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Toronto Notes 2019 Environmental Injuries
• fluidbolusesifunstable
■ Parkland Formula: Ringer’s lactate 4 cc/kg/%BSA burned; give half in first 8 h, half in next 16 h;
maintenance fluids are also required if patient cannot tolerate PO hydration
■ urine output is best measure of resuscitation, should be 40-50 cc/h or 0.5 cc/kg/h; avoid diuretics
• painrelief:continuousmorphineinfusionwithbreakthroughbolus
• investigations: CBC, electrolytes, U/A, CXR, ECG, ABG, carboxyhemoglobin
• burnwoundcare:preventinfection,clean/debridewithmildsoapandwater,steriledressings
• escharotomyorfasciotomyforcircumferentialburns(chest,extremities)
• topicalantibiotics,burnvictimsarehighlysusceptibletoinfection(portalofentrywithreduced
immune function) – systemic antibiotics are often required
• tetanusprophylaxisifburnisdeeperthansuperficialdermis
Disposition
• admit
■ 2nd degree burns >10% BSA, or any significant 3rd degree burns
■ 2nd degree burns on face, hands, feet, perineum, or across major joints
■ electrical, chemical burns, and inhalation injury
■ burn victims with chronic medical conditions or immunosuppressed patients
Inhalation Injury
Etiology
• carbonmonoxideorcyanidepoisoning
• directthermalinjury:limitedtoupperairway(abovethevocalcords)
• smokecausesbronchospasmandedemafromparticulatematterandtoxicinhalants(tissueasphyxiates,
pulmonary irritants, systemic toxins)
History and Physical Exam
• riskfactors:closedspacefires,periodofunconsciousness,noxiouschemicalsinvolved • cherryredskin(unreliable,usuallypost-mortemfinding)
• singednasalhairs,sootonoral/nasalmembranes,sootysputum
• hoarseness, stridor, dyspnea
• decreasedLOC,confusion
• PO2normalbutO2saturationlowsuggestsCOpoisoning
Investigations
• measurecarboxyhemoglobinlevels,co-oximetry • ABG
• CXR±bronchoscopy
Management
• COpoisoning:100%O2±hyperbaricO2(controversial)
• directthermalinjury:humidifiedoxygen,earlyintubation,pulmonarytoilet,bronchodilators,and
mucolytics (N-acetylcysteine)
Bites
MAMMALIAN BITES
• seePlasticSurgery,PL11
History
• timeandcircumstancesofbite,symptoms,allergies,tetanusimmunizationstatus,comorbidconditions, risk of rabies exposure/transmission, HIV/hepatitis risk (human bite)
• highmorbidityassociatedwithclenchedfistinjuries,“fightbites”
Physical Exam
• assesstypeofwound:abrasion,laceration,puncture,crushinjury
• assessfordirecttissuedamage:skin,bone,tendon,neurovascularstatus
Investigations
• ifbonyinjuryorinfectionsuspected,checkforfractureandgasintissuewithx-rays
• getskullfilmsinchildrenwithscalpbitewounds±CTtoruleoutcranialperforation
• ultrasoundmaybehelpfulforidentifyingabscessformationaswellaslocatingradiolucentforeign
bodies in infected wounds
Initial Management
• woundcleaningandcopiousirrigationassoonaspossible
• irrigate/debridepuncturewoundsiffeasible,butnotifsealedorverysmallopenings;avoid
hydrodissection along tissue planes
• debridementisimportantincrushinjuriestoreduceinfectionandoptimizecosmeticandfunctionalrepair
Emergency Medicine ER47
Use palm of the patient’s hand to estimate 1% of BSA affected
Burn Causes
• Thermal (flame, scald)
• Chemical
• Radiation (UV, medical/therapeutic) • Electrical
Always look for inhalational injury in patients with burns. Intubate early if you suspect inhalation injury, as airway can become obstructed due to edema