APPROACH TO A BURN PATIENT3 February 2010 BLOCK 9A San Gabriel Katrina SanianoRegner Santos Joy Santos Socorro Sison Meg Sorreda Jay Sotalbo Karen
Objectives • To present a clinical case of a burn patient • To know the approach to a burn patient in the emergency room • To discuss the management principles in a burn patient • To differentiate the different types of burn injuries
Patient Profile • JG 25 M • Chief complaint: electrical injuries • 25 minutes post-injury
Primary Survey1310hrs (25 mins post-injury) • Patient arrived via a jeepney and immediately brought to the triage area • Patient was seen still with clothes on and with companions complaining of electrocution • Patient was breathing spontaneously but was disoriented and in pain • Vitals: BP110/70 mmHg HR 96 bpm RR 18 • Clothes were cut & removed, injuries were inspected • Extensive burn injuries to both arms, front of chest and abdomen and posterior axillary areas
1315hrs • Patient was transferred to the ACU c/o surgery • Minimal bleeding seen from wounds, full and equal pulses for both arms and hands • Normal vital signs noted
1320hrs:Resuscitation Area (35 mins post-injury) • Double line G18 inserted both ankle areas • Fast drip with 1L Lactated Ringer’s solution • Blood extracted for CBC, PT/PTT, blood typing, crossmatching and electrolytes • Foley catheter inserted, noted initial urine output ~200cc clear yellow urine
Secondary Survey • JG, 26 yo/M, married, RC from Bulacan • brought to ER due to electrical injury 25 minutes post injury. • Pt is a construction worker at a building in Remedios St., Malate
Secondary Survey • While working on the electrical connection for the building lighting, he accidentally made contact with the building’s main power line • Contact point was the patient’s abdomen. Patient was in contact for less than a second, then was thrown back. • + disorientation • + loss of consciousness • + blister formation on upper extremities, anterior chest, and abdomen
Secondary Survey • Past Medical History • no known medical conditions or illnesses • no known allergies to food or medication • no past surgeries or hospitalizations • Family History • Hypertension –father • Personal and Social History • Smoker for 5 pack years • Alcoholic beverage drinker consuming (3) 500ml bottles of beer two times a week
Secondary Survey • Review of Systems • (-)vomiting • (-) dyspnea • (-) chest pain • (-) palpitations
Physical Examination • awake, conscious, coherent and in pain • HEENT: anictericsclerae, pink conjunctivae, no cervical lymphadenopathy, no neck vein engorgement, no tonsillopharyngeal congestion • Chest: adynamicprecordium, distinct heart sounds, normal rate regular rhythm, no murmurs • Lungs: equal chest expansion, clear breath sounds, no crackles, no rales, no wheezes • Abdomen: soft, with pain & tenderness normoactive bowel sounds
Physical Examination • Extremities: pink nailbeds, full and equal pulses over all extremities, (-) edema (-) cyanosis • Neurologic: Patient is oriented to time place and person and is aware of the events that occurred prior to being shocked. Patient can move all four extremities and fingers, 50% light touch perception on fingertips, <25% light touch perception on chest, abdomen and arms.
Physical Examination • Burn Injury: extensive electrical burn injuries over hands, arms, chest, abdomen, periorbital area and posterior axillary area • multiple pale areas over abdomen and hands, minimal bleeding • burn injuries were mostly dry with some pain on skin contact.
