and DPL to rule out diaphragmatic injury or peritoneal

violation. For victims of blunt trauma, the work-up

generally includes an upright CXR to look for intraperitoneal free air, gross diaphragmatic rupture, and pneumothorax/hemothorax along with plain films of the pelvis to

rule out fracture. These images are usually followed by

abdominal CT to exclude injuries to the solid abdominal

viscera. Additional findings that warrant emergent laparotomy include retained foreign bodies, eviscerations, frank

peritonitis, hematemesis or gross rectal bleeding, and imaging studies documenting hollow viscus or diaphragmatic

perforation (Figures 88-4 and 88-5).

TREATMENT

Initiate aggressive volume resuscitation and address any

emergent life threats encountered in the primary survey.

Concurrently search for any sources of active hemorrhage

to determine the need for operative intervention as

described previously.

A growing percentage of solid organ injuries in hemodynamically stable patients are being managed nonoperatively. This decision should be made on a case-by-case basis

in consultation with the trauma service. The conservative

"watch and wait" approach has a failure rate of 1 0% for

liver injuries and 20% for injuries to the spleen. The evolving use of angiographic embolization for bleeding vessels

has decreased the need for laparotomy in many cases.

DISPOSITION

..... Admission

Admit all patients who require laparotomy. Hemodynamically stable patients with CT evidence of liver or

splenic injury warrant admission for serial physical exams

and laboratory testing.

..... Discharge

Patients with abdominal SWs and tangential low-velocity

GSWs that clearly spare the peritoneal, retroperitoneal,

and intrathoracic cavities can be safely discharged.

Normal CT imaging in hemodynamically stable patients

with blunt abdominal trauma has an excellent negative

predictive value. In the absence of other injuries, these

patients can be safely discharged.

SUGGESTED READING

Isenhour JL, Marx JA. Abdominal trauma. In: Marx JA,

Hockberger RS, Walls RM. Rosen's Emergency Medicine:

Concepts and Clinical Practice. 7th ed. Philadelphia, PA:

Mosby-Elsevier, 2010, pp. 414-434.

Nishijima DK, Simel DL, Wisner DH, et a!. The rational clinical

examination: Does this adult patient have a blunt intraabdominal injury? lAMA. 2012;307:1 5 17.

Sca!ea TM, Boswell SA. Abdominal injuries. ln: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, McGraw-Hill, 20 11, pp. 1699-1708.

Laparotomy

ABDOMI NAL TRAUMA

Lapa rotomy

Observation vs

CT scan to detect

retroperitoneal

injury

Vital signs unstable

Laparotomy

Lapa rotomy

.A. Figure 88-4. Abdominal trauma diag nostic al gorithm for pe netrating abdominal

trauma. CT, computed tomography; FAST, focused assessment with sonography for

trauma.

'''Peritonitis, free air, diaphragmatic inju ry, evisceration, gross blood from stomach or

rectum, reta ined stabbing implement, positive diag nostic test, or any non-tangential

GSW (i ntraperitoneal penetration).

Laparotomy

Positive

(splenic or

hepatic injury)

Laparotomy,

angiography, or

observation

CHAPTER 88

Laparotomy Consider other

sou rces of

hemorrhagic

shock

Abdominal

CT scan

when stable

.A Figure 88-5. Abdominal trauma diagnostic algorithm for blunt abdominal trauma. CT, computed

tomography; FAST, focused assessment with sonography for trauma.

'''Peritonitis, free air, diaphragmatic injury, gross blood from stomach or rectum, positive diagnostic test.

Burns

Gim A. Tan, MBBS

Key Points

• Pursue early endotracheal intu bation in patients with

significant inhalation injuries.

• Emergency escharotomy may be a life- or limb-saving

procedure in patients with evidence of respiratory compromise or limb ischemia.

INTRODUCTION

Burn injuries can occur from thermal, chemical, or

electrical mechanisms. Of the 3, thermal burns are the

most common and occur with either scalding or flame

injuries. Chemical burns occur secondary to exposures to

strong acids or alkali and account for 5-1 0% of all burn

admissions. Electrical burns result from the flow of current

through susceptible tissue and are frequently much more

severe than initially visible.

The prevalence of burns is highest in patients between

18 and 35 years of age. Scald burns from hot liquids are

most common in children under the age of 5 and the

elderly, and approximately 20% of pediatric burns are

attributable to either abuse or neglect. The American Burn

Association estimates that burns account for more than

450,000 emergency department (ED) visits, 45,000

hospitalizations, and 3,500 deaths annually in the United

States. There are currently 1 25 specialized burn centers in

the United States that account for more than half of these

admissions.

