Burn Care in the 21s t Century

1. Burn Care in the 21s t Century James H. Holmes IV, MD Director, WFUBMC Burn Center Assistant Professor of Surgery Wake Forest University School of Medicine

2. Epidemiology ~500,000 pts/yr seek medical care for burns 40,000 require hospital adm (avg <15% TBSA) >90% preventable; ~50% d/t substance abuse ~4000 die �... vs. ~15,000 deaths in 1970 LD50 > 70% TBSA �� vs. ~30% in 1970 >50% return to pre-burn functioning Mechanism is age-related & situational: < 8 yoa ? scalds all others ? flame burns work ? chemical/electrical/molten

3. Burn LD50 & Advances in Care

4. A.B.A. Referral Guidelines PT burns > 10% TBSA Any FT burns Burns involving the face, hands, feet, genitalia, perineum, or major joints Electrical burns Chemical burns Inhalation injury Burns