Calculate the percentage of total body surface area (TBSA)

involved with second- and third-degree burns. The "rule of

nines" can help with this assessment (Figure 89-1).

Immersion burns will appear as circumferential tissue

damage with sparing of the flexor creases and are

pathognomonic for abuse in pediatric patients.

DIAGNOSTIC STUDIES

� Laboratory

Obtain an electrolyte panel and renal function in all patients

and calculate the anion gap. Significant metabolic acidosis

suggests hemodynamic shock, carbon monoxide poisoning,

or cyanide toxicity. Check an arterial blood gas in patients

with potential CO poisoning to measure the carboxyhemoglobin level. Order a creatine phosphokinase to exclude

rhabdomyolysis in patients with electrical injuries.

� Imaging

Obtain a chest x-ray (CXR) in patients with potential inhalation burns, keeping in mind that infraglottic burns may

take several hours to evolve. Their appearance on CXR

typically mimics ARDS.

PROCEDURES

Emergency escharotomy is indicated in all patients with

circumferential burns and evidence of either impaired

limb perfusion or restricted respiratory mechanics

secondary to the development of an inflexible skin eschar

with underlying edema. For the limbs, opposing midmedial and mid-lateral incisions should be made down the

entire length of the eschar, including the digits if necessary.

For the chest, bilateral incisions should be made along the

anterior axillary lines. An additional transverse horizontal

incision is occasionally necessary to fully free the restricted

chest wall. Regardless of location, the incisions must completely penetrate through the entire eschar and into the

subcutaneous fat.

Consider co and CN"" poisoning in

critically ill patients with smoke exposure

BURNS

MEDICAL DECISION MAKING

Perform an appropriate primary survey and address any

emergent life threats, including concomitant trauma.

Secure the airway early in all patients with evidence of

significant supraglottic inhalation injury. Rule out CO

and CN- poisoning in all seriously ill patients with any

history of smoke exposure. Use the history and a comprehensive secondary survey to identify the extent and severity of injury. Calculate the TBSA involved and initiate

aggressive volume resuscitation in patients with burns

involving more than 20%. Consider early transfer to an

appropriate burn center in such patients (Figure 89-2).

TREATMENT

Administer 02 via a nonrebreather mask to all patients and

administer pain medications as needed. If intubation is

required, succinylcholine can be used safely within the first

24 hours after a burn, but its use should be avoided

after this point to avoid precipitating life-threatening

Burn victim

Primary survey, IV access, 1 00% Fi02,

cardiac monitor, analgesia

Criteria for admission or transfer

to regional burn center

Calculate OfoTBSA involved and

initia l fluid requirements

(Parkland formula)

Figure 89-2. Burns diag nostic algorithm. TBSA, total body surface area.

CHAPTER 89

hyperkalemia. This can occur because significant burns

drastically increase the n umber of postsynaptic acetylcholine

receptors in the affected tissues, which can induce a massive

efflux of potassium ions into the extracellular space in

response to succinylcholine administration.

Treat CO poisoning with 1 00% oxygen and possibly

hyperbaric 02 (see Chapter 58) and CN-toxicity with either

the cyanide antidote kit (use only the sodium thiosulfate

with concurrent CO poisoning) or hydroxocobalamin (5 g

intravenously [IV] over 15 minutes).

Initiate aggressive volume resuscitation in all patients

with burns that involve �20% TBSA. Use the Parkland

formula (4 mL/kg x o/oTBSA given over 24 hours with

the first half given over the initial 8 hours) to estimate

initial volume needs, but titrate as necessary to maintain

hemodynamic stability and a urine output of 0.5-1 mg/

kg/hr. For example, an 80-kg patient with a 50% TBSA

burn requires 16 L of total fluid over a 24-hour period

with an initial rate of 1 L/hr for the first 8 hours. Use

either Lactated Ringer's or isotonic saline, as colloid

fluids have never been shown to improve survival.

Irrigate all thermal and chemical burns with cool

running water to minimize further tissue injury, and

remove affected clothing to limit ongoing chemical

exposure. Brush off any adherent solid chemicals before

irrigation. Apply nonadherent sterile dressings to all

superficial injuries. Deeper burns will require debridement

of necrotic tissue and protection with a topical antiseptic

such as silver sulfadiazine. Most of these injuries will

eventually require surgical excision and skin grafting. As

local wound care is exceptionally painful, burn victims

require aggressive analgesia with parenteral narcotics.

Update your patient's tetanus status as necessary.

DISPOSITION

� Admission

The criteria for admission or transfer to a burn center are

listed in Table 89- 1.

