New Approaches in Burn Management

Ken Butler D.O.

Associate Professor
Associate Residency Director
Emergency Medicine Residency Program
University of Maryland
 New Concepts in the Management of
Thermal Injuries
 Objectives
 Smoke inhalation--who can be sent home?

 What really predicts intubation in smoke inhalation?

 RSI in smoke inhalation

 Whose palm is it anyway?

 Is the rule of nines really the rule?

 Challenging the Parkland formula

 New imaging for burn depth

 Blister management

 Hands
 Prehospital Care
 Pain Management by EMS

 EMS personnel hesitate to give an appropriate amount of

pain medication to burn patients

 Airway Management

 EMS personnel are concerned about the airway NOT about

making it to the regional burn center.

 so these patients show up in your ED

 Know the Burn Depth
“Lingo”
For the Consultants

 Emergency Physicians

 1st Degree

 2nd Degree

 3rd Degree
 Know the Burn Depth
“Lingo”
For the Consultants

 Plastic Surgeons

 3 Zones

 Partial Thickness

 Full Thickness
 Epidemiology as Easy as Two-
Three
 2/3 male
 2/3 white
 2/3 drunk
 2/3 have flammable liquid
 2/3 reduction in death due
to smoke detectors
 23 mean age
 Mechanisms
 Six groups based on mechanism of injury

 Scalds 30%
 Contact burns 30%
 Fire 30%
 Chemical 3%
 Electrical 5%
 Radiation 1%

 Flash Burns
 lighting BBQ – microsecond of exposure

singed facial hairs – NO INHALATIONAL BURN

 Chemistry Flash Backs
 Tar Burns
 “Likes dissolve likes”
 Excellent removal with butter

 Wet Cement
 CaOH-
 Treat like an ocular alkali burn

 Hydrofluoric Acid Burn

Dissolve 10% calcium gluconate solution
in 3 times the volume of a water-soluble
lubricant.
For burns to the fingers, retain gel in a
latex glove.
 Chemistry Flash Backs
 Microwaves cause “superheating”

 Heating a liquid to a temperature above

its normal boiling point, making it
unstable.

 Microwave energy burns are based on the

water content of tissue

 Muscle burns more than fat

 Delay between time of injury and signs of

skin damage or pain
Alexander RC, Surrel JA, Cohle SD. Microwave oven burns to children: An unusual manifestation of child
abuse. Pediatrics. 1988;79(2):255-260.
 Just Admit Him for Syncope?
 Fireman has sudden collapse at a house fire
 His firefighter partner called it a “Knock Down Fire”

 This is classic presentation of CN

 CO requires longer exposure for symptoms

 Smoke Inhalation
Who Can We Discharge Home?

 Arterial blood gases, chest radiography and carboxyhemoglobin

estimation rarely influence immediate management.

 Bottom Line
 Patients presenting with normal vital signs and examination
and short smoke exposure may be safe to discharge from the
emergency department without further investigation.

Mushtag,F, et al, Discharge from the accident and emergency department after smoke inhalation: influence
of clinical factors and emergency investigations. J Emerg Med. 2004 Jun;11(3):141-4.
 Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

 No statistically significant correlation was found between

intubation and any of the “classic symptoms” of smoke
inhalation:
 stridor

 hoarseness

 drooling

 dysphagia (all p = 1.0)

Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke
Inhalation Injury Ear Nose Throat J. 2006 Apr ;85(4):278-80
 Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

 Intubation positively correlates with the physical examination

findings of

 soot in the oral cavity (p < 0.001)

 facial burns (p = 0.025)

 body burns (p = 0.025)

Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke
Inhalation Injury Ear Nose Throat J. 2006 Apr;85(4):278-80
 Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

 Conclusion

Patients with
1. soot in the oral cavity,
2. facial burns, or
3. body burns

have a higher likelihood of laryngeal

edema and the need for intubation.
Madnani DD, et al, Ear Nose Throat J. 2006 Apr;85(4):278-80
 Intubation and Smoke Inhalation

 “Take it early” as it never gets better !

 Prevent a “DOA”
 Developing Obstructed Airway due to progressive edema

 First attempt is best attempt - This is for the most

experienced intubator NOT a junior resident
 Three Factors of Smoke Inhalation
That
Produce a Difficult Airway
 Thermal damage – Upper airway takes the brunt and causes
edema due to the poor conductivity of air and the high
amount of dissipation that occurs in the upper airways.

Air inhaled at 142°C - by the time it reaches the carina it

will have cooled to 38°C.

 Asphyxiation – Tissue hypoxia alone - with CO or CN??

