Monday 9 July 2012

LUKA BAKAR


BURN

Initial assessment

1.     Type of burns eg. Scalding, flame, electrical.
2.     Exact time of burn
3.     Weight of patient
4.     Area of burn

i)                   Rule of Nine          Upper limbs 9% BSA each
Lower limbs 18% BSA each
Head 9% BSA
Trunk, front and back 18% each
Perineum 1%

ii)                 Rough estimate by comparing the area of the patient’s hand to area burnt: 1 hand is equal to approximately 1% BSA

iii)               Using Lund Browder chart:


Age
0
1
5
10
15
Adult
A = ½ of head
9 ½
8 ½
6 ½
5 ½
4 ½
3 ½
B = ½ of thigh
2 ¾
3 ¼
4
4 ¼
4 ¼
4 ¾
C = ½ of one leg
2 ½
2 ½
2 ¾
3
3 ¼
3 ½

HEAD INJURIES


HEAD INJURIES

The goal of head injury management is to prevent or reverse secondary insult to the injured brain and provide the best environment for the recovery of the dysfunctional or damaged brain tissues.
Initial assessment

Follow the format of Primary survey and resuscitation, secondary survey and definitive management of any trauma patient. The detection of previous extracranial injuries e.g. hypovolaemic shock and tension pneumothorax will takes priority over the management of head injury.

Assess:
A: Airway with cervical spine control
B: Breathing. Acceptable ABG PaO2 > 100mmHg, PaCo2 < 40 mmHg
C: Circulation. Maintain BP. If hypovolaemic shockwas present on the arrival of the patient, it is very unlikely due to head injury and other cause must be ruled out.
D: Dysfunctional of CNS. Check GCS, pupils, limb movement, gag reflex, and ventilator pattern.
E: Exposure and X-ray
The extent of investigation and management of patients suffering from head injuries depend on the severity of the head injuries, as assessed by GCS and associated injuries.

Citeria for skull X-ray after recent head injury:
SXR can be helpful but clinical judgement is necessary and the following criteria will be refined by further experience. The presence of one or more of the following indicates the need for SXR in patient with a history of recent head injury.
1.       Loss of consciousness or amnesia at any time
2.       Neurological symptoms and signs
3.       CSF or blood from nose or ear
4.       Suspected penetrating injury or scalp bruising or swelling
5.       Alcohol intoxication
6.       Difficulty in assessing the patient (e.g. the young, epileptic)
Note: Simple laceration is not a criterion for SXR

Risk of intracranial clot:
No fracture and conscious           1:5900
No fracture & unconscious          1:300
Fracture and conscious                  1:32
Fracture and unconscious            1:4
A fracture is present in 90% of extradural (EDH) and 75% of intradural haematoma

Indications of CT Brain in Head Injuries:

In first 6 hours
-          Focal signs (conscious and unconscious)
-          Deteriorating level of consciousness
-          Fluctuating level of consciousness
-          Coma (differential diagnosis)
-          Epilepsy (focal or general)
-          Penetrating injury
-          Depressive fracture
-          Combined head and facial injury

In first week
-          Repeat scan at 3 days may be needed for all the above condition
-          Post operative
-          In CSF leak
-          Intracranial infection

In first month
-          Chronic subdural haematoma
-          Hydrocephalus
-          CSF fistula
-          Intracranial infection
-          Aerocele

On admission 30% of severely head injured patients are hypovolaemic and 15% are hypotensive. These need to be rectified to prevent secondary brain damage.
If deterioration of conscious level is apparent the following possibilities should be investigated.
Secondary deterioration in conscious level:

Extracranial causes:

-          Hypoxia e.g. airway obstruction, hypoventilation
-          Hypotension e.g. bleeding
-          Metabolic derangement e.g. dehydration, hypoglycaemia, fluid overload, hyponatraemia
-          Fever

Intracranial causes:

-          Brain oedema
-          Intracranial haematoma
-          Epilepsy
-          Meningitis, brain abscess
-          Aerocele

Check respiratory rate, pulse rate, blood pressure
Full blood count, BUSE, RBS, ABG, CXR, ECG
Consider CT scan

Management of Head Injuries

For minor head injuries where patient is conscious, ambulant and without major associated injuries and without neurological symptoms, the patient is allowed light food or nourishing fluid. Intravenous drip is not required. However, head chart hourly is required for the first 24 hours.

