greater than expected and out of Compartment syndromes may also present with
proportion to the stimulus or injury circumferential chest and abdominal burns, leading
to increased peak inspiratory pressures or abdominal
•• Pain on passive stretch of the affected muscle compartment syndrome. Chest and abdominal escha-
•• Tense swelling of the affected compartment rotomies performed along the anterior axillary lines
with a cross-incision at the clavicular line and the
n BACK TO TABLE OF CONTENTS
178 CHAPTER 9 n Thermal Injuries
junction of the thorax and abdomen usually relieve Wound Care
the problem.
Partial-thickness burns are painful when air currents
To maintain peripheral circulation in patients with pass over the burned surface, so gently covering the
circumferential extremity burns, the clinician should: burn with clean sheets decreases the pain and deflects
air currents. Do not break blisters or apply an antiseptic
•• Remove all jewelry and identification or allergy agent. Remove any previously applied medication
bands on the patient’s extremities. before using antibacterial topical agents. Application
of cold compresses can cause hypothermia. Do not
•• Assess the status of distal circulation, checking apply cold water to a patient with extensive burns (i.e.,
for cyanosis, impaired capillary refill, and > 10% TBSA). A fresh burn is a clean area that must
progressive neurologic signs such as paresthesia be protected from contamination. When necessary,
and deep-tissue pain. Assessment of peripheral clean a dirty wound with sterile saline. Ensure that
pulses in patients with burns is best performed all individuals who come into contact with the wound
with a Doppler ultrasonic flow meter. wear gloves and a gown, and minimize the number of
caregivers within the patient’s environment without
•• Relieve circulatory compromise in a circumfer- protective gear.
entially burned limb by escharotomy, always with
surgical consultation. Escharotomies usually are Pitfall prevention
not needed within the first 6 hours of a burn injury.
Patient develops deep- • Remember that edema
•• Although fasciotomy is seldom required, it may tissue injury from takes time to develop.
be necessary to restore circulation in patients constricting dressings
with associated skeletal trauma, crush injury, and ties. • Reassess or avoid
or high-voltage electrical injury. circumferential ties
Patient develops deep- and dressings.
•• Although standard escharotomy diagrams are tissue injury from
generally followed, always attempt to incise constricting burn eschar. • Remove constricting
the skin through the burned, not the unburned rings and clothing early.
skin (if unburned skin is present), as the burned
skin will likely be debrided by the burn center. • Recognize that burned
skin is not elastic.
Gastric Tube Insertion Circumferential
burns may require
Insert a gastric tube and attach it to a suction setup if escharotomies.
the patient experiences nausea, vomiting, or abdomin-
al distention, or when a patient’s burns involve more Antibiotics
than 20% total BSA. To prevent vomiting and possible
aspiration in patients with nausea, vomiting, or There is no indication for prophylactic antibiotics in
abdominal distention, or when a patient’s burns involve the early postburn period. Reserve use of antibiotics
more than 20% total BSA, insert a gastric tube and for the treatment of infection.
ensure it is functioning before transferring the patient.
Tetanus
Narcotics, Analgesics, and Sedatives
Determination of the patient’s tetanus immunization
Severely burned patients may be restless and anxious status and initiation of appropriate management
from hypoxemia or hypovolemia rather than pain. is very important. (See Tetanus Immunization.)
Consequently, manage hypoxemia and inadequate
fluid resuscitation before administering narcotic Unique burn in jur ie s
analgesics or sedatives, which can mask the signs of
hypoxemia and hypovolemia. Narcotic analgesics Although the majority of burn injuries are thermal,
and sedatives should be administered in small, frequent there are other causes of burn injury that warrant special
doses by the intravenous route only. Remember that
simply covering the wound will decrease the pain.
n BACK TO TABLE OF CONTENTS
UNIQUE BURN INJURIES 179
consideration, including chemical, electrical, and tar small-caliber cannula can be fixed in the palpebral
burns, as well as burn patterns that indicate abuse. sulcus for irrigation. Certain chemical burns (such as
hydrofluoric acid burns) require specialized burn unit
Chemical Burns consultation. It is important to ascertain the nature
of the chemical and if possible obtain a copy of the
Chemical injury can result from exposure to acids, Material Safety Data Sheet to address any systemic
alkalies, and petroleum products. Acidic burns cause a toxicity that may result. Providers must also take care to
coagulation necrosis of the surrounding tissue, which protect themselves from inadvertent exposure during
impedes the penetration of the acid to some extent. the decontamination process.
Alkali burns are generally more serious than acid burns,
as the alkali penetrates more deeply by liquefaction Electrical Burns
necrosis of the tissue.
Electrical burns result when a source of electrical
Rapid removal of the chemical and immediate power makes contact with a patient, and current is
attention to wound care are essential. Chemical transmitted through the body. The body can also serve
burns are influenced by the duration of contact, as a volume conductor of electrical energy, and the
concentration of the chemical, and amount of the agent. heat generated results in thermal injury to tissue.
If dry powder is still present on the skin, brush it away Different rates of heat loss from superficial and deep
before irrigating with water. Otherwise, immediately tissues allow for relatively normal overlying skin to
flush away the chemical with large amounts of warmed coexist with deep-muscle necrosis. Therefore, electrical
water, for at least 20 to 30 minutes, using a shower burns frequently are more serious than they appear on
or hose (n FIGURE 9-6). Alkali burns require longer the body surface, and extremities, particularly digits,
irrigation. Neutralizing agents offer no advantage over are especially at risk. In addition, the current travels
water lavage, because reaction with the neutralizing inside blood vessels and nerves and can cause local
agent can itself produce heat and cause further tissue thrombosis and nerve injury. Severe electrical injuries
damage. Alkali burns to the eye require continuous usually result in contracture of the affected extremity.
irrigation during the first 8 hours after the burn. A A clenched hand with a small electrical entrance
wound should alert the clinician that a deep soft-tissue
Pitfall prevention injury is likely much more extensive than is visible
to the naked eye (n FIGURE 9-7). Patients with severe
Patient presents with • Obtain the manu- electrical injuries frequently require fasciotomies and
chemical burn and facturer’s Material Safety should be transferred to burn centers early in their
exposure to unfamiliar Data Sheet or contact a course of treatment.
compound. poison center to identify
potential toxicities.
n FIGURE 9-6 Chemical Burn. Immediately flush away the chemical n FIGURE 9-7 Electrical Burn. A clenched hand with a small
with large amounts of water, continuing for at least 20 to 30 minutes. electrical entrance wound should alert the clinician that a deep
soft-tissue injury is likely much more extensive than is visible to the
naked eye. This patient has received a volar forearm fasciotomy to
decompress the muscle.
n BACK TO TABLE OF CONTENTS
180 CHAPTER 9 n Thermal Injuries
Immediate treatment of a patient with a significant molten tar can be very high—up to 450°F (232°C)—
electrical burn includes establishing an airway and if it is fresh from the melting pot. A complicating
ensuring adequate oxygenation and ventilation, factor is adherence of the tar to skin and infiltration
placing an intravenous line in an uninvolved extremity, into clothing, resulting in continued transfer of heat.
ECG monitoring, and placing an indwelling bladder Treatment includes rapid cooling of the tar and care
catheter. Electricity can cause cardiac arrhythmias that to avoid further trauma while removing the tar. A
may produce cardiac arrest. Prolonged monitoring is number of methods are reported in the literature;
reserved for patients who demonstrate injury from the the simplest is use of mineral oil to dissolve the tar.
burn, loss of consciousness, exposure to high voltage The oil is inert, safe on injured skin, and available in
(>1,000 volts) or cardiac rhythm abnormalities or large quantities.
arrhythmias on early evaluation.
