2.2 Acute Occupational Traumas, Wounds & Burns

2.2 Acute Occupational Traumas, Wounds & Burns

Occupational traumatic injuries—ranging from minor lacerations to catastrophic amputations, ocular trauma, and chemical or thermal burns—require rapid clinical decision-making, systematic primary assessment, and immediate evidence-based stabilization by the occupational health nurse (OHN). Proper initial management minimizes long-term morbidity, preserves organ and tissue function, and ensures compliance with occupational safety and trauma standards.

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Management of Acute Occupational Traumas & Wounds

Lacerations and Punctures

• Primary Clinical Assessment: Evaluate wound location, depth, border clean/jagged nature, underlying structural involvement (tendons, nerves, blood vessels), and distal neurovascular status (capillary refill, sensation via two-point discrimination, distal motor strength).
• High-Pressure Injection Injuries: Occur when paint sprayers, hydraulic lines, or grease guns rupture, injecting fluids under extreme pressure (often > 2,000 psi) into the skin. Although entry puncture wounds appear deceptively small and benign, injected fluids rapidly travel along fascial planes, causing massive tissue necrosis, chemical inflammation, and acute compartment syndrome. Emergency Hand / Orthopedic Surgical Consultation is required immediately; conservative wound care alone is contraindicated.
• Tetanus Prophylaxis Protocol:
  • Clean, minor wounds: Administer Tetanus Toxoid (Td or Tdap) if more than 10 years have elapsed since the last tetanus dose.
  • Dirty, contaminated, or deep puncture wounds: Administer Td/Tdap if more than 5 years have elapsed since the last dose. For patients with unknown or incomplete primary tetanus immunization series (< 3 doses), administer both Tdap and Tetanus Immune Globulin (TIG) in separate anatomical sites.

Crushed Extremities and Crush Syndrome

• Pathophysiology: Severe compressive force applied to skeletal muscle blocks local blood flow, inducing cell ischemia. Upon relief of pressure (reperfusion), damaged muscle cells release massive quantities of potassium, phosphorus, myoglobin, and creatine kinase into systemic circulation, leading to Crush Syndrome.
• Complications:
  • Hyperkalemia: Causes life-threatening cardiac dysrhythmias (peaked T waves, QRS widening, cardiac arrest).
  • Myoglobinuria & Acute Tubular Necrosis: Insoluble myoglobin precipitates in renal tubules, leading to acute kidney injury (AKI). Marked by dark brown ("tea-colored") urine.
  • Compartment Syndrome: Swelling within non-yielding fascial compartments elevates tissue pressure above capillary perfusion pressure. Monitored using the 5 P's: Pain (out of proportion to physical findings, exacerbated by passive stretch), Paresthesia, Pallor, Paralysis, and Pulselessness (late sign).
• Immediate Nursing Management: Initiate aggressive isotonic IV crystalloid hydration (0.9% Normal Saline) prior to or immediately upon release of compressive loads to maintain high renal tubule flow (> 200–300 mL/hr), monitor continuous ECG, and prepare for emergency surgical fasciotomy if compartment syndrome develops.

Ocular Trauma Assessment

• Ocular Foreign Bodies: Perform visual acuity testing prior to intervention unless a chemical splash is involved. Inspect the cornea and conjunctival sacs under penlight and cobalt blue light following fluorescein staining. Superficial, non-embedded foreign bodies may be gently irrigated with sterile saline. If an intraocular foreign body or globe rupture is suspected (irregular pupil, teardrop pupil, hyphema, loss of anterior chamber depth):
  • DO NOT press on the eye, rub the eye, or apply a pressure patch.
  • Place a protective, rigid metal or plastic eye shield (Fox shield) resting on the surrounding bony orbit.
  • Keep patient NPO and transfer immediately to an ophthalmologist.

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Immediate Eye Flushing Protocol

Chemical splashes to the eye represent true ocular emergencies where immediate action dictates visual outcomes.

