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  1. 1. Burn Management Burn Management Tad Kim, M.D. UF Surgery (c) 682-3793; (p) 413-3222
  2. 2. Burn Management Overview • Pathophysiology of Burns • Burn Classifications • Criteria for Transfer to Burn Center • Initial Assessment & Management • Airway Management – Smoke Inhalation Injury • Shock & Fluid Resuscitation • Burn Wound Management – Electrical Injury & Chemical Burns
  3. 3. Burn Management Pathophysiology of Burns • Burns cause coagulative necrosis – Chemical/Electricity also cause direct injury to cell membranes, in addition to heat transfer • Causes: – Flame, Scald, Contact, Chemical, Electricity • Depth of burn depends on: – 1. Temperature – 2. Time exposed – 3. Specific heat (higher for grease)
  4. 4. Burn Management Pathophysiology of Burns • Burns a/w release of inflamm. mediators • Increased capillary permeability – Leak proteins into interstitium • Get edema in burned & non-burned skin • Large fluid loss due to fluid shifts & also losses from exposed burned skin • Characteristic “Ebb and Flow” of burns – Ebb: Low metabolism/cardiac output, ↓Temp – Flow: hypermetabolism, high cardiac output, hyperglycemia, increased heat produx
  5. 5. Burn Management Classification of Burn Depth • 1st degree: localize to epidermis (sunburn) • 2nd degree: injury to both dermis/epidermis – Superficial 2nd : papillary dermis • Typically red, painful, blister, “wet” appearing • Regen in 7-14 days from hair follicles/sweat glands – Deep 2nd : reticular dermis • Typically more pale/mottled, dry, ↓sensation • 3rd degree: full thickness epidermis/dermis – Hard, leathery eschar, painless • 4th degree: involves muscle, bone, etc.
  6. 6. Burn Management Classification of Burn Depth
  7. 7. Burn Management Criteria for Burn Center Referral • Partial thickness > 10% • Inv. face, hands, feet, genital/perineum, joints • Any full thickness burn • Electrical injury • Chemical burn • Inhalational injury • Comorbidities (CHF) • Concomitant trauma • Children • Special emotional, social, or rehab needs
  8. 8. Burn Management Initial Assessment • Called to the ER for a 35yo male rescued from housefire w face/trunk/extrem burns • Always start with ABC – In trauma/burns, ABCDE (disability/exposure) • Airway can be an issue with severe burns or inhalational injury (esp. with indoor fire) – Direct injury from heated air/smoke -> edema – Edema from inflammatory response to burns – Edema from the resuscitation fluids
  9. 9. Burn Management Initial Assessment • Suspect airway injury if: – Facial burns, singed nasal hairs, wheezing, carbonaceous sputum, tachypnea • Give pt oxygen & put on pulse oximetry • Progressive hoarseness is a sign of impending airway obstruction • Pre-emptively intubate anyone with: – Respiratory distress, inhalational injury, large burns (due to inevitable edema from resusc) – Bronchoscopy to help dx inhalational injury
  10. 10. Burn Management Initial Assessment • Breathing (Breath sounds, chest rise, ET CO2) – Chest escharotomies if constrictive eschar • Circulation: get vitals (HR & BP) – 2 large bore IV (unburned before burned skin) – Start burn resuscitation with Lactated Ringer’s – Place patient on continuous EKG / monitor – Palpate or doppler extremity signals with circumferential extremity burns • Disability (GCS less than eight -> intubate) • Exposure: remove all clothing
  11. 11. Burn Management Initial Assessment • AMPLE history – Allergies – Medications (also ask about last tetanus) – Past medical history (CHF – careful w fluids) – Last meal – Events regarding the injury (how did the fire start, how long was the exposure, what type of exposure – flame, grease)
  12. 12. Burn Management Initial Assessment • Burn Resuscitation with Lactated Ringer’s • Figure out burn size by “rule of nines” or entire palmar surface of pt’s hand = 1% • Parkland formula – 4 x Wt(kg) x %TBSA = mL to give in 1 day – Half over 1st 8hrs (subtract what was given) – Give other Half over next 16 hours – In reality, titrate to UOP of 0.5mL/kg/hr in adults and 1mL/kg/hr in children • Do not give colloid in first 24 hrs
  13. 13. Burn Management Burn Resuscitation • 70kg male with 40% TBSA – EMS administered 1.5L of fluids already • What rate of LR should he receive?
  14. 14. Burn Management Burn Wound Management • Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation • Assess for the 6 P’s – Pain, pallor, pulselessness (check Doppler), paresthesias, paralysis, poikilothermia – Directly measure tissue pressure (30 is cutoff) • Dx: Compartment syndrome • Tx: Escharotomy • (Give tetanus toxoid if not up to date)
  15. 15. Burn Management Burn Wound Management • Burn patients are susceptible to infection – Due to immunologic insult of large burns – Also because dead tissue is easily colonized • Initially clean/debride & cover with topical antimicrobial (no data for oral or IV abx) • Superficial 2nd : can use temporary pigskin • 3rd & (most) deep 2nd need early excision & grafting, except palm/soles/face/genitals – Perform at ~3-7 days post-burn
  16. 16. Burn Management Topical Antimicrobials • Sulfamylon for ears – Good at penetrating eschar & is painful – Side effect: metabolic acidosis via carbonic anhydrase inhibition • Bacitracin for face – Few side effects • Silvadene for trunk, neck, extremities – Does not penetrate eschar very well – Side effects: neutropenia/thrombocytopenia
  17. 17. Burn Management Electrical Burns • Most significant injury is within deep tissue • Edema can compromise circulation • Be ready to perform eschar-/fasciotomies • Explore & debride necrotic tissue • May have to re-explore questionable areas • EKG if heart was in conduction path • Follow serial CPK & urine myoglobin due to possibility of rhabdomyolysis
  18. 18. Burn Management Chemical Burns • Speed is essential • ABCDE – remove all clothing • Irrigate with 15-20L of water – Brush off any dry powder before irrigation • Alkalis generally cause worse damage • Do not attempt to counteract acid burns using alkali or alkali burns using acid
  19. 19. Burn Management Take Home Points • Always start with ABCDE for trauma/burns • Know what can compromise airway in burn patients – Chest escharotomy may be needed • Know and apply the Parkland formula • Recognize the need for limb escharotomy • Know depths of burn & which req excision • Know the types & side effects of topicals • Basics of treating chemical/electrical burns