Burn Patterns Indicating Abuse
Because electricity causes forced contraction of
muscles, clinicians need to examine the patient for It is important for clinicians to maintain awareness
associated skeletal and muscular damage, including that intentional burn injury can occur in both children
the possibility of fracture of the spine. Rhabdomyolysis and adults. Patients who are unable to control their
from the electricity traveling through muscle results environment, such as the very young and the very
in myoglobin release, which can cause acute renal old, are particularly vulnerable to abuse and neglect.
failure. Do not wait for laboratory confirmation before Circular burns and burns with clear edges and unique
instituting therapy for myoglobinuria. If the patient’s patterns should arouse suspicion; they may reflect a
urine is dark red, assume that hemochromogens are cigarette or other hot object (e.g., an iron) being held
in the urine. ABA consensus formula guidelines are against the patient. Burns on the soles of a child’s
to start resuscitation for electrical burn injury at 4 feet usually suggest that the child was placed into hot
mL/kg/%TBSA to ensure a urinary output of 100 water versus having hot water fall on him or her, as
mL/hr in adults and 1–1.5 mL/kg/hr in children contact with a cold bathtub can protect the bottom of
weighing less than 30 kg. Once the urine is clear of the foot. A burn to the posterior aspect of the lower
pigmentation, titrate the IV fluid down to ensure a extremities and buttocks may be seen in an abused
standard urine output of 0.5cc/kg/hr. Consult a local elder patient who has been placed in a bathtub with
burn unit before initiating a bicarbonate infusion or hot water in it. Old burn injuries in the setting of a
using mannitol. new traumatic injury such as a fracture should also
raise suspicion for abuse. Above all, the mechanism
Tar Burns and pattern of injury should match the history of
the injury.
In industrial settings, individuals can sustain injuries
secondary to hot tar or asphalt. The temperature of Patient Transfer
Pitfall prevention The criteria for transfer of patients to burn centers has
been developed by the American Burn Association.
Patient with an • Remember, with electrical burns,
electrical burn that muscle injury can occur with Criteria for Transfer
develops acute few outward signs of injury.
renal failure. The following types of burn injuries typically require
• Test urine for hemochromogen, transfer to a burn center:
and administer proper volume to
ensure adequate urine output. 1. Partial-thickness burns on greater than
10% TBSA.
• Repeatedly assess the patient
for the development of 2. Burns involving the face, hands, feet, genitalia,
compartment syndrome, perineum, and major joints
recognizing that electrical burns
may need fasciotomies. 3. Third-degree burns in any age group
4. Electrical burns, including lightning injury
• Patients with electrical injuries
may develop cardiac arrhythmias
and should have a 12-lead ECG
and continuous monitoring.
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COLD INJURY: LOCAL TISSUE EFFECTS 181
5. Chemical burns Pitfall prevention
6. Inhalation injury
7. Burn injury in patients with preexisting medical Patient loses airway • Reassess airway frequently
during transfer. before transfer.
disorders that could complicate management,
prolong recovery, or affect mortality (e.g., • When the patient has risk
diabetes, renal failure) factors for inhalation injury
8. Any patient with burns and concomitant trauma or has received significant
(e.g., fractures) in which the burn injury poses amounts of resuscitation
the greatest risk of morbidity or mortality. fluid, contact the receiving
In such cases, if the trauma poses the greater facility to discuss intu-
immediate risk, the patient may be initially bation before transfer.
stabilized in a trauma center before being
transferred to a burn unit. Physician judgment Patient experiences • Provide adequate
is necessary in such situations and should be severe pain with analgesia before
considered in concert with the regional medical dressing change. manipulating burns.
control plan and triage protocols.
9. Burned children in hospitals without qualified • Use non-adherent
personnel or equipment for the care of children dressings or burn sheets
10. Burn injury in patients who will require special to protect burn from con-
social, emotional, or rehabilitative intervention tamination before transfer.
Because these criteria are so comprehensive, cli- The receiving hospital • Ensure that appropriate
nicians may elect to consult with a burn center is unable to discern the information is relayed
and determine a mutually agreeable plan other burn wound size from by using transfer forms
than transfer. For example, in the case of a partial- the documentation. or checklist.
thickness hand or face burn, if adequate wound care
can be taught and oral pain control tolerated, follow- The receiving hospital is • Ensure that the flow
up at an outpatient burn clinic can avoid the costs of unable to discern the sheets documenting IV
immediate transfer to a burn center. amount of fluid resus- fluids and urinary output
citation provided from are sent with the patient.
the documentation.
Transfer Procedures Types of Cold Injury
Transfer of any patient must be coordinated with the Two types of cold injury are seen in trauma patients:
burn center staff. All pertinent information regarding frostbite and nonfreezing injury.
test results, vital signs, fluids administered, and urinary
output should be documented on the burn/trauma Frostbite
flow sheet that is sent with the patient, along with any Damage from frostbite can be due to freezing of tissue,
other information deemed important by the referring ice crystal formation causing cell membrane injury,
and receiving doctors. microvascular occlusion, and subsequent tissue anoxia
(n FIGURE 9-8). Some of the tissue damage also can result
Cold In jury: Lo c a l Tis sue from reperfusion injury that occurs on rewarming.
Effects Frostbite is classified into first-degree, second-degree,
third-degree, and fourth-degree according to depth
The severity of cold injury depends on temperature, of involvement.
duration of exposure, environmental conditions,
amount of protective clothing, and the patient’s gene- 1. First-degree frostbite: Hyperemia and edema are
ral state of health. Lower temperatures, immobilizat- present without skin necrosis.
ion, prolonged exposure, moisture, the presence of
peripheral vascular disease, and open wounds all 2. Second-degree frostbite: Large, clear vesicle
increase the severity of the injury. formation accompanies the hyperemia and
edema with partial-thickness skin necrosis.
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182 CHAPTER 9 n Thermal Injuries
local infection, cellulitis, lymphangitis, and gangrene
can occur. Proper attention to foot hygiene can prevent
the occurrence of most such complications.
n FIGURE 9-8 Frostbite. Frostbite is due to freezing of tissue with Management of Frostbite and
intracellular ice crystal formation, microvascular occlusion, and Nonfreezing Cold Injuries
subsequent tissue anoxia.
Treatment should begin immediately to decrease the
3. Third-degree frostbite: Full-thickness and duration of tissue freezing. Do not attempt rewarming
subcutaneous tissue necrosis occurs, commonly if there is a risk of refreezing. Replace constricting,
with hemorrhagic vesicle formation. damp clothing with warm blankets, and give the patient
hot fluids by mouth, if he or she is able to drink. Place
4. Fourth-degree frostbite: Full-thickness skin the injured part in circulating water at a constant
necrosis occurs, including muscle and bone with 40°C (104°F) until pink color and perfusion return
later necrosis. (usually within 20 to 30 minutes). This treatment is best
accomplished in an inpatient setting in a large tank,
Although the affected body part is typically hard, cold, such as a whirlpool tank, or by placing the injured limb
white, and numb initially, the appearance of the lesion into a bucket with warm water running in. Excessive
changes during the course of treatment as the area dry heat can cause a burn injury, as the limb is usually
warms up and becomes perfused. The initial treatment insensate. Do not rub or massage the area. Rewarming
regimen applies to all degrees of insult, and the initial can be extremely painful, and adequate analgesics
classification is often not prognostically accurate. The (intravenous narcotics) are essential. Warming of
final surgical management of frostbite depends on large areas can result in reperfusion syndrome, with
the level of demarcation of the perfused tissue. This acidosis, hyperkalemia, and local swelling; therefore,
demarcation may take from weeks to months to reach monitor the patient’s cardiac status and peripheral
a final stage. perfusion during rewarming.
