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Initial Burn Care. Lee D. Faucher, MD FACS Director UW Burn Center Associate Professor of Surgery & Pediatrics. Objectives. Discuss burn pathophysiology Outline treatment modalities Understand why some treatments better than others. What is a burn?.

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Initial Burn Care


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    1. Initial Burn Care Lee D. Faucher, MD FACS Director UW Burn Center Associate Professor of Surgery & Pediatrics

    2. Objectives • Discuss burn pathophysiology • Outline treatment modalities • Understand why some treatments better than others

    3. What is a burn? • Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

    4. First Degree Burns • Epidermis only • No blisters • Erythema • Mild to absent systemic response • Heals in 3-4 days

    5. Superficial partial thickness • Papillary dermis • Blisters • Homogenous pink • Painful, hypersensitive • Blanches • Hair usually intact • Does not scar, may pigment differently

    6. Sup 2nd degree

    7. Deep partial thickness • Reticular dermis • Mottled red and white • Not painful to pinprick or pressure • Does not blanch • Heals > 3 weeks • Usually scars • Need to excise and graft

    8. Deep dermal

    9. Full thickness burns • Into fat or deeper • Red, white, brown, black, etc. • Diminished sensation • Dry, may be leathery • Depressed • Heals only from the periphery • Always excise and graft

    10. Full-thickness

    11. Etiology

    12. Types of burns

    13. Where do burns occur

    14. Circumstances of injury

    15. Admissions by age

    16. % of admissions vs. burn size

    17. Inhalation injury diagnosis • Closed-space fire • Face burns

    18. Terminology • Inhalation injury “nonspecific” • Thermal injury • Upper airway • Local chemical irritation • Throughout airway • Systemic toxicity • CO

    19. History and physical Exposure Duration Enclosed space Diagnostic studies Clinical diagnosis

    20. Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea Other signs and symptoms

    21. Poison management = CO • 500 unintentional deaths each year • Persistent Neurologic Sequelae • May improve over time • Delayed Neurologic Sequelae • Relapse later

    22. Poison management = CO • Treatment • CO level means nothing to predict outcome • Length of hypoxia is the determining factor • Oxygen • HBO • No studies show benefit in treatment

    23. Pathophysiology • The main factor responsible for mortality in thermally injured patients • Carbon monoxide the most common toxin • 200 times greater affinity • Competitive inhibition with cytochrome P-450

    24. Reduction of CO

    25. Objective data • Bronchoscopy • Edema • Infraglottic soot • Hyperemia • Mucosal sloughing • Sensitivity near 100% under IDEAL circumstances

    26. Grading of injury • No reliable indicators of progressive respiratory failures • No studies have found any correlation with initial findings and clinical outcomes and progress

    27. Resuscitation

    28. Field resuscitation • Start IV with LR, in burn OK • < 6 years = 125mL/hr • 6-13 years = 250mL/hr • >13 years = 500mL/hr

    29. Rule of Nines

    30. Lund and Browder Chart

    31. IV access • < 15% TBSA – oral resuscitation • 15 – 40% TBSA – one large bore IV • > 40% -- two large bore IV’s • IV’s should be in the upper extremities • Suture IV’s started through burns

    32. Crystalloid solution • Ringer’s Lactate • [Na+] 130 mEq (serum 140 mEq) • Osmolality 272 mOsm (serum 300mOsm) • Advantages of crystalloid • Effective in maintaining perfusion • Costs less than colloids • Can be mobilized with a diuretic

    33. Resuscitation first 24 hours • Baxter formula • 4 mL/kg/% TBSA burned • Give ½ the volume in first 8 hours and other ½ over next 16 hours.

    34. If < 20kg • Same Baxter formula for LR • Add 4mL/kg of D5 ¼ NS • Infuse at constant rate, increase LR if needed for adequate urine output

    35. Monitor urine output • Place foley if > 20% TBSA • Urine output goal • 2 mL/kg/hr very young • 1 mL/kg/hr child • 0.5 mL/kg/hr adult • Diuretics are NEVER used to increase urine output • Increase urine output to > 100mL/hr if pigment present

    36. How to do this • Maintain continuous IV fluid replacements • AVOID boluses • Only bolus IV fluids if hypotensive

    37. Zones of burn injury

    38. Pain control

    39. Non-medication methods • Cover burns with plastic wrap • 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

    40. Ice Pack-----DO NOT USE EVER • DOES NOT • Reverse temperature • Inhibit destruction • Prevent edema • DOES • Delay edema • Reduce pain

    41. Medication • Medications • Opioids • Narcotics • Pain medications • IV Analgesia

    42. Summary • Airway • Circulation/Resuscitation • Pain control