Mzantsi Medics

CONTENTS

• MIST Handover
• Supplemental oxygen (O₂)
• Adjuncts to the Primary Survey
• Secondary Survey
• Breathing Emergency
• Potentially life-threatening conditions
• Shock
• Traumatic Brain injury (TBI)
• Spinal Trauma
• Obstetric Trauma
• Thermal injuries
• Important Parameters

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INITIAL ASSESSMENT

Primary Survey

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

https://mzantsimedics.org/trauma

” MIST” HANDOVER

M	MECHANISM + TIME	– Vehicle collision – Pedestrian vehicle accident (PVA) – Fall from height – Gunshot wound (GSW) – Time of accident – Burns – Number of causalities
I	INJURIES FOUND	– Chest stab – Chest bruising – Lacerations – Fractures opened or closed – Exposed abdominal organs.
S	SYMPTOMS AND SIGNS	– Difficulty breathing – Hypotension – Tachycardia (shock / anxiousness)
T	TREATMENT INITIATED	– 1 x IV line inserted – 1 L N/S given – OPA – Bandages over laceration

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.	COMPONENT	Possible resuscitation interventions
A	AIRWAY	– Cervical collar – High flow oxygen – Pulse oximeter – Remove foreign body – Suction secretion/blood – Jaw thrust – Advanced airway (OPA/NPA) – Definitive airway – Surgical airway
B	BREATHING	– SaO2: 94 – 98% – ETCO: 35 – 45 mm Hg – Face mask with a reservoir bag – Needle/finger Decompress thorax – Tube thoracostomy – Surgeon thoracotomy??? – Blood transfusion – haemothorax
C	CIRCULATION	– Direct Manual Pressure – 14G – 18G IV lines x 2 – 1 Litre warm NS / RL (20ml/kg paediatrics) – Bloods: FBC, UEC, cross-match, pregnancy – Blood gas and lactate  – Blood transfusion (Class 2, 3, 4)  – Tranexamic infusion < 3 hours – Chest decompression??? – Pelvic sheet / Binder – Extremity splints  – Chest, Abdominal, pelvic X ray – FAST, DPL – Gastric catheter – Urinary catheter – Definitive control specialist – Definitive control measures
D	DISABILITY	– Transfer brain injury. – Correct hypoglycaemia.
E	EXPOSURE	– Completely undress the patient  – Warm the room  – Warm blankets – External warming device – Warm intravenous fluids to 39OC

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Supplemental oxygen (O₂)

Every injured patient should receive supplemental O₂ and aim for an SaO₂ of between 94 – 98%. The following 3 oxygen delivery devices can be used: 

1. Nasal cannula. 
2. Simple O₂ face mask.
3. Non rebreathing face mask with O₂ reservoir.

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Adjuncts to the primary survey include:

• CO₂ monitoring (capnography).
• Ventilatory rate.
• Pulse oximetry.
• ECG.
• ABG.
• X-ray examinations.
• Urine catheter.
• Gastric catheters.
• FAST / e-FAST.
• DPL.

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ADJUNCT	PICTURE	COMMENTS
CO2 monitoring + Ventilatory rate		– Ventilation – Continuous quantitative waveform capnography. – Avoid hypoventilation: ETCO2 > 45 mm Hg. – Avoid hyperventilation: ETCO2 < 35 mm Hg. – Normal ETCO2 35 – 45 mm Hg. – A fall in the height of capnography may indicate developing shock.
Pulse oximetry		– Oxygenation – Head injury patients are commonly hypoxic. – Aim for SaO2 94% to 98%.
ECG		– Continuous ECG monitoring  – Important for cardiac contusion – PVC is commonly associated with cardiac contusion. – Look out for Right ventricular injury (STEMI: leads II, III, aVR, V1, and V4R). – Hypovolemia, Tension Pneumothorax, Tamponade cardiac and Trauma (6 H’s and 6’T) are reversible causes of PEA.
ABG		Shock – Low pH – Low base excess
X-rays		– Chest, Abdomen, pelvis, c-spine and limbs.
Urine		– Measures volume status and renal perfusion. – Helps to identify source of bleeding – bladder injury. – Confirm urethral integrity before insertion. – Retrograde urethrogram.
Gastric catheter		– Decompress stomach. – Reduce the risk of aspiration. – Upper gastrointestinal haemorrhage and trauma.
FAST / e-FAST		– Helpful in identification of intraperitoneal fluid. – Free blood in thorax and abdomen.   Four common areas  – Pericardium (pericardial sac)– 90 to 95% accurate – Perihepatic (hepatorenal fossa) – Perisplenic (splenorenal) – Peritoneum (Pelvis or pouch of Douglas)
DPL		– Useful in blunt and penetrating abdominal trauma – When CT or FAST are not available – Can be performed urgently  – Performed in the Resuscitation area – Determines the need for surgery   Decompress the stomach and the bladder before DPL is performed

mzantsimedics.org/trauma

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Secondary Survey

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History

SAMPLE mnemonic is used to collect history from a trauma patient during the secondary survey.

S	– Symptoms
A	– Allergies.
M	– Medications currently used.
P	– Past illnesses. – Pregnancy.
L	– Last meal.
E	– Events leading to injury. – Environment related to the injury.

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AIRWAY SUMMARY

Maj (Dr) S.S.V Siko [https://mzantsimedics.org/trauma]

AIRWAY DEVICES	EXAMPLES	PICTURES
Pharyngeal Devices	1. Nasopharyngeal airway. 2. Oropharyngeal airway.
Supraglottic Devices	1. Laryngeal mask airway (LMA). 2. Laryngeal Tube Airway (LTA). 3. Multi-lumen oesophageal airway
Definitive Airways	1. Orotracheal Tube. 2. Nasotracheal Tube. 3. Surgical airway – cricothyroidotomy – tracheostomy

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Potentially difficult airway: 

• C-spine injury.
• Severe arthritis of the c-spine.
• Significant maxillofacial or mandibular trauma.
• Limited mouth opening.
• Obesity.
• Anatomical variations (receding chin, overbite, and a short, muscular neck).
• Paediatric patients.

L	Look Externally	– External features of difficult incubation:  * Facial trauma * Small mouth/jaw * Large overbite
E	Evaluation Rule 3-3-2	– Evaluation rule 3-3-2 is measured with the patient in supine position * 3 finger breadths for the inter incisors distance * 3 finger breadths for the distance from chin to hyoid bone (chin-hyoid) * 2 finger breadths for the distance from mouth floor to thyroid notch
M	Mallampati Class	Class I – Whole of uvula is well and easily visualized. Class II – Tip of the uvula seems to be sitting on the tongue or obstructed by tongue. Class III – Most of the uvula is obstructed only the base and hard palate is visible. Class IV – Uvula not visible only hard palate visible.
O	Obstruction	BOOTS mnemonic for difficult ventilation. B   – Beard O   – Obesity O   – Old patients T    – Toothlessness S    – Snores / stridor
N	Neck mobility	– Atlanto-occipital extension is Important. – Good Atlanto-occipital extension allows sniffing position for vocal cord visualisation. – Nick injury or arthritis might restrict atlanto-occipital extension

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Drug Assisted Intubation (DAI) / Rapid Sequence Intubation (RSI)

1	PREPARE WELL	1. Patient 2. Equipment 3. Drugs 4. Team members
2	PRE-OXYGENATION	– Tight fitting mask – 3 – 5 minutes – 100% O2 – inadequate ventilation: self-inflating device with 8 VC breaths.
3	PREMEDICATION??	NOT ROUTINE PROCEDURE At least 3 minutes before induction – lignocaine is 1-2 mg/kg IV [maximum dose 100 mg]. (In patients with hyperactive airways, decreases away reactivity) – Atropine 0.1- 0.5 mg (Counteracts Bradycardia in paediatrics). – fentanyl 2-3 mcg/kg IV (neuroprotection in head injury) – Rocuronium (defasciculating dose) 0.1 mg/kg IV (To prevent fascinations of Suxamethonium)
4	INDUCE	– Etomidate 0.2 – 0.3 mg/kg slow IV over 30 – 60 seconds. – Ketamine 1 – 2 mg/kg slow IV over 60 seconds. – Propofol 1.5 – 2.5 mg/kg slow (Give 40 mg every 10 seconds and check response).
5	PARALYZE	– Administer immediately after the induction agent – Succinylcholine (Suxamethonium) 1-2 mg/kg. (1st choice) – Rocuronium (high dose) 0.9 – 1.6 mg/kg. (2nd choice) – Vecuronium 0.2 to 0.3mg/kg (3rd choice)
6	POSITION PATIENT	– Maintain in-line cervical stabilization. – Remove anterior portion of C-collar.
7	PLACE ETT + PROVE	* After 45 to 60 seconds post paralytic agent – Insert ETT past vocal cords. – Use Chula formula for ETT depth. – Attach CO2 detector for ETCO2. – Attach ventilati0n device to ETT. * Confirm placement – 5-point Auscultation: (left axilla, right axilla, epigastrium, left hemithorax, right hemithorax). – ETCO2. *Secure ETT Consider bite block
8	POST INTUBATION CARE	Sedation – Lorazepam 0.05 mg/kg IVP – Midazolam   Maintenance

