GEMC: Introduction to Burns: Resident Training

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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 Robworldwide@Gmail.com

    Enlarge, Wikimedia Commons

    3

  • 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

    ***

    4

  • Physical

    Face

    Anterior thorax

    Right arm, anterior and posterior, upper

    Left arm, anterior aspect, entire limb

    Face

    Source Undetermined

    5

  • 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)

    6

  • 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

    ***

    ***

    7

  • LABS

    WBC: 13; Hgb: 15 Platelets: 390

    8

    0.5 25

    141

    4.0

    106 101

    8

  • Chest Xray

    Source Undetermined

    9

  • Critical Actions

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

    suitable other method)

    10

  • Webaware, Wikimedia Commons 11

  • First degree burn

    Jmh649, Wikimedia Commons

    Bejinhan, Wikimedia Commons

    12

  • Superficial partial-thickness (2nd)

    1Veertje, Wikimedia Commons 13

  • Deep partial-thickness (2nd)

    Westchaser, Wikimedia Commons

    14

  • Deep partial-thickness (2nd)

    Source Undetermined

    15

  • Full Thickness (3rd)

    Source Undetermined

    Source Undetermined 16

  • The initial evaluation and management of burn injury

    Its never just a burn!

    17

  • 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 Dont waste time initially looking for specific antidoes*

    18

  • 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

    19

  • 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

    20

  • Three types of Inhalation Injury

    Carbon Monoxide Poisoning Upper Airway Pulmonary

    21

  • 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 from 2.5 hrs to 40 min

    22

  • 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.

    23

  • 30 minutes post-burn

    Source Undetermined

    24

  • 6 hours post-burn

    Source Undetermined

    25

  • 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

    26

  • 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

    27

  • Fluid Resuscitation is the Primary Objective of Initial

    Burn Treatment!

    Step 4: Fluid Resuscitation

    28

  • Step 4: Fluid Resuscitation

    Calculate Total Body Surface Area

    29

  • 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

    30

  • Calculating burn size

    1. Best done after debridement.

    2. First-degree (non-blistered) burns dont count.

    7mike5000, Wikimedia Commons

    31

  • Step 4: Fluid Resuscitation

    Calculate Total Body Surface Area Estimate fluid requirement with formula