Nonfreezing Injury Local Wound Care of Frostbite
Nonfreezing injury is due to microvascular endothelial The goal of wound care for frostbite is to preserve
damage, stasis, and vascular occlusion. Trench foot or damaged tissue by preventing infection, avoiding
cold immersion foot (or hand) describes a nonfreezing opening uninfected vesicles, and elevating the injured
injury of the hands or feet—typically in soldiers, sailors, area. Protect the affected tissue by a tent or cradle, and
fishermen, and the homeless—resulting from long- avoid pressure to the injured tissue.
term exposure to wet conditions and temperatures
just above freezing (1.6°C to 10°C, or 35°F to 50°F). When treating hypothermic patients, it is important
Although the entire foot can appear black, deep- to recognize the differences between passive and active
tissue destruction may not be present. Alternating rewarming. Passive rewarming involves placing the
arterial vasospasm and vasodilation occur, with the patient in an environment that reduces heat loss (e.g.,
affected tissue first cold and numb, and then progress using dry clothing and blankets), and relies on the
to hyperemia in 24 to 48 hours. With hyperemia comes patient’s intrinsic thermoregulatory mechanism to
intense, painful burning and dysesthesia, as well as generate heat and raise body temperature. This method
tissue damage characterized by edema, blistering, is used for mild hypothermia. Active rewarming
redness, ecchymosis, and ulcerations. Complications of involves supplying additional sources of heat energy
to the patient (e.g., warmed IV solution, warmed
packs to areas of high vascular flow such as the groin
and axilla, and initiating circulatory bypass). Active
rewarming is used for patients with moderate and
severe hypothermia.
Only rarely is fluid loss massive enough to require
resuscitation with intravenous fluids, although patients
may be dehydrated. Tetanus prophylaxis depends on
the patient’s tetanus immunization status. Systemic
antibiotics are not indicated prophylactically, but are
n BACK TO TABLE OF CONTENTS
CHAPTER SUMMARY 183
reserved for identified infections. Keep the wounds core temperature below 32°C (89.6°F). Hypothermia is
clean, and leave uninfected nonhemmorhagic blisters common in severely injured individuals, but further loss
intact for 7 to 10 days to provide a sterile biologic of core temperature can be limited by administering
dressing to protect underlying epithelialization. only warmed intravenous fluids and blood, judiciously
Tobacco, nicotine, and other vasoconstrictive agents exposing the patient, and maintaining a warm
must be withheld. Instruct the patient to minimize environment. Avoid iatrogenic hypothermia during
weight bearing until edema is resolved. exposure and fluid administration, as hypothermia
can worsen coagulopathy and affect organ function.
Numerous adjuvants have been attempted in an
effort to restore blood supply to cold-injured tissue. The signs of hypothermia and its treatment are
Unfortunately, most are ineffective. Sympathetic explained in more detail in Appendix B: Hypothermia
blockade (e.g., sympathectomy or drugs) and vaso- and Heat Injuries.
dilating agents have generally not proven helpful in
altering the progression of acute cold injury. Heparin TeamWORK
and hyperbaric oxygen also have failed to demonstrate
substantial treatment benefit. Retrospective case series The team leader must:
have suggested that thrombolytic agents may show
some promise, but only when thrombolytic therapy was •• Ensure that the trauma team recognizes the
administered within 23 hours of the frostbite injury. unique aspects of applying the ATLS principles
to treating burn-injured patients.
Occasionally patients arrive at the ED several days
after suffering frostbite, presenting with black, clearly •• Help the team recognize the importance of
dead toes, fingers, hands, or feet. In this circumstance, limiting exposure to minimize hypothermia in
rewarming of the tissue is not necessary. the patient and infection of the burn.
With all cold injuries, estimations of depth of injury •• Encourage the trauma team to communicate
and extent of tissue damage are not usually accurate early and regularly regarding concerns
until demarcation is evident. This often requires about the challenges of resuscitating a burn-
several weeks or months of observation. Dress these injured patient (e.g., IV access and need for
wounds regularly with a local topical antiseptic to escharotomies).
help prevent bacterial colonization, and debride them
once demarcation between live and dead tissue has
developed. Early surgical debridement or amputation
is seldom necessary, unless infection occurs.
Cold In jury: Sys temic C h a p ter Summ ary
Hypothermia
1. Burn injuries are unique; burn inflammation/ede-
Trauma patients are susceptible to hypothermia, ma may not be immediately evident and requires
and any degree of hypothermia in them can be comprehension of the underlying pathophysiology.
detrimental. Hypothermia is any core temperature
below 36°C (96.8°F), and severe hypothermia is any 2. Immediate lifesaving measures for patients with
burn injury include stopping the burn process,
Pitfall prevention recognizing inhalation injury and assuring an
adequate airway, oxygenation and ventilation,
Patient becomes • Remember, thermoregulation and rapidly instituting intravenous fluid therapy.
hypothermic. is difficult in patients with burn
injuries. 3. Fluid resuscitation is needed to maintain
perfusion in face of the ongoing fluid loss from
• If irrigating the burns, use warmed inflammation. The inflammatory response that
saline. drives the circulatory needs is directly related to
the size and depth of the burn. Only partial and full
• Warm the ambient temperature. thickness burns are included in calculating burn
• Use heating lamps and warming size. The rule of nines is a useful and practical guide
to determine the size of the burn, with children
blankets to rewarm the patient. having proportionately larger heads.
• Use warmed IV fluids.
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184 CHAPTER 9 n Thermal Injuries
4. Attention must be paid to special problems unique 7. Gentilello LM, Cobean RA, Offner PJ, et al.
to thermal injuries. Carbon monoxide poisoning Continuous arteriovenous rewarming: rapid
should be suspected and identified. Circumferential reversal of hypothermia in critically ill patients.
burns may require escharotomy. J Trauma 1992;32(3):316–327.
5. Nonthermal causes of burn injury should be 8. Gonzaga T, Jenebzadeh K, Anderson CP,
recognized and appropriate treatment started. Mohr WJ, Endorf FW, Ahrenholz DH. Use of
Chemical burns require immediate removal intraarterial thrombolytic therapy for acute
of clothing to prevent further injury, as well treatment of frostbite in 62 patients with review
as copious irrigation. Electrical burns may of thrombolytic therapy in frostbite. J Burn Care
be associated with extensive occult injuries. Res, 2015.
Patients sustaining thermal injury are at risk for
hypothermia. Judicious analgesia should not 9. Halebian P, Robinson N, Barie P, et al. Whole
be overlooked. body oxygen utilization during carbon monoxide
poisoning and isocapneic nitrogen hypoxia. J
6. The American Burn Association has identified Trauma 1986;26:110–117.
types of burn injuries that typically require
referral to a burn center. Transfer principles are 10. Jurkovich GJ. Hypothermia in the trauma patient.
similar to non-burned patients but include an In: Maull KI, Cleveland HC, Strauch GO, et al., eds.
accurate assessment of the patient’s burn size Advances in Trauma. Vol. 4. Chicago, IL: Yearbook;
and depth. 1989:11–140.
