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Project: Ghana Emergency Medicine Collaborative Document Title: Introduction to Burns Author(s): Robert Preston, MD License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/

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Introduction to Burns Robert Preston, MD

Division of Emergency Medicine Division of Burn, Trauma, and Critical Care

University of Utah [email protected]

Enlarge, Wikimedia Commons

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HPI •  9 year old with no significant medical history •  He lit his shirt on fire in his room •  He was able to extinguish the flames on his shirt,

but larger fire started in his room •  Neighbor/Ambulance staff rescued him from

bedroom, no longer on fire himself but confused and with obvious burns to much of his body

•  Initial Vitals: •  T 37.2 HR 121 BP 155/78 RR 24 S 92%ra

***

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Physical Face

Anterior thorax

Right arm, anterior and posterior, upper

½

Left arm, anterior aspect, entire limb

Face

Source Undetermined

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ABCs

•  General: Shaking, moaning •  A: Verbal, but confused. •  B: Crackles at bases. •  C: Thready, rapid, regular pulses •  D: Opens eyes to pain; Localizes to pain

(crossing midline)

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Physical •  VS: 155/78 P122 T 37.2

RR 24 Sat% 92% ra •  Gen: Shaking, moaning. •  Neuro: GCS 12; No FND •  HEENT: PERRL. Soot in

nose. •  Resp: Tachypenic.

Crackles at bases bilaterally

•  CV: Regular, rapid rate. No r,m,g. Burns to anterior chest

•  Abd: Tender to palpation due to burns. Not distended.

•  Skin: Burns to torso, front and back, as well as to upper anterior right arm, upper anterior and posterior left arm;

•  Extremities: Pulses 2/4 throughout in all extremities

***

***

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LABS

•  WBC: 13; Hgb: 15 Platelets: 390

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0.5 25

141

4.0

106 101

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Chest Xray

Source Undetermined

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Critical Actions ü  A-B-C approach ü  Pain control offered, provided ü  Tetanus status assessed ü  Identify probable inhalation injury and proceed with intubation ü  Estimate TBSA of burn (Rule of 9s or suitable other method) ü  Initiate adequate initial fluid resuscitation (Parkland formula or or

suitable other method)

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Webaware, Wikimedia Commons 11

First degree burn������

Jmh649, Wikimedia Commons

Bejinhan, Wikimedia Commons

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Superficial partial-thickness (2nd)

1Veertje, Wikimedia Commons 13

Deep partial-thickness (2nd)���

Westchaser, Wikimedia Commons

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Deep partial-thickness (2nd)���

Source Undetermined

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Full Thickness (3rd)���

Source Undetermined

Source Undetermined 16

The initial evaluation and management of burn injury

It’s never just a burn!

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Step 1: Decontamination

•  Flame and Scald injuries –  Remove clothing and use cool water/cloth to cool

•  Electrical injury –  C-spine precautions –  Assess for myocardial injury

•  Chemical –  Dilute, dilute, dilute –  Don’t waste time initially looking for specific antidoes*

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Step 2: Primary Survey & Airway Management

•  The burn patients is a multi-trauma patient •  A: Airway

–  Facial and oropharyngeal swelling progresses 24 –  Succinylcholine (?)

•  B: Breathing –  Assess for inhalation injury

•  C: Circulation –  Evaluate for circumferential burns –  Assess pulses frequently

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Inhalation injury •  Responsible for most deaths from fires •  Hot gases and chemicals in the smoke •  Signs and symptoms

–  Burns to face or oropharynx –  Singed nasal/facial hair –  Carbonaceous sputum –  Typical resp symptoms: cough, tachypnea, wheeze,

stridor, excessive secretion/sputum production –  Dysphonia –  Changed in mental status/LOC

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Three types of Inhalation Injury

•  Carbon Monoxide Poisoning •  Upper Airway •  Pulmonary

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Carbon Monoxide Poisoning

•  Not a pulmonary toxin – rather, a circulatory problem –  Hgb unable to transport oxygen

•  Symptoms –  Progressive mental status deterioration with confusion,

somnolence, can lead to coma and seizures.

•  Diagnose with ABG not pulse-ox •  Treatment – Oxygen, Oxygen, Oxygen

–  FiO2 1.0 reduces T ½ from 2.5 hrs to 40 min

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Upper Airway

•  A THERMAL burn to the face/mouth/oropharynx. •  Symptoms primarily caused by SWELLING:

Hoarseness, stridor, airway obstruction. •  Can occur from non-flame injuries (scalds, chemicals). •  Remember that edema is PROGRESSIVE over 24

hours: re-evaluate patients frequently.