 Pulmonary irritation – Particulate matter causes a decrease

in all lung volumes and lung compliance
 CHEMICAL COMPONENTS OF SMOKE

COMPOUNDS SOURCE EFFECT TIMING

  Ammonia CLOTHING, FURNITURE,  Mucous membrane Early onset (first

irritation, several hours)
  SULFUR DIOXIDE WOOL, SILK bronchospasm,
bronchorrhea
  CHLORINE  

HYDROGEN PLYVINYL CHLORIDE, Severe mucosal Delayed often 1-2

CHLORIDE damage; ulcers, days
mucous plugging,
  PHOSGENE FURNITURE, (WALL, FLOOR mucosal slough,
COVERINGS) pulmonary edema
  ACETALDEHYDE WALL PAPER  immediate
  FORMALDEHYDE LACQUERED WOOD

  ACROLEIN COTTON, ACRYLIC

  CYANIDE POLYURETHANE  UPHOLSTERY Tissue hypoxia immediate

 CARBON NYLON (ANY COMBUSTIBLE

MONOXIDE SUBSTANCE)
 RSI in Burn Patients

 Don’t take away what they already have

 Should be your thought before pushing any paralytic

 Why a 7.5 ETT ?

 What is your plan B ?

 The Difficult Airway in Smoke
Inhalation
You’re in. All you see is a “pink dead end” with charcoal.
No landmarks.

You reposition. Still a “pink dead end.”

Now what?
With your right hand, press down on the lower rib cage.
LOOK FOR “tiny bubbles.”
Now pass the tube or bougie.
Hypotension Post Intubation in a Burn
Patient

Now the patient is intubated but your bagging is becoming an

isometric exercise.

And the patient is developing hypotension.

Why?
Is this burn shock?
Is the vent setting wrong?
What else might the patient need?
 Escharotomy
 “SNAP, CRACKLE, POP”
 The Palm and the Assessment of
TBSA #1 Problem
 The area of the palm alone is
 0.5 percent TBSA in males

 0.4 percent TBSA in females

 Whereas the area of the palm plus the palmar surface of the
five digits is
 0.8 percent BSA in males

 0.7 percent BSA in females

Therefore, if a hand alone is used to assess

the size of a burn, the percent BSA is overestimated.
Rossiter ND et al. How big is a hand? Burns. 1996 May;22(3):230-1.
 Palmar Estimation and BMI
#2 Problem
 The mean HSA diminishes significantly as BMI increases in
both sexes (P<0.001).

 This difference is more pronounced in women, particularly

those with a BMI >31 kg/m2

 Awareness of the potential for overestimation of burn surface

area using this method alone may improve the accuracy of
burn area estimation.
Berry MG et al. The influence of body mass index on burn surface area
estimated from the area of the hand. Burns. 2001 Sep;27(6):591-4.
The Rule of Nines Isn’t Always the
Rule
 The Rule of Nines Isn’t Always the
Rule
 The Rule of Nines provides reasonable estimates of body
surface area for patients ranging from 10 to 80 kg.

 For obese patients weighing more than 80 kg, a rule of fives is

proposed:
 5% body surface area for each arm
 5 x 4 or 20% for each leg
 10 x 5 or 50% for the trunk
 and 2% for the head

Livingston EH. Percentage of burned body surface area determination in obese and nonobese
patients. J Surg Res. 2000 Jun 15;91(2):106-10
 5%
50%

20%

Livingston EH. Percentage of burned body surface area determination in obese and nonobese patients J Surg Res.
2000 Jun 15;91(2):106-10.
 Fluids and Formulas
 Lactated Ringer’s in all burn resuscitation

 Burn resuscitation requires more fluid than trauma resuscitation.

 Prevent hyperchloremic acidosis and buffer lactate

 Fluids and Formulas
 On the Horizon

 Adjuvant administration of high-dose ascorbic acid

(66 mg/kg/hr) during the first 24 hours after thermal injury
significantly reduces

 resuscitation fluid volume requirements by 30%

 wound edema

 severity of respiratory dysfunction

Reduction of Resuscitation Fluid Volumes in Severely Burned Patients Using Ascorbic Acid
Administration Arch Surg. 2000;135:326-331.
 Fluids and Formulas
 Formulas

 Parkland LR 4 mL/kg per percent burn ????

 Modified Brook LR 2 mL/kg per percent burn

 Galveston LR 5000 ml/m² BSA burned/day plus

2000 ml/m² BSA total/day
(also used in TEN)
Barret J.P et al. Survival of paediatric burns involving 100% total body surface area Ann
Burns Fire Disasters 1999; 12:139.
Spies et al. Treatment of extensive toxic epidermal necrolysis in children Pediatrics
2001;108:1162-1168.
How Well Does the Parkland Formula Estimate
Actual Fluid Resuscitation Volumes?

 Despite its effectiveness, the Parkland formula underestimates

the volume requirements in most adults with isolated cutaneous
burns, especially in those with large full thickness burns.

