11.4 Trauma, Burns, Poisoning & Environmental Emergencies

Trauma, Burns, Poisoning and Environmental Emergencies

Accidents and trauma form a full category of the CARICOM Blueprint's common health problems. They include burns, fractures, head injuries, gunshot injuries, road traffic accidents, wounds, poisoning, foreign bodies, asphyxiation and industrial accidents. This section applies the ABCDE approach (Section 10.1) to these emergencies and adds the calculations and Caribbean-specific poisonings that RENR items use.

Major Trauma: Priorities

• Catastrophic external bleeding first: use direct pressure, then a tourniquet for life-threatening limb bleeding. Note the time applied. Then go through A–E with cervical spine protection where the mechanism suggests it.
• Penetrating injuries (gunshot, stab):
  • Do not remove an impaled object. Stabilise it with bulky dressings.
  • Cover an open ("sucking") chest wound with a vented chest seal or a dressing taped on three sides, then watch for tension pneumothorax.
  • Cover eviscerated organs with moist sterile dressings (Section 7.1).
  • Preserve clothing and evidence according to policy, and notify the police according to institutional procedure.
• Head injury: record the GCS and pupils, and look for signs of basilar skull fracture: periorbital bruising ("raccoon eyes"), bruising behind the ear (Battle's sign), or CSF leaking from the nose or ear. Do not pack the nose or ear. Discharge advice tells the family to return at once for:
  • a worsening headache;
  • repeated vomiting;
  • increasing drowsiness or confusion;
  • a seizure;
  • unequal pupils; or
  • new weakness.
• Fractures: splint in the position found, check neurovascular status before and after, and watch for compartment syndrome (Section 7.4).
• Child injuries that do not match the history may indicate abuse. Mandatory reporting applies (Section 2.2).

Burns

First Aid

1. Stop the burning process and remove clothing and jewellery that are not stuck to the skin.
2. Cool the burn with cool running water for 20 minutes (useful up to about 3 hours after the injury). Do not use ice.
3. Cover with cling film or a clean non-adherent dressing.
4. Keep the client warm, because large burns cause hypothermia.
5. For chemical burns, brush off any dry powder, then irrigate with large volumes of water.
6. For electrical burns, make the scene safe first, then put the client on a cardiac monitor. Deep tissue damage is greater than the skin suggests.

Assessing Size and Depth

Rule of nines (adult):

• head and neck: 9%;
• each arm: 9%;
• anterior trunk: 18%;
• posterior trunk: 18%;
• each leg: 18%;
• perineum: 1%.

Children have proportionally larger heads, so use a Lund-Browder chart. For scattered burns, the client's own palm with fingers is about 1% of the body surface area. Superficial (epidermal) burns, which are red, painful and unblistered like sunburn, are not counted in the total body surface area (TBSA).

Fluid Resuscitation

Fluid resuscitation is indicated for burns of more than about 20% TBSA in adults (about 10% in children). The classic Parkland formula is:

$$\text{24-h fluid (mL)} = 4 \times \text{weight (kg)} \times \text{\%TBSA}$$

Give half in the first 8 hours from the time of the burn (not from arrival) and the rest over the next 16 hours, using Hartmann's (Ringer's lactate). Example: a 70 kg adult with 30% TBSA burns needs $4 \times 70 \times 30 = 8{,}400$ mL. That is 4,200 mL in the first 8 hours and 4,200 mL over the next 16 hours. If the client arrives 2 hours after the burn, the first 4,200 mL must go in over the remaining 6 hours, which is 700 mL/h. Current trauma courses often start lower (about 2 mL/kg/%TBSA for adult thermal burns) and titrate to urine output: about 0.5 mL/kg/h in adults and 1 mL/kg/h in children. Follow the prescription and local protocol.

Other Burn Priorities

• Inhalation injury: suspect it with burns in an enclosed space, facial burns, singed nasal hair, soot in the mouth or sputum, hoarseness or stridor. Arrange early airway assessment and intubation before swelling closes the airway.
• Carbon monoxide: pulse oximetry reads falsely normal, so give 100% oxygen.
• Circumferential full-thickness burns of a limb or chest may need escharotomy.

Then:

• give analgesia;
• prevent infection;
• update tetanus protection;
• provide high-protein, high-energy nutrition;
• position and splint to prevent contractures; and
• give psychological support.

Poisoning

General Approach

1. ABCDE, including a bedside glucose.
2. Find out what was taken, how much, when and by what route. Bring the container.
3. Contact poison information.
4. Do not induce vomiting.
5. Activated charcoal (about 1 g/kg) may help within about an hour if the airway is protected. It does not bind alcohols, iron, lithium, corrosives or hydrocarbons.

Specific Agents

Environmental Emergencies

• Heat exhaustion (heavy sweating, weakness, normal mental status): move the client to a cool place and give oral fluids.
• Heat stroke: core temperature above 40 °C with altered mental status. It is an emergency: cool rapidly (water and fanning, ice packs to the groin and axillae) and support ABCs.
• Drowning: hypoxia is the problem. Open the airway and give rescue breaths early, start CPR if there is no normal breathing, and watch for delayed lung injury even if the client seems well.
• Marine injuries: for some jellyfish stings, rinse with vinegar or seawater (not fresh water) and remove tentacles. For sea-urchin spines, soak in hot water and refer for spine removal if needed.