Burn Management students[1]

8/7/2019 Burn Management students[1]

1/19

Burn Management

Burn Management

Tad Kim, M.D.

UF Surgery

[email protected]

(c) 682-3793; (p) 413-3222


2/19

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


3/19


4/19

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


5/19

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.


6/19

Burn Management

Classification of Burn Depth


7/19

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


8/19


9/19

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, largeburns (due to inevitable edema from resusc)

Bronchoscopy to help dx inhalational injury


10/19

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 Ringers

Place patient on continuous EKG / monitor

Palpate or doppler extremity signals withcircumferential extremity burns

Disability (GCS less than eight -> intubate)

E

xposure: remove all clothing


11/19

Burn Management

Initial Assessment

AMPLE history

Allergies

M

edications (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 typeof exposure flame, grease)


12/19

Burn Management

Initial Assessment

Burn Resuscitation with Lactated Ringers

Figure out burn size by rule of nines or

entire palmar surface of pts 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


13/19

Burn Management

Burn Resuscitation

70kg male with 40% TBSA EMS administered 1.5L of fluids already

What rate of LR should he receive?


14/19

Burn Management

Burn Wound Management

Circumferential deep 2nd or 3rd degree

extremity burn can compromise circulation

Assess for the 6 Ps

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)


15/19

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


16/19

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


17/19

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 dueto possibility of rhabdomyolysis


18/19

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 burnsusing 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

Burn Management students[1]

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