MANAGEMENT OF BURNS

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MANAGEMENT OF BURNS

• CPT Allen Proulx, MPAS, PA-C

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OBJECTIVES

• Describe the differences between partial and
  full-thickness burns.
• Describe how to estimate the size of a burn.
• Describe initial care of burns.
• Describe follow-up care of partial thickness
  burns.

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References for photos

• Advanced Burn Life Support Course,
• American Burn Association, 1994
• Textbook of Military Medicine, Part I, Vol 5
• Conventional Warfare, OTSG, 1991
• Textbook of Surgery, Sabiston, editor
• W. B. Saunders, 1986
• SESAP VI,
• American College of Surgeons, 1988
• Burn care product info

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Depth of burn

• Partial thickness burn
• involves epidermis
• Deep partial thickness
• involves dermis
• Full thickness
• involves all of skin

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Partial thickness burns

• Sunburn is a very superficial burn.
• Expect blistering and peeling in a few days.
• Maintain hydration orally.
• Heals in 3-6 days- generally no scaring
• Topical creams provide relief.
• No need for antibiotics

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Deeper partial thickness

• Blisters are typical of partial thickness burns.
• Dont be in a hurry to break the blisters.
• Heals in 14-21 days
• Blisters provide biologic dressing and comfort.
• Once blisters break, red raw surface will be very
  painful.

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Full thickness burn

• Yellow, leathery appearance or charred
• Often have no sensation (nerve endings destroyed)
• Outer edges might be partial thickness.
• Initial management same as partial thickness.
• Later will need skin grafts.

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Mixed partial and full thickness

• Central yellow area might be full thickness.
• Outer edges are probably partial thickness.
• Initial management is the same.
• Later will need skin grafts for the full
  thickness areas.

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Zones of Burn Wounds

• Zone of Coagulation
• devitalized, necrotic, white, no circulation
• Zone of Stasis circulation sluggish
• may covert to full thickness, mottled red
• Zone of Hyperemia
• outer rim, good blood flow, red

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Wound excision until fine punctate bleeding
occurs
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Estimate the size of the burn

• The patients own palm is about 1 of his body
  surface area.
• Rule of Nines

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Rule of 9s
ABA
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American Burn Assoc says send these to a burn
center

• Partial thickness burns gt10 BSA
• Burns involving the face, hands, feet, genitalia,
  perineum, or major joints
• full thickness/3 degree burn
• Electrical, Chemical, and Inhalation burns
• In combat, all but the most superficial burn
  should be evacuated

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Burn care products

• lt 20 TBSA 2nd degree Silvadene (SVC) Cream
  BID
• Any gt 20 TBSA-SVC and Sulfamylon (SMC) alt BID
• 3rd degree burn SVC and SMC alt BID
• SMC only to the ears Bacitracin Opth
  to face

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Care of small burnsWhat can YOU do?
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Care of small burns

• Clean entire limb with
• soap and water (also under nails).
• Apply antibiotic cream
• (no PO or IV antibiotic).
• Dress limb in position of function,
  and elevate it.
• No hurry to remove blisters unless infection
  occurs.
• Give pain meds as needed (PO, IM, or IV)
• Rinse daily in clean water in shower is very
  practical.
• Gently wipe off with clean gauze.

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Blisters

• In the pre-hospital setting, there is no hurry
  to remove blisters.
• Leaving the blister intact initially is less
  painful and requires fewer dressing changes.
• The blister will either break on its own,
  or the fluid will be resorbed.

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Blisters break on their own

• Upper arm burn day 1 day 2

Burn looks worse the next day because of
blisters breaking and oozing
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Upper arm burn
121

• Blisters show probable partial thickness burn.
• Area without blister might be deeper partial
  thickness.

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Debride blister using simple instruments
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Medic debriding blister
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After debridement
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Before and after debridement

• Removing the blister leaves a weeping, very
  tender wound, that requires much care.

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Silver sulfadiazene
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Arm burn 4 days
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Arm burn 7 days note the exudate
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Foot burn debridement
Before debriding and applying cream,
clean entire foot (including toes and nails).
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Silver- impregnated dressings
(Silverlon)

• Apply wet silver dressing
• directly on the burn.
• Creams or dressings
• under the silver dressing
• impede the antimicrobial action.
• Keep it moist!
• Remove it, rinse it out, replace it on the burn.

