Burn Management

Burn Management
Tad Kim, M.D.
UF Surgery
tad.kim@surgery.ufl.edu
(c) 682-3793; (p) 413-3222
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
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)
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
Burn Management
Classification of Burn Depth
1
st
degree: localize to epidermis (sunburn)
2
nd
degree: injury to both dermis/epidermis
Superficial 2
nd
: papillary dermis
Typically red, painful, blister, wet appearing
Regen in 7-14 days from hair follicles/sweat glands
Deep 2
nd
: reticular dermis
Typically more pale/mottled, dry, sensation
3
rd
degree: full thickness epidermis/dermis
Hard, leathery eschar, painless
4
th
degree: involves muscle, bone, etc.
Burn Management
Classification of Burn Depth
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
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
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
Burn Management
Initial Assessment
Breathing (Breath sounds, chest rise, ET CO
2
)
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 with
circumferential extremity burns
Disability (GCS less than eight -> intubate)
Exposure: remove all clothing
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)
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 1
st
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
Burn Management
Burn Resuscitation
70kg male with 40% TBSA
EMS administered 1.5L of fluids already
What rate of LR should he receive?
Burn Management
Burn Wound Management
Circumferential deep 2
nd
or 3
rd
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)
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 2
nd
: can use temporary pigskin
3
rd
& (most) deep 2
nd
need early excision
& grafting, except palm/soles/face/genitals
Perform at ~3-7 days post-burn
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
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
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
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