BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
Burn Injuries: The ProblemBurn Injuries: The Problem
2002 burns responsible for 322,000 deaths world 2002 burns responsible for 322,000 deaths world widewide
44thth as cause of unintentional child injury death in as cause of unintentional child injury death in the USAthe USA
33rdrd leading cause of unintentional death in leading cause of unintentional death in aboriginal community in NAaboriginal community in NA
Most burns occur in the urban environmentMost burns occur in the urban environment
adverse consequences more common in the rural adverse consequences more common in the rural environment environment
BURN RESUSCITATIONBURN RESUSCITATION
EARLY ACUTE CARE IMPACTS THE EARLY ACUTE CARE IMPACTS THE LONG TERM OUTCOME IN BURN LONG TERM OUTCOME IN BURN PATIENTSPATIENTS
MOST INITIAL CARE IS PROVIDED MOST INITIAL CARE IS PROVIDED OUTSIDE THE BURN CENTREOUTSIDE THE BURN CENTRE
BURN RESUSCITATIONBURN RESUSCITATION
Burn resuscitation begins at the sceneBurn resuscitation begins at the scene
Stop the burning processStop the burning processKeep the patient warmKeep the patient warmO2O2Assess for other injuriesAssess for other injuriesSmall burns ( partial thickness) < 10% can Small burns ( partial thickness) < 10% can
be cooledbe cooled
BURN RESUSCITATIONBURN RESUSCITATION
On arrival at hospitalOn arrival at hospital
History of the injuryHistory of the injuryPast medical historyPast medical historyMedicationsMedicationsAllergiesAllergiesLocation, depth and Location, depth and
size of the burnsize of the burn
ABCABC’’SS
AIRWAY INJURYAIRWAY INJURY Present in 10 Present in 10 –– 20 % of 20 % of burn patientsburn patients
Identified in 60 Identified in 60 –– 70 % 70 % of patients who die in of patients who die in burn centersburn centers
RISK FACTORS:RISK FACTORS:Extremes of ageExtremes of agePhysical disabilityPhysical disabilityChemically impairedChemically impairedLoss of consciousnessLoss of consciousnessLarge BSA burnLarge BSA burn
BURN RESUSCITATIONBURN RESUSCITATION
Often present without Often present without burn injuryburn injury
Potential early Potential early problem due to problem due to edema edema
BURNBURN RESUSCITATIONRESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
Carbon monoxide poisoningCarbon monoxide poisoning
Awake:Awake:Hi flow O2Hi flow O2Until Until COHgbCOHgb < 5%< 5%
Obtunded:Obtunded:IntubateIntubate & provide & provide
100% O2 via 100% O2 via ventilatorventilator
BURN RESUSCITATIONBURN RESUSCITATION
StridorStridor or Respiratory Distress &/OR Deep burns or Respiratory Distress &/OR Deep burns of the head & neckof the head & neck
If AbsentIf Absent::
100% O2100% O2Look for signs of airway Look for signs of airway InjuryInjury? ? LaryngocoscopyLaryngocoscopyIf edema present If edema present INTUBATE NOWINTUBATE NOW
BURN RESUSCITATIONBURN RESUSCITATION
Upper Airway ManagementUpper Airway Management
StridorStridor or Respiratory Distress &/OR Deep burns of the or Respiratory Distress &/OR Deep burns of the head & neckhead & neck
If presentIf present::
INTUBATE NOW !!INTUBATE NOW !!Ideally before excessive edema developsIdeally before excessive edema develops
Adequate tube size and lengthAdequate tube size and lengthPEEPPEEPElevate HOBElevate HOBTransfer to Burn CenterTransfer to Burn Center
BURN RESUSCITATIONBURN RESUSCITATION
Management of Lower Airway InjuryManagement of Lower Airway Injury
Asymptomatic: Asymptomatic: no treatmentno treatment
Symptomatic:Symptomatic:Cough, Wheeze, Good Gas Exchange, Cough, Wheeze, Good Gas Exchange, BronchorreheaBronchorrehea
100% O2, aggressive pulmonary toilet, 100% O2, aggressive pulmonary toilet, bronchodilators, monitor O2bronchodilators, monitor O2CONTINUED REASSESSMENTCONTINUED REASSESSMENT
BURN RESUSCITATIONBURN RESUSCITATION
Management of Lower Airway:Management of Lower Airway:
Symptomatic:Symptomatic:
Short of breath, progressive symptomsShort of breath, progressive symptomsimpaired gas exchangeimpaired gas exchange
IntubateIntubate, 100% O2 (maintain Sat > 92%), 100% O2 (maintain Sat > 92%)Baseline CXR, bronchodilatorsBaseline CXR, bronchodilatorschest wall chest wall escharotomyescharotomy if indicatedif indicated
AS INJURY / RESUSCITATION EVOLVES AS INJURY / RESUSCITATION EVOLVES MODIFICATIONS WILL BE NECESSARY!!!MODIFICATIONS WILL BE NECESSARY!!!
