Thermal Burns PFN: SOMEML07

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Slide 1JSOMTC, SWMG(A)

Thermal BurnsPFN: SOMEML07

Hours: 3.0

Instructor:


Terminal Learning Objective

Action: Communicate knowledge of thermal burns

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Tintinalli’s Emergency Medicine, 7th Edition, 2010

PHTLS, 7th Edition, 2010

Mosby Paramedic Textbook, 3rd Edition, Chapter 23, pages 558‐579

Joint Theater Trauma System Clinical Practice Guidelines

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References

Tactical Combat Casualty Care Guidelines

Tactical Medical Emergency Protocols

Tactical Trauma Protocols


Reason


Agenda

Identify the pathophysiology of local and systemic responses to burn injury

Classify burn injury according to depth, extent, and severity

Identify key components in the assessment of a thermal burn casualty

Identify the pathophysiology, clinical presentation, and management of toxic inhalation injury

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Agenda

Identify the pathophysiology and clinical presentation of a direct inhalation injury

Define the management plan of a thermal burn casualty

Calculate fluid requirements and rates for a thermal burn casualty using the Parkland formula and the Rule of Ten

Define the key components of burn wound care


Agenda

Identify the indications and procedural steps for an escharotomy

Review Drip Calculation Homework


Pathophysiology of Local and Systemic Responses to Burn Injury

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Pathophysiology of Thermal Injury

Heat changes the molecular structure of tissue through 'denaturing'

Extent of burn damage depends on:

Temperature of agent

Concentration of heat

Duration of exposure


Pathophysiology of Thermal Injury

Ability to resist burn injury depends on:

Water content of skin tissue

Thickness of skin

Insulating substances

Peripheral circulation of skin

• Co‐morbidities? Underlying medical conditions?


Response to Burn Injury

Cellular damage is distributed over a spectrum of injury

Immediate destruction

Irreversible injury

Reversible injury

•Mediated by rapid and appropriate intervention

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Jackson’s Thermal Wound Theory

Three 'zones'

Zone of Coagulation

Closest to heat source ('concentration')

Nonviable tissue

Zone of Stasis

Area of ischemia

Zone of Hyperemia

Peripheral area with increased blood flow


Local Response to Burn Injury

Damaged cells initiate inflammatory response

Increased blood flow to cells

Release of chemical mediators; triggers:

Increase in capillary permeability

Fluid shift from intravascular space into damaged tissue

Injury to sodium pump

Sodium enters damaged cells

Increases flow of vascular fluid into wound


Systemic Response to Burn Injury

Small burn

Local events occur at the site

Large burn

Greater release of mediators and damage to sodium pumps

Widespread capillary leak

Significant fluid shift from intravascular to extravascular space

Multi‐system involvement

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Burn Shock

Emergent Phase

Pain response

Catecholamine release

• Tachycardia, tachypnea, mild hypertension, and anxiety

Fluid Shift Phase

Systemic capillary leak

• Shift of fluid from intravascular to extravascular space

Hypovolemia and massive edema

Reaches peak in 8 to 12 hours

• Lasts up to 24 hours


Burn Shock

Resolution Phase

24‐48 hours post burn

Capillary integrity reestablished

Progression to normal function

Hypermetabolic Phase

Lasts for days to weeks

Incredible increase in nutrient requirements



Cardiovascular response

Increased capillary permeability/damaged pumps

Electrolyte and conduction abnormalities

Decreased intravascular volume

Decreased cardiac output

Burn shock

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Renal response

Decreased renal perfusion

Hemolysis and rabdomyolysis

• Increased hemoglobin and myoglobin levels

Gastrointestinal response

Decreased splanchnic perfusion

Adynamic ileus; vomiting and aspiration; stress uclers

Translocation of gut flora



Pulmonary response

Hyperventilation to meet increased needs

Inhalation injury

• Upper airway edema

• Pulmonary tissue damage

Respiratory distress

• Obstruction

• Bronchoconstriction

• Pulmonary edema

• Circumferential burns



Immune response

Altered immunity

Eventual depressed inflammatory response

Emotional response

Pain

Isolation, fear, and altered self‐image

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Systemic Complications

Hypovolemia

Shock

Multi‐organ dysfunction

Renal failure

Electrolyte abnormalities

Respiratory compromise

Hypothermia

Infection

Decreased mobility

Depression


Burn Injury Classifications


Classification of Burn Injury

Classified according to depth

Superficial burn

Partial‐thickness burn

Full‐thickness burn

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Superficial Burn (1st Degree)

