Burn injuries ATLS 2018

1. THERMAL INJURIES
THERMAL INJURY
ATLS 10
Update 2018
Dr. YAHYA GAFAR

2. INTRODUCTION
The most significant difference between burns
and other injuries is that the consequences of
burn injury are directly linked to the extent of
the inflammatory response to the injury.

3. PRIMARY SURVEY AND
RESUSCITATION
Stopping the burning process, ensuring that
airway and ventilation are adequate, and
managing circulation are lifesaving measures

4. Remove clothing, do
not peel off.
Brush any dry
chemical powders.
Rinsing & irrigate with
warm saline.
Cover the patient
,prevent hypothermia.
Stop Burning
Process

5. ESTABLISH AIRWAY CONTROL
The airway can become obstructed not only from
direct injury (e.g., inhalation injury) but also from
the massive edema resulting from the burn injury.

6. ABLS
Indications
For early
intubation.
- Signs of airway obstruction .
- BSA > 40%–50%.
- Extensive and deep facial or mouth burns.
- Significant edema or risk for edema.
- Signs of respiratory compromise.
- Decreased level of consciousnes.
- Difficulty swallowing.
- Anticipated patient transfer without qualified
personnel to intubate en route.

7. PITFALL
Airway obstruction in a
patient with burn injury
may not be present
immediately.
- Recognize smoke
inhalation.
- Evaluate the patient for
circumferential burns of the
neck and chest.
-May require bronchoscopy
place an adequately sized
Airway.

8. ENSURE ADEQUATE
VENTILATION
Direct thermal injury to the lower airway is
very rare and essentially occurs only after
exposure to superheated steam or ignition of
inhaled flammable gases.

9. Breathing
concerns
CO
poisoning
Hypoxia
smoke
inhalation

10. HigherCOlevels
headache & nausea
(20%–30%)
Confusion
(30%–40%)
Coma
(40%–60%)
death
(>60%)

11. CO TREATMENT
any patient in whom CO exposure could have
occurred should receive high-flow (100%)
oxygen via a non-rebreathing mask.

12. SIZE OF ETT
Efforts should be made to use endotracheal
tubes at least 7.5 mm ID or larger in an adult
and size 4.5 mm ID ETT in a child.

13. USE OF PULSE OXIMETRY
Pulse oximetry cannot be relied on to rule out
carbon monoxide poisoning, as most oximeters
cannot distinguish oxyhemoglobin from
carboxyhemoglobin.

14. ROLE OF HYPERBARIC OXYGEN
There is no role for hyperbaric oxygen therapy
in the primary resuscitation of a patient with
critical burn injury.

15. DIAGNOSIS OF SMOKE INHALATION
exposure to a
combustible agent
Signs the lower
airway, below the
vocal cords, seen on
bronchoscopy
Smoke
inhalation
(ABLS)

16. SMOKE INHALATION (WORKUP)
normal CXR & ABG on admission do not exclude
inhalation injury.

17. SMOKE INHALATION
TREATMENT
SUPPORTIVE
Intubation
Head elevation
30 d
Escharotomy.

18. MANAGE CIRCULATION WITH BURN
SHOCK RESUSCITATION
Burn resuscitation is required to replace the
ongoing losses from capillary leak due to
inflammation.

19. WHEN TO START?
Resuscitation fluids for deep partial and full-
thickness burns larger than 20% TBSA, taking
care not to over-resuscitate.

20. I.V ACCESS
If the extent of the burn precludes placing the
catheter through unburned skin, place the IV
through the burned skin into an accessible vein.
• Lower& upper limb?
• Number?
• Size?

21. WHICH FLUID??
Warmed isotonic crystalloid solution,
preferably lactated Ringer’s solution.

22. INITIAL FLUID RATE??
2 ml of lactated Ringer’s x patient’s body
weight in kg x % TBSA for second- and third-
degree burns.
• ½ over the first 8 h

23. For pediatric 3 mL/kg/% TBSA
If < 30 kg, should receive maintenance fluids of
D5LR

24. PITFALL
- Remember that edema takes time to develop.
- Use long IV catheters.
- Do not cut endotracheal tubes, and regularly assess their
position.
Intravenous catheters and endotracheal tubes
can become dislodged after resuscitation.

