Management
of the trauma patient is guided by well-defined
principles of prioritization as is the care of the
burn patient. However, the most dangerous
situation is the unrecognized traumatic injury in
the patient perceived to only have a burn injury.
There are several reasons for this latter
situation. First, there is usually an overwhelming
desire to move the major burn patient out of the
emergency room as soon as possible.
The
incidence of a combined injury is not well
defined, but the problem is certainly not rare.
The
initial approach to the combined trauma and burn
injury should follow the same basic guidelines for
trauma resuscitation, which include airway,
breathing, circulation, and neurologic assessment.
Airway
In
the case of a compromised airway and a facial
burn, the standard approach of naso- or
oropharyngeal intubation with C-spine control is
initiated. If there are clear indications for a
surgical airway because of traumatic injuries,
e.g., facial fractures, one should not hesitate to
perform a cricothyrotomy even if a neck burn is
present. Neck burn can then be excised and grafted
within 24 to 48 hours when the patient is more
stable, the cricothyrotomy can be removed, and a
tracheostomy placed through the new skin graft,
preferably a sheet graft.
Another
important airway consideration relates to the
trauma patient who has a patent airway and a
facial burn that by itself does not require an
immediate artificial airway. However, if a
surgical procedure is planned, e.g., internal
fixation of a fracture within the first 24 hours,
it will be extremely difficult to place a tube at
the time of the operation due to massive edema
with considerable distortion of anatomic
landmarks. This consideration needs to be made in
the early resuscitation period (Table 18-1).
Breathing
The
same immediate concerns over adequate breathing
that affect the trauma patient are present in the
combined injury. Tension pneumothorax, open chest
wound, and flail chest with underlying contusion
remain major concerns with trauma. Management,
even in the presence of a chest burn, should be
the same. If a chest tube is required, it should
be placed through nonburn tissue, if possible.
However, a tube placed through burn has a minimal
risk of infection if changed within the first 24
to 48 hours. As with the airway, deep burn in the
area of the tube can be excised and grafted within
24 to 48 hours and a new tube placed through a
graft. If an immediate thoracotomy is indicated,
the incision site and surrounding burn can be
excised and grafted and the wound closed in a
standard fashion. The amount of excision depends
on the stability of the patient. If skin grafting
for some reason cannot be immediately performed,
the local area preferably with a several inch
border can be excised and the wound sealed with a
skin substitute (synthetic, e.g.,)
Circulation
There
are two important considerations to be made in the
combined injury in regards to initially assessing
the circulation:
It
is crucial to be able to recognize that a volume
loss in a burn patient is in excess of what is
expected with the burn alone. This clue will
greatly assist in the diagnosis of an
unappreciated traumatic injury.
Once
diagnosed, the initial management of the traumatic
injury should not be dramatically altered by the
presence of a burn. There are two important
considerations regarding the management of the
circulation:
