In the latest Case Record of the Massachusetts General Hospital, a 16-year-old girl was admitted to the hospital because of trauma and extensive burns sustained in a car accident. She had traumatic brain injury, crush injuries to the limbs, and inhalation injury. Management decisions were made.
After primary resuscitation with fluids in a patient with burns and severe trauma, initial care requires clear identification and prioritization of injuries. This is often difficult, since management priorities for the different injuries can conflict with one another. The diagnosis of injuries is also difficult, since the presence of a large burn can obscure deeper injuries and impair the accuracy of serial physical examinations. Management principles include serial examinations, liberal use of imaging, and a high index of suspicion based on the mechanism of injury.
• What is the leading cause of trauma-related deaths in children and adolescents?
Trauma is the leading cause of death in children and adolescents, and most trauma-related deaths are due to traumatic brain injury (TBI) and intracranial hypertension. Severe TBI (score on the Glasgow Coma Scale [GCS], <8; GCS scores range from 3 to 15, with lower scores indicating reduced levels of consciousness) contributes to worse outcome in patients with trauma.
• What are the characteristics of inhalation injury?
The diagnosis of inhalation injury may be confirmed with bronchoscopy, with findings of carbonaceous debris and edema in the major airways. An inhalation injury is a clinical syndrome that usually includes some degree of early airway obstruction and late failure of gas exchange; inhalation injuries are also associated with increases in mortality among patients with a burn of a given size up to 30%. Intubation prevents edema-related upper-airway obstruction and its consequences. Typically, gas exchange is initially normal but deteriorates during the next few days as endobronchial debris accumulates and alveolar edema worsens.
Morning Report Questions
Q: What are risk factors for cerebral edema in a patient with traumatic brain injury?
A: Risk factors for cerebral edema include a high-speed motor-vehicle accident, which can produce subarachnoid and intraparenchymal hemorrhage, young age, the fluid resuscitation required for massive burns, and hypercarbia. Therapy for traumatic brain injury is directed toward controlling intracranial pressure and preventing the secondary insults known to worsen outcome. Surgical management includes evacuation of mass lesions (hematomas and contusions), drainage of cerebrospinal fluid, and monitoring of intracranial pressure.
Q: What are common psychiatric issues in the recovery of a patient after severe trauma?
A: Initial psychiatric goals include mitigating the patient’s acute stress and the effect of gradually dawning traumatic memories when sedation is tapered. Subsequent goals, during the intermediate postinjury period, are to help the patient cope mentally and emotionally with sadness and the symptoms of post-traumatic stress disorder (PTSD), which may include nighttime agitation and sleep disturbance. Management of PTSD during the intermediate period is essential to early restoration of function. Management involves clear explanations of what has transpired, control of pain, and treatment of sleep disturbance, anxious despair, and panic with anxiolytic and antipsychotic agents. Uncontrolled anxiety substantially impairs participation in critical aspects of rehabilitation, especially physical therapy.