7. Early management of cold-injured patients in- 11. Jurkovich GJ, Greiser W, Luterman A, et al. Hy-
cludes adhering to the ABCDEs of resuscitation, pothermia in trauma victims: an ominous
identifying the type and extent of cold injury, predictor of survival. J Trauma 1987;27:
measuring the patient’s core temperature, pre- 1019–1024.
paring a patient-care flow sheet, and initiating
rapid rewarming techniques. 12. Latenser BA. Critical care of the burn patient:
the first 48 hours. Crit Care Med 2009 Oct;37
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1. Baxter CR. Volume and electrolyte changes 13. Moss J. Accidental severe hypothermia. Surg
in the early postburn period. Clin Plast Surg Gynecol Obstet 1986;162:501–513.
1974;4:693–709.
14. Mozingo DW, Smith AA, McManus WF,
2. Bruen KJ, Ballard JR, Morris SE, et al. Reduction et al. Chemical burns. J Trauma 1988;28:
of the incidence of amputation in frostbite 642–647.
injury with thrombolytic therapy. Arch
Surg 2007 Jun;142(6):546–551; discussion 15. Perry RJ, Moore CA, Morgan BD, et al. Determining
551–553. the approximate area of burn: an inconsist-
ency investigated and reevaluated. BMJ 1996;
3. Cancio L. Airway management and smoke 312:1338.
inhalation injury in the burn patient. Clin Plast
Surg 2009 Oct;36(4):555–567. 16. Pham TN, Gibran NS. Thermal and electrical
injuries. Surg Clin North Am 2007 Feb;87(1):185–
4. Cancio LC. Initial assessment and fluid re- 206, vii–viii. Review.
suscitation of burn patients. Surg Clin North Am
2014 Aug;94(4):741–754. 17. Pruitt BA. Fluid and electrolyte replacement in
the burned patient. Surg Clin North Am 1978,
5. Cancio LC, Lundy JB, Sheridan RL. Evolving 58;6:1313–1322.
changes in the management of burns and envi-
ronmental injuries. Surg Clin North Am 2012 18. Reed R, Bracey A, Hudson J, et al. Hypothermia
Aug;92(4):959–986, ix. and blood coagulation: dissociation between
enzyme activity and clotting factor levels. Circ
6. Carta T, Gawaziuk J, Liu S, et al. Use of mineral Shock 1990;32:141–152.
oil Fleet enema for the removal of a large tar
burn: a case report, J Burns, 2015 Mar;41(2): 19. Saffle JR, Crandall A, Warden GD. Cataracts: a
e11-4. long-term complication of electrical injury. J
Trauma 1985;25:17–21.
20. Schaller M, Fischer A, Perret C.
Hyperkalemia: a prognostic factor during
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22. Sheridan RL, Chang P. Acute burn procedures.
Surg Clin North Am 2014 Aug;94(4):755–764.
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BIBLIOGRAPHY 185
23. Stratta RJ, Saffle JR, Kravitz M, et al. Management 24. Vercruysse GA, Ingram WL, Feliciano DV. The
of tar and asphalt injuries. Am J Surg 1983;146: demographics of modern burn care: should most
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J Surg 2011;201:91–96.
n BACK TO TABLE OF CONTENTS
10 PEDIATRIC TRAUMA
Injury remains the most common cause of death and disability in childhood. Injury morbidity
and mortality surpass all major diseases in children and young adults, making trauma the
most serious public health and health care problem in this population.
CHAPTER 10 Outline Abdominal Trauma
• Assessment
Objectives • Diagnostic Adjuncts
• Nonoperative Management
Introduction • Specific Visceral Injuries
Types and Patterns of Injury Head Trauma
• Assessment
Unique Characteristics of Pediatric Patients • Management
• Size, Shape, and Surface Area
• Skeleton Spinal Cord Injury
• Psychological Status • Anatomical Differences
• Long-Term Effects of Injury • Radiological Considerations
• Equipment
Musculoskeletal Trauma
Airway • History
• Anatomy • Blood Loss
• Management • Special Considerations of the Immature Skeleton
• Fracture Splinting
Breathing
• Breathing and Ventilation Child Maltreatment
• Needle and Tube Thoracostomy
Prevention
Circulation and Shock
• Recognition of Circulatory Compromise Teamwork
• Determination of Weight and Circulating Blood Volume
• Venous Access Chapter Summary
• Fluid Resuscitation and Blood Replacement
• Urine Output Bibliography
• Thermoregulation
Cardiopulmonary Resuscitation
Chest Trauma
OBJECTIVES
After reading this chapter and comprehending the knowledge pediatric patients, the anatomic and physiologic
components of the ATLS provider course, you will be able to: differences that affect resuscitation, and the
different equipment needs when compared with
1. Identify the unique characteristics of children as adult trauma patients.
trauma patients, including common types and
patterns of injuries, the anatomic and physiologic 3. Identify the injury patterns associated with child
differences from adults, and the long-term effects maltreatment, and describe the factors that lead to
of injury. suspicion of child maltreatment.
2. Describe the primary management of trauma 4. List the ABCDEs of injury prevention.
in children, including related issues unique to
nnBBAACCKKTTOOTTAABBLLEEOOFFCCOONNTTEENNTTSS 187
188 CHAPTER 10 n Pediatric Trauma
I njury remains the most common cause of death table 10-1 common mechanisms of
and disability in childhood. Each year, more than 10 injury and associated patterns of
million children—nearly 1 of every 6 children—in injury in pediatric patients
the United States require emergency department care
for the treatment of injuries. Each year, more than MECHANISM COMMON PATTERNS
10,000 children in the United States die from serious OF INJURY OF INJURY
injury. Injury morbidity and mortality surpass all major
diseases in children and young adults, making trauma Pedestrian struck • Low speed: Lower-extremity
the most serious public health and healthcare problem by motor vehicle fractures
in this population. Globally, road traffic accidents
are the leading cause of adolescent deaths. Failure • High speed: Multiple trauma,
to secure a compromised airway, support breathing, head and neck injuries, lower-
and recognize and respond to intra-abdominal and extremity fractures
intracranial hemorrhage are the leading causes of
unsuccessful resuscitation in pediatric patients with Occupant in • Unrestrained: Multiple trauma,
severe trauma. Therefore, by applying ATLS principles motor vehicle head and neck injuries, scalp and
to the care of injured children, trauma team members collision facial lacerations
can significantly affect ultimate survival and long-
term outcomes. • Restrained: Chest and abdominal
injuries, lower spine fractures
Fall from a height • Low: Upper-extremity fractures
• Medium: Head and neck injuries,
Types and Patterns of Injury
upper- and lower-extremity
Injuries associated with motor vehicles are the most fractures
common cause of death in children of all ages, whether • High: Multiple trauma, head and
they are occupants, pedestrians, or cyclists. Deaths due neck injuries, upper- and lower-
to drowning, house fires, homicides, and falls follow extremity fractures
in descending order. Child maltreatment accounts
for the great majority of homicides in infants (i.e., Fall from a • Without helmet: Head and neck
children younger than 12 months of age), whereas bicycle lacerations, scalp and facial lacera-
firearm injuries account for most of the homicides in tions, upper-extremity fractures
children (over age 1) and adolescents. Falls account for
the majority of all pediatric injuries, but infrequently • With helmet: Upper-extremity
result in death. fractures
Blunt mechanisms of injury and children’s unique • Striking handlebar: Internal
physical characteristics result in multisystem injury abdominal injuries
being the rule rather than the exception. Clinicians
should presume, therefore, that multiple organ systems Unique C h arac ter is tic s
may be injured until proven otherwise. n TABLE 10-1 of Pedi atr ic Patients
outlines common mechanisms of injury and associated
patterns of injury in pediatric patients. The priorities for assessing and managing pediatric
trauma patients are the same as for adults. However,
The condition of the majority of injured children the unique anatomic and physiologic characteristics
will not deteriorate during treatment, and most of this population combine with the common
injured children have no hemodynamic abnormal- mechanisms of injury to produce distinct injury
ities. Nevertheless, the condition of some children patterns. For example, most serious pediatric trauma
with multisystem injuries will rapidly deteriorate, is blunt trauma that involves the brain. As a result,
and serious complications will develop. Therefore, apnea, hypoventilation, and hypoxia occur five times
early transfer of pediatric patients to a facility capa- more often than hypovolemia with hypotension in
ble of treating children with multisystem injuries children who have sustained trauma. Therefore,
is optimal. treatment protocols for pediatric trauma patients
emphasize aggressive management of the airway
The Field Triage Decision Scheme (see Figure 1-2 in and breathing.