For severely injured head injured patient, the principle of management are outlined as followed:

1)      Constant observation
o   Glasgow coma scale chart hourly for at least the first 24 hours

2)      Patient position
o   Propped up position 30 degree with head in neutral position

3)      Nasogastric tube and urinary catheterization
o   Nil orally initially but enteral feeding subsequently

4)      Prophylaxis against gastric ulcer
o   IV ranitidine 50 mg tds

5)      Fluid balance
o   In adult, 1000 mls 0.9% NS and 500 mls dextrose 5% over 24 hours
o   However, fluid restriction should not be pursued at the expense of cardiovascular stability or renal function
o   Check electrolytes

6)      Nursing care
o   In preventing of pressure sore, Ducolax suppositories for constipation

Physiotherapy
Chest and limbs physiotherapy
Respiratory rate
Oxygen therapy
If respiratory distress, find and treat the cause.

When ventilation or ABG or both are too poor to allow spontaneous ventilation, consider endotracheal intubation (referral for ICU management)
PaO2 < 65 mmHg breathing air
          < 100 mmHg receiving supplemental O2
PaCO2 > 40 mmHg
Prevention of factors causing secondary deterioration in conscious level.

Antibiotics.
Indicated investigations: Compound vault fracture
                                             Basal fracture- with CSF leak: absolute
                                             Without CSF leak: relative
                                             Suspected or proven meningitis
For prophylactic
i)                    Iv benzylpenicillin 1 mega unit qid OR
ii)                   Iv bactrim 10mls bd or oral bactrim 2bd OR
iii)                 Iv sulphadamide  500mg qid OR
iv)                 Iv cloxacillin 500mg qid OR
v)                  A combination of the above
Duration of treatment 1 week

In meningitis, high dose antibiotics should be used
       Iv benzylpenicillin 2-4 mega unit qid
       Iv chloramphenicol 1000mg qid

Treatment of epilepsy
Phenytoin- loading dose 250-500 mg slow iv, followed by maintenance 100 mg tds
Indication: Compound skull fracture with dural penetration
                    Acute subdural hematoma
                   Early epilepsy (24h to 1 week)
Mannitol
A powerful osmotic diuretic and may be life saving but it carries danger. Consult surgeon before using it,
Dose: 0.5-1 g/kg body weight, given as iv bolus over 10-30 mins. Usually 200 ml of a 20% solution.
Make sure a urinary catheter is inserted before giving.
Mannitol may be give together with iv frusemide.

Indications for controlled ventilation:
      Emergency reduction of ICP (cerebral resuscitation)
     Cranial gunshot wound
     Associated chest injury
     Aspiration pnemonitis
     Control of epilepsy
     Diffuse brain swelling especially in children

Indications for neurological consultations of patient with recent head injury
i)                    Skull fracture with confusion or impairment of consciousness, focal neurological signs, fits or any other neurological signs and symptoms.
ii)                   Coma, continuing after resuscitation (GCS < 8)
iii)                 Deterioration in level of consciousness
iv)                 Confusion or other neurological disturbances persisting more than 6-8 hours even if there is no skull fracture
v)                  Compound depressed fracture of the vault of skull
vi)                 Suspected fracture of the base of skull (CSF rhinorrhoe or otorrhoea, bilateral orbital haematoma, mastoid haematoma) or other penetrating injury (eg. Gunshot etc)
Notes: Patient in categories i) to iii) should refer urgently. In all cases the diagnosis and initial treatment of serious extracranial injuries take priority over the transfer of patient to the neurosurgical unit.

Preparation for interhospital transfer of severely head injured pt
  1. Consult the neurosurgical unit
  2. Send notes on clear description of all injuries, GCS, pupils size and reponse, BP, results of investigations, drugs and iv fluid given and x rays
  3. Transport pt only after complete resuscitation. Consider endotracheal intubation and ventilation prior transfer.
  4. Ensure ambulance is fully equipped and with trained staff. Personnel should be able to insert or to reposition ET tune and to initiate or maintain ventilation.
  5. Smooth and slow journey
Patient discharged from ward should be taken care of by a responsible adult. They should be warned. If the patient develops any of the following problems he or she should be brought back to the hospital without delay:
  1. Drowsiness or excessive sleepiness
  2. Confusion or disorientation
  3. Severe headache, vomiting or fever
  4. Weakness of any limbs or double vision
  5. Convulsion, seizure or passing out
  6. Discharge of blood or fluid from ears or nose

TRAUMA


TRAUMA

PRIMARY SURVEY

The aim of Primary survey and resuscitative phase is to diagnose and treat life threatening problem.

