Acute Burn Care

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Acute Burn Care
February 2006

• James F. Williams PA-C, MPAS, WCC
• U.S. Army Institute of Surgical Research

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Hierarchy of Burn Management

• Life Limb
• Initial Burn Management
• Limb Function
• Function Cosmesis

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Rescue

• ABCs
• Stop the burning
• Decontaminate chemical casualty at the scene
• Avoid injury to the rescuer
• Careful with high voltage electrical wires
• Assume other injuries/toxic ingestion
• History mechanism, level of consciousness,
  closed space, clothing ignition

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Primary Survey
- Airway - Breathing - Circulation
- Disability - Exposure
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ABCs of Emergency Burn Care (Advanced Burn Life
Support)

• A Airway (with cervical spine assessment)
• B Breathing
• C Circulation
• D Disability
• E Exposure and Environmental Control
• F Fluid Resuscitation based on Burn Size and
  Weight Measurement
• Secondary Survey

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A Airway

• Upper airway edema due to inhalation injury.
• Assess the patients airway.
• Rapid or delayed progression.
• Decision to intubate individualized
• Mild symptoms observe in ICU
• Pre-transport prophylactic intubation
• When in doubt, intubate.

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Airway

• Method any method you can do well
• Anesthesia
• Beware of general anesthesia using barbituates or
  narcotics in hypovolemic patients.
• Ketamine is generally safe.

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Facial Edema May Mandate Intubation
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Cervical Spine Assessment

• Assess if the patient is at risk
• High voltage electrical injury.
• Motor vehicle accident.
• Jumped from a burning building.
• Explosion, thrown.
• Burns are a distracting injury clinical exam may
  be unreliable due to pain and / or narcotics.

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B Breathing

• Look, listen, feel for breath sounds and chest
  movement.
• Give 100 oxygen to all victims of major burn
  beginning in the field.
• Pulse oximetry.
• Arterial blood gases with cooximetry.
• Required for definitive diagnosis of CO.
• Baseline chest x-ray.

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Breathing

• Intubated patients can be bag-ventilated over
  long distances (transoceanic flight) by untrained
  individuals.

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Inhalation Injury Clues to Diagnosis

• Closed space injury or explosion.
• Noxious fumes at the scene.
• Facial burns.
• Elderly.
• Large burns.
• Carbonaceous sputum.
• Hoarseness, abnormal lung exam.

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Carbonaceous Sputum
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Fiberoptic BronchoscopyDefinitive Diagnosis of
Inhalation Injury
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C Circulation

• Who needs fluid resuscitation?
• All 20 total body surface area burned (TBSA).
• Young and old with 10 TBSA.
• 2 large bore peripheral IVs.
• Unburned skin / Burned skin.
• Central access.
• Cutdown/ Interosseous.
• Lactated Ringers solution (or similar).

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No Bolus

• Burn shock is gradual in onset.
• Too much fluid causes too much edema.
• Exceptions profound hypotension,
• delayed resuscitation.
• pre-existing dehydration.
• mechanical trauma.

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D Disability (Neurologic Exam)

• Assess level of consciousness AVPU -
• Alert.
• Responds to verbal stimuli.
• Responds to painful stimuli.
• Unresponsive.
• Alteration in mental status is not normal.
• Pupils.
• Moves extremities.

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E Exposure and Environmental Control

• Remove clothing, jewelry.
• Keep warm
• metallic blankets.
• warm I.V. fluids.
• heating lamps.
• heat the room.
• Do not place patient in wet linens!

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Keep the Patient Warm
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No Wet Dressings!!!
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F Fluid Resuscitation(Based on Burn Size and
Weight)

• Determine fluid needs based on burn size and
  weight.
• Burn size include 2nd and 3rd degree only.
• Rule of Nines.
• One hand one percent.
• Lund-Browder chart.
• Overestimation by referring hospitals is common.
• Weight pre-burn weight.

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Rule of Nines

• In infants,
• head is 18,
• lower extremities are 14

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Lund Browder Chart
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Secondary Survey

• Follows primary survey
• Complete head to toe evaluation.
• History and Physical Exam.
• Radiographic Laboratory Studies.

