Burn Management

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Burn Management

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

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Overview

• Pathophysiology of Burns
• Burn Classifications
• Criteria for Transfer to Burn Center
• Initial Assessment Management
• Airway Management
• Smoke Inhalation Injury
• Shock Fluid Resuscitation
• Burn Wound Management
• Electrical Injury Chemical Burns

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Pathophysiology of Burns

• Burns cause coagulative necrosis
• Chemical/Electricity also cause direct injury to
  cell membranes, in addition to heat transfer
• Causes
• Flame, Scald, Contact, Chemical, Electricity
• Depth of burn depends on
• 1. Temperature
• 2. Time exposed
• 3. Specific heat (higher for grease)

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Pathophysiology of Burns

• Burns a/w release of inflamm. mediators
• Increased capillary permeability
• Leak proteins into interstitium
• Get edema in burned non-burned skin
• Large fluid loss due to fluid shifts also
  losses from exposed burned skin
• Characteristic Ebb and Flow of burns
• Ebb Low metabolism/cardiac output, ?Temp
• Flow hypermetabolism, high cardiac output,
  hyperglycemia, increased heat produx

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Classification of Burn Depth

• 1st degree localize to epidermis (sunburn)
• 2nd degree injury to both dermis/epidermis
• Superficial 2nd papillary dermis
• Typically red, painful, blister, wet appearing
• Regen in 7-14 days from hair follicles/sweat
  glands
• Deep 2nd reticular dermis
• Typically more pale/mottled, dry, ?sensation
• 3rd degree full thickness epidermis/dermis
• Hard, leathery eschar, painless
• 4th degree involves muscle, bone, etc.

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Classification of Burn Depth
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Criteria for Burn Center Referral

• Partial thickness gt 10
• Inv. face, hands, feet, genital/perineum, joints
• Any full thickness burn
• Electrical injury
• Chemical burn
• Inhalational injury

• Comorbidities (CHF)
• Concomitant trauma
• Children
• Special emotional, social, or rehab needs

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Initial Assessment

• Called to the ER for a 35yo male rescued from
  housefire w face/trunk/extrem burns
• Always start with ABC
• In trauma/burns, ABCDE (disability/exposure)
• Airway can be an issue with severe burns or
  inhalational injury (esp. with indoor fire)
• Direct injury from heated air/smoke -gt edema
• Edema from inflammatory response to burns
• Edema from the resuscitation fluids

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Initial Assessment

• Suspect airway injury if
• Facial burns, singed nasal hairs, wheezing,
  carbonaceous sputum, tachypnea
• Give pt oxygen put on pulse oximetry
• Progressive hoarseness is a sign of impending
  airway obstruction
• Pre-emptively intubate anyone with
• Respiratory distress, inhalational injury, large
  burns (due to inevitable edema from resusc)
• Bronchoscopy to help dx inhalational injury

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Initial Assessment

• Breathing (Breath sounds, chest rise, ET CO2)
• Chest escharotomies if constrictive eschar
• Circulation get vitals (HR BP)
• 2 large bore IV (unburned before burned skin)
• Start burn resuscitation with Lactated Ringers
• Place patient on continuous EKG / monitor
• Palpate or doppler extremity signals with
  circumferential extremity burns
• Disability (GCS less than eight -gt intubate)
• Exposure remove all clothing

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Initial Assessment

• AMPLE history
• Allergies
• Medications (also ask about last tetanus)
• Past medical history (CHF careful w fluids)
• Last meal
• Events regarding the injury (how did the fire
  start, how long was the exposure, what type of
  exposure flame, grease)

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Initial Assessment

• Burn Resuscitation with Lactated Ringers
• Figure out burn size by rule of nines or entire
  palmar surface of pts hand 1
• Parkland formula
• 4 x Wt(kg) x TBSA mL to give in 1 day
• Half over 1st 8hrs (subtract what was given)
• Give other Half over next 16 hours
• In reality, titrate to UOP of 0.5mL/kg/hr in
  adults and 1mL/kg/hr in children
• Do not give colloid in first 24 hrs

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Burn Resuscitation

• 70kg male with 40 TBSA
• EMS administered 1.5L of fluids already
• What rate of LR should he receive?

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Burn Wound Management

• Circumferential deep 2nd or 3rd degree extremity
  burn can compromise circulation
• Assess for the 6 Ps
• Pain, pallor, pulselessness (check Doppler),
  paresthesias, paralysis, poikilothermia
• Directly measure tissue pressure (30 is cutoff)
• Dx Compartment syndrome
• Tx Escharotomy
• (Give tetanus toxoid if not up to date)

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Burn Wound Management

• Burn patients are susceptible to infection
• Due to immunologic insult of large burns
• Also because dead tissue is easily colonized
• Initially clean/debride cover with topical
  antimicrobial (no data for oral or IV abx)
• Superficial 2nd can use temporary pigskin
• 3rd (most) deep 2nd need early excision
  grafting, except palm/soles/face/genitals
• Perform at 3-7 days post-burn

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Topical Antimicrobials

• Sulfamylon for ears
• Good at penetrating eschar is painful
• Side effect metabolic acidosis via carbonic
  anhydrase inhibition
• Bacitracin for face
• Few side effects
• Silvadene for trunk, neck, extremities
• Does not penetrate eschar very well
• Side effects neutropenia/thrombocytopenia

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Electrical Burns

• Most significant injury is within deep tissue
• Edema can compromise circulation
• Be ready to perform eschar-/fasciotomies
• Explore debride necrotic tissue
• May have to re-explore questionable areas
• EKG if heart was in conduction path
• Follow serial CPK urine myoglobin due to
  possibility of rhabdomyolysis

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Chemical Burns

• Speed is essential
• ABCDE remove all clothing
• Irrigate with 15-20L of water
• Brush off any dry powder before irrigation
• Alkalis generally cause worse damage
• Do not attempt to counteract acid burns using
  alkali or alkali burns using acid

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Take Home Points

• Always start with ABCDE for trauma/burns
• Know what can compromise airway in burn patients
• Chest escharotomy may be needed
• Know and apply the Parkland formula
• Recognize the need for limb escharotomy
• Know depths of burn which req excision
• Know the types side effects of topicals
• Basics of treating chemical/electrical burns