a)      Airway and control of the cervical spine
-Always assume that the cervical spine is damaged especially if there is any suspicion of any injury above the clavicle. This keeps a rigid cervical collar. Do not move or turn patient unnecessarily.
-Ensure and secure a clear airway. Remove any liquid vomit with a rigid sucker. If there is no gag reflex the only safe way to ventilate the patient and the airway is by using a cuffed endotracheal tube.
-Every patient with multiple injuries should receive 100% oxygen

b)      Breathing
-Ensure that the air entry on both sides of the lungs is adequate.
-Inspect and auscultate the chest.
-Count the respiratory rate. If the respiratory rate is more than 20 per min, find the cause. Beware of tension pneumothorax, open pneumothorax, flail chest and lungs contusion.

c)       Circulation and control of haemorrhage
-Control any major external haemorrhage with direct pressure.
-Record the blood pressure and pulse rate.
Note: Carotid pulse palpable sys BP> 60mmHg
           Femoral pulse palpable sys BP> 70mmHg
           Radial pulse palpable sys BP> 80mmHg
-Shock in a multiply injured patient, the following need to be ruled out:

Haemorrhage- ext wounds, major fracture eg pelvic, thorax, peritoneal cavity, retroperitoneum

Tension pneumothorax

Cardiac tamponade, myocardial contusion and concurrent AMI. In the first two, there are suggested by distended neck veins.

Spinal shock
-In bleeding patient, insert 2 iv lines (large bore cannula size gauge 14 or 16)
-FBC, BUSE, RBS, GXM, ABG
-Consider CVP line
-Resuscitate with crystalloid, colloid, plasma expander, and blood transfusion is required in severe bleeding
-Insert NG tube and urinary catheter if not contraindicated

d)      Dysfunction of the central nervous system
-Rapid assessment-Alert
                                    Response to vocal stimuli
                                    Response to painful stimuli
                                    Unresponsive
e)      Exposure
-All clothing should be removed. Cut clothing to ensure minimal movement. However, keep the patient warm by covering him or her with blanket when not being examined.

Secondary survey

This entailed a full head to toe examination. In addition it is advisable to perform a lateral cervical spine, chest and pelvic x-ray for patient with blunt trauma or unconscious patient.

Scalp- Palpate from posterior to anterior. Palpate for fracture at the base of the laceration.

Neurological State- Record using Glasgow Coma Scale. Deterioration in GCS may not be due to the primary injury to the brain but may reflect hypoxia or hypotension.

Base of skull- Check for rhinorrhoea or otorrhoea (ENT bleed). Look for bruising of the mastoid process.

Eyes- Look for haemorrhage, foreign body and any signs of penetrating injury. Test papillary response.

Face- Palpate for deformities and tenderness. Check for loose or lost teeth.

Neck- Look for any deformity, bruising or laceration. Palpate each of the cervical processes to detect tenderness and step off deformities.
            Note: A lateral cervical spine x-ray showing all 7 cervical vertebrae is essential in patient with multiple injuries.

Chest- Inspect the chest for bruising, wounds, signs of respiratory obstruction and asymmetry of movements. The bruising resulting from pressure exerted by a diagonal seat belt may overlay a fracture clavicle, a tear in the thoracic aorta, pulmonary contusion and a lacerated pancreas. The mark caused by impact with the central steering wheel suggest a sterna fracture with cardiac contusion, palpate for the position of trachea. Palpate the chest for crepitus and tenderness. Auscultate to detect air entry between the two sides.

Heart- As mentioned above, sternal bruising and tenderness may be associated with cardiac contusion. Penetrating thoracic injury may damage the heart and produce pericardial tamponade.
            Signs of pericardial tamponade: Beck’s triad: Raised jugular venous pressure, muffeld heart   
                                                                      sound, reduced BP
                                                                      Pulses paradoxicus
                                                                      Raised pulse rate

Abdomen- Inspect for bruising, movement and wounds. Palpate the abdomen. Auscultate for bowel sounds. Squeeze the pelvis for tenderness. Check the perineum and genitalia. PR examination.

Limbs- Look for bruising, wound, and deformities.
Check distal pulses, sensation, and movement.
Splint all fractures

Spine
Spinal injuries can be partial and complete
Test for sensory and motor deficit
If there is evidence of spinal injury the patient should not be moved
X-ray of the affected site is required
If there is no neurological deficit, the patient can be log rolled and the whole of the back examined.

 Useful informations can maybe available from patient, relatives, ambulance crew
Allergies
Medicine
Past medical history
Last meal
Event leading to the injury