Blood Type • Blood Type: “A” positive
Radiologic Findings • Normal Chest X-ray AP • Pelvis APL normal
Electrical injury 35% cutaneous burn (26% SPT torso, B UE, 9% DPT torso Plan: Admit to Burn unit (1400Hrs) Refer to Ophtha Assesment/Plan
Admitted at BURN Unit…1 hr & 30 min post injury • Monitor VS Q1, UO Q1, TQ4 (UO>50 cc/hr) • IVF: load PLR 2 L, then regulate at 600 cc/hr for 6 hrs • If UO>50 cc/hr for 3 hrs, decrease IVF to 500 cc/hr • Decrease IVF by 50 cc/hr if UO is >50cc/hr until 100 cc/hr is reached
Medications • Tramadol 50 mg/tab 1 tab q8 • MV with zinc, 1 cap OD • VitC, 500 mg/cap; 2 caps OD
Post Burn- Day 1 • UO ~ 100 cc/hr • Tmax 37.6 • BP 110/70 • IVF decreased by 300 cc/hr, then decreased to 150 cc/hr later that day • Diet: 2725 cal/day ( 3 meals, 2 snacks) • CHON 220 cal • CHO 1665 cal • Fats-rest
Post-Burn Day 2 • Tmax=38.4 • Treg=36.9 • UO=325cc/8 hrs • BP=120/70 • IVF: D5NR 1L x 100 cc/hr, decrease by 10cc/hr if UO>30cc/hr until 10cc/hr, then discontinue foley and IV
Post-Burn Day 3 • Wound inspection • Torso 3% DPT • L arm 1.5% DPT • R arm 0.5% DPT • MEBO ointment and semi-open dressing • IVF: heplock, foley discontinued
Post-Burn Day 3… • Tmax=39.0 • Treg=37.5 • UO= 3580/1870 • BP=120/70 • Wounds: 3% DPT torso, B UE • Rest SPT • (-) BWI
Referred to Rehab Med • For PT/OT/psych referral • Splinting of B wrist and hand • Encourage sitting with legs dangling • Ambulation with fall precautions
US DATA • Deaths from fires and burns are the 5th most common cause of unintentional injury deaths in the United States (CDC 2006) and the 3rd leading cause of fatal home injury (Runyan 2004). • In 2008, someone died in a fire about every 158 minutes, and someone was injured every 31 minutes (Karter 2009). • Four out of five U.S. fire deaths in 2008 occurred in homes (Karter 2009).
Selected Statistics on Admissions to Burn Centers, 1995-2005 Survival Rate: 94.4%Total Body Surface Area Burned (TBSA): Over one-third of admissions (38%) exceeded 10% TBSA, and 10% exceeded 30% TBSA. Most included severe burns of such vital body areas as the face, hands and feet. Gender: 70% male, 30% female Ethnicity: 62% Caucasian, 18% African-American, 12% Hispanic, 8% Other Burn Cause: 46% fire/flame, 32% scald, 8% hot object contact, 4% electrical, 3% chemical, 6% other Place of Occurrence: 43% home, 17% street/highway, 8% occupational, 32% other
US DATA Groups at increased risk of fire-related injuries and deaths include: • Children 4 and under (CDC 1998; Flynn 2008); • Older Adults ages 65 and older (CDC 1998; Flynn 2008); • African Americans and Native Americans (CDC 1998; Flynn 2008); • The poorest Americans (Istre 2001; Flynn 2008); • Persons living in rural areas (Ahrens 2003; Flynn 2008); • Persons living in manufactured homes or substandard housing (Runyan 1992; Parker 1993).
THERMAL INJURIES • SCALDS —70% of burns in children;They also often occur in elderly people. Water at 140°F (60°C) creates a deep partial-thickness or full-thickness burn in 3 seconds. At 156°F (69°C), the same burn occurs in 1 second. Scald burns from grease or hot oil are usually deep partial-thickness or full-thickness burns, as the oil or grease may be in the range of 400°F (200°C).
THERMAL INJURIES • FLAME — often associated with inhalational injury and other concomitanttrauma. Flame burns tend to be deep dermal or full thickness.Flame burns are the second most common mechanism of thermal injury. • CONTACT—In order to get a burn from direct contact, theobject touched must either have been extremely hot or the contactwas abnormally long. Burns from brief contact with very hot substances are usuallydue to industrial accidents. Contact burns tend to be deep dermalor full thickness.
THERMAL INJURIES • FLASH - Explosions of natural gas, propane, butane, petroleum distillates, alcohols, and other combustible liquids, as well as electrical arcs cause intense heat for a brief time period. Flash burns generally have a distribution over all exposed skin, with the deepest areas facing the source of ignition. Are typically epidermal or partial thickness, their depth depending on the amount and kind of fuel that explodes