Chapter 1) and Pediatric Trauma Score n TABLE 10-2 are
both useful tools for the early identification of pediatric
patients with multisystem injuries.
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UNIQUE CHARACTERISTICS OF PEDIATRIC PATIENTS 189
table 10-2 pediatric trauma score
ASSESSMENT +2 SCORE -1
COMPONENT >20 kg (>44 lb) +1 <10 kg (<22 lb)
10–20 kg (22–44 lb)
Weight
Airway Normal Oral or nasal airway, oxygen Intubated, cricothyroido-
Systolic Blood Pressure tomy, or tracheostomy
Level of Consciousness >90 mm Hg; good periph- 50–90 mm Hg; carotid/ <50 mm Hg; weak or no pulses
Fracture eral pulses and perfusion femoral pulses palpable
Cutaneous Awake Coma, unresponsive
Totals: Obtunded or any loss of
None seen or suspected consciousness Open or multiple
None visible Tissue loss, any gunshot wound
Single, closed or stab wound through fascia
Contusion, abrasion, lacer-
ation <7 cm not through fascia
Source: Adapted with permission from Tepas JJ, Mollitt DL, Talbert JL, et al. The pediatric trauma score as a predictor of injury severity in the injured
child. Journal of Pediatric Surgery 1987; 22(1)15.
Size, Shape, and Surface Area to occur in children, even when they have sustained
internal organ damage. For example, rib fractures in
Because children have smaller body mass than adults, children are uncommon, whereas pulmonary contu-
the energy imparted from objects such as fenders and sion is not. Other soft tissues of the thorax and medias-
bumpers, or from falls, results in greater force being tinum also can sustain significant damage without
applied per unit of body area. This concentrated energy evidence of bony injury or external trauma. The
is transmitted to a body that has less fat, less connective presence of skull and/or rib fractures in a child sug-
tissue, and a closer proximity of multiple organs than gests the transfer of a massive amount of energy; in
in adults. These factors result in the high frequency of this case, underlying organ injuries, such as traumatic
multiple injuries seen in the pediatric population. In brain injury and pulmonary contusion, should
addition, a child’s head is proportionately larger than be suspected.
an adult’s, which results in a higher frequency of blunt
brain injuries in this age group. Psychological Status
The ratio of a child’s body surface area to body mass The potential for significant psychological ramifications
is highest at birth and decreases as the child matures. should be considered in children who sustain trauma.
As a result, thermal energy loss is a significant stress In young children, emotional instability frequently
factor in children. Hypothermia may develop quickly leads to a regressive psychological behavior when
and complicate the treatment of pediatric patients stress, pain, and other perceived threats intervene in
with hypotension. the child’s environment. Children have a limited ability
to interact with unfamiliar individuals in strange and
Skeleton difficult situations, which can make history taking and
cooperative manipulation, especially if it is painful,
A child’s skeleton is incompletely calcified, contains extremely difficult. Clinicians who understand these
multiple active growth centers, and is more pliable characteristics and are willing to soothe an injured
than an adult’s. Therefore, bone fractures are less likely
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190 CHAPTER 10 n Pediatric Trauma
child are more likely to establish a good rapport, which and studies are obtained using the lowest possible
facilitates a comprehensive assessment of the child’s radiation doses.
psychological and physical injuries.
Nevertheless, the long-term quality of life for
The presence of parents or other caregivers during children who have sustained trauma is surprisingly
evaluation and treatment, including resuscitation, positive, even though in many cases they will expe-
may assist clinicians by minimizing the injured child’s rience lifelong physical challenges. Most patients
natural fears and anxieties. report a good to excellent quality of life and find
gainful employment as adults, an outcome justifying
Long-Term Effects of Injury aggressive resuscitation attempts even for pediatric
patients whose initial physiologic status might
A major consideration in treating injured children is suggest otherwise.
the effect of that injury on their subsequent growth
and development. Unlike adults, children must recover Equipment
from the traumatic event and then continue the normal
process of growth and development. The potential Successful assessment and treatment of injured
physiologic and psychological effects of injury on children depends on immediately available equipment
this process can be significant, particularly in cases of the appropriate size (n TABLE 10-3; also see Pediatric
involving long-term function, growth deformity, or Equipment on MyATLS mobile app). A length-based
subsequent abnormal development. Children who resuscitation tape, such as the Broselow® Pediatric
sustain even a minor injury may have prolonged Emergency Tape, is an ideal adjunct for rapidly
disability in cerebral function, psychological adjust- determining weight based on length for appropriate
ment, or organ system function. fluid volumes, drug doses, and equipment size. By
measuring the child’s height, clinicians can readily
Some evidence suggests that as many as 60% of determine his or her ’estimated weight. One side of the
children who sustain severe multisystem trauma have tape provides drugs and their recommended doses for
residual personality changes at one year after hospital pediatric patients based on weight, and the other side
discharge, and 50% show cognitive and physical identifies equipment needs for pediatric patients based
handicaps. Social, affective, and learning disabilities on length (n FIGURE 10-1). Clinicians should be familiar
are present in one-half of seriously injured children. with length-based resuscitation tapes and their uses.