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:Visually deceiving burnsVisually deceiving burnsDestroyed epidermis still remains on the Destroyed epidermis still remains on the
woundwoundExtent/depth of injury is underestimated Extent/depth of injury is underestimated
unless removedunless removed
BURN RESUSCITATIONBURN RESUSCITATION
Burn DepthBurn DepthAll burns All burns ““progressprogress”” over the first 24 over the first 24 –– 36 36 hourshours
As a result all burns will appear to worsen As a result all burns will appear to worsen over the 1over the 1stst day or 2day or 2
BURN RESUSCITATIONBURN RESUSCITATION
Burn Shock:Burn Shock:outcome of a multiple factors including outcome of a multiple factors including hypovolemiahypovolemia, microcirculation changes, , microcirculation changes, and release of local and systemic and release of local and systemic inflammatory mediators which result in the inflammatory mediators which result in the bodybody’’s ability to meet cellular needss ability to meet cellular needs
The mainstay of treatment is fluid The mainstay of treatment is fluid resuscitationresuscitation
BURN RESUSCITATIONBURN RESUSCITATION
FLUID RESUSCITATION:FLUID RESUSCITATION:Rule of NinesRule of Ninesquick and easy method to estimate BSA burnedquick and easy method to estimate BSA burned
*most people forget*most people forgetthe differences the differences adult and infantadult and infant
* most burn sizes are * most burn sizes are GROSSLY over estimatedGROSSLY over estimated
BURN RESUSCITATIONBURN RESUSCITATION
FLUID RESUSCITATION:FLUID RESUSCITATION:Lund Lund BowderBowder ChartChartmore complicatedmore complicatedand time consuming and time consuming method to estimate method to estimate BSA burnedBSA burned
BUT MORE BUT MORE ACCURATE!!ACCURATE!!
BURN RESUSCITATIONBURN RESUSCITATION
Parkland (Baxter) Formula:Parkland (Baxter) Formula:most commonly used formula todaymost commonly used formula today
4cc/Kg/%BSA burn4cc/Kg/%BSA burn1/2in the first 8 hrs1/2in the first 8 hrs½½ in the next 16 hrsin the next 16 hrs
Lactated RingersLactated RingersUsing urine output as a clinical guideUsing urine output as a clinical guide
GOAL: 30GOAL: 30--50 cc50 cc’’s /hrs /hr1cc/kg in patients less than 30 1cc/kg in patients less than 30 kgskgs
Accurate in about Accurate in about 70%70% burn patientsburn patients12%12% require morerequire more, 18%, 18% require lessrequire less
Plasma can be given at any time but is most effective after Plasma can be given at any time but is most effective after 24 24 –– 36 hrs36 hrs
Can be of benefit in patients who do not respond to initial Can be of benefit in patients who do not respond to initial predicted fluid needspredicted fluid needs
BURN RESUSCITATIONBURN RESUSCITATION
Not all burn patients require INTRAVENOUSNot all burn patients require INTRAVENOUSfluid resuscitationfluid resuscitation
LESS THAN 10 LESS THAN 10 –– 15 %15 %if patient cooperative, no nausea and if patient cooperative, no nausea and vomitingvomitingDO NOTDO NOT allow unrestricted access to plain allow unrestricted access to plain water, especially in childrenwater, especially in children
BURN RESUSCITATIONBURN RESUSCITATION
New Problem: New Problem: FLUID CREEPFLUID CREEPPatients frequently receive fluid in excess Patients frequently receive fluid in excess of the predicted requirements!!of the predicted requirements!!
