A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns.What do you estimate the total body surface area (TBSA) of his burns to be?
Answer(s): C
Burn injuries can be very serious and very intimidating for the patient and physician alike. In an ER setting, the most efficient way to estimate the extent of the burn injury is to use the "rule of nines." In determining the percentage of the TBSA that is involved, it is important only to consider second- and third-degree burns in this calculation. In this system, the head and neck are 9%; each arm represents 9%; the anterior trunk, posterior trunk, and each lower extremity carry a value of 18%; the genitalia are estimated to be 1%. For the patient in this question, the burns cover his anterior face and neck (4.5%), anterior trunk (18%), and bilateral upper extremities (18%) for a TBSA of approximately 40%. Having identified the extent of the thermal damage, it is critical to initiate resuscitation immediately. The thermal injury itself causes the release of many inflammatory mediators that result in a profound capillary leak. As a result of this profound increase in capillary permeability, the patient's intravascular volume and thus overall perfusion can drop rapidly and dramatically. In order to compensate, burn patients will require aggressive fluid resuscitation. Furthermore, as in any trauma situation, the fluid used in the initial resuscitation should be isotonic such as Ringer's lactate. The Parkland formula (4 mL/kg/%TBSA) is a common equation used to estimate the fluid needs in the first 24 hours for thermal injuries. Typically, one-half of this total volume is given in the first 8 hours. In this particular case, an 80-kg man with 40% TBSA burns would require 12.8 L of fluid in the first 24 hours. So for the first 8 hours, you would plan to run isotonic fluid at 800 mL/h.
A 35-year-old 80-kg male was transported to the regional burn center at your hospital after suffering second- and third-degree burns from the eruption of a brush fire fueled with gasoline. He was intubated by EMS to secure his airway for transport. On arrival, he is found to have burns across his face, anterior neck, chest, and anterior abdomen, as well as bilateral circumferential upper extremity burns. Over the first 8 hours of his resuscitation, you estimate that he will require which of the following?
Answer(s): D
You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot. Realizing that there is compromised blood supply to the patient's right foot, you immediately do which of the following?
Answer(s): B
It is important to consider vascular injuries in the setting of extremity trauma. This is particularly true in the setting of fractures, dislocations, or penetrating trauma in the vicinity of major vascular structures. When evaluating patients for traumatic vascular injuries, the first step is evaluation of peripheral pulses. This should be done after the initial resuscitation in order to rule out hypovolemia as the source for diminished peripheral perfusion. In the presence of fractures or dislocations, if diminished or absent pulses are identified, it is critical to reduce the fracture or the dislocation and then re-evaluate the perfusion. By placing the bony structures in the anatomical position, you rule out a kink in the vessel as the source of the arterial obstruction. After reduction or relocation, if the pulse is still absent or diminished compared to an uninjured extremity, then further investigation of the vasculature is indicated. In the case described, posterior knee dislocations have a very high incidence of concomitant popliteal artery injury. If vascular compromise is identified after relocation of the knee, operative exploration is indicated for emergent repair of the popliteal artery with a venous interposition graft. It would not be indicated in this setting to delay operative repair for an arteriogram. Arteriograms are indicated in the evaluation of extremity trauma if there are diminished distal pulses after restoring anatomical alignment and the ankle-brachial indices are <0.9.
You are called to the trauma bay to evaluate a 42-year-old male who suffered a blow to his knee at the construction site where he works. He is awake, alert, and his vital signs have been stable in transport. After completing your primary survey, you continue with your secondary survey and determine that his only injury is to his right leg. It is clear that he has suffered a posterior knee dislocation. As part of your examination, you determine that you cannot feel a pulse in his right foot.Later that night after the patient had been treated and stabilized, you are called to the patient's room to evaluate severe pain in his right lower leg. Upon examining the patient, you determine that he has a bounding pulse in his right foot. However, the patient does state that he has a tingling sensation in his foot and he is in excruciating pain when you flex his foot. Which of the following should be the next step in his treatment?
Answer(s): E
You are called to the ER to assist with a series of trauma patients who arrived following a multiple vehicle accident. You are assigned to a 22-year-old male who was an unrestrained driver involved in a head-on collision. After you confirm the presence of an adequate airway and equal breath sounds bilaterally, you address his hypotension and tachycardia by giving 2 L of lactated Ringer's solution. His pulse remains elevated at 130 and his blood pressure is 92/55. His pelvic x-ray returns and demonstrates a widening of the pubic symphysis. In addition to continued fluid resuscitation, what is your next step in management?
Answer(s): A
The x-ray described demonstrates an open book pelvic fracture. This type of injury can often be associated with significant hemorrhage. It is most commonly seen in frontal impacts involving anterior- posterior compression. The majority of the bleeding occurs from the tearing of pelvic veins in the posterior of the pelvis. The initial treatment for open book pelvic fractures is to reduce the pelvic volume to decrease the amount of hemorrhage. In the trauma bay, this can easily be accomplished by wrapping a sheet around the superior iliac crests and twisting the sheet tight using a dowel or by applying the pneumatic compression garment. These are useful techniques in the short term, but definitive treatment will be necessary. This involves formal repair of the pelvis with external fixation or open reduction and internal fixation. If hemorrhage persists despite reduction of the pelvic fracture, pelvic angiography would be the next step in the treatment algorithm to attempt to identify the source of the hemorrhage and embolize the vessel. Given the difficulty of identifying a bleeding vessel in an expanding pelvic hematoma, exploratory laparotomy is not recommended. Finally, an unstable patient should never be transported for imaging studies.
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