Management of Burn patient in ER settings

1. BURN INJURY
1- Rayan Abdullah
2- Mohammad Alamer
3-Abdullah Almzyad
4-Abdlurahman Aldosary
5-Abdullah Alsoghair
6-Abdulmajeed Alzahrani

2. Objectives
• Initial assessment of a patient with a burn injury
• Discuss inhilation injury and it’s treatment
• Intubation indications , concerns , and types
• Evaluation of a burn injury
• Calculate Total Body Surface Area burned
• Explain Parkland Formula
• Patient with a Burn and Trauma
• When to refer a patient to burn center
• Discuss Pain control
• Considerations in burn care in children

3. Types of burns
• Thermal (most common)
• Solar (i.e. sunburn)
• Chemical
• Electrical
• Radiation

4. Initial assessment
• Always start with the ABCs.
• Airway: evaluation for inhalation injury is critical early
in the patient’s course.
• Breathing: Assess respiratory status, and provide
supplemental oxygen if necessary.
• Circulation: vital signs, pulses, and capillary refill, the
hypovolemic shock is a feature of severe burns.

5. complete secondary survey:
• Evaluation of burn size and depth.
• Trauma, and possible cervical spine injury:
particularly seen with blast injuries and in those
who have jumped from buildings to escape fire.
• past medical history, medications, allergies, and
tetanus immunization status are also important.
Also, it is important to know, How long was the
patient exposed to fire and smoke?

6. Evaluate for inhalation injury
• which may be associated with flame burns,
exposure to smoke in an enclosed space.
• Signs of possible inhalation injury:
• burns around the face and mouth, soot in the
nose or mouth, and carbonaceous sputum.
• Respiratory symptoms such as dyspnea,
hoarseness, wheezing, and stridor are highly
suggestive of inhalation injury.

7. smoke asphyxiation
• Two asphyxiates produced in fires include
carbon monoxide (CO) and cyanide gas (CN)
Both of these molecules cause cellular death
from cellular hypoxia and asphyxia.
• In these cases, the patient often has an airway
and is capable of being ventilated, but the
tissues are not capable of utilizing the oxygen
that is delivered to them.

8. Treatment of CO and CN toxicity
• The half-life of carbon monoxide is
approximately 4 to 5 hours at room air, When
the patient is placed on 100% oxygen, the
half-life of CO-hemoglobin is reduced to 40 to
60 minutes.
• Patients with carbon monoxide toxicity should
be considered at risk for CN poisoning , A safe
cyanide antidote, hydroxocobalamin , also
known as vitamin B12a.

9. Airway
Usually thermal burn affects Upper airway way more common then lower
airway , manifested as mucosal edema , erythema , and ulceration
Indications for Intubation :
1-Evidance of airway involvement: voice changes , stridor , wheezing ,
mucosal edema
2-Low O2 saturation
3- sever burn to the face and neck
Note : Inhalation injury can produce a rapid progression of edema that can
make intubation difficult or impossible
Types of Intubation: 1- Orotracheal Rapid Sequance Intubation
2-Fiberopric Intubation : used for stable patients
3- Emergency Cricothyrotomy : used when airway edma prevent orotracheal
tube placement

10. • Difficulties of Intubation :
• 1- burned facial skin commonly shears off , weeps
fluid , making adhesive taped ineffective , so to
secure the endotrachel tube you can use
umbilical tube or intravenous tubing
• 2-Displacement of airway is common with
patients movement , for this reason the position
of airway should always be reconfirmed following
each movement of the patient

11. Burn Degree
• First Degree : only involve epidermis , usually erythematous ,
painful , and without blisters
• Second Degree : either superficial or deep partial thickness
• Superficial Partial Thickness : erythematous , with thin walled fluid
filled blisters which usually heals within 2-3 weeks without scarring
• Deep Partial Thickness : extend into the dermis , thick walled
blisters , heals in 3-9 weeks but tend to develop hypertrophic scar ,
surgery is necessary
• Third Degree Burns : all layers of dermis , skin is firm , white or
charred and leathery , represent complete tissue destruction ,
surgery is necessary
• Forth Degree Burn : extend into deeper tissue including
subcutaneous fat , muscle , and bone , significant debridement and
reconstruction are required
• Note: usually first degree burn don’t count when calculating TBSA

14. circumferential full-thickness burns
• leather-like full-thickness burn prevents tissue
expansion causing compression of internal
structures.

15. circumferential full-thickness burns
• Circumferential burns of the neck : compression
of the jugular veins and increased intracranial
pressure or airway compromise.
• Circumferential burns of the chest: can lead to
decreased chest wall compliance, increasing
diffculty ventilating, and respiratory insuffciency.
• Circumferential burns to the extremities: can
cause vascular compromise similar to
compartment syndrome.

16. circumferential full-thickness burns
• PE: Evaluate pulses and look for Signs of poor
perfusion like cyanosis, deep tissue pain,
paresthesias, and cold skin.
• Management: Prompt escharotomy

17. Management of burning process
• initially Remove clothing and jewelry as these
items will retain residual heat.
• The most effective cooling technique is irrigation
with copious amounts of room-temperature
water.
• Immediate cooling with tap water (15º C) is
almost twice as effective.
• Application of ice is contraindicated because it
will increase the extent of tissue damage.
• The hazard of cooling larger burns is causing the
patient to become hypothermic.

18. How is % TBSA burned calculated ?
• The rule of nines (not applicable to children)

19. The Lund and Browder chart (can be
used to evaluate infants and children)

20. • With either chart, document the areas of
second- and third-degree burns on the chart
and calculate a total percentage of TBSA
burned.