Painful, red, dry; blanches with pressure

Prolonged exposure to low‐intensity heat or short duration flash

Heals in 2 to 3 days


Superficial Partial‐Thickness Burn (2nd Degree)

Injury extends into the dermis

Red, wet, and painful

Blisters

Generally heals without scarring within 14 days


Deep Partial‐Thickness Burn (2nd Degree)

Involves basal layer of dermis

Dark red to yellowish‐white

Less moist

Less painful

Wound infection risk

Heals within 3 to 4 weeks

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Full‐Thickness Burn (3rd Degree) Through all three layers

'Pearly' white, charred, or 'leathery'

Eschar often present

Insensate

Vessel thrombosis

Infection, sepsis, and severe scarring

Evac consideration: will need grafting!


Burn Depth


Depth of Burn Injury?

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Extent of Burn Injury

Percent Total Body Surface Area (% TBSA)

Includes partial and full‐thickness burns

Three common methods of estimation

Rule of Nines

Rule of Palms

Lund and Browder Chart

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Rule of Nines

Expedient tool to measure extent of burn

Divides TBSA into regions that are multiples of 9

Rough estimate


Rule of Palms

Uses patient’s palm as comparison guide

Patient’s palm is equal to 1% of TBSA

Works for adult, child, or infant


Lund and Browder Chart

Assigns numerics to smaller anatomic areas

Best used for pediatric patients in clinical environment

Extremely accurate method

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Assessment of a Thermal Burn Casualty


Thermal Burn Assessment

Scene survey!

Trauma Patient

Assessment (TPA)!



Consider:

Source of burning agent

Enclosed space?

↓LOC

Explosion?

Major Traumatic Injuries?

Tetanus status

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Approximate extent of injury

Burn depth

% TBSA

Specific at‐risk body areas affected

Circumferential ('ringing') burns

Inhalation injury


Pathophysiology, Clinical Presentation, and Management of

Toxic Inhalation Injury


Inhalation Injury

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Inhalation Injury

Accounts for ½ of all fire related deaths

Amplified in enclosed space(s)

Two categories:

Toxic inhalation

Direct injury

• Supraglottic injury

• Infraglottic injury

Early recognition is crucial


Toxic Inhalation

Physical irritant

Smoke

Systemic poisoning

Synthetic resin combustion

Releases toxic gases

• Carbon monoxide, cyanide, and hydrogen sulfide

Diffuse across alveolar‐capillary membrane

Interfere with oxygen delivery or consumption


Carbon Monoxide

Colorless/odorless/tasteless in pure form

Product(s) of incomplete combustion of carbon fuels

Hemoglobin has a 250x greater affinity for CO over oxygen

Carboxyhemoglobin carries less oxygen and holds onto oxygen more tightly

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Pathophysiology

COHb‐mediated hypoxia

Interferes with cellular respiration

Cascade of inflammatory events

Brain ischemic reperfusion injury

CO binds to myoglobin causing myocardial impairment


Clinical Manifestations

Nonspecific

Frontal headache

Dizziness

Nausea

CNS and cardiac (most sensitive to CO)

Syncope, ataxia, and coma

Chest pain, dyspnea, and myocardial ischemia

Delayed neurologic S/Sx


Diagnostic Testing

COHb level

A very specific lab test; usually Hospital

Pulse oximetry misinterprets COHb as oxyhemoglobin = false normal reading

Co‐oximeter or breath sampling

Also very specific testing

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Diagnostic Testing

Glucose level

HCG

Cardiac monitoring/12 lead ECG

Neuro exam and mini‐mental status exam

Neuroimaging

CT, MRI, and SPECT

Where is the closest CT scanner?


Venous Blood Sample


Management

Half‐life of CO

4 to 5 hours at room air

60 to 90 minutes on 100% oxygen

15 to 25 minutes on hyperbaric oxygen

Treatment

Airway and ventilatory support

100% oxygen x 4 hours

Hyperbaric oxygen if warranted by symptoms

•Where is the closest chamber?

