Burn Triage and Treatment.doc

Burn Triage and Treatment: Thermal Injuries

General Information Diagnosis of Burns American Burn Association Burn Unit Referral Criteria Treatment Special Burns American Burn Association Information ReferencesCaveat: This page describes the diagnosis and treatment of skin injury due tothermal effects.

For skin injury due toradiation effects, see REMM'sCutaneous Radiation Syndromepage.

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General Information

After a radiation mass casualty incident, especially anuclear detonation, trauma with or withoutthermal burns (flash burns or flame burns)will be common, especially inareas closer to the epicenter.

Anair burstnuclear detonationwill result in more burn victims than will aground burstdetonation of equal magnitude

Thermal burn patients will complicate the comprehensive medical response to radiological/nuclear mass casualty events, as burn care itself requires additional specialized staff, resources, and equipment for prolonged periods of time, well beyond the acute or initial phase of the medical response

Staff: Healthcare providers (both physicians and nurses) with significant burn care expertise are needed to optimize chances for survival and may be in short supply locally

Resources: Complex, expensive, resource-intensive care for the most severely burned patients will be required well beyond the acute/initial medical response phase

Equipment/Beds: Given the overall limited number of dedicated and available burn beds and burn specialists in any one region of the US, transfer of patients to specialized burn centers throughout the country will likely be needed. Consultation with anAmerican Burn Association-verified burn centeris recommended.

Thermal burns after concomitant radiation injury decrease the likelihood of survival, as do other types ofcombined injury.

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Diagnosis of Burns

Definition: A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy.

Burn severity is dictated by:

Percent total body surface area (TBSA) involvement

Burns >20-25% TBSA require IV fluid resuscitation

Burns >30-40% TBSA may be fatal without treatment

In adults:"Rule of Nines" is used as a rough indicator of % TBSA

Rule of Nines for Establishing Extent of Body Surface BurnedAnatomic Surface

% of total body surface

Head and neck

9%

Anterior trunk

18%

Posterior trunk

18%

Arms, including hands

9% each

Legs, including feet

18% each

Genitalia

1%

In children,adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults

Lund-Browder diagrams improve the accuracy of the % TBSA for children.

Palmar hand surface is approximately 1% TBSA

Estimating Percent Total Body Surface Area in Children Affected by Burns

(A) Rule of "nines"(B) Lund-Browder diagram for estimating extent of burns(Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969) Depth of burn injury (deeper burns are more severe)

Superficial burns (first-degree and superficial second-degree burns)

First-degree burns

Damage above basal layer of epidermis

Dry, red, painful ("sunburn")

Second-degree burns

Damage into dermis

Skin adnexa (hair follicles, oil glands, etc,) remain

Heal by re-epithelialization from skin adnexa

The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization)

Moist, red, blanching, blisters, extremely painful

Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks

Deep burns (deep second-degree to fourth-degree burns)

Deep second-degree burns (deep partial-thickness)

Damage to deeper dermis

Less moist, less blanching, less pain

Heal by scar deposition, contraction and limited re-epithelialization

Third-degree burns (full-thickness)

Entire thickness of skin destroyed (into fat)

Any color (white, black, red, brown), dry, less painful (dermal plexus of nerves destroyed)

Heal by contraction and scar deposition (no epithelium left in middle of wound)

Fourth-degree burns

Burn into muscle, tendon, bone

Need specialized care (grafts will not work)

Deep burns usually need skin grafts to optimize results and lead to hypertrophic (raised) scars if not grafted

Age

Mortality for any given burn size increases with age

Children/young adults can survive massive burns

Children require more fluid per TBSA burns

Elderly may die from small (35-40% TBSA should be endotracheally intubated

Burns to the head

Burns inside the mouth

Intubate early if massive burn or signs of obstruction

Intubate if patients require prolonged transport and any concern with potential for obstruction

If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating

Signs of airway obstruction

Hoarseness or change in voice

Use of accessory respiratory muscles

High anxiety

Tracheostomies not needed during resuscitation period

Remember: Intubation can lead to complications, so do not intubate if not needed

Breathing

Hypoxia

Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries

Carbon monoxide (CO)

Byproduct of incomplete combustion

Binds hemoglobin with 200 times the affinity of oxygen

Leads to inadequate oxygenation

Diagnosis of CO poisoning

Nondiagnostic

PaO2(partial pressure of O2dissolved in serum)

Oximeter (difference in oxy- and deoxyhemoglobin)

Patient color ("cherry red" with poisoning)

Diagnostic

Carboxyhemoglobin levels

40% is severe intoxication

Treatment

Remove source

100% oxygen until CO levels are