In addition, childhood injuries have a significant
impact on the family—personality and emotional Pitfall prevention
disturbances are found in two-thirds of uninjured
siblings. Frequently, a child’s injuries impose a strain on Incorrect doses of • Recognize the need for
the parents’ personal relationship, including possible fluids or medications weight-based dosing, and
financial and employment hardships. Trauma may are administered use a resuscitation tape to
affect not only the child’s survival but also the quality estimate weight from length.
of the child’s life for years to come. Hypothermia rapidly
develops • Recognize the significance
Bony and solid visceral injuries are cases in point: of a high body surface area
Injuries through growth centers can cause growth in children, and keep the
abnormalities of the injured bone. If the injured bone environment warm and the
is a femur, a leg length discrepancy may result, causing child covered.
a lifelong disability in running and walking. If the
fracture is through the growth center of one or more Airway
thoracic vertebra, the result may be scoliosis, kyphosis,
or even gibbus deformity. Another example is massive The “A” of the ABCDEs of initial assessment is the
disruption of a child’s spleen, which may require a same in the child as for adults. Establishing a patent
splenectomy and predisposes the child to a lifelong risk airway to provide adequate tissue oxygenation is
of overwhelming postsplenectomy sepsis and death. the first objective. The inability to establish and/or
maintain a patent airway with the associated lack
Ionizing radiation, used commonly in evaluation of oxygenation and ventilation is the most common
of injured patients may increase the risk of certain
malignancies and should be used if the information
needed cannot obtained by other means, the information
gained will change the clinical management of the
patient, obtaining the studies will not delay the
transfer of patients who require higher levels of care,
n BACK TO TABLE OF CONTENTS
AIRWAY 191
table 10-3 pediatric equipmenta
AIRWAY AND BREATHING
AGE O2 ORAL BAG- LARYNGO- ET TUBE STYLET SUCTION
AND MASK AIRWAY VALVE SCOPE
WEIGHT
Premie Premie, Infant Infant 0 straight 2.5–3.0 6 Fr 6–8 Fr
3 kg newborn no cuff
0–6 mos Newborn Infant, Infant 1 straight 3.0–3.5 6 Fr 8 Fr
3.5 kg small no cuff
6–12 mos Pediatric Small Pediatric 1 straight 3.5–4.0 6 Fr 8-10 Fr
7 kg cuffed or
uncuffed
1–3 yrs Pediatric Small Pediatric 1 straight 4.0–4.5 6 Fr 10 Fr
10–12 kg cuffed or
uncuffed
4–7 yrs Pediatric Medium Pediatric 2 straight or 5.0–5.5 14 Fr 14 Fr
16–18 kg curved no cuff
8–10 yrs Adult Medium, Pediatric, 2-3 straight 5.5–6.5 14 Fr 14 Fr
24–30 kg large adult or curved cuffed
CIRCULATION SUPPLEMENTAL EQUIPMENT
AGE BP CUFF IV OG/NG CHEST URINARY CERVICAL
AND CATHETERb TUBE TUBE CATHETER COLLAR
WEIGHT
Premie Premie, newborn 22–24 ga 8 Fr 10-14 Fr 5 Fr feeding —
3 kg
0–6 mos Newborn, infant 22 ga 10 Fr 12-18 Fr 6 Fr or 5–8 Fr —
3.5 kg feeding
6–12 mos Infant, child 22 ga 12 Fr 14-20 Fr 8 Fr Small
7 kg
1–3 yrs Child 20-22 ga 12 Fr 14-24 Fr 10 Fr Small
10–12 kg
4–7 yrs Child 20 ga 12 Fr 20-28 Fr 10-12 Fr Small
16–18 kg
8–10 yrs Child, adult 18-20 ga 14 Fr 28-32 Fr 12 Fr Medium
24–30 kg
aUse of a length-based resuscitation tape, such as a BroselowTM Pediatric Emergency Tape, is preferred.
bUse of the largest IV catheter that can readily be inserted with reasonable certainty of success is preferred.
n BACK TO TABLE OF CONTENTS
192 CHAPTER 10 n Pediatric Trauma
AB
n FIGURE 10-1 Resuscitation Tape. A. A length-based resuscitation tape, such as the Broselow® Pediatric Emergency Tape, is an ideal
adjunct to rapidly determine weight based on length for appropriate fluid volumes, drug doses, and equipment size. B. Detail, showing
recommended drug doses and equipment needs for pediatric patients based on length.
cause of cardiac arrest in children. Therefore, the Plane of face is not
child’s airway is the first priority. (Also see Chapter 2: parallel to spine board
Airway and Ventilatory Management, and Appendix G:
Airway Skills.)
Anatomy A
The smaller the child, the greater is the disproportion Plane of face is
between the size of the cranium and the midface. The parallel to spine board
large occiput results in passive flexion of the cervical
spine, leading to a propensity for the posterior pharynx B
to buckle anteriorly. To avoid passive flexion of the
cervical spine, ensure that the plane of the midface n FIGURE 10-2 Positioning for Airway Maintenance. A. Improper
is maintained parallel to the spine board in a neutral positioning of a child to maintain a patent airway. The disproportion
position, rather than in the “sniffing position” (n FIGURE between the size of the child’s cranium and midface leads to a
10-2A). Placement of a 1-inch layer of padding beneath propensity for the posterior pharynx to buckle anteriorly. The
the infant or toddler’s entire torso will preserve neutral large occiput causes passive flexion of the cervical spine. B. Proper
alignment of the spinal column (n FIGURE 10-2B). positioning of a child to maintain a patent airway. Avoid passive
flexion of the cervical spine by keeping the plane of the midface
Several anatomical features of children affect airway parallel to the spine board in a neutral position, rather than in the
assessment and management. The soft tissues of an “sniffing position.” Placement of a 1-inch layer of padding beneath
infant’s oropharynx (i.e., the tongue and tonsils) are the infant’s or toddler’s entire torso will preserve neutral alignment
relatively large compared with the tissues in the oral of the spinal column.
cavity, which may compromise visualization of the
larynx. A child’s larynx is funnel shaped, allowing mainstem bronchus, inadequate ventilation, accidental
secretions to accumulate in the retropharyngeal area. tube dislodgment, and/or mechanical barotrauma. The
The larynx and vocal cords are more cephalad and optimal endotracheal tube (ETT) depth (in centimeters)
anterior in the neck. The vocal cords are frequently can be calculated as three times the appropriate
more difficult to visualize when the child’s head is in the
normal, supine, anatomical position during intubation
than when it is in the neutral position required for
optimal cervical spine protection.
An infant’s trachea is approximately 5 cm long and
grows to 7 cm by about 18 months. Failure to appreciate
this short length can result in intubation of the right
n BACK TO TABLE OF CONTENTS
AIRWAY 193
tube size. For example, a 4.0 ETT would be properly (See Infant Endotracheal Intubation video on MyATLS
positioned at 12 cm from the gums. mobile app.) However, the use of cuffed ETTs, even in
toddlers and small children, provides the benefit of
Management improving ventilation abnlodoCdOf2lomwa.nPargeevmioeunst, resulting
in improved cerebral concerns
In a spontaneously breathing child with a partially about cuffed endotracheal tubes causing tracheal
obstructed airway, optimize the airway by keeping the necrosis are no longer relevant due to improvements
plane of the face parallel to the plane of the stretcher in the design of the cuffs. Ideally, cuff pressure should
or gurney while restricting motion of the cervical be measured as soon as is feasible, and <30 mm Hg is
spine. Use the jaw-thrust maneuver combined with considered safe.
bimanual inline spinal motion restriction to open the A simple technique to gauge the ETT size needed for
airway. After the mouth and oropharynx are cleared of a specific patient is to approximate the diameter of the
secretions and debris, administer supplemental oxygen. child’s external nares or the tip of the child’s smallest
If the patient is unconscious, mechanical methods finger and use a tube with a similar diameter. Length-
of maintaining the airway may be necessary. Before based pediatric resuscitation tapes also list appropriate
attempting to mechanically establish an airway, fully tube sizes. Ensure the ready availability of tubes that
preoxygenate the child. are one size larger and one size smaller than the
predicted size. If using a stylet to facilitate intubation,
Oral Airway ensure that the tip does not extend beyond the end of
An oral airway should be inserted only if a child is the tube.
unconscious, because vomiting is likely to occur Most trauma centers use a protocol for emergency
if the gag reflex is intact. The practice of inserting intubation, referred to as drug-assisted or drug-
the airway backward and rotating it 180 degrees facilitated intubation, also known as rapid sequence
is not recommended for children, since trauma intubation. Clinicians must pay careful attention to the
and hemorrhage into soft-tissue structures of the child’s weight, vital signs (pulse and blood pressure),
oropharynx may occur. Insert the oral airway gently and level of consciousness to determine which branch
and directly into the oropharynx. Using a tongue blade of the Algorithm for Drug-Assisted Intubation (n FIGURE
to depress the tongue may be helpful. 10-3) to use. (Also see Drug-Assisted Intubation in
Pediatric Patients on MyATLS mobile app.)
