Burns in the Emergency Department

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Burns in the Emergency Department

• Nicole Coyne, MBS, MMS, PA-C
• Arizona Burn Center

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Learning Objectives

• Understand the parameters of burn injury
• Properly evaluate burns
• Recognize the need for early referral
• Appropriately manage the burn and other system
  abnormalities that occur as a result of burns

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The Basics

• Skin Anatomy
• Epidermis
• 10 skins thickness
• Acts as barrier
• Dermis
• 90 skins thickness
• Contains accessory structures
• Collagen, elastin
• Mechanoreceptors

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The Basics

• Skin Functions
• Protection
• Sensation
• Heat regulation
• Barrier to fluid loss
• Storage
• Absorption
• Water resistance

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Evaluation of burn depth
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Superficial Burns

• Only epidermis involved
• Red, painful, no blisters
• EX sunburn
• Heal within 7 days without scarring

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Superficial Burn
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Superficial Burn
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Partial Thickness Burns

• Extends partially into dermis
• Divided in to superficial and deep
• Superficial
• EX hot water scald
• Pink, moist, blisters, painful
• Deep
• EX hot grease scald
• Pale pink to white, decreased cap refill, may be
  less painful
• Most will heal without grafting in 7-21 days
• Minimum to severe scars

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Superficial Partial Thickness Burn
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Superficial Partial Thickness Burn
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Deep Partial Thickness Burn
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Indeterminate Partial Thickness Burn
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Full Thickness Burn

• AKA third degree burn
• Epidermis and full thickness dermis involved
• Hard, leathery, insensate
• Flame burn is a good example
• Only small burns will heal
• Almost always requires surgery

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Full Thickness Burn
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Full Thickness Burn
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Full Thickness Burn
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Beyond Full Thickness

• Involvement of
• Muscle
• Tendon
• Bone
• Blood vessel
• Nerve

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More than skin deep
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Initial evaluation of burns
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ABCs

• Airway
• Does mechanism suggest airway compromise?
• Will the patient require large amounts narcotics?
• Only give IV
• Volume of distribution disrupted by burn shock
• Breathing
• 100 oxygen non-rebreather
• Circulation
• 2 large bore IVs, preferably in unburned skin
• Need to resuscitate?
• Calculate TBSA to determine

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Airway Management

• Intubate if
• History suggests airway compromise
• Closed space injury
• Carbonaceous sputum
• Facial burns
• COHbgt5
• Hoarse voice
• Singed facial hair
• Patient unable to protect airway due to trauma or
  large doses of narcotics
• Pulse ox not reliable
• Carbon monoxide has 100x higher affinity for Hb,
  oximeter reads as O2

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Airway Management

• Intubate?
• 63 year old male with COPD, smoking with nasal
  cannula 1/6/12

NO!
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Airway Management

• Same patient
• 7/24/12

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Breathing

• All patients should be placed on 100 oxygen by
  non-rebreather
• Better to intubate early and not need it than
  wait and have a difficult airway

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Circulation

• Large bore IVs, through unburned skin if possible
• Parkland resuscitation for burns 20 or greater

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Circulation Calculating TBSA

• Rule of Nines

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Circulation Calculating TBSA

• Lund-Browder

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Circulation Resuscitation

• Patients with gt20 TBSA at highest risk for burn
  shock
• Magnitude influenced by
• Depth and extent of burn
• Pre-existing illness
• Presence of inhalation injury

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Circulation ResuscitationBurn Shock
Pathophysiology

• Edema forms rapidly after injury
• Peaks at 12 hours post burn
• Increased perfusion to injured area
• Increased capillary permeability
• Release of histamine, prostaglandins, kinins
• Causes edema in non-burned tissues
• Decreased oncotic pressure (Starling)
• Leakage of proteins into interstitial
• Decreased cell transmembrane potential
• Cellular swelling due to influx of sodium

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Circulation Resuscitation Goals

• Maintain adequate tissue perfusion to end organs
• End point urine output
• Adults 0.5 mL/kg/hr
• Children 1 mL/kg/hr
• Electrical burns 1-2mL/kg/hr
• Diuretics not indicated in acute setting
• Use foley catheter to monitor