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Steps in using silver-impregnated dressings

• Clean the burn and surrounding area.
• Soak silver-impregnated dressing and gauze in
• STERILE WATER or BOTTLED DRINKING WATER
• Apply silver-impregnated dressing
  (over-lapping edges are
  best).
• Wrap with the moist gauze.
• Secure with mesh, gauze, or tape.
• Keep it moist with WATER, every 12h or so More
  frequent in hot arid environments

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pics
Soak silver dressings and gauze in WATER (not
saline).
Apply the silver dressing.
Wrap with moist gauze. Secure
with mesh, gauze, or tape.
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First few days

• Moisten dressing with WATER every 12h or so.
• Remove outer gauze and silver dressing every day.
• Inspect the burn.
• Rinse exudate off burn.
• Rinse exudate off silver dressing with WATER.
• Return same silver dressing to the burn.
• Apply new outer gauze moistened with WATER.

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pics
Moisten with WATER q12h or so.
Moisten well to remove it each day. Rinse it out,
and put it back on the burn.
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After several days

• Replace silver dressing
• every 2 - 5 days
• depending on amount of exudate, cellular debris
• First wet the silver dressing before removing it.
• Dont pull on it if its stuck moisten it more.
• Apply new moist silver dressing and gauze.

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QUESTIONS ABOUT SMALL BURNS?

• SUMMARY
• Describe the differences between partial and
  full-thickness burns.
• Describe how to estimate the size of a burn.
• Describe initial care of small burns.
• Describe follow-up and post-burn care.
• NEXT TOPIC - BURNS OF SPECIAL AREAS

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Burns of special areasof the body

• Face
• Mouth
• Neck
• Hands and feet
• Genitalia

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Face

• Be VERY concerned for the airway!!
• Eyelids, lips and ears often swell alarmingly.
• In fact, they look even worse the next day.
• But they will start to improve daily after that.
• Cleanse eyes with warm water or saline.
• Apply antibiotic ointment or liquid tears until
  lids are no longer swollen shut.
• Bacitracin cream/ointment will serve

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Hands and feet

• This is rather deep and might require
  grafting.
• But initial management is basic.

Dressings should not impede circulation.
Leave tips of fingers exposed. Keep limb
elevated.
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Hands and feet

• Allow use of the hands in dressings by day.
• Splint in functional position by night.
• Keep elevated to reduce swelling.

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Hands and feet

• Fingers might develop contractures if active
  measures are not taken to prevent them.

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Genitalia

• Shower daily, rinse off old cream, apply new
  cream.
• Insert Foley catheter if unable to urinate due to
  swelling.

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Large Burns
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Causes of death in burn patients

• Airway
• Facial edema, and/or airway edema
• Breathing
• Toxic inhalation (CO, /- CN)
• Respiratory failure due to smoke injury or ARDS

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Edema Formation

• Amount of edema can be immense (even without
  facial burns)
• Depression of mental status can worsen problem
• Edema peaks at 12 to 24 hours
• Pediatric patients even more concerning

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Causes of death in burn patients

• Circulation failure of resuscitation
• Cardiovascular collapse, or acute MI
• Acute renal failure
• Other end organ failure
• Missed non-thermal injury

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Patients with larger burns

• First assess
• CBAs
• Disability (brief neuro exam)
• Expose
• Later
• Examine rest of patient
• Calculate IV fluids
• Treat burn

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Airway?

• Flash burns may refer to those that suddenly
  flare up, then die down
  quickly.
• Patients may have burnt facial hair and carbon on
  lips.
• Patients with this kind of facial burn will
  probably NOT need an artificial airway.
• Give humidified oxygen while under close
  observation.

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Circulation

• Record vital signs.
• Check distal pulses and nail beds.
• Keep him warm!
• Loss of skin impairs ability to retain heat and
  fluids.
• Being cold will cause vasoconstriction.
• Monitor urine output (in larger burns, insert
  Foley catheter for hourly urine output).
  30/50cc/hr
• Monitor at least HCT and urine specific gravity.
• When available, monitor electrolytes.

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Neuro status

• The burn itself does not alter the level of
  consciousness.
• If patient is not alert, think of other causes
• hypovolemia
• carbon monoxide
• head injury
• Dont allow swollen eyelids to prevent you from
  examining the pupils.
• Test sensation and motion in burned extremities.

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Expose

• Undress the patient to examine the whole body.
• But burned patients lose body heat quickly, so
  keep them warm.
• To keep warm, use whatever means available
• blankets
• heating lamps
• bed frame
• large box covered with blankets

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Head to toe exam

• Obtain history and examine rest of body.
• Ask about allergies, meds, medical conditions.
• Look for other injuries.

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Calculate fluid requirements

• wt in kg x burn x
  2 - 4cc / kg /
• 100 kg patient with 50 TBSA burn
• 100 x 50 x 2 10,000cc 10 liters RL
• This is calculated for the first 24 hours
  post-burn.
• Give half of this in first 8 hours.
• Half of 10,000cc 5000cc in 8 hrs 400 cc / hr
  initially

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Calculate fluid requirements

• Half of 10,000cc 5000cc in 8 hrs 400 cc /
  hr initially
• How do we know if this is too much fluid, or too
  little?
• Monitor at least
• urine output - in adults, around 50 cc / hr
• Decreasing urine output need for more fluids.