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Complete Physical Examination

• Head to Toe Exam Head Maxillofacial
  Cervical Spine Neck Chest Abdomen
  Perineum, genitalia Back Buttocks
  Musculoskeletal Vascular Neurological

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Initial Burn Wound Care

• Thermal Burns
• Cover with clean, dry cloth
• No ice or cold water soaks
• Most common form of burn
• Direct contact heat
• flash, contact, steam
• Examples scolds, flame,

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Initial Burn Wound Care

• Electrical Burn
• Cutaneous internal injury (Full-Thickness Burn)
  
• Consider electrical current cardiac effect
• Cardiac monitoring x 24 hrs

• Ex Contact with high / low voltage
• Most destructive burn

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Initial Burn Wound Care
Chemical Burns

• Brush powders from skin.
• Flush with copious amounts of water.
• Remove contaminated clothing.

• Eye irrigation, if involved.
• Exposure protection for ED personnel.

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Initial Burn Wound Care

• Chemical Burns
• Contact with caustic substance.
• Time of contact determines burn depth.
• Ex acids, alkalis, white phosphorous.
• Radiant Burns
• Contact with radiation.
• Ex Nuclear, x-rays, sunburn.

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Referral Criteria
The ABA identifies the following as injuries
requiring a Burn Center referral

• 2nd degree burns 10 TBSA
• Burns to face, hands, feet, genitalia, perineum,
  major joints
• 3rd degree burns

• Electric injury (lightning included)

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Referral Criteria

• Chemical burns.
• Inhalation injuries.
• Burns accompanied by pre-existing medical
  conditions.
• Burns accompanied by trauma, where burn injury
  poses greatest risk of morbidity or mortality.
• Burns to children in hospitals without pediatric
  services.
• Patients with special social, emotional or
  rehabilitative needs.

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Determine Burn Severity

• BSA involved Depth of injury

• Age Associated / pre-existing disease or illness

• Burns to face, hands, genitalia

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Extent of Burn
Initial Estimate of PT and FT
Rule of NinesAdult
anatomical areas 9 BSA (or multiple)

• Not accurate for infants / children due to
  larger BSA of head smaller BSA of legs. Burn
  diagrams illustrate adult and child differences.

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Extent of Burn
Patients palmar surface(hand fingers) 1
TBSA
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Burn Shock

• Plasma loss from the intravascular space into the
  surrounding tissues.
• Edema formation.
• Burn shock hypovolemia.

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Fluid Accumulation

• Early Rapid wound fluid accumulation.
• Hypovolemic Shock.

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Fluid Accumulation

• Edema Formation
• Impaired respiration.
• Impaired blood flow.

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Burn Shock Hypovolemia due to edema formation
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Stabilization Procedures Pre-Hospital or ED

• Stop the Burning Process.
• Universal Precautions.
• Initiate Fluid Resuscitation
• containing fluids unless otherwise clinically
  contraindicated.

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Stabilization Procedures Pre-Hospital or ED

• Initiate Fluid Resuscitation
• 20 - IV Lactated Ringers (LR) calculated _at_ 2
  cc x kg x TBSA. ½ 1st 8 hrs then
  titrated to maintain an hourly UOP of 30-50
  cc/hr, adjusting every 2 hrs.

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Smoke Inhalation Injury

• Upper airway injury and obstruction.
• Lung and small airway injury.
• Carbon monoxide/ cyanide poisoning.

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Layers of the Skin and Burn Depth
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Superficial Burn 1st degree

• Inconvenience Seldom clinically significant.
• Epidermis only.

• Pain Redness Analgesia and early elevation
  and range of motion exercises

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Superficial Burn 1st degree
No Risk for Contracture
Heals in 3-7 days outer injured epithelial cells
peel.
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Superficial PTB 2nd degree

• Pain, blisters, weeps fluid, intact capillary
  refill.
• Entire epidermis and part of dermis (Pink).
• Analgesia and early elevation AROM
  exercises.

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Second Degree Burn
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PTB Superficial 2nd Degree

• Uninjured dermis epidermal appendages at risk.
  
• Heals spontaneously in 2-3 weeks.

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PTB Superficial 2nd degree Post Burn Day 28
Minimal Risk for Contracture
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PTB Deep 2nd degree

• Blisters Minimal Pain. Skin graft may improve
  functional cosmetic outcome.
• Moderate Risk for Contracture and hypertrophic
  scarring.