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Circulation Resuscitation Formula

• Parkland Formula
• Burns 20 TBSA and greater
• 4mL LR x Weight in kg x TBSA 24 hour post burn
  total
• Half of volume given in first 8 hours post burn
• Rest given in remaining 16 hours
• Use of colloid
• Rescue vs. standard protocol

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Circulation Resuscitation Formula

• Example
• 70 kg male with flash burn to face, chest,
  abdomen and volar surfaces of BUE

TBSA?
31 4 face, 18 chest and abdomen, 4.5 each
upper extremity
Resuscitation?
YES! (4mL)(70kg)(31 TBSA)8680 in 24 hrs 542.5
mL/hr for first 8 hours 271.25 mL/hr next 16 hours
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Circulation Resuscitation

• Factors influencing fluid requirements
• Burn depth
• Inhalation injury
• Can increase needs by 30-50
• Delay in resuscitation
• Compartment syndrome
• Electrical burns
• Myoglobinuria

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Under-Resuscitation

• Intravascular volume depletion
• Hemoconcentration elevated hematocrit
• Suboptimal tissue perfusion
• End organ failure
• Death

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Over-Resuscitation

• Results in resuscitation morbidity
• Abdominal compartment syndrome
• Decreased renal blood flow, leading to renal
  failure
• Intestinal ischemia
• Respiratory failureincreased peak airway
  pressure
• Airway obstruction
• Extremity compartment syndrome
• Pulmonary edema

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Referral to a burn center
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In Arizona

• Only one nationally verified burn center
• 450,000 burn injuries yearly require treatment
  nationally (2011 data)
• 45,000 require hospitalization
• 3,500 deaths per year (approx 8)
• 70 Patients male
• Arizona Burn Center 2010
• 947 admissions
• 9 deaths (less than 1)
• Over 5500 outpatient visits

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ABA Referral Criteria

• Partial-thickness burns of greater than 10 of
  the total body surface area
• Burns that involve the face, hands, feet,
  genitalia, perineum, or major joints
• Third-degree burns in any age group
• Electrical burns, including lightning injury
• Chemical burns
• Inhalation injury
• Burn injury in patients with preexisting medical
  disorders that could complicate management,
  prolong recovery, or affect mortality
• Any patients with burns and concomitant trauma
• Burned children in hospitals without qualified
  personnel or equipment for the care of children
• Burn injury in patients who will require special
  social, emotional, or rehabilitative intervention
  

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Complicated injuries
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Need for Specialized Care

• Chemical burns
• Electrical burns
• Circumferential burns

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Chemical Burns

• Can be from acids or bases
• May not appear to be as deep initially
• Must be copiously irrigated with WATER
• Delay transport for decon
• Do not try to neutralize

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Electrical Burns

• Good history important
• Monitor for cardiac abnormalities
• Injuries may be much worse than they appear
• Risk of rhabdomyolysis

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Circumferential Burns

• Compartment Syndrome
• Circumferentially burned extremities at highest
  risk
• Clinical diagnosis vs. measured compartment
  pressures
• 6 Ps
• Pain
• Paresthesia
• Pallor
• Paralysis
• Poikliothermia
• Pulselessness
• Escharotomy
• Incision through burned skin to underlying
  subcutaneous tissue
• Fasciotomy
• Incision through the fascia overlying muscle
  compartments of an extremity

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Escharotomy/Fasciotomy

• Extend incisions through unburned tissue
  proximally and distally if possible
• Incisions made mid-medial and mid-lateral on
  extremity
• Shield escharotomy used in patients with
  circumferential torso burns to improve
  ventilation
• Do at bedside if patient unstable

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Escharotomy vs Fasciotomy

• Escharotomy

• Fasciotomy

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Summary

• Depth of injury determined largely by mechanism
• Early referral to a specialized burn center
  improves both morbidity and mortality
• Other system abnormalities may occur as a result
  of burns and require specialized treatment

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Thank You!

• Questions?
• Contact information

Nicole Coyne, PA-C Arizona Burn
Center 602-344-5726 Nicole_Coyne_at_dmgaz.org