 New data suggest 5.5-6.0 ml/kg per TBSA%

Cartotto RC et. al. How well does the Parkland formula estimate actual fluid resuscitation
volumes? Burn Care Rehabil. 2002 JulAug;23(4):258-65.

Mitra B et.al. Fluid resuscitation in major burns J Surg. 2006 Jan-Feb;76(1-2):35-8.

Inhalation and Fluid Requirements

 Patients with flame burns and inhalation injury have a mean

fluid requirement of

 2 ml/kg/% burn above patients with flame burns without

inhalation injury for adequate resuscitation.

Dai NT et al. The comparison of early fluid therapy in extensive flame burns between
inhalation and noninhalation injuries. Burns 1998 Nov;24(7):671-5.
 Early Fluid Resuscitation Improves
Outcomes in the Pediatric Patient
 The incidence of sepsis, renal failure, death due to cardiac
arrest, and overall mortality is significantly higher in burned
children receiving fluid resuscitation that was delayed >2 hr.

 Fluid resuscitation, given within 2 hr of a thermal injury, may

be one of the most important steps in the prevention of multi-
organ failure and mortality.

Barrow RE et al. Early fluid resuscitation improves outcomes in

severely burned children. Resuscitation. 2000 Jul;45(2):91-6.
 Emergency Department Fluid Resuscitation of
Burn Patients Transferred to a Burn Center

 The average total body surface area (TBSA) estimated by the

referring emergency department staff was 23.9%

 Compared with the burn intensive care unit staff’s average

estimation of 17.8%

 More importantly 47% were underresuscitated.

Hagstrom M et al. A review of emergency department fluid resuscitation of burn

patients transferred to a regional, verified burn center. Ann Plast Surg. 2003;51:173-6.
 Emergency Department Fluid Resuscitation of
Burn Patients Transferred to a Burn Center

 Bottom Line

 Early communication permits review of estimated TBSA burn

evaluation and permits cooperative calculations and optimal
delivery of early fluid resuscitation.

 Burn center practitioners can improve care of patients before

arrival by appropriately guiding the referring physician.
Hagstrom M et al. A review of emergency department fluid resuscitation
of burn patients transferred to a regional, verified burn center.
Ann Plast Surg. 2003 Aug;51(2):173-6.
 Advances in Modalities Used for the
Assessment of Burn Wound Depth

 Depth dictates prognosis

 Although bedside clinical evaluation remains the most

widespread and cost-effective method, it is accurate only 2/3
of the time and is limited by poor interrater reliability

 New techonological modalities are now in use

 Laser Doppler Imaging (LDI)

 Burn Assessment by Laser Doppler Imaging

 Noncontact scanning technique that measures the entire burn wound

surface.
 Color-coded perfusion map corresponds to varying burn depth.

 Accuracy up to 99%

 The latest, most accurate, most advanced modality of diagnosing burn

depth
Lara Devgan, BA, Modalities for the Assessment of Burn Wound Depth J Burns Wounds.
February 2006; 5: e2.
 Management of Blisters in the
Partial-Thickness Burn

 Previously a controversial topic

 Preservation: intact blister provides natural biological

protection to the wound; blister fluid supports wound
healing

 Blister debridement and fluid evacuation; components of

blister fluid are detrimental to wound healing
 Management of Blisters in the
Partial-Thickness Burn
 Blisters do not indicate burn depth

 Blisters typically signify the presence of a superficial

partial- thickness wound.

 We can get into trouble: they may occur over deeper

dermal injuries that require excision and skin grafting.

 It is imperative to accurately identify the depth, as it

correlates with the risk of wound infection.
 Visually Deceiving Burns
 Many burn injuries involve various depths of burn.

 Debridement of blisters aids in accurate wound depth

identification by allowing direct visualization of the wound
bed.

Flame burn (direct contact) looks superficial with

blisters.

When gently cleansed, the wound is found to be a

combination of deep second- and third-degree burn.
 Management of Blisters in the
Partial-Thickness Burn
 Infection
 3 Zones of Injury
 Coagulation
 central devitalized tissue
 Stasis
 marginally perfused
 Hyperemia
 outlying tissue
 Management of Blisters in the
Partial-Thickness Burn
 Knowledge of these zones and the associated risk of
conversion of partial-thickness to full-thickness injury requires
ongoing assessment, especially during the first 48 hours.

 Prevention of wound conversion is key.

 Debridement of Burn Blisters
 Protective to the fragile zone of stasis in the early stages of
injury

 Inflammatory mediators within blister fluid contribute to

increasing size of the blister as the result of effect on
microcirculation and increased capillary permeability

 Mechanical pressure from the blister on ischemic tissue

contributes to deepening the wound
 Debridement of Burn Blisters
 Prevention of wound conversion reduces the risk of infection.

