Initial Burn Care
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Transcript of Initial Burn Care
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Initial Burn Care
Lee D. Faucher, MD FACS
Director UW Burn Center
Associate Professor of Surgery & Pediatrics
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Objectives• Discuss burn pathophysiology
• Outline treatment modalities
• Understand why some treatments better than others
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What is a burn?
• Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.
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First Degree Burns
• Epidermis only
• No blisters
• Erythema
• Mild to absent systemic response
• Heals in 3-4 days
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Superficial partial thickness
• Papillary dermis• Blisters• Homogenous pink• Painful, hypersensitive• Blanches• Hair usually intact• Does not scar, may pigment differently
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Sup 2nd degree
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Deep partial thickness
• Reticular dermis
• Mottled red and white
• Not painful to pinprick or pressure
• Does not blanch
• Heals > 3 weeks
• Usually scars
• Need to excise and graft
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Deep dermal
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Full thickness burns
• Into fat or deeper
• Red, white, brown, black, etc.
• Diminished sensation
• Dry, may be leathery
• Depressed
• Heals only from the periphery
• Always excise and graft
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Full-thickness
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Etiology
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Types of burns
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Where do burns occur
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Circumstances of injury
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Admissions by age
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% of admissions vs. burn size
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Inhalation injury diagnosis
• Closed-space fire
• Face burns
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Terminology
• Inhalation injury “nonspecific”– Thermal injury
• Upper airway
– Local chemical irritation• Throughout airway
– Systemic toxicity• CO
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Clinical diagnosis
• History and physical– Exposure– Duration– Enclosed space
• Diagnostic studies
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Other signs and symptoms
• Lacrimation• Cough• Hoarseness• Dyspnea• Disorientation• Anxiety• Wheezing
• Conjunctivitis• Carbonaceous
sputum• Singed hairs• Stridor• Bronchorrhea
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Poison management = CO
• 500 unintentional deaths each year
• Persistent Neurologic Sequelae– May improve over time
• Delayed Neurologic Sequelae– Relapse later
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Poison management = CO
• Treatment– CO level means nothing to predict outcome– Length of hypoxia is the determining factor– Oxygen– HBO
• No studies show benefit in treatment
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Pathophysiology
• The main factor responsible for mortality in thermally injured patients
• Carbon monoxide the most common toxin– 200 times greater affinity– Competitive inhibition with cytochrome P-
450
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Reduction of CO
0
20
40
60
80
0 20 40 60 80
Time in Minutes
% C
O
Room Air100% Oxygen3 ATM
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Objective data
• Bronchoscopy– Edema– Infraglottic soot– Hyperemia– Mucosal sloughing
• Sensitivity near 100% under IDEAL circumstances
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Grading of injury
• No reliable indicators of progressive respiratory failures
• No studies have found any correlation with initial findings and clinical outcomes and progress
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Resuscitation
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Field resuscitation• Start IV with LR, in burn OK
– < 6 years = 125mL/hr– 6-13 years = 250mL/hr– >13 years = 500mL/hr
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Rule of Nines
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Lund and Browder ChartAArreeaa 00--11
yyrr.. 11--44 yyrr..
55--99 yyrr..
1100--1144 yyrr..
1155 yyrr..
AAdduulltt 22 33 TToottaall
HHeeaadd 1199 1177 1133 1111 99 77 NNeecckk 22 22 22 22 22 22 AAnntt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 PPoosstt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 RR.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ GGeenniittaalliiaa 11 11 11 11 11 11 RR.. UU.. AArrmm 44 44 44 44 44 44 LL.. UU.. AArrmm 44 44 44 44 44 44 RR.. LL.. AArrmm 33 33 33 33 33 33 LL.. LL.. AArrmm 33 33 33 33 33 33 RR.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ RR.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ LL.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ RR.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 LL.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 RR.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ LL.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½
TToottaall
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IV access
• < 15% TBSA – oral resuscitation
• 15 – 40% TBSA – one large bore IV
• > 40% -- two large bore IV’s
• IV’s should be in the upper extremities
• Suture IV’s started through burns
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Crystalloid solution
• Ringer’s Lactate– [Na+] 130 mEq (serum 140 mEq)– Osmolality 272 mOsm (serum 300mOsm)
• Advantages of crystalloid– Effective in maintaining perfusion– Costs less than colloids– Can be mobilized with a diuretic
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Resuscitation first 24 hours
• Baxter formula– 4 mL/kg/% TBSA burned
• Give ½ the volume in first 8 hours and other ½ over next 16 hours.
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If < 20kg• Same Baxter
formula for LR• Add 4mL/kg of D5 ¼
NS– Infuse at constant
rate, increase LR if needed for adequate urine output
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Monitor urine output• Place foley if > 20% TBSA
• Urine output goal– 2 mL/kg/hr very young– 1 mL/kg/hr child– 0.5 mL/kg/hr adult
• Diuretics are NEVER used to increase urine output• Increase urine output to > 100mL/hr if pigment
present
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How to do this
• Maintain continuous IV fluid replacements
• AVOID boluses
• Only bolus IV fluids if hypotensive
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Zones of burn injury
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Pain control
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Non-medication methods
• Cover burns with plastic wrap– Wet dressings will stick and cause more
pain– Other burn dressings are expensive and
not necessary– Quik Clot is expensive and will not provide
any patient benefit
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Ice Pack-----DO NOT USE EVER
• DOES NOT– Reverse temperature– Inhibit destruction– Prevent edema
• DOES– Delay edema– Reduce pain
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Medication
• Medications– Opioids– Narcotics– Pain medications– IV Analgesia
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Summary
• Airway
• Circulation/Resuscitation
• Pain control
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Questions?