up to 48% MORE !!up to 48% MORE !!Problems: compartment syndrome Problems: compartment syndrome
(extremity & (extremity & abdabd.).)ARDS / pulmonary edemaARDS / pulmonary edemacerebral edemacerebral edemamultiple organ failuremultiple organ failure
BURN RESUSCITATIONBURN RESUSCITATION
Most burn resuscitation fails to meet the standard Most burn resuscitation fails to meet the standard set forth by the set forth by the PARKLAND PARKLAND formulaformula
Emphasis needs to be placed onEmphasis needs to be placed on MONITORINGMONITORING the response to fluid resuscitation rather than the response to fluid resuscitation rather than following the formulafollowing the formula
Best monitor is Best monitor is URINE OUTPUTURINE OUTPUT1 ml/kg/hr 1 ml/kg/hr CBC CBC –– hemoconcentrationhemoconcentrationABGABG’’ss -- acidosisacidosis
BURN RESUSCITATIONBURN RESUSCITATION
Other monitoringOther monitoring::Pulse Pulse -- young patient young patient -- < 120 reasonable< 120 reasonable
> 130 fluid> 130 fluid-- elderly / heart disease elderly / heart disease -- pulse not apulse not a
good reflection of perfusiongood reflection of perfusionECG ECG -- > 40 > 40 yoyoBlood pressure Blood pressure –– only useful if lowonly useful if lowElectrolytesElectrolytesPTT / INRPTT / INRProtein / AlbuminProtein / AlbuminCVP / Central pressures only if patient not CVP / Central pressures only if patient not
responding to predicted requirementsresponding to predicted requirements
BURN RESUSCITATIONBURN RESUSCITATION
RISK FACTORS FOR REQUIRING INCREASED RISK FACTORS FOR REQUIRING INCREASED RESUSCITATION FLUID VOLUMESRESUSCITATION FLUID VOLUMES
80% BSA burn80% BSA burn
Extremes of ageExtremes of age
Electrical injury Electrical injury –– current flowcurrent flow
Associated inhalation injuryAssociated inhalation injury
Associated traumaAssociated trauma
Delayed resuscitationDelayed resuscitation
MyoglobinuriaMyoglobinuria
BURN RESUSCITATIONBURN RESUSCITATION
MyoglobinuriaMyoglobinuria
If present requires increased volumes to flush the If present requires increased volumes to flush the pigment form the systempigment form the system
If persists > 12 hours risk of renal failureIf persists > 12 hours risk of renal failureu/ou/o of 100 of 100 –– 200 cc200 cc’’s /hours /hourAlkalinize the urineAlkalinize the urineUse Use manitolmanitol to force to force diuresisdiuresisMay need to use central pressure monitoring to May need to use central pressure monitoring to
assess response to fluids as urine output no assess response to fluids as urine output no longer usefullonger useful
BURN RESUSCITATIONBURN RESUSCITATION
Management of the burn wound:Management of the burn wound:
Tetanus Tetanus ProphlaxisProphlaxisAnalgesiaAnalgesiaDebrideDebride the woundthe wound
chlorhexidinechlorhexidine, hydrotherapy, hydrotherapyTopical antibiotics Topical antibiotics -- ointmentsointments
-- flamazineflamazine creamcreamConsider closed dressings except for the face & perineumConsider closed dressings except for the face & perineum
Dressings protect the injured skin, reduce heat loss & provDressings protect the injured skin, reduce heat loss & provide ide comfortcomfort
NEW OPTIONS:NEW OPTIONS:silver containing dressingssilver containing dressingsacticoatacticoataquacelaquacel AgAg
IF IN DOUBT STERILE NONIF IN DOUBT STERILE NON--ADHERENT DRESSING LIKE JELONET ADHERENT DRESSING LIKE JELONET OR ADAPTIC UNTIL DEFINITIVE DEPTH CAN BE DETERMINED!OR ADAPTIC UNTIL DEFINITIVE DEPTH CAN BE DETERMINED!
