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Vascular Injury and Burns
Vascular Injury and Burns
Investigations8:313 Post-Operative
• X-ray • Close monitoring of vital signs
o Fractured bones • Distal pulses
o Dislocations • Distal saturation
• Arteriography • Continue anticoagulation6
o Should not delay vascular intervention • Look out for
o Compartment syndrome1:314
Treatment o Reperfusion injury1:421
• ATLS protocol 1:992
§ Rising creatinine levels
• External compression1:993 § Reduced urine output
• Intravenous heparin7:484 § SOB
o After excluding head injury and if patient does not have multiple
trauma7:643
• Associated fracture must be stabilized before the vascular repair8:314
o External fixator
• Viable limb + Ealry presentation: Vascular repair7:484,485
• Viable limb + Late presentation (Close to 6 hours or more): Fasciotomy +
Vascular repair7:484,485, 8:314
• Non-viable limb: Amputation8:314
2
BURNS
You are the house officer at the Ampara General Hospital. You have gone home for a weekend after a long time, for a well deserved break. You’re at home
watching the your favourite TV programme when your neighbor rushes into the house saying that their 18 year old daughter has set hersekf on fire.
Clinical Surgery
3
Hospital Care
Superficial Deep
Epidermal Superficial Partial Thickness Deep Partial Thickness Full Thickness Beyond Skin
Eg: • Sun burns • Hot water burns • Hot liquids, steam, • Flame, hot oil, steam • Flame
grease, or flame
Degree I • II • II • III • IV
• Epidermis • Epidermal + Papillary • Up to reticular dermis • All layers of skin • Subcutaneous Fat
dermis • Hair follicles, and • All epidermal + dermal • Muscle
Depth • Deeper layers of the dermis, sweat and sebaceous structures are destroyed • Bone
hair follicles, and sweat and glands are burned
sebaceous glands are spared
Colour • Red • Red • Pale white/ yellow • Charred, pale and leathery • Charred
Blisters • No • Yes: HALLMARK • Yes/No • No • No
Capillary Refill/ Blanching • Yes • Yes • No: HALLMARK • No • No
Pain • Yes • Yes • No • No2:233 • No
Healing • 1/52 • 2 - 3/52 • 3/52 – 2/12 • No spontaneous healing • No spontaneous
healing
• No scar • No/ minimal scar • Scar+ • Need skin graft5:667 • Life threatening
• Full return of function • Surgical debridement • Significant scar+ • Extensive
Prognosis and skin grafting reconstruction
MAY be necessary to • Amputation
obtain maximum
function
Clinical Surgery
Treatment
Initial2:237-239 Subsequent
• Weigh the patient • High calorie, high protein diet
• NG tube • Wound management
o Paralytic ileus: Shock can lead to ischaemia of the gut o Face and perineum
o Nutrition1:626 § Open
• IV cannulation2:233 § Povidone iodine
• Catheterize o Rest of the body
• Fluid resuscitation proportional to burned BSA § Closed
o Parkland Formula: 4ml X % BSA X weight § Silver sulfadiazine (SSD)1:630
o Crystalloid: Hartmann’s/ Hypertonic saline1:624 • Splint joints
§ 50% in the first 8hours • In neck burns: Cervical collar in extended position
§ 50% in next 16 hours • Physiotherapy1:627
o Colloid : Human Albumin Solution1:624 o Chest, limbs
• Monitoring • Psychological support1:627
o BP/PR/RR/SaO2, • Surgery
o UOP 0.5 - 1ml/kg/h: Best guide for fluid resuscitation o Escharotomy2:238
• Drugs § Limbs, neck, chest
o Analgesics o Skin graft1:629
§ IV Morphine, Pethidine, Fentanyl, Tramadol
AVOID IM as absorption is unpredictable1:626
o H2 receptor blockers: For stress ulcers
o Tetanus prophylaxis
Clinical Surgery
nd
On the 2 day patient becomes dyspnoic and you notice a reduction in UOP References:
despite adequate fluid resuscitation. 1. Bailey and Love's Short Practice of Surgery – 27th Edition
2. Advanced Trauma Life Support – Student Course Manual – 9th Edition
What are the possible causes?
3. Neurology and Neurosurgery Illustrated – Kenneth Lindsay, Ian Bone,
Complications Geraint Fuller – 5th edition
4. Davidson's Principles and Practice of Medicine – 22nd Edition
• Renal: Acute tubular necrosis 5. Apley's System of Orthopaedics and Fractures – 9th Edition
o Hypovolaemia 6. UpToDate
o Myoglobinuria 7. Oxford Handbook of Clinical Surgery – 4th Edition
8. Churchill’s Pocketbooks – Surgery – 4th Edition
• Cardio-Vascular
o Hypovolaemia
o DVT
o Acute bacterial endocarditis
• Pulmonary
o Inhalation injury1:618,621
o Respiratory failure
o ARDS
o Pneumonia
• Gastrointestinal
o Ulcers in the stomach/duodenum: Curlings ulcer
o Paralytic ileus
o Acalculous cholecystitis
• Scarring
• Contractures
Clinical Surgery