Burned skin classically undergoes a coagulative necrosis

by which denatured skin proteins constrict to form a firm

and potentially constricting eschar. A subsequent cascade

of inflammatory reactions leads to the development of

significant localized edema and the potential for further

tissue loss. This inflammatory response becomes systemic

• Consider concurrent carbon monoxide andcyanide poisoning in all fire victims.

• Never overlook the possibil ity of concomitant mu ltisystem trauma, and always consider the possibility of

abuse or neglect in bu rned children or the elderly.

when more than 30% of the patient's total body surface

area is involved, resulting in multisystem organ injury.

Burns can be clinically classified as first, second, or

third degree. First-degree burns are limited to the

superficial epidermis and heal within 7 days without any

long-term sequelae (eg, sunburn). Second-degree burns

are partial-thickness injuries that extend into the dermis.

They are further subdivided into superficial and deep

partial thickness injuries. Deep partial thickness burns

result in destruction of the deeper dermal structures

including the hair follicles and sweat and sebaceous glands,

whereas these tissues are spared with superficial partial

thickness injuries. Superficial partial thickness burns tend

to heal within a period of 2-3 weeks with minimal longterm scarring, whereas their deep counterparts often

necessitate skin grafting for definitive care. Third-degree

burns extend deep into the subcutaneous tissues and

represent full-thickness injuries of the skin. All dermal

structures including the capillary networks and neuronal

tissues are destroyed, leaving behind an avascular and

insensate skin. Skin grafting is invariably required.

From a physiologic standpoint, the skin functions to

reduce evaporative water loss, in addition to creating a

barrier to infection and controlling body temperature.

Hypovolemic shock is common with severe burns as a result

of a combination of increased peripheral blood flow with

evaporative fluid losses and excessive capillary leak with

387

CHAPTER 89

circulating volume third-spacing. The decreased cardiac output that frequently complicates the systemic reaction to significant burns further exacerbates the circulatory

insufficiency.

Inhalational injuries are common in fire victims who are

found in enclosed spaces. They can be divided anatomically

into supraglottic and infraglottic injuries. Supraglottic

burns represent direct thermal injury to the face and pharyngeal tissues. They develop very rapidly, within minutes of

exposure, and often necessitate emergent endotracheal intubation. Infraglottic burns represent chemically mediated

injury to the bronchioles and alveoli. They develop much

more slowly over the course of several hours and clinically

mimic acute respiratory distress syndrome (ARDS).

CLINICAL PRESENTATION

� History

Details concerning the nature of the injury are extremely

important. Identify the mechanism of injury, as this may

provide a clue its severity. For example, scald injuries

usually result in partial-thickness burns, whereas flash and

flame exposures more commonly produce full-thickness

injuries. Deeper injuries should be suspected in patients

with electrical or chemical burns, especially those with

high voltage or strong alkali exposures, respectively. Identify

all victims of closed space fires, as they have an increased

potential for inhalational injuries, carbon monoxide (CO)

poisoning, and cyanide (CN-) toxicity. Cyanide is formed

by the combustion of nitrogen-containing compounds ( eg,

wool, silk, polyurethane, vinyl), and toxicity is not uncommon in victims of industrial fires. Obtain a very detailed

history in all pediatric burn victims to uncover any possibility for abuse or neglect.

� Physical Examination

Always start with a primary survey and address any

emergent life threats. Carefully document all vital signs,

remembering that circumferential extremity burns may

limit adequate blood pressure measurement. Assess the

patient for any signs of inhalation injury, including singed

facial hairs, carbonaceous sputum, stridor, wheezing, and

dysphonia. Carefully assess the adequacy of respiration in

all patients with significant thoracic burns to detect any

evidence of an evolving compromise in chest wall

compliance. Completely undress all patients and perform a

comprehensive secondary survey, as concomitant traumatic

injuries are common. Assume an occult C-spine injury

until proven otherwise in all nonverbal or unreliable

patients and immobilize appropriately. Ensure intact neu ­

rovascular function in all 4 extremities and take note of

any circumferential burns.

Perform a detailed skin exam in all patients. Firstdegree burns are red in appearance and very tender. Skin

blistering should not be present. Superficial seconddegree burns present with red blistered skin, a moist

1 8% front

1 8% back

9%

1%

1 8%

Figure 89-1 . The "rule of nines" to calculate the

% total body surface area of the burn. Reprinted with permission from Schwartz LR, Balakrishnan c. Chapter 210.

Thermal Burns. In: Tintinalli JE, Stapczynski JS, Cline OM,

Ma OJ, Cydulka RK, Meckler GO, eds. Tintinalli's Emergency

Medicine: A Comprehensive Study Guide. 7th ed. New

York: McGraw-Hill, 201 1.

exposed dermis, and good capillary refill. Deep seconddegree burns, on the other hand, present with an

exposed dermis that is a pale white to yellow in appearance with absent capillary refill. Third-degree burns are

leathery, pale, and insensate with possible evidence of

char formation.