Burn management
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Burn Management. Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222. Overview. Pathophysiology of Burns Burn Classifications Criteria for Transfer to Burn Center Initial Assessment & Management Airway Management Smoke Inhalation Injury

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Burn Management

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Burn management

Burn Management

Tad Kim, M.D.

UF Surgery

[email protected]

(c) 682-3793; (p) 413-3222


Overview

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


Pathophysiology of burns

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)


Pathophysiology of burns1

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


Classification of burn depth

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.


Classification of burn depth1

Classification of Burn Depth


Criteria for burn center referral

Partial thickness > 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

Criteria for Burn Center Referral


Initial assessment

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 -> edema

    • Edema from inflammatory response to burns

    • Edema from the resuscitation fluids


Initial assessment1

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


Initial assessment2

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 Ringer’s

    • Place patient on continuous EKG / monitor

    • Palpate or doppler extremity signals with circumferential extremity burns

  • Disability (GCS less than eight -> intubate)

  • Exposure: remove all clothing


Initial assessment3

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)


Initial assessment4

Initial Assessment

  • Burn Resuscitation with Lactated Ringer’s

  • Figure out burn size by “rule of nines” or entire palmar surface of pt’s 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


Burn resuscitation

Burn Resuscitation

  • 70kg male with 40% TBSA

    • EMS administered 1.5L of fluids already

  • What rate of LR should he receive?


Burn wound management

Burn Wound Management

  • Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation

  • Assess for the 6 P’s

    • 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)


Burn wound management1

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


Topical antimicrobials

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


Electrical burns

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


Chemical burns

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


Take home points

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


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