THINGS WE CAN DO BETTER!THINGS WE CAN DO BETTER!
ASSESSMENT OF AIRWAYASSESSMENT OF AIRWAYACCURATE ASSESSMENT OF BSA ACCURATE ASSESSMENT OF BSA
BURNSBURNSACCURATE ASSESSMENT OF BURN ACCURATE ASSESSMENT OF BURN
DEPTHDEPTHMORE CAREFUL MONITORING OF THE MORE CAREFUL MONITORING OF THE
RESPONSE TO FLUIDS ADMINISTEREDRESPONSE TO FLUIDS ADMINISTERED
THANK YOUTHANK YOU
QUESTIONS ????QUESTIONS ????
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
Burn Depth:Burn Depth:
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
BURN RESUSCITATIONBURN RESUSCITATION
Burn Shock:Burn Shock:Circulatory collapse when blood pressure Circulatory collapse when blood pressure is too low to maintain tissue perfusionis too low to maintain tissue perfusion
The magnitude of intravascular fluidThe magnitude of intravascular fluidloss can be easily underestimated loss can be easily underestimated much of the fluid accumulates beneath much of the fluid accumulates beneath the burnthe burn
BURN RESUSCITATIONBURN RESUSCITATION
Burn Resuscitation & Cholera??Burn Resuscitation & Cholera??
Dr. ODr. O’’Shaughnessy 1831 analyzed cholera Shaughnessy 1831 analyzed cholera patients noting diarrhea leads to dehydration, patients noting diarrhea leads to dehydration, electrolyte depletion, acidosis and Nitrogen electrolyte depletion, acidosis and Nitrogen retention retention
Treatment depended on IV Treatment depended on IV fluiidfluiid replacement of replacement of deficient salt and waterdeficient salt and water
1854 Ludwig von Buhl correlated the 1854 Ludwig von Buhl correlated the hemoconcentrationhemoconcentration seen in both burns and seen in both burns and cholera patients due to fluid losscholera patients due to fluid loss
ReccomendedReccomended saline either orally, saline either orally, subcutaneoulysubcutaneouly or intravenouslyor intravenously
BURN RESUSCITATIONBURN RESUSCITATION
Burns and the Theatre??Burns and the Theatre??
Dr. Frank Dr. Frank UnderhilUnderhil: The Rialto Theatre fire 1921 New : The Rialto Theatre fire 1921 New Haven Conn. Rudolph Valentino in the Haven Conn. Rudolph Valentino in the ShiekShiek
Showed blister fluid was similar to plasmaShowed blister fluid was similar to plasmaConcluded burn shock was due to fluid shiftsConcluded burn shock was due to fluid shiftsRecommended replacement of fluid with salt and protein Recommended replacement of fluid with salt and protein
using using HgbHgb as a guideas a guide
Coconut Grove Fire Boston Mass. 1942 Drs. Cope & Coconut Grove Fire Boston Mass. 1942 Drs. Cope & Moore Moore
patients treated with IV fluid resuscitation based on body patients treated with IV fluid resuscitation based on body surface area surface area
Monitored Monitored HctHct, U/O, BUN, U/O, BUNPatients with inhalation injury required more fluidPatients with inhalation injury required more fluidBUDGET FORMULA resuscitation was not based on BUDGET FORMULA resuscitation was not based on
patient sizepatient size