Burn Management

1. Burn Management Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

2. 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

3. 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)

4. 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

5. Classification of Burn Depth • 1st degree: localize to epidermis (sunburn) • 2nd degree: injury to both dermis/epidermis • Superficial 2nd: papillary dermis • Typically red, painful, blister, “wet” appearing • Regen in 7-14 days from hair follicles/sweat glands • Deep 2nd: reticular dermis • Typically more pale/mottled, dry, ↓sensation • 3rd degree: full thickness epidermis/dermis • Hard, leathery eschar, painless • 4th degree: involves muscle, bone, etc.

6. Classification of Burn Depth

7. 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 Criteria for Burn Center Referral

8. 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

9. 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

10. Initial Assessment • Breathing (Breath sounds, chest rise, ET CO2) • Chest escharotomies if constrictive eschar • Circulation: get vitals (HR & BP) • 2 large bore IV (unburned before burned skin) • Start burn resuscitation with Lactated Ringer’s • 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

11. 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)

12. Initial Assessment • Burn Resuscitation with Lactated Ringer’s • Figure out burn size by “rule of nines” or entire palmar surface of pt’s hand = 1% • Parkland formula • 4 x Wt(kg) x %TBSA = mL to give in 1 day • Half over 1st 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

13. Burn Resuscitation • 70kg male with 40% TBSA • EMS administered 1.5L of fluids already • What rate of LR should he receive?

14. Burn Wound Management • Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation • Assess for the 6 P’s • 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)

15. 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 2nd: can use temporary pigskin • 3rd & (most) deep 2nd need early excision & grafting, except palm/soles/face/genitals • Perform at ~3-7 days post-burn

16. 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

17. 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

18. 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

19. 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