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Cyanide

↑suspicion of cyanide toxicity in patients with severe AMS or LOC

Treatment

Airway management and ventilatory support

100% O2

Cyanide antidote kit


Pathophysiology and Clinical Presentation of a Direct Inhalation

Injury


Supraglottic Inhalation Injury

Upper airway is susceptible to injury from high temperatures

Large

Moist

Vascular

Risk factors

Standing in the burn environment

Enclosed Space?

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Signs & Symptoms

Singed facial and/or nasal hair

Black sputum (nose and/or mouth)

Facial burns

Hoarseness and/or dyspnea

Stridor


Probability of Upper Airway Obstruction



What’s wrong with this picture?

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Infraglottic Inhalation Injury

Not as common as supraglottic

MOIs

Superheated steam

Scalding liquid aspiration

Explosions

Risk factors

Screaming

Enclosed space?


Infraglottic Inhalation Injury

Signs and symptoms often delayed

Wheezing, crackles, or rhonchi

Cough

Hypoxemia


Management Plan of a Thermal Burn Casualty

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Goals of Burn Management

Manage life threats

Maintain airway patency

O2/support ventilation

Hypothermia prevention

Fluid resuscitation

Pain management

Wound management

Psychological and emotional support


Thermal Burn Management:Minor Burns

Local cooling

Remove clothing and jewelry

Analgesics

Topical antibiotic ointment

Bulky, sterile dressing

Tetanus


Thermal Burn Management

Consider early definitive airway:

Direct inhalation injury

S/Sx airway obstruction

Burns > 40% TBSA

Consider procedural analgesia protocol/ local anesthetic for cricothyrotomy

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Thermal Burn Management

Vascular access

Large‐bore IV catheter

Best site you can access

IV CAN go through burned skin

IO if unable to gain IV access

Titrate analgesia and sedation

Aggressive fluid therapy


Additional Considerations

Elevate head 30+° to minimize edema of facial burns

If not contraindicated by spinal trauma

Place NG tube; anticipate ileus

Consider ulcer prophylaxis; H2 blocker


Fluid Requirements and Rates for a Thermal Burn Casualty

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Fluid Resuscitation

Therapy aimed at supporting patient through hypovolemic shock

Volume replacement

Crystalloids preferred

LR is fluid of choice

Hextend® (up to 1000 ml) can be used

Delayed or inadequate resuscitation:

Suboptimal perfusion, end‐organ failure


Fluid Resuscitation

Casualties with severe burns, extensive soft tissue trauma, inhalation injury, or electrical injury often require increased amounts of fluid

Certain patients, despite optimal resuscitation, will not recover from burn shock


Fluid Resuscitation

Parkland Formula

2‐4ml LR x pt wt (kg) x % TBSA burned = initial 24 hour fluid requirement

½ given in the first 8 hours from the time of burn

½ given over the subsequent 16 hours

*These formulas are an estimate*

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Parkland Formula Demonstration

132‐pound male sustained these burns 2 hours ago



4 ml LR x weight in kg x % BSA burn = total 24 hour fluid requirement

First convert 132 pounds to kilograms

132 pounds / 2.2 = 60 kg

Next determine the % BSA using the Rule of 9’s

Head = 9

Anterior Torso = 18

Left arm = 9

Total = 36 % BSA burn

4ml LR x 60 kg x 36% BSA = 8640 ml LR total fluid requirement for the first 24 hours



Administer ½ of the total volume in the first 8 hrs

8640 ml LR / 2 = 4320ml (first 1/2 of fluid requirements)

Subtract the 2 hours since the time of the injury from the 8 hours

8 ‐ 2 = 6 hours to get the first ½ in

4320 ml / 6 = 720ml LR / hr for the first 6 hours

Then administer ½ of the volume in the next 16 hrs

4320 ml LR / 16 hrs = 270ml LR / hr for the subsequent 16 hours

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The Rule of Ten

Army’s new prehospital burn formula

Fairly easy to remember

Gives us an hourly initial flow rate

Still an estimate


The Rule of Ten

Estimate %TBSA to the nearest TEN (10)

% TBSA x 10 = initial fluid rate (for adult patients weighing 40‐80 kg)

For every 10 kg above 80 kg, increase rate by 100 ml/hr


Rule of TenApplication

132‐pound male sustained these burns 2 hours ago

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Estimate burn size to the nearest TEN

36% TBSA burn = 40

% TBSA x 10 = initial fluid rate (for adult patients 40 ‐ 80 kg)

40 x 10 = 400


N/A

Estimated fluid requirements = 400 ml/hr



What would the fluid rate be if these same burns were sustained in a 100 kg patient?

