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 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? • Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.
First Degree Burns • Epidermis only • No blisters • Erythema • Mild to absent systemic response • Heals in 3-4 days
Superficial partial thickness • Papillary dermis • Blisters • Homogenous pink • Painful, hypersensitive • Blanches • Hair usually intact • Does not scar, may pigment differently
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
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
Inhalation injury diagnosis • Closed-space fire • Face burns
Terminology • Inhalation injury “nonspecific” • Thermal injury • Upper airway • Local chemical irritation • Throughout airway • Systemic toxicity • CO
History and physical Exposure Duration Enclosed space Diagnostic studies Clinical diagnosis
Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea Other signs and symptoms
Poison management = CO • 500 unintentional deaths each year • Persistent Neurologic Sequelae • May improve over time • Delayed Neurologic Sequelae • Relapse later
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
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
Objective data • Bronchoscopy • Edema • Infraglottic soot • Hyperemia • Mucosal sloughing • Sensitivity near 100% under IDEAL circumstances
Grading of injury • No reliable indicators of progressive respiratory failures • No studies have found any correlation with initial findings and clinical outcomes and progress
Field resuscitation • Start IV with LR, in burn OK • < 6 years = 125mL/hr • 6-13 years = 250mL/hr • >13 years = 500mL/hr
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
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
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.
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
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
How to do this • Maintain continuous IV fluid replacements • AVOID boluses • Only bolus IV fluids if hypotensive
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
Ice Pack-----DO NOT USE EVER • DOES NOT • Reverse temperature • Inhibit destruction • Prevent edema • DOES • Delay edema • Reduce pain
Medication • Medications • Opioids • Narcotics • Pain medications • IV Analgesia
Summary • Airway • Circulation/Resuscitation • Pain control