Orotracheal Intubation Preoxygenate children who require an endotracheal
Orotracheal intubation is indicated for injured children tube for airway control. Infants have a more pro-
in a variety of situations, including nounced vagal response to endotracheal intubation
than do children and adults, and they may experience
•• a child with severe brain injury who requires
controlled ventilation
•• a child in whom an airway cannot be
maintained
•• a child who exhibits signs of ventilatory failure
•• a child who has suffered significant
hypovolemia and has a depressed sensorium or
requires operative intervention
Orotracheal intubation is the most reliable means of n FIGURE 10-3 Algorithm for Drug-Assisted Intubation/Rapid
establishing an airway and administering ventilation Sequence Intubation in Pediatric Patients.
to a child. The smallest area of a young child’s airway
is at the cricoid ring, which forms a natural seal
around an uncuffed ETT, a device that is commonly
used in infants because of their anatomic features.
n BACK TO TABLE OF CONTENTS
194 CHAPTER 10 n Pediatric Trauma
bradycardia with direct laryngeal stimulation. Brad- Cricothyroidotomy
ycardia in infants is much more likely to be due to When airway maintenance and control cannot be
hypoxia. Atropine sulfate pretreatment should be accomplished by bag-mask ventilation or orotracheal
considered for infants requiring drug-assisted intu- intubation, a rescue airway with either laryngeal
bation, but it is not required for children. Atropine mask airway (LMA), intubating LMA, or needle
also dries oral secretions, enabling visualization of cricothyroidotomy is necessary. Needle-jet insufflation
landmarks for intubation. via the cricothyroid membrane is an appropriate,
temporizing technique for oxygenation, but it does
After inserting the endotracheal tube, ensure that not provide adequate ventilation, and progressive
its position is assessed clinically (see below) and, if hypercarbia will occur. LMAs are appropriate adjunct
correct, the tube carefully secured. If it is not possible to airways for infants and children, but their placement
place the ETT after the patient is chemically paralyzed, requires experience, and ventilation may distend the
ventilate the child with 100% oxygen administered patient’s stomach if it is overly vigorous.
with a self-inflating bag-mask device until a definitive
airway is secured. Surgical cricothyroidotomy is rarely indicated for
infants or small children. It can be performed in older
Orotracheal intubation under direct vision with children in whom the cricothyroid membrane is easily
restriction of cervical motion is the preferred method palpable (usually by the age of 12 years).
of obtaining definitive airway control. Do not perform
nasotracheal intubation in children, as it requires Pitfall prevention
blind passage around a relatively acute angle in the
nasopharynx toward the anterosuperiorly located Patient’s oxygen Use the “Don’t be a DOPE”
glottis, making intubation by this route difficult. saturation mnemonic as a reminder of the
The potential for penetrating the child’s cranial vault decreases common causes of deterioration in
or damaging the more prominent nasopharyngeal intubated patients:
(adenoidal) soft tissues and causing hemorrhage also • D—Dislodgment can easily occur,
discourages the use of the nasotracheal route for
airway control. as the trachea of an infant or child
is short. Secure the tube well and
Once the ETT is past the glottic opening, position it 2 recognize the situation early if it
to 3 cm below the level of the vocal cords and carefully occurs. Use monitoring equipment,
secure in place. Next, conduct primary confirmation especially during transport, to help
techniques, such as auscultation of both hemithoraces alert the provider of this problem.
in the axillae, to ensure that right mainstem bronchial • O—Obstruction with secretions or
intubation has not occurred and that both sides of secondary to kinking can occur, as
the chest are being adequately ventilated. Then use the diameter of the tubes is small.
a secondary confirmation device, such as a real-time Suctioning can clear secretions,
waveform capnograph, a colorimetric end-tidal carbon but tube replacement may
dioxide detector, or an esophageal detector device, to be necessary.
document tracheal intubation, and obtain a chest x-ray • P—Pneumothorax. Tension
to accurately identify ETT position. pneumothorax can develop with
positive pressure in patients with
Because young children have short tracheas, any underlying pneumothorax from
movement of the head can result in displacement of the traumatic injury or barotrauma
ETT, inadvertent extubation, right mainstem bronchial related to mechanical ventilation.
intubation, or vigorous coughing due to irritation of the This conditions warrants
carina by the tip of the tube. These conditions may not decompression.
be recognized clinically until significant deterioration • E—Equipment failure. Ventila-
has occurred. Thus, clinicians should evaluate breath tors, pulse oximeters, and oxygen
sounds periodically to ensure that the tube remains in delivery devices can malfunction.
the appropriate position and identify the possibility of Ensure that equipment is
evolving ventilatory dysfunction. well maintained and properly
functioning, and use backup
If there is any doubt about correct placement of the equipment when necessary.
ETT that cannot be resolved expeditiously, remove the
tube and replace it immediately. The mnemonic, “Don’t
be a DOPE” (D for dislodgment, O for obstruction, P
for pneumothorax, E for equipment failure) may be a
useful reminder of the common causes of deterioration
in intubated patients.
n BACK TO TABLE OF CONTENTS
CIRCULATION AND SHOCK 195
breathing over-the-needle catheters in infants and small children,
as the longer needle length may cause rather than cure
A key factor in evaluating and managing breathing a tension pneumothorax.
and ventilation in injured pediatric trauma patients
is the recognition of impaired gas exchange. This Chest tubes need to be proportionally smaller (see
includes oxygenation and elimination of carbon n TABLE 10-3) and are placed into the thoracic cavity by
dioxide resulting from alterations of breathing caused tunneling the tube over the rib above the skin incision
by mechanical issues such as pneumothorax and lung site and then directing it superiorly and posteriorly
injury from contusion or aspiration. In such cases, along the inside of the chest wall. Tunneling is especially
apply appropriate countermeasures such as tube important in children because of their thinner chest
thoracostomy and assisted ventilation. wall. The site of chest tube insertion is the same in
children as in adults: the fifth intercostal space, just
Breathing and Ventilation anterior to the midaxillary line. (See Chapter 4: Thoracic
Trauma, and Appendix G: Breathing Skills.)