36% = 40

40 x 10 = 400


Add 200 ml/hr

Estimated fluid requirements = 600 ml/hr


Fluid Resuscitation

Maintain end‐organ perfusion

Avoid under and over‐resuscitation

Fluids must be titrated

Maintain urine output 30‐50 ml/hr

Peds: urine output at 1 ml/kg/hr (under 30 kg)

Adjust rates 20% per hour as needed

Assess lung fields

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Fluid Resuscitation

Burn resuscitation fluid estimates are in addition to any fluids required for initial patient resuscitation

Fluid resuscitation for hemorrhagic shock takes precedence over burn resuscitation

Oral fluids may be acceptable in burns up to 40% TBSA if crystalloid supplies are limited


Burn Wound Care


Wound Care

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Wound Care

What do we cover the burns with?

What do we do with the blisters?

When do we use topical antibiotics?

When do we use systemic antibiotics?

What topical antibiotic do we use on the face?


Wound Care

Cover with dry, sterile (clean) dressings

Burn dressing

Sheets

Towels

Chux

Kerlex


Wound Care

Separate burned fingers and toes

Avoid pillow use if ears are burned

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Wound Care Field debridement only when necessary

Evac ˂ 12 hours?

do not apply topical antibiotics

Evac ˃ 12 hours?

apply antimicrobial

Silvadene® or Sulfamylon cream

Sulfamylon wraps

Silver dressings


Wound Care

Face – Bacitracin QID

Ears – Sulfamylon cream BID

Eyelids – Bacitracin ophthalmic ointment QID

Eyes – Erythromycin ophthalmic ointment QID

Shave face and scalp

Tetanus


Systemic Antibiotics

DO NOT give prophylactic systemic antibiotics for burn‐only patients

DO give appropriate antibiotic therapy to patients with concomitant wounds

If you’re forced into extended management with a burn‐only patient, initiate systemic antibiotics if signs of infection develop

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Indications and Procedural Steps for an Escharotomy


Thermal Burn ManagementEschars

Thick, leathery constriction of dead tissue

Circumferential, full‐thickness burns

Extremities

• Distal circulation!

Chest

• Decreased tidal volume!

Critical to restore distal circulation and adequate ventilation with escharotomy


Escharotomy

Provide procedural sedation

Incise mid‐lateral side

Incise into subcutaneous fat

Extend incisions the entire length of the FTB, including joints

Circulation not restored? Incise the mid‐medial aspect

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Escharotomy Incision Sites

Dashed lines indicate preferred sites for incisions


Midmedial Escharotomy


Midlateral and MidmedialEscharotomies

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Circumferential Truncal BurnEscharotomy

Incisions

Anterior axillary line

Horizontal at/below the level of xiphoid process

May need to include the abdominal wall


Burn Consult

Consult the USAISR Burn Center

DSN 312‐429‐2876

(210) 916‐2876

usarmy.jbsa.medcom‐[email protected]


Review Calculation Homework

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Questions?


Terminal Learning Objective

Action: Communicate knowledge of thermal burns

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Reason

34


Agenda

Identify the pathophysiology of local and systemic responses to burn injury

Classify burn injury according to depth, extent, and severity

Identify key components in the assessment of a thermal burn casualty

Identify the pathophysiology, clinical presentation, and management of toxic inhalation injury


Agenda

Identify the pathophysiology and clinical presentation of a direct inhalation injury

Define the management plan of a thermal burn casualty

Calculate fluid requirements and rates for a thermal burn casualty using the Parkland formula and the Rule of Ten

Define the key components of burn wound care


Agenda

Identify the indications and procedural steps for an escharotomy

Review Drip Calculation Homework

Thermal Burns PFN: SOMEML07

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