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PTB Deep 2nd degree
Moist appearance with no capillary refill and
ivory/white/mottled color
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Full Thickness 3rd degree

• Entire thickness of epidermis dermis

• No pain blisters
• Dry white
• Leathery / charred
• Absent capillary refill

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Full Thickness 3rd degree

• Heals by contracture epithelial ingrowth from
  edges, or excision grafting.

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Third Degree Burn
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4th degree Burns Involve Deep Structures

• Similar to deep FT 3rd degree but involves damage
  to muscle, tendon and/or bone.

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Electrical Burns

• Most destructive type of burn.
• Skin internal structural injury.
• FTB or 4th Degree Burn.

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Electrical Burns
Contact with high / low voltage
Typical Hand Position
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Monitoring

• Required for 20 TBSA
• Foley catheter.
• Initial and daily weights.
• Accurate hourly record of fluid input and output.
• Continuous EKG.
• Initial 12-lead EKG in older patient.
• Nasogastric tube.
• Pulse oximetry.

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Secondary Survey

• Rule out non-thermal injury.
• Eyes fluorescein exam.
• Tympanic membranes blast injury.
• Exam may be difficult
• Skeletal x-rays.
• Diagnostic peritoneal lavage.
• Obtain AMPLE history allergies, medications,
  past medical history, last meal, events of
  accident.

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AMPLE History Events of Accident
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Wound Care

• Prior to transfer leave blisters intact, do not
  apply topical agents.
• Tetanus status (dirty wound)
• Adequate booster if 5y.
• Inadequate booster plus TIG.
• IV antibiotics not needed.
• Delayed transfer (24 h) cleanse with
  chlorhexidine gluconate, debride, agents.

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Wash and Debride
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Wound Care

• Topical antimicrobial creams
• Silver sulfadiazine (Silvadene, Flamazine)

• Mafenide acetate (Sulfamylon)

• Silver Nitrate

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Extremity Burns

• Elevate (pillows).
• Exercise burned hands q hour.
• Examine pulses at least q hour.
• Doppler US
• Radial, ulnar, palmar arch in hand
• Posterior tibialis, dorsalis pedis.
• Loss of pulses hypotension vs. eschar.

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Hands Evaluate, Exercise, Elevate
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Eschar Syndrome

• Burned skin (eschar) is inelastic.
• Swelling occurs beneath it.
• Full-thickness eschar encircling a limb acts like
  a tourniquet.
• Impaired venous return, then arterial inflow.
• Ischemia, nerve and muscle damage, limb loss,
  sepsis.

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Diagnosis of Eschar Syndrome Check pulses
hourly (doppler flowmeter)
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Escharotomy

• Indications for vascular compromise
• Deep PT or FT or electrical burns.
• Circumferential burn.
• Loss of Pulses.
• Restricted skin excursion.

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EscharotomyDone for loss or progressive
decrease in pulses.
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Escharotomy Method

• Scalpel/electrocautery at bedside.
• Midlateral and/or midmedial line.
• Joints particularly important sites.
• Watch ulnar nerve.
• Document pulse restoration.
• Stay out of viable tissue.
• Fasciotomy rarely indicated!

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Escharotomy Method, cont.
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Finger Hand Escharotomy
Hand and dorsum escharotomy indication

• Intact radial ulnar pulses.
• Loss of palmar arch pulse.
• Full-thickness dorsum burns.

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Chest Escharotomy

• Increased peak pressures, impaired ventilation,
  decreased compliance, impaired chest rise and
  fall on exam.
• Clavicles, anterior axillary lines, across upper
  abdomen along costal margins.

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Chest Escharotomy

• Indicated to relieve respiratory distress due to
  restricted chest wall excursion.

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Escharotomies of Lower Extremities
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Escharotomy Effectiveness
Before
After
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Fasciotomies
Carpal tunnel release
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Triage

• Applies only to mass casualty situations and
  scarce resources demand overwhelms supply.
• Definition sort patients so as to do the
  greatest good for the greatest number.
• D.I.M.E. Delayed- Immediate- Minimal- Expectant.

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Triage Rule of Thumb

• Age plus TBSA 100 high probability of death
  triage as expectant.
• 20 yo 80 TBSA burns
• 80 yo 20 TBSA burns
• 80 TBSA expectant for all ages.
• Devote resources to the 10-80 group.

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Army Burn Team (210)-222-BURN