 Partial thickness wounds

 retain intact vascular supply and tissue viability

 are therefore less susceptible to microbial invasion

 CLINICAL PRACTICE
GUIDELINES
 Bottom line of blister management

 Blisters should be debrided to

 stop burn wound conversion
 remove non-viable tissue
 allow proper visualization of the wound bed
 evacuate fluid that will increase the size of the blister
 evacuate fluid that suppresses local and systemic
immune function

Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review.
J Burn Care Res. 2006;27(1):66-81
 Hand Burns
 Disability
 Edema hinders motion contraction compartment syndrome
 Elevation is crucial
 Evaluation of radial, ulnar, and palmar arch pulses by
palpation/Doppler hourly
 “If they can’t make a fist, make it to a Burn Center.”
 Two Bedside Tests for the Detection of
Developing Compartment Syndrome of a Digit

 Use a pulse oximeter to detect extremity

hypoxia.
 <95% O2 saturation may require escharotomy

 Place an 18-gauge needle on the pressure tubing

used to monitor arterial pressure and insert the
needle into the compartment.
 Pressures >30 mmHg require escharotomy
 Hand Burn Contractures
 The typical contracture is an "intrinsic minus" position:
the MP joints are fixed in hyperextension and the PIP joints are
fixed in flexion.

 For this reason, positioning of the burned hand should place the
MP joints at maximum flexion (90 degrees) to maximally stretch
the collateral ligaments.
 Hand Burn Devices

 A vacuum-assisted closure device for treatment of hand burns is in

prospective clinical trials.

 This device reduces edema and provides an excellent method of

splinting.
 Synthetic Skin Substitutes
 Biobrane® is a bilayer synthetic skin substitute

 An outer epidermal analog is constructed of a thin silicone

film that functions comparable to skin.
 Small pores in the silicone allow exudate removal and
permeability to topical antibiotics.

 An inner dermal analog is composed of a three-dimensional

irregular nylon filament weave to which type I collagen
peptides are bonded.
Synthetic Skin Substitutes
Synthetic Skin Substitutes
 Outpatient Management of Partial-
Thickness Burns: Biobrane versus 1%
Silver Sulfadiazine

 Across multiple trials comparing rates of healing in partial-

thickness wounds, Biobrane® significantly reduced healing time
without increased infection rates compared with topical SSD.

 When used on properly selected wounds, Biobrane therapy

significantly decreases pain and total healing time without
increasing the cost of outpatient burn care.

Gerding RI et al. Outpatient management of partial thickness burns. Biobrane versus

1% silver sulfadiazine. Ann Emerg Med 1990:19:121-124.
 Sulfamylon
 Mafenide acetate diffuses through devascularized tissue.

 80% is delivered to burned tissue over the first 4 hours

following topical application.

 Sulfamylon® exerts bacteriostatic action against many gram-

negative and gram-positive organisms, including
Pseudomonas aeruginosa and certain strains of anaerobes.
 Silver Sulfadiazine
SSD
 The use of SSD in partial-thickness wounds delays healing.
 Use of SSD requires dressing changes BID, which may cause
trauma to the epidermal cellular bed.
 Despite its availability, its soothing effects and ease of application
make its use widespread.

 Contraindicated
 Pregnancy

 Nursing mothers

 Allergy to sulfa

 Facial burns
  
The Fallout:
'I Felt My Face Just
Melting'
Burn units struggle to cope with
Aug. 8, 2005 Issue
the flow of meth users straining
their resources.
 Methamphetamine Burn Patients:
What Makes Them Different?
 Key points

 A 2-year retrospective revealed that the methamphetamine

burn patient requires two to three times the standard
Parkland formula resuscitation.

 Methamphetamine burns larger than 40% TBSA have a

100% mortality.

Warner P et al. The methamphetamine burn patient J Burn Care Rehabil. 2003;24:275-8.
 Burns in Pregnancy
 Clinical Challenges

 Intravascular volume is increased by 50%

 Fall in colloid pressure – increases extravasation
 Increase in TBSA
 Parkland formula is inaccurate
 INCREASE IN FLUID LOSS VS NONPREGNANT
 Third-trimester patients may require TWICE the Parkland
formula for adequate resuscitation

Pacheoco LD. et al. Burns in Pregnancy Obstet Gynecol. 2005 106:1210-2.

 Outcome and Changes in Survival Following
Severe Burns (1985 to 2004)

 Outcome was evaluated in relation to the presence of three

major risk factors for death:

 age 60 years or over

 total burned surface area 40% or more
 inhalation injury

 When zero, one, two, or three risk factors were present,

mortality was respectively 0.5%, 9.9%, 48.0%, and 90.5%.

Brusselaers N. et al. Outcome and changes over time in survival following severe burns from
1985 to 2004 Intensive Care Med. 2005;31(12):1648-53