21. burn shock
• Fluid loss is due to tissue destruction at the
burn site that causes increased vascular
permeability.
• Fluid shifts into the extravascular space and is
quickly lost through
the damaged skin.

22. fluid resuscitation
in the burn patient
• Following a burn injury, the patient has
profound shifts in intravascular fluids and an
initial reduction in cardiac output. Several
formulas exist for the determination of fluid
resuscitation needs; however, the Parkland
formula is the most well known and most widely
applied. The Parkland formula provides an
estimate of the initial fluid needs of the severely
burned patient.
•

23. Parkland formula
Fluid required = body weight(kg) x %TBSA burn
(second and third degree) x 4 mL
The fluid requirement of lactated Ringer’s or
Normal Saline solution is calculated for the first
24 hours. One half of this is administered over
the first 8 hours. The second half is administered
over the following 16 hours.

24. • Remember, this is an estimate. Monitor
adequacy of fluid resuscitation by following
vital signs and urine output. Goal urine output
is 30 mL/hr in adults and 1 to 2 mL/kg/hr in
children.

25. example
• Let’s use an example of an 80-kg patient who has sustained
a 30% body surface area burn
24-hour fluid total = 4ml x 80 kg x 30% TBSA = 9600 ml
Fluids given in the first 8 hours: 9,600 mL/2 = 4800 mL
Fluid rate in first 8 hours 4,800 mL/8 hours = 600 mL/hr
The remaining 16 hours = 4800 mL
Fluid rate in the last 16 hours , 4,800 mL/16 hours = 300 mL/hr

26. pitfalls with using the Parkland
formula
• not required for burns less than 20% TBSA
• The first half of the fluids should be
administered within 8 hours from the time of
the injury, not from the time after
presentation.

27. Burns and Trauma management:
• are at higher risk for inhalation injury and tend
to require greater fluid resuscitation than
isolated burn patients.
• Generally, aggressive burn resuscitation
should be started, and life-threatening
traumatic injuries should be treated initially.
• Transfer to a burn unit can be delayed until
the traumatic injuries have been stabilized

28. The criteria for referral to a burn
center
• Partial-thickness burns . 10% TBSA.
• Burns that involve the face, hands, feet, genitalia, perineum, or major joints.
• Third-degree burns.
• Electrical burns, including lightning injury.
• Chemical burns.
• Inhalation injury.
• Burns in patients with preexisting medical disorders that could complicate
management, prolong recovery, or affect mortality.
• Any patient with burns and concomitant trauma in which the burn injury poses the
greatest risk of morbidity or mortality.
• Burned children in hospitals without qualified personnel or equipment for the care
of children.
• Burn injury in patients who will require special social, emotional, or long-term
rehabilitative intervention.

29. • Partial-thickness burns involving less than 10%
TBSA or full-thickness burns involving less
than 2% TBSA without risk of functional or
cosmetic complications can usually be treated
as an outpatient.

30. Outpatient burns treatment in the ED:
• All burns should be cleaned with saline or water
and a mild cleanser. Ruptured blisters should be
débrided.
• Topical antibiotics such as bacitracin ointment or
silver sulfadiazine should be applied liberally and
covered with a nonadhesive dressing and a bulky
bandage.
• The patient should follow up in 24 hours in the
ED or with a physician experienced in burn care.

31. Special need for facial burn
• Facial burns should not be treated with silver
sulfadiazine, because it caouse pigmentation
change in healing process . Antibiotic
ointment alone, without dressings is enough .
• follow-up in 24 hours is recommended
• tetanus immunization status:
• Always check the status of tetanus
immunization and update if needed

32. Pain control
• large doses of narcotics are sometimes
necessary. Intravenous narcotics can be
started in the field and repeated if needed
• Proper pain control my require solid dose of
medication .
• only be withheld if administration is life
threatening due to hemodynamic status.
• Don’t forget outpatient managmnet for oral
analgesic

33. Special need in burn for children
• Children who under 2 years high mortality and
morbidity then others , so think about admission
even for minor burn .
• 20 % of pediatric burn result of intentional burn ,
so don’t forget about . nonaccidental trauma
• Ask about condition around home , assess safety
• The reliability of the parents evaluation
considered for inpatient management
• Don’t forget if you suspetion of child about →
report to child protective

34. intentional burns in children
• forcible immersion : most common form of intentional
burn injury in children , commonly occur when an adult
places a child in hot water as a form of punishment,
often with toilet training commonly have secondand
third-degree burns of the hands and feet in a glove or
stocking type pattern , should be suspicion especially
when these injurey symmetrical and lack splash pattern
.
• When a child is lowered into hot water, the child will
assume a defensive posture ,tightly flexing their arms
and legs. These burns will produce sparing of the
flexion creases in the antecubital fossa, popliteal fossa,
and groins

35. • Contact burns: second most common form of
burn-related child abuse , Accidental contact
burns typically have irregular burn depth and
edges , because dropped hot objects will often
strike and deflect off the curvature of the various
body surface
• intentional contact burns, the instrument causing
the burn is typically pressed onto the body
surface. This therefore produces a burn pattern
that has sharp lines of demarcation

36. special considerations in adults
• HIV
• immune suppression (transplants,steroids)
• Diabetes
• cardiac disease
• COPD
• substance abuse
• Age > 60
• may all require inpatient management of minor
burns to monitor and treat complications of the
chronic disease

37. •Thank you
•Any question ?

38. Reference
• http://unaizacm.org/elu/pluginfile.php/19485
/mod_resource/content/1/burns%20JITT.pdf