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Burn size in small children

• The head accounts for about 18 (instead of 9).
• The legs account for about 13 (instead of 18).

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Fluid requirements in children

• Use same formula for fluids to replace loss from
  burns.
• In children, add this amount to normal
  maintenance rate
• 10 kg - about 40 cc / hr maintenance fluids
• 20 kg - about 60 cc / hr
• 30 kg - about 70 cc / hr
• Expected urine output for child 1 cc / kg /hr
  
• for
  infant 2 cc/ kg / hr

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Fluids requirements in children

• 20 kg child with 30 burn
• 20 (kg) x 30() x 2 (cc/kg/) 1200 cc in
  24 hr
• Half of this in first 8 hr 600 cc in 8 hr 75
  cc / hr initially
• 75 cc / hr for burn loss normal 60 cc / hr
  maintenance
• 135 cc / hr initially
• How do you know if the patient is getting too
  much fluid,
• or too little?
• Check urine output, urine specific gravity,
  HCT

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• Be sure the patients airway, breathing and
  circulation are secure.
• Then treat the burn wound itself.
• In patients with large burns, do not initially
  spend much time carefully calculating fluids.
• Instead, start an IV and start giving fluids
  rather rapidly while exam is being performed. DO
  NOT BOLUS! 500cc/hr is a good rule.
• Later do the calculations.

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Special types of burn

• Circumferential burn
• Burn requiring escharotomy
• Electrical burn
• Chemical burn

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Circumferential burn

• Limb is burned all the way around.
• Soft tissues under the skin always swell with
  burns
• (due to capillary leak of fluids in first day
  or so).
• There is a loss of skin expansion due to the loss
  of turgor/elasticity in burned tissue
• Pressure inside limb gradually increases.
• Eventually, pressure inside limb exceeds arterial
  pressure.
• This requires escharotomy to relieve the pressure.

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Escharotomy - indications

• Circulation to distal limb is in danger due to
  swelling.
• Progressive loss of sensation / motion in hand /
  foot.
• Progressive loss of pulses in the distal
  extremity by palpation or doppler.
• In circumferential chest burn, patient might not
  be able to expand his chest enough to ventilate,
  and might need
  escharotomy of the skin of the chest.

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Escharotomy - complications

• COMPLICATIONS
• Bleeding might require ligation of superficial
  veins
• Injury to other structures arteries, nerves,
  tendons
• NOT every circumferential burn requires
  escharotomy.
• In fact, most DO NOT need escharotomy.
• Repeatedly assess neuro-vascular status of the
  limb.
• Those that lose circulation and sensation need
  escharotomy.

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Escharotomy

• Eschar burned skin
• Escharotomy cut burned skin to relieve
  underlying pressure
• Similar to bivalving a tight cast.
• Cut along inside and outside of limb from good
  skin to good skin
• Knife can be used, or cautery.
• Use local or no anesthesia.
• (Full-thickness burn should have no
  sensation, but underlying tissues do!)

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Escharotomy of forearm

• Incise along medial and/or lateral surfaces.
• Avoid bony prominences.
• Avoid tendons, nerves, major vessels.

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Escharotomy

• Patient had escharotomy of
• both legs.
• Incisions will heal.
• They will not be closed by DPC.
• These large burns are often
• treated by the open technique,
• that is, without dressings.

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Electrical burn

• Outer skin might
• not appear too bad.
• But heat was conducted
• along the bone.
• Causes the most damage.
• Burns from inside out.
• Usually requires fasciotomy

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Fasciotomy

• Fascia thick white covering of muscles.
• Fasciotomy fascia is incised (and often
  overlying skin)
• Skin and fascia split open due to underlying
  swelling.
• Blood flow to distal limb is improved.
• Muscle can be inspected for viability.

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Phosphorus

• Particles of phosphorus must be removed from
  under the skin.
• Pick them off with forceps.
• Must apply wet dressing to prevent re-igniting.

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QUESTIONS?SUMMARY

• Describe how to estimate the body surface area of
  burn.
• Describe how to calculate initial fluid
  requirements in a patient with a large burn.
• Describe intial management of a patient with a
  large burn.
• Discuss indications and complications of
  escharotomy.

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BURN DOWN DIRTY

• Educate your Task Force!
• proper technique for burning waste,
  wear of clothing
• Do not hesitate to evacuate.
• Burns other than inhalation generally dont kill
  at point of injury- Bleeding and breathing
  injuries do!
• Oral Abx if managing burn at BAS ?