Chemical Irrigation Standards

• IMMEDIATE Continuous Irrigation: Flushing must commence instantly at the job site using an emergency eyewash station or Morgan Lens before taking a medical history or performing visual acuity testing.
• Duration: Irrigate continuously for a minimum of 15 to 20 minutes for mild irritants or acids. Strong alkalis (e.g., sodium hydroxide, ammonia, lye, wet cement) cause liquefactive necrosis, saponifying cell membrane lipids and rapidly penetrating deep into the cornea and anterior chamber; alkali burns require continuous flushing for 30 to 60 minutes or longer.
• Irrigation Solutions: Sterile 0.9% Normal Saline or Lactated Ringer's solution are preferred; clean lukewarm tap water must be used immediately if medical intravenous fluids are not instantly at hand.

Post-Irrigation Evaluation & pH Endpoint

1. Stop irrigation and wait 5 to 10 minutes to allow natural tear fluid to balance.
2. Test conjunctival sac pH using neutral pH indicator test paper.
3. Target Goal: Sustained neutral pH between 7.0 and 7.4.
4. If pH remains acidic (< 7.0) or alkaline (> 7.4), resume continuous flushing immediately for another 15–20 minutes and re-test.
5. Secondary ocular evaluation and ophthalmology referral take place only after achieving a sustained neutral pH.

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Traumatic Amputation & Digit Preservation Protocol

When managing traumatic amputations (e.g., finger, thumb, or hand severed by industrial machinery), the OHN must simultaneously stabilize the patient and preserve the severed tissue to maximize microvascular reimplantation success.

Protocol Steps for Tissue Preservation:

1. Rinse: Gently rinse gross dirt and debris from the amputated tissue using sterile normal saline. DO NOT scrub the tissue, use soap, or apply chemical disinfectants (hydrogen peroxide, alcohol).
2. Wrap: Wrap the severed tissue in sterile gauze moistened with sterile normal saline (damp, not soaking wet).
3. Seal: Place the wrapped tissue inside a clean, leak-proof, sealed plastic bag.
4. Cool: Place the sealed plastic bag into an outer container packed with an ice-water slurry (a mixture of approximately 50% crushed ice and 50% cold water).
5. CRITICAL CONTRAINDICATION: NEVER submerge the amputated tissue directly in ice or water, and NEVER allow the tissue to freeze. Direct ice contact causes cellular membrane destruction, frostbite necrosis, and renders successful surgical microvascular revascularization impossible.

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Thermal, Chemical, and Electrical Burn Assessment

Burn Classification and Surface Area Estimation

• Rule of Nines (Adults): Head (9%), Entire Left Arm (9%), Entire Right Arm (9%), Anterior Torso (18%), Posterior Torso (18%), Entire Left Leg (18%), Entire Right Leg (18%), Perineum (1%).

Initial Emergency Stabilization by Burn Type

• Thermal Burns: Stop the burning process immediately. Cool partial-thickness burns with cool water (do NOT apply ice water, which causes vasoconstriction and systemic hypothermia). Remove smoldering clothing unless adhered to skin. Calculate initial fluid requirements for burns > 20% TBSA using the Parkland Formula:

$\text{Total 24-Hour IV Fluid (Lactated Ringer's)} = 4\text{ mL} \times \text{Body Weight (kg)} \times \% \text{TBSA (Partial and Full Thickness)}$

Administration Schedule: Administer 50% of total volume over the first 8 hours post-injury, and the remaining 50% over the subsequent 16 hours.

• Chemical Burns: Remove all contaminated clothing immediately. Flush skin with high-volume, low-pressure water for 20 to 30 minutes. Exception: Dry chemical powders (e.g., dry lime) must be brushed off dry skin completely before flushing with water to prevent an exothermic reaction. NEVER attempt chemical neutralization on the skin, as neutralizing chemical reactions produce heat that worsens tissue burns.

• Electrical Burns: Ensure scene safety and power de-energization before approaching patient. Electrical injury acts as an "iceberg," causing minimal skin entrance/exit wounds but vast internal tissue thermal necrosis along blood vessels and nerves. High risk for ventricular fibrillation, internal compartment syndrome, and rhabdomyolysis. Maintain continuous ECG monitoring, immobilize spine if fall occurred, and administer IV fluids to maintain high urine output (1.0–1.5 mL/kg/hr).