The respiratory rate in children decreases with age. An
infant breathes 30 to 40 times per minute, whereas an Circulation and Shock
older child breathes 15 to 20 times per minute. Normal,
spontaneous tidal volumes vary from 4 to 6 mL/kg Key factors in evaluating and managing circulation
for infants and children, although slightly larger tidal in pediatric trauma patients include recognizing
volumes of 6 to 8 mL/kg and occasionally as high as circulatory compromise, accurately determining the
10 mL/kg may be required during assisted ventilation. patient’s weight and circulatory volume, obtaining
Although most bag-mask devices used with pediatric venous access, administering resuscitation fluids
patients are designed to limit the pressure exerted and/or blood replacement, assessing the adequacy of
manually on the child’s airway, excessive volume resuscitation, and achieving thermoregulation.
or pressure during assisted ventilation substantially
increases the potential for iatrogenic barotrauma due Recognition of Circulatory
to the fragile nature of the immature tracheobronchial Compromise
tree and alveoli. When an adult bag-mask device is used
to ventilate a pediatric patient, the risk of barotrauma Injuries in children can result in significant blood
is significantly increased. Use of a pediatric bag-mask loss. A child’s increased physiologic reserve allows for
is recommended for children under 30 kg. maintenance of systolic blood pressure in the normal
range, even in the presence of shock (n FIGURE 10-4). Up
Hypoxia is the most common cause of pediatric to a 30% decrease in circulating blood volume may be
cardiac arrest. However, before cardiac arrest occurs, required to manifest a decrease in the child’s systolic
hypoventilation causes respiratory acidosis, which is
the most common acid-base abnormality encountered
during the resuscitation of injured children. With
adequate ventilation and perfusion, a child should be
able to maintain relatively normal pH. In the absence
of adequate ventilation and perfusion, attempting
to correct an acidosis with sodium bicarbonate can
result in further hypercarbia and worsened acidosis.
Needle and Tube Thoracostomy n FIGURE 10-4 Physiological Impact of Hemodynamic Changes on
Pediatric Patients.
Injuries that disrupt pleural apposition—for example,
hemothorax, pneumothorax, and hemopneumothorax,
have similar physiologic consequences in children
and adults. These injuries are managed with pleural
decompression, preceded in the case of tension
pneumothorax by needle decompression just over
the top of the third rib in the midclavicular line. Take
care during this procedure when using 14- to 18-gauge
n BACK TO TABLE OF CONTENTS
196 CHAPTER 10 n Pediatric Trauma
blood pressure. This can mislead clinicians who are not diastolic pressure should be about two-thirds of the
familiar with the subtle physiologic changes manifested systolic blood pressure. (Normal vital functions by
by children in hypovolemic shock. Tachycardia and age group are listed in n TABLE 10-5.) Hypotension in
poor skin perfusion often are the only keys to early a child represents a state of decompensated shock
recognition of hypovolemia and the early initiation of and indicates severe blood loss of greater than 45% of
appropriate fluid resuscitation. When possible, early the circulating blood volume. Tachycardia changing
assessment by a surgeon is essential to the appropriate to bradycardia often accompanies this hypotension,
treatment of injured children. and this change may occur suddenly in infants. These
physiologic changes must be treated by a rapid infusion
Although a child’s primary response to hypovolemia of both isotonic crystalloid and blood.
is tachycardia, this sign also can be caused by pain,
fear, and psychological stress. Other more subtle Pitfall prevention
signs of blood loss in children include progressive
weakening of peripheral pulses, a narrowing of pulse Failure to recognize and • Recognize that tachy-
pressure to less than 20 mm Hg, skin mottling (which treat shock in a child cardia may be the only
substitutes for clammy skin in infants and young physiologic abnormality.
children), cool extremities compared with the torso
skin, and a decrease in level of consciousness with a • Recognize that children
dulled response to pain. A decrease in blood pressure have increased physio-
and other indices of inadequate organ perfusion, logic reserve.
such as urinary output, should be monitored closely,
but generally develop later. Changes in vital organ • Recognize that normal
function by degree of volume loss are outlined vital signs vary with the
in n TABLE 10-4. age of the child.
The mean normal systolic blood pressure for children • Carefully reassess the
is 90 mm Hg plus twice the child’s age in years. The patient for mottled skin
lower limit of normal systolic blood pressure in children and a subtle decrease in
is 70 mm Hg plus twice the child’s age in years. The mentation.
table 10-4 systemic responses to blood loss in pediatric patients
SYSTEM MILD BLOOD MODERATE BLOOD SEVERE BLOOD
VOLUME LOSS VOLUME LOSS VOLUME LOSS
(30%–45%)
(<30%) (>45%)
Cardiovascular Increased heart rate; weak, Markedly increased heart rate; Tachycardia followed by
thready peripheral pulses; weak, thready central pulses; bradycardia; very weak or
normal systolic blood absent peripheral pulses; low absent central pulses; absent
pressure (80 − 90 + 2 × age in normal systolic blood pressure peripheral pulses; hypotension
years); normal pulse pressure (70 − 80 + 2 × age in years); (<70 + 2 × age in years); narrowed
narrowed pulse pressure pulse pressure (or undetectable
diastolic blood pressure)
Central Nervous Anxious; irritable; Lethargic; dulled Comatose
System confused response to paina
Skin Cool, mottled; prolonged Cyanotic; markedly prolonged Pale and cold
capillary refill capillary refill
Urine Outputb Low to very low Minimal None
aA child’s dulled response to pain with moderate blood volume loss may indicate a decreased response to IV catheter insertion.
bMonitor urine output after initial decompression by urinary catheter. Low normal is 2 ml/kg/hr (infant), 1.5 ml/kg/hr (younger child), 1 ml/kg/hr
(older child), and 0.5 ml/hg/hr (adolescent). IV contrast can falsely elevate urinary output.
n BACK TO TABLE OF CONTENTS
CIRCULATION AND SHOCK 197
table 10-5 normal vital functions by age group
AGE GROUP WEIGHT HEART RATE BLOOD RESPIRATORY URINARY
RANGE (beats/min) PRESSURE RATE OUTPUT
(in kg) (mL/kg/hr)
(mm Hg) (breaths/min)
2.0
Infant 0–10 <160 >60 <60
0–12 months
Toddler 10-14 <150 >70 <40 1.5
1–2 years
Preschool 14-18 <140 >75 <35 1.0
3–5 years
School age 18-36 <120 >80 <30 1.0
6–12 years
Adolescent 36-70 <100 >90 <30 0.5
≥13 years
Determination of Weight and in young children (n FIGURE 10-5; also see Intraosseous
Circulating Blood Volume Puncture video on MyATLS mobile app.) or insertion
of a femoral venous line of appropriate size using
It is often difficult for emergency department (ED)
personnel to estimate a child’s weight, particularly A
when they do not often treat children. The simplest
and quickest method of determining a child’s weight
in order to accurately calculate fluid volumes and drug
dosages is to ask a caregiver. If a caregiver is unavail-
able, a length-based resuscitation tape is extremely
helpful. This tool rapidly provides the child’s approx-
imate weight, respiratory rate, fluid resuscitation
volume, and a variety of drug dosages. A final method
for estimating weight in kilograms is the formula ([2
× age in years] + 10).
The goal of fluid resuscitation is to rapidly replace
the circulating volume. An infant’s blood volume can
be estimated at 80 mL/kg, and a child age 1-3 years at
75 mL/kg, and children over age 3 years at 70 mL/kg.
Venous Access B
Intravenous access in young children with hypovo- n FIGURE 10-5 Intraosseous Infusion, A. Distal femur, B. Proximal
lemia can be a challenging skill, even in the most tibia. If percutaneous access is unsuccessful after two attempts,
experienced hands. Severe hypovolemic shock is consider starting intraosseous infusion via a bone-marrow needle (18
typically caused by the disruption of intrathoracic or gauge in infants, 15 gauge in young children).
intra-abdominal organs or blood vessels. A peripheral
percutaneous route is preferable to establish venous
access. If percutaneous access is unsuccessful after
two attempts, consider intraosseous infusion via a
bone-marrow needle: 18-gauge in infants, 15-gauge
n BACK TO TABLE OF CONTENTS
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