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30 minutes post-burn

Source Undetermined

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6 hours post-burn

Source Undetermined

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Pulmonary Injury

•  The true inhalation Injury, it is actually a CHEMICAL injury to the tracheo-bronchial mucosa –  Loss of cilia action, sloughing, bronchiectasis, air trapping,

consolidation, infection

•  NOT an indication for intubation: Oxygen! •  May be absent for 72 hours before manifesting

–  Hypoxia –  ARDS-like (not really, though) –  Infection (mimic or co-existant)

•  Facilitates MODF (usual cause of death) •  Confirm with bronch

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Step 3: Secondary Survey •  Head-to-toe exam looking for all injuries •  De-bride burns and assess extent and depth •  Document with diagrams if possible •  Keep patient warm •  Multiple trauma is common in burn patients

–  An unconscious patient is unconscious for some other reasons until proven otherwise

–  Consider abuse/assault –  Other care as per non-burn trauma patient

•  Suture lacs, stabilize fractures etc

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Fluid Resuscitation is the Primary Objective of Initial

Burn Treatment!

Step 4: Fluid Resuscitation

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Step 4: Fluid Resuscitation

•  Calculate Total Body Surface Area

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Adult Anatomic structure Surface area Anterior head 4.5% Posterior head 4.5% Anterior torso 18% Posterior torso 18% Anterior leg each 9% Posterior leg each 9% Anterior arm each 4.5% Posterior arm each 4.5% Genitalia/perineum 1% Child Anatomic structure Surface area Anterior head 9% Posterior head 9% Anterior torso 18% Posterior torso 18% Anterior leg each 6.75% Posterior leg each 6.75% Anterior arm each 4.5% Posterior arm each 4.5% Genitalia/perineum 1%

Estimating Burn Size

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Calculating burn size

1.  Best done after debridement.

2.  First-degree (non-blistered) burns don’t count.

7mike5000, Wikimedia Commons

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Step 4: Fluid Resuscitation

•  Calculate Total Body Surface Area •  Estimate fluid requirement with formula •  Don’t forget maintenance requirements •  Parkland is most popular starting point

–  4 ml/kg x %BSA – ½ over first 8 hours, then over 16 –  Titrate to patient response – urine output*

•  If not making –  Time = 0 is time of burn, not ED arrival

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Step 4: Fluid Resuscitation

•  Example: 70 kg man with 40% TBSA Burns •  Parkland: 70kg x 4ml LR x 40%

= 11.2 L over 24 hours

•  Give half over first 8 hours, i.e. 5.6 L / 8 = 700 ml/hr + maintenance (125/hr)

= 825 ml/hr •  Give the other half over 16 hours, i.e.

5.6 / 16 = 350 ml/hr + maintenance (125/hr) = 475 ml/hr

•  Increase or decrease hourly based on urine output

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Step 4: Fluid Resuscitation���Expect extra requirements in:

•  Very young –  Average 5.8 cc/kg x %TBSA

•  Very deep burns •  Electrical injuries (‘tip of the iceberg’) •  Inhalation •  Delay before ED presentation

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Step 4: Fluid Resuscitation���Complications

•  Facial/airway swelling –  Re-assess frequently for stridor, eyes swollen shut

•  Limb swelling - Compartment Syndrome –  In both burned and unburned extremities

•  Torso swelling –  Look for respiratory compromise –  Measure bladder pressures

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Escharotomy Sites • Incise to subcutaneous level

• Consider using a Bovie/cautery to minimize bleeding

• Cut through entire length of eschar

Original Image, Sjef, Wikimedia Commons Altered Image, Lena Carleton, University of Michigan

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Limb Escharotomy

Wikimedia Commonsآآررممیینن.,

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Torso Escharotomy

Source Undetermined

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Torso and Abdominal Escharotomy

Source Undetermined

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Step 5: Wound Care

•  Debride blisters, dirt, old or non-professionally-applied ointments. Shave adjacent hair

•  Wrap fingers individually •  Avoid Occlusive dressings •  Use a non-stick gauze or leave open •  Use a non-sulfa containing silver product •  Change q12h

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Burn Pearls •  Don’t soak/pack in ice/ice water:

–  Frostbite and hypothermia are real risks –  Just cool – helps if performed immediately

•  Keep them comfortable – Pain Control is key •  Make sure tetanus up to date •  Consider an NG tube if > 25% BSA •  Outpatient therapy may be appropriate

–  Less than 10% BSA –  Pain is controlled on oral meds (and tolerating POs) –  Able to perform wound care AND therapy (encourage

active range of motion) 41