Table 89-1. Criteria for admission or transfer

to a burn center.

Partial·thickness burns: >200fo TBSA in all age groups, > 1 OOfo TBSA

for patients <1 0 or >50 years of age

Burns involving face, hands, feet, genitalia, perineum, or major joints

Third·degree burns >50fo in any age group

Electrical burns (including lightning)

Chemical burns

lnhalational injury

Patients with preexisting medical disorders that could complicate

management

Children when the originating hospital does not treat children

TBSA, tota l body su rface area.

� Discharge

Patients with minor burns can be safely discharged with

appropriate follow-up arranged within 48 hours.

SUGGESTED READING

Kao LW, Nunagas KA. Carbon monoxide poisoning. Emerg Med

Clin North Am. 2004;22:985-1018.

Monafo WW. Initial management of burns. N Engl J Med. 1 996;

335: 158 1-1586.

Pomerantz WJ. Emergency management of paediatric burns.

Pediatric Emerg Care. 2005;21:1 1 8-129.

Schwartz LR, Balakrishnan C. Thermal bums. In: Tintinalli JE,

Stapczynski JS, Reed JL, Ma OJ, Cline DM, Cydulka RK, Meckler

GD. Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th eel. New York, NY: McGraw-Hill, 2011, pp. 1374-1380.

U pper Extremity Inj uries

George Chiampas, DO

Matthew S. Patton, MD

Key Points

• When assessing a painful extremity, vascular compromise must be excluded first.

• A patient who has fallen on an outstretched hand and has

tenderness in the anatomical snuffbox of the wrist and

a negative radiograph should have a thumb spica splint

placed until a scaphoid fracture is definitively excluded.

INTRODUCTION

Traumatic injuries to the upper extremity are common

presenting emergency department (ED) complaints. It is

the clinician's objective to distinguish benign ( eg, sprains,

contusions) from emergent injuries (eg, open fractures,

dislocations, vascular compromise). A systematic approach

to identifying and classifying orthopedic injuries is needed

to properly manage, treat, and disposition patients. This

requires a thorough knowledge of orthopedic anatomy

and function. The upper extremity contains several important articulations and long bones, which are at risk for

dislocations and fractures during falls or by direct force.

� Shoulder and Arm Injuries

The glenohumeral joint of the shoulder is the most mobile

joint in the body and, unsurprisingly, the most commonly

dislocated joint, accounting for 50% of all major dislocations seen in the ED. Anterior dislocations account for 95%

of all shoulder dislocations (Figure 90- 1). They occur most

commonly when the arm is abducted, externally rotated,

and extended and a posterior directed force is applied to

the humerus. Axillary nerve injury is present in 1 2% of

cases and is noted by testing sensation over the deltoid

muscle and strength of abduction. Posterior dislocations

391

• Avoid nonsteroidal anti-i nflammatory drugs after fractures. These medications inh ibit bone healing.

• In the upper extremity, compartment syndrome is most

common in the forearm, especially after displaced

supracondylar fractures in children.

are less common (5%) and present with inability to abduct

and externally rotate. The classic mechanism that causes a

posterior shoulder dislocation is a seizure.

.A. Figure 90-1 . AP view of an anterior shoulder dislocation.

CHAPTER 90

Figure 90-2. Humerus fracture. Th is

fracture is described as a spiral, distal-third

humerus fracture, with comminution, 1 00%

displacement, and no angulation.

Shoulder separation is a soft tissue injury to the

acromioclavicular and coracoclavicular ligaments, which

provide stability to the acromioclavicular joint. These typically occur after a fall with direct impact onto the shoulder

and are divided by severity into first-, second-, and thirddegree injuries. First-degree injuries are sprains of the

acromioclavicular ligament without significant separation

of the acromion and clavicle. Second-degree injuries are the

result of complete disruption of the acromioclavicular liga ­

ment but an intact coracoclavicular ligament. Widening of

the acromioclavicular joint is present on radiographs.

Third-degree injuries occur when both ligaments are disrupted, producing widening of the acromioclavicular joint

and cephalad displacement of the clavicle.

Humerus fractures occur anywhere on the shaft of the

humerus (Figure 90-2). Fractures of the distal third of the

humerus are associated with radial nerve injuries in 5-1 5%

of cases .

..... Elbow Injuries

The elbow is the second most common large joint

dislocation, 80-90% of which are posterior. Common

elbow fractures include the radial head and olecranon in

adults and the supracondylar humerus in children.

Displaced supracondylar fractures in children are prone to

developing compartment syndrome.