25. HOW TO MONITER?
Urine output (30 and 50 cc/hr).

26. PATIENT ASSESSMENT
ASSESSMENT
AMPLE
history
Allergies. Medication. PMH. Last meal. Event.
TBSA
DEPTH OF
THE BURN

27. THE ADULT BODY
The palmar surface (including the
fingers) of the patient’s hand represents approximately
1% of the patient’s body surface
4.5%
18%
4.5% 4.5%
9% 9%
4.5%
1%
18%
9%9%
4.5% 4.5%

28. THE PEDIATRIC BODY
9%
18%
4.5%
4.5%
7%7%
13%
2.5%
4.5%
7%
9%
4.5%
7%
2.5%

29. PITFALL
Overestimating or
underestimating burn
size
- Do not include
superficial burns.
- Use the rule of nines.
- For irregular or oddly
sized burns, use the
patient’s palm.
- Remember to logroll
the patient to assess
their posterior aspect

30. DEPTH OF BURN
Important in evaluating the severity of a burn,
planning for wound care, and predicting
functional and cosmetic results.

31. DEPTH OF BURN
FIRST DEGREE
• Superficial.
• Erythema and
pain.
• No I.V fluid.
SECOND
DEGREE
• Partial thickness
• Painfully,
hypersensitive
,blistered and
blanch to touch.
• I.V fluid.
THIRD DEGREE
• Full-thickness.
• Painless,leathery
or waxy white.
• I.V fluid

32. SECONDARY SURVEY AND
RELATED ADJUNCTS
 Documentation.
 Baseline investigation.
 Peripheral Circulation in Circumferential Extremity
Burns.
 Gastric Tube Insertion.
 Narcotics, Analgesics, and Sedatives(covering the
wound will decrease the pain).

33. WOUND
CARE
- Do not break blisters.
- Do not apply an antiseptic agent.
- Do not apply cold water to a patient with
extensive burns (i.e.,> 10% TBSA).
- Remove any previously applied medication
before using antibacterial topical agents.
- Cover the wound.

34. ANTIBIOTICS
There is no indication for prophylactic
antibiotics in the early post burn period.

35. TETANUS
Determination of the patient’s tetanus
immunization status and initiation of
appropriate management is very important.

36. Burn Patterns Indicating Abuse
It is important for clinicians to maintain
awareness that intentional burn injury can
occur in both children and adults.

37. BURN PATTERNS INDICATING ABUSE
 Circular burns and burns with clear edges and
unique Patterns.
 Burns on the soles of a child’s.
 A burn to the posterior aspect of the lower
extremities and buttocks.
 Old burn injuries in the setting of a new traumatic
injury.
 Above all, the mechanism and pattern of injury
should match the history of the injury.

38. PATIENT TRANSFER
 Partial-thickness burns on greater than 10% TBSA.
 Burns involving the face, hands, feet, genitalia,
perineum, and major joints.
 Third-degree burns in any age group
 Electrical burns, including lightning injury ,Chemical
burns or Inhalation injury.
 Burn injury in patients with preexisting medical
disorders.
 Any patient with burns and concomitant trauma.
 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 rehabilitative intervention.

39. PITFALL
Patient loses airway during transfer.
- Reassess airway before transfer.
- When the patient has risk factors for inhalation injury or
has received significant amounts of resuscitation fluid,
contact the receiving facility to discuss intubation before
transfer.

40. PITFALL
- Patient experiences
severe pain with dressing
change.
- Provide adequate
analgesia before
manipulating burns.
- Use non-adherent
dressings or burn sheets
to protect burn from
contamination before
transfer

41. PITFALL
Ensure that appropriate
information is relayed
by using transfer forms or checklist
The receiving hospital is unable to discern the
burn wound size from the documentation.

42. PITFALL
The receiving hospital is unable
to discern the amount of fluid
resuscitation provided from the
documentation.
Ensure that the flow sheets
documenting IV fluids and
urinary output are sent
with the patient.

43. TEAMWORK
• ATLS principles.
importance of limiting exposure (minimize
hypothermia).
Communicate early and regularly regarding
concerns.

44. THANKS