6.3 Multisystem Trauma & Burns
Key Takeaways
- The ATLS primary survey prioritizes life-threatening injuries in the sequence of Airway, Breathing, Circulation, Disability, and Exposure (ABCDE).
- Traumatic Brain Injury management focuses on preventing secondary injury by maintaining adequate cerebral perfusion pressure (CPP) and avoiding hypoxemia and hypotension.
- The Rule of Nines is used to estimate TBSA for partial and full-thickness burns, guiding initial fluid resuscitation via the Parkland/Consensus formula.
- Burn fluid resuscitation must be titrated dynamically to a target urine output of 0.5 mL/kg/hour in adults, avoiding rigid adherence to initial formula calculations.
- Carbon monoxide poisoning causes falsely elevated pulse oximetry readings; diagnosis requires co-oximetry, and treatment is 100% oxygen.
Multisystem Trauma & Burns
Management of the critically ill trauma or burn patient requires a systematic, prioritized approach to identify and treat life-threatening injuries rapidly. The AGACNP frequently co-manages these complex patients, necessitating a deep understanding of primary and secondary surveys, resuscitation principles, and the unique pathophysiologic changes associated with severe thermal injury.
The ATLS Framework: Primary and Secondary Survey
The Advanced Trauma Life Support (ATLS) algorithm is the gold standard for initial trauma management. The primary survey is designed to address immediately life-threatening conditions.
- A - Airway with C-spine Protection: Establish airway patency. Assume a cervical spine injury in all blunt trauma patients until cleared clinically or radiographically. Indications for definitive airway (intubation) include GCS ≤ 8, severe maxillofacial trauma, impending airway edema (inhalation injury), and refractory hypoxemia.
- B - Breathing and Ventilation: Assess for tension pneumothorax, massive hemothorax, open pneumothorax, and flail chest. Immediate interventions include needle thoracostomy (followed by chest tube) for tension pneumothorax and three-sided occlusive dressings for open wounds.
- C - Circulation with Hemorrhage Control: Assess pulses, skin color, and capillary refill. Identify external hemorrhage and apply direct pressure or tourniquets. Identify internal hemorrhage (chest, abdomen, retroperitoneum, pelvis, long bones). Establish dual large-bore IV access (14G or 16G) or central venous access. Resuscitate with blood products (1:1:1 ratio) rather than large volumes of crystalloid.
- D - Disability (Neurologic Evaluation): Perform a rapid neurologic assessment using the Glasgow Coma Scale (GCS) and pupil examination (size, symmetry, reactivity) to identify severe traumatic brain injury (TBI) or increasing intracranial pressure (ICP).
- E - Exposure and Environmental Control: Completely undress the patient for a full examination, but aggressively prevent hypothermia using warm blankets and warmed IV fluids.
The secondary survey is a head-to-toe evaluation and history-taking that occurs only after the primary survey is complete and life-threatening issues have been stabilized.
Management of Specific Traumatic Injuries
Traumatic Brain Injury (TBI): Management focuses on preventing secondary brain injury from hypoxia or hypotension. Maintain adequate cerebral perfusion pressure (CPP = MAP - ICP). Target goals often include MAP > 80 mmHg, avoiding hypoxemia, maintaining normocarbia (PaCO2 35-45 mmHg, avoiding prophylactic hyperventilation), and utilizing hyperosmolar therapy (mannitol or hypertonic saline) for signs of herniation or elevated ICP.
Blunt Thoracic Trauma: May result in pulmonary contusion, rib fractures, and blunt cardiac injury. Pain management is paramount for rib fractures to allow for adequate ventilation and prevent pneumonia. Thoracic epidurals or regional blocks are highly effective. Blunt cardiac injury requires telemetry monitoring and serial troponins; treatment is generally supportive.
Blunt Abdominal Trauma: The spleen and liver are the most commonly injured organs. Hemodynamic stability dictates management. Unstable patients with a positive FAST (Focused Assessment with Sonography for Trauma) exam require immediate exploratory laparotomy. Stable patients often undergo CT imaging and may be managed non-operatively with close observation.
Burn Pathophysiology and Management
Severe thermal injuries (typically >20% Total Body Surface Area [TBSA]) trigger a massive systemic inflammatory response. Burn shock is a unique combination of hypovolemic, distributive, and cardiogenic elements due to massive fluid extravasation, systemic vasodilation, and myocardial depression.
Assessment and Resuscitation
- Estimate TBSA: The "Rule of Nines" is commonly used for adults (Head 9%, Each Arm 9%, Anterior Trunk 18%, Posterior Trunk 18%, Each Leg 18%, Perineum 1%). Note: Only partial-thickness (2nd degree) and full-thickness (3rd degree) burns are included in the TBSA calculation; superficial (1st degree) burns are excluded.
- Fluid Resuscitation (Parkland/Consensus Formula): The fundamental goal is to maintain end-organ perfusion while avoiding over-resuscitation (which can lead to abdominal compartment syndrome and pulmonary edema).
- Formula: $2-4 mL \times kg (body weight) \times % TBSA$ of Lactated Ringer's.
- Administration: Half of the calculated total volume is given in the first 8 hours (calculated from the time of injury, not the time of arrival), and the remaining half is given over the next 16 hours.
- Titration: The calculated fluid requirement is merely a starting point. Fluid rates MUST be titrated based on urine output. The target urine output for adults is 0.5 mL/kg/hour (or 30-50 mL/hour). If urine output drops, the fluid rate is increased; if it is excessive, the rate is decreased.
Inhalation Injury
Inhalation injury significantly increases mortality and fluid requirements. Suspect inhalation injury if burns occur in an enclosed space, there are facial burns, singed nasal vibrissae, carbonaceous sputum, or hoarseness.
- Carbon Monoxide (CO) Poisoning: CO binds to hemoglobin with significantly higher affinity than oxygen, shifting the oxyhemoglobin dissociation curve to the left. Standard pulse oximetry is unreliable (will show falsely high readings). Diagnosis requires a co-oximeter (carboxyhemoglobin level). Treatment is 100% oxygen via non-rebreather mask or endotracheal tube until levels normalize.
Special Considerations in Burns
- Pain Management: Requires aggressive, multimodal analgesia, frequently utilizing high doses of intravenous opioids due to increased tolerance and altered pharmacokinetics.
- Nutrition: Burn patients are profoundly hypermetabolic. Early enteral nutrition is crucial to support wound healing, maintain gut mucosal integrity, and mitigate the hypermetabolic response.
- Infection: Sepsis is the leading cause of death in patients who survive the initial burn resuscitation. Prophylactic systemic antibiotics are generally not recommended; treatment should be targeted based on cultures and clinical signs of infection (which can be challenging to differentiate from the baseline hypermetabolic state).
An 80kg patient arrives in the Emergency Department with severe thermal burns spanning their anterior trunk, entire right arm, and entire right leg. Using the Rule of Nines, what is the estimated Total Body Surface Area (TBSA) burned, and what is the target urine output during fluid resuscitation?
During the primary survey of a trauma patient involved in a high-speed motor vehicle collision, the patient exhibits hypotension, muffled heart tones, and distended neck veins. What is the most likely diagnosis and the immediate necessary intervention?
A patient with severe inhalation injury from a house fire is receiving 100% oxygen via a non-rebreather mask. The pulse oximeter reads 99%, but the patient is obtunded and tachycardic. Which of the following is the most appropriate next step in management?