Burns Today, Burns Tomorrow

1. Burns Today, Burns Tomorrow Cindy Schmitz RN, MS, ANP Melissa Beltran, MSN, RN, CCRN Carl Hershey

2. Objectives • Describe initial evaluation and management of a burn patient • Review Burn Center locations and referral criteria • Discuss life after burn injury from a patient’s perspective

3. Types of Burns

4. Where Burns Occur

5. Admissions by Age

6. % of Admissions vs. Burn Size

7. Skin Anatomy

10. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

11. Smoke Inhalation Assessment • Flame burns • Enclosed space • Burns to face, mucosal membranes • Singed eyelashes, nasal hairs • Carbonaceous sputum • Hoarseness • Difficulty swallowing • Wheezing, stridor • Restlessness, confusion

12. Smoke Inhalation Carbon Monoxide Poisoning Time to CO clearance CO levels associated symptoms

13. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

14. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

15. Estimate % TBSA Burned Rule of Nines Patient’s palmar surface = 1% TBSA

16. Lund and Browder Chart Estimate % TBSA Burned

17. Estimate Burn Depth Factors • Temperature • Duration of contact • Dermal thickness • Blood supply • Special Consideration: Very young and very old have thinner skin

18. Burn Depth

19. Superficial : 1st Degree • Epidermis only • Pain & redness • Heals in few days; • outer injured epithelial cells peel • Seldom clinically significant

20. Partial Thickness: 2nd Degree • Entire epidermis & portion of dermis • Pain, blisters, moist, capillary refill • Uninjured dermis & epidermal appendages at risk • Heals spontaneously in 2-3 weeks • Deeper partial thickness -Skin graft may improve functional & cosmetic outcome

21. Full Thickness: 3rd degree • All skin layers are affected • white, hemorrhagic, brown, black, or charred • Inelastic and leathery • painless or numb • Requires skin grafting for definitive closure

22. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

23. IV Access • Large burn -2 large bore IV’s • Smaller burn (< 15% TBSA) – one IV is OK • oral resuscitation possible • IV through non-burn area if possible • Suture IV’s started through burns

24. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

25. American Burn Association Recommendations • For Burns over 20% TBSA burned • EMT/Paramedics Start IV Fluid: • Adults: LR @ 500 mL/hour • Children (<40 kg): LR @ 250 mL/hour • Children (<10 kg): D5LR @ 125 mL/hour Pre-hospital Fluids

26. Calculated Resuscitation in First 24 Hours • Parkland formula - LR • 2 mL x weight in kg x % TBSA burned • Give ½ the volume in first 8 hours • Give other ½ over next 16 hours • Example • 2 ml x 100 kg x 45% TBSA burned • 2 x 100 x 45 = 9,000 ml over the first 24 hours • ½ of that is 4,500 over first 8 hours • Start LR at 560 ml/hour

27. Calculated Resuscitation in First 24 Hours • Pediatric patients <20 kg • Parkland Formula - LR • 2 ml x 13 kg x 45% tbsa burned • 1170 ml • Start LR at 75 ml/hr • Also run maintenance fluid • D5 LR at maintenance rate • Calculated Using the "4-2-1" Rule: • For 0-10kg: 4 mL/kg/hr • For 10-20kg: + 2 mL/kg/hr • For >20kg: + 1 mL/kg/hr • 46 ml/hr • Continuous infusion- don’t titrate

28. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • Keep patient warm

29. Monitor Urine Output • Place Foley if > 20% TBSA • Adequate output is: • 1mL/kg/hr in children • 0.5 mL/kg/hr in adults (30 – 50 mL/hr) • Titrate LR to maintain urine output • Do not use diuretics to increase urine output • Urine output goal 100mL/hr if concern for myoglobinuria

30. Initial Evaluation & Management • Assess airway/breathing • Ensure source of heat removed • Estimate extent of burn • Obtain/ensure adequate IV access • Initiate/continue resuscitation • Closely monitor urine output • KEEP PATIENT WARM!!!!!

31. Next Priorities • Insert NG tube • Escharotomies • Medications • Wound care

32. Next Priorities • Insert NG tube • Escharotomies • Medications • Wound care

33. Escharotomies • Only for leathery, circumferential, full-thickness burns • Rarely needed if transport < 12 hours • Almost always done at the Burn Center • Emergent indications: • Unable to ventilate • Pulseless, painful extremity

34. Next Priorities • Insert NG tube • Escharotomies • Medications • Wound care

35. Medications • Pain control • Pain control • More pain control • Tetanus immunization • NO need for systemic antibiotics

36. Non-Medication Methods • Cover burns with plastic wrap • Keeps air off wound less pain • Wet dressings will stick and cause more pain • Other burn dressings are expensive and not necessary • Quik Clot is expensive and will not provide any patient benefit • Distraction

37. Ice Pack---DO NOT USE EVER! • DOES NOT • Reverse temperature • Inhibit destruction • Prevent edema • DOES • Delay edema • Reduce pain • can worsen tissue distruction

38. Pain Medications • IV Narcotics • Dilaudid • Fentanyl • Morphine • Oral Narcotics • Oxycodone

39. Next Priorities • Insert NG tube • Escharotomies • Medications • Wound care

40. Wound Care • Debridement and dressings done after transfer • Transport patient in DRY sheet or plastic wrap and blanket • If transport delayed > 12 hours • Debride loose tissue and clean with soap and water • Apply Silver Sulfadiazine and wrap loosely with gauze

41. Burn Center Referral • All burned children • Any burn > 10% TBSA • Any full-thickness burn • Burns to hands, face, feet or perineum • Any Electrical or Chemical burns • Inhalation injury • Burns and concomitant trauma when the burn injury poses the greatest risk • Burn and preexisting medical problems Excerpted from Guidelines for the Operation of Burn Centers (pp. 79-86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons

42. Regional Burn Centers Dwan Burn Center in Duluth, MN University of Chicago Burn Center in Chicago, IL • Hennepin County Medical Center Burn Center in Minneapolis, MN The Burn Center – Regions Hospital in Minneapolis, MN • Columbia St. Mary’s Hospital Regional Burn Center in Milwaukee, WI • UW Health Burn Center in Madison, WI • Children’s Hospital of Wisconsin in Milwaukee, WI • Sumner L. Koch Burn Center in Chicago, IL • Loyola University Medical Center near Chicago, IL

43. Key Take Aways • Transport patient in plastic wrap and DRY sheets or blankets • Give fluids as recommended by the American Burn Association for burns greater than 20% TBSA • Burns hurt! Provide narcotics and non-pharmacological methods to control pain.

44. Questions??

45. Meet Carl

46. References • American College of Surgeons (2014). Guidelines for Trauma Centers Caring for Burn Patients. Resources for Optimal Care of the Injured Patient (2014). Chicago, IL: Committee on Trauma, American College of Surgeons • Burn Center Regional Map (n.d.). Retrieved from http://ameriburn.org/public-resources/burn-center-regional-map/ • Burn Incidence and Treatment in the United States: 2016 (n.d.). Retrieved from http://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/ • National Burn Repository (n.d.). Retrieved from http://ameriburn.org/quality-care/quality-and-burn-registry-programs/