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THORACIC TRAUMA

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Breathing Emergencies

NO.	EMERGENCY	RESUSCITATION
1	TENSION PNEUMOTHORAX	– Needle/finger decompression. – Tube thoracostomy.
2	OPEN PNEUMOTHORAX	– Chest seal / 3-side flutter chest seal. – Tube thoracostomy far from wound. – Surgical closure of wound.
3	MASSIVE HEMOTHORAX	Warmed IV crystalloids Emergency blood transfusion  Tube thoracostomy 5th IC anterior to MAL Urgent thoracotomy
4	CARDIAC TAMPONADE	Emergency thoracotomy or sternotomy Pericardiocentesis

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Potentially life-threatening conditions:

1. Simple pneumothorax
2. Haemothorax 
3. Flail chest 
4. Pulmonary contusion 
5. Blunt cardiac injury 
6. Traumatic aortic disruption  
7. Traumatic diaphragmatic injury
8. Blunt esophageal rapture  

1	Simple pneumothorax	– Oxygen – Tube thoracostomy. * 5th IC space, just anterior to the midaxillary line. – Chest X-ray.
2	Haemothorax	– Oxygen – Tube thoracostomy. * 5th IC space, just anterior to the midaxillary line. – Chest X-ray.
3	Flail chest	– Oxygen – Ventilation – Fluid resuscitation – Analgesia
4	Pulmonary contusion	– Oxygen – Ventilation – Fluid resuscitation – Analgesia
5	Blunt cardiac injury	– Cardiac monitoring – Treatment based on clinical status
6	Traumatic aortic disruption	– Endovascular or open surgical repair
7	Traumatic diaphragmatic injury	– Surgical repair
8	Blunt esophageal rapture	– Surgical repair

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SHOCK

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Definition: Shock is an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation.

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Shock signs

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Types of shock

1. Hypovolemic shock
2. Distributive (neurogenic, anaphylactic, septic)
3. Cardiogenic
4. Obstructive
5. Mixed

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Haemorrhage Classes

	Class 1	Class 2	Class 3	Class 4
Blood loss	< 15%	15 – 30%	31 – 40%	> 40%
HR	Unchanged	Unchanged / Tachycardia	Tachycardia	Marked Tachycardia
Bp	Unchanged	Unchanged	Hypotensive (Decompensated)	Hypotensive (Decompensated)
PP	Unchanged	Low PP < 40 mm Hg	Low PP < 40 mm Hg	Low PP < 40 mm Hg
RR	Unchanged	Unchanged	Unchanged / Tachypnoea	Unchanged / Tachypnoea
Urine Output	Unchanged	Unchanged	Oliguria	Oliguria
CNS	Unchanged	Anxious Afraid Hostile	Low GCS	Low GCS
BD	0 to -2 mmol/L	-2 to -6 mmol/L	-6 to -10 mmol/L	-10 mmol/L or less
BLOOD TRANSFUSION	Monitor	Possible	Yes	MTP

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Haemorrhage Classes

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Shock index (SI). The normal range for shock index 0.5 to 0.7. Shock index values that are close to 1.0 are associated with shock. In the trauma setting it is used to decide as to which patients will need Massive Transfusion Protocol (MTP). Patients with a shock index > 1 qualify for Massive Transfusion Protocol.

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Blood transfusion indications

• Unresponsive to initial crystalloids (1 L N/S)
• Pelvic fractures
• Massive haemothorax (1.5 L blood or 200 ml/hour for 2 to 4 hours).
• Class 3 haemorrhage 
• Class 4 haemorrhage
• ±Class 2 haemorrhage
• Shock index > 1.0

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Massive Blood transfusion

• > 10 units of pRBC within the first 24 hours post admission.
• > 4 units of pRBC within 1 hours post admission

Time elapsed	Units of pRBC given
< 24 hours	10 Units pRBC
< 1 hour	4 Units pRBC

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Balanced / Damage control / Hemostatic resuscitation

This resuscitation includes packed RBC, frozen plasma and platelets. This form of resuscitation is aimed at combating the lethal Triade of Trauma which is hypothermia, acidosis and coagulopathy.

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Bleeding Sites in Trauma

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Anti-fibrinolytic

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Massive transfusion: 1st dose: 1 g of TXA in 100 ml normal saline or ringers lactate and give over 10 minutes. 2nd dose 1 g
TXA infused over 8 hours.

Cardiogenic shock 

Cardiogenic Shock can be caused by blunt cardiac injury, cardiac tamponade, an air embolus or myocardial infarction. Even though cardiac tamponade is mainly caused by penetrating chest, trauma blunt thoracic trauma can also cause cardiac tamponade.

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Neurogenic shock / Shock due to sympathetic fallout.

• Cervical and upper thoracic (T6) spinal cord injuries
• Presenting with hypotension due to loss of sympathetic tone.
• Presentation: isolated hypotension without the other findings such as tachycardia, cutaneous vasoconstriction or narrow pulse pressure.

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

Dr S.S.V Siko [https://mzantsimedics.org/trauma]

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Head trauma

Maj (Dr) S.S.V Siko. [https://mzantsimedics.org/trauma]

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Traumatic brain injury (TBI)

• ABCDE approach still applies
• Primary goal of TBI treatment is to is to prevent secondary brain injury
  • Treat hypovolemia and shock aggressively
• • Treat hypotension
• • Treat hypoxia
• • Treat high ICP
• Treat seizures
• CT scan must not delay definitive treatment.
• Hypovolemia is dangerous and is treated aggressively.
• Crystalloids for resuscitation, avoid dextrose.
• Do not administer 20% mannitol in hypovolemic patients.
• Administer 20% mannitol in normovolemia patients for raised ICP.
• Administer hypertonic.
• Administer 20% mannitol in uncal herniation immediately in euvolemic patients: 1 g/kg rapidly over 5 minutes
• Perform neurological exam before a paralytic agent is given.
• Consult neurosurgeon for depressed and open skull fracture.

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Uncal herniation. The uncus is the medial part of the temporal lobe. Normal ICP is ±10 mm Hg and ICP of > 22 mm Hg has poor prognosis. A focal brain lesion that increases ICP causes the uncus (medial part of temporal lobe) to herniate through the tentorium and compress the corticospinal tract of the midbrain. Uncal herniation typically presents with ipsilateral pupil dilatation and contralateral hemiparesis.

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Cerebral perfusion

Cerebral blood flow and perfusion forms the cornerstone in the treatment of head injury patients. Perfusion is improved in the following manners: 

1. Reducing intracranial pressure
2. Maintaining normal intravascular volume and MAP
3. Ensuring oxygenation and ventilation
4. Early evacuation of haematomas
5. Early removal of lesions that increase intracranial pressure

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Glasgow coma scale

The GCS should be assessed during the primary survey under “DISABILITY” of the ABCDE approach.

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GCS and head injury severity

A GCS 8 is defined as severe brain injury and coma. If there is asymmetrical motor response between left and right it is advised to use the side with the best motor response as it is the best outcome predictor.

BRAIN INJURY SEVERITY
Severe (Coma)	Moderate	Mild
GCS 3-8	GCS 9-12	GCS 13-15

Skull fractures

There 2 broad categories for skull fractures are Vault and Basilar. Vault fractures may be linear, stellate, depressed or non-depressed. Basilar skull might have a component of CSF leak or CN7 compression and palsy. High energy force is required to cause skull fracture and therefore skull fractures should not be underestimated.

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Signs of basilar skull fracture include:

1. Periorbital ecchymosis – Raccoon eyes
2. Retroauricular / mastoid ecchymosis – Battle’s sign
3. Rhinorrhea
4. Otorrhea
5. Dysfunction of cranial nerve 7 – Facial paralysis
6. Dysfunction of cranial nerve 8 – hearing loss

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Intracranial lesions

1. Diffuse Brain injuries
2. Focal brain injuries

Diffuse brain injuries

May range from concussion to DAI. A concussion is TBI with transient brain dysfunction which mostly presents with, loss of consciousness, no localising signs and normal CT findings. More severe diffuse brain injuries result from hypoxia and ischemia post injury. Ct scan might be normal initially but changes will develop later on as the insult evolves.

INTRACRANIAL LESIONS
Diffuse brain injuries	Focal brain injuries
Concussion Hypoxic Ischemia  DAI	Epidural hematomas Subdural haematomas Contusion Intracerebral haematoma

Epidural hematomas

Epidural hematomas are rare and occur in 0.5% of patients with brain injury and 9% in TBI patients who are comatose. The temporal region is commonly affected and the middle meningeal artery is the most often cause. The bleeding of the artery is result of the artery being torn by an adjacent skull fracture. The bleeding pushes dura mater interlly away from skull. They typically present with a lucid interval and deterioration later on.

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Subdural haematomas

More common and more severe than epidural haematomas. Subdural hematomas occur in 30% of brain injuries. Subdural haematomas are caused by tearing of bridging veins or arteries after a brain contusion. Subdural hematomas are more dangerous because they cause damage to the underlying parenchyma. Mortality of subdural hematomas is very high between 60 – 90%.

Brain contusion

Contusions are common. It is advised that patients with brain contusion have a repeat CT scan within 24 hours from initial scan.

CT Scans

All brain injury patients must get a CT scan but obtaining a CT scan must not delay or hinder the resuscitation efforts.

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CT scan indications for mild head injury (GCS 13 – 15)

• Open skull fracture
• Base of skull fracture
• Vomiting > 2 episodes
• Elderly > 65 years
• LOC > 5 minutes
• Retrograde amnesia > 30 minutes

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Hypotension and brain injury

In patients with brain injury it is important to correct hypotension first because neurological examination in hypotensive patient is not reliable. Aim for systolic blood pressure >100 in patients 50 to 69 years and systolic blood pressure 110 in patient 15 to 49 years.

Important CT finding

• Intracranial haemorrhage
• Contusions,
• Midline Shift ≥ 5 mm
• Obscured basal cisterns

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SPINE TRAUMA SUMMARY

Notes

• Spinal injury must always be considered in patient presenting with multiple injuries.
• Do not keep patient on hard spinal board for a long duration.
• Atropine may be used for the bradycardia of neurogenic shock.
• All spine cord injuries with radiological evidence and neurological deficits must be considered unstable.
• Neurogenic shock is not treated by fluids alone.
• Treatment of neurogenic shock includes careful use of fluids, vasopressors (Phenylephrine, Dopamine, noradrenalin) and atropine.
• There is insufficient evidence with regards to the use of steroids in spinal injury.
• Use NEXUS Criteria or Canadian C-Spine rule to guide with regards to use of radiological tests.

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Neurogenic shock / Shock due to sympathetic fallout.

Presence of shock in patient with a head injury is an indication to search for other causes.  Cervical and upper thoracic spinal cord injuries can present with hypotension due to loss of sympathetic tone. The classic presentation of neurogenic shock is isolated hypotension without the other findings such as tachycardia, cutaneous vasoconstriction or narrow pulse pressure. The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggests either continuing haemorrhage or neurogenic shock.

Level of spinal injury 

No	LEVEL	NOTES
1	Bony level	Vertebral level of bone fracture or damage.
2	Neurological level	Most caudal level with both normal sensory and motor function bilaterally.
3	Sensory level	Most caudal segment with normal sensory function.
4	Motor level	Lowest muscle myotome that has a muscle-strength grade of at least 3/6
5	Zone of partial preservation	Area just below the injury level where some impaired sensory and/or motor function is found.

CERVICAL SPINE IMAGING

• NEXUS Criteria (1992)
• Canadian C-Spine Rule (CCR) [2001]

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NEXUS CRITERIA

No.	Criteria	Notes.
1	No focal neurological deficit.
2	No posterior midline cervical spine tenderness.
3	No altered level of consciousness
4	No intoxication evidence
5	No painful distracting injury

Canadian C-Spine Rule (CCR)

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Obstetric Trauma

Notes in pregnancy

• ABCDE sequence still applies
• Optimally resuscitating the mother first is the best treatment for the foetus
• All female trauma victims within reproductive age are pregnant until otherwise proven by confirmation β-HCG or pelvic ultrasound.
• Order X-rays, pregnancy is not a contraindication.
• Consult obstetrician and surgeon early.

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Anatomy points

• Uterus is intrapelvic until about 12 weeks
• Uterus reaches umbilicus at 20 weeks
• Uterus reaches coastal margin at 34 – 36 weeks
• The bowel is pushed posteriorly and superiorly and protected in blunt trauma.
• Peritonitis (peritoneal irritation) is rare in pregnancy as result clinical examination becomes inconclusive
• Further examinations are advised in pregnancy
• In late gestation foetal head descends into pelvis and vulnerable in the case of pelvic fracture
• Amniotic fluid may cause embolism and intravascular coagulation if it mixes with the maternal intravascular space
• The placenta is less elastic as compared to the myometrium increasing risk of abruption placenta in trauma.
• The placental blood vessels are hypersensitive to catecholamine
• A decrease in maternal vascular volume can result in significant uterine vasoconstriction with normal maternal vital signs.

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Thermal injuries

Notes

1. Stop the burning process.
2. Establish an airway.
3. Massive oedema will cause airway obstruction.
4. Children are at higher risk of airway obstruction.
5. Stridor is a late signs of airway compromise.
6. Direct measurement of carboxyhaemoglobin (HbCO) is useful in burn patients.
7. Carboxyhaemoglobin level > 10% suggests an inhalation injury.
8. CO poisoning must be assumed in patients who burned in enclosed spaces.
9. CO poisoning symptoms begin at carboxyhemoglobin > 20%.
10. 100% Oxygen via non-rebreathing mask reduces the ½ life of HbCO from 4 hours to 40 minutes.
11. Inflammation causes capillary leak and ongoing fluid losses.
12. Fluids for deep partial and full-thickness burns > 20% TBSA
13. Superficial (1^st degree) burns are not included when counting the burn size.
14. Be aware of compartment syndrome.
15. Escharotomy for compartment syndrome.

Indications for early intubation

• Airway obstruction hoarseness, stridor,
• Respiratory distress signs suprasternal retraction
• Respiratory compromise
  • Inability to clear secretions
  • Respiratory fatigue
  • Poor oxygenation
  • Ventilation
• TBSA burn > 40%
• Extensive and deep facial burns
• Intraoral burns
• Dysphagia
• Edema
• Edema potential
• Decreased level of consciousness where airway protective reflexes are impaired
• Anticipated patient transfer of large burn with airway issue without qualified personnel to intubate en route.

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Fluid management

The problem that needs to be addressed in burn patients is ongoing fluid losses due to capillary leak. According to ATLS guidelines fluid resuscitation is given for deep partial thickness burns and full thickness burns with TBSA ≥ 20%. The crystalloid used for burn resuscitation is warmed Ringer’s lactate. Fluid resuscitation is addressed after airway and breathing and other life-threatening injuries have been addressed. The Parkland formula has a potential of over-resuscitating the patient. The initial fluid resuscitation formula for deep partial thickness and full thickness is shown below. The first half of the total fluid volume resuscitation is given over the first 8 hours and the second half is given over the next 16 hours. The fluid resuscitation should be adjusted according to the desired urine output which is 0.5 ml/kg/hr in adults and 1 ml/kg/hr. inhalation burns and deeper burns require more fluid resuscitation.

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IMPORTANT PARAMETERS

PARAMETER	UTILIZATION	NORMAL
BE	Acidosis	< – 5
Circulating Blood volume	Shock	7% of body in litres
Carboxyhaemoglobin	Inhalation burns	< 10%
ETCO2	Intubation Ventilation	35 – 45 mm Hg
Lactate	Acidosis	< 2
Pulse pressure	Shock	> 40 mm Hg adults > 20 mm Hg paediatrics
Shock index	Transfusion	0.5 – 0.7
Urine output (ml/kg/hr)	Perfusion	Adults: 0.5 (burns) Paediatrics: 1 (burns)

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Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider’s examination and assessment of a patient’s specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. Mzantsi Medics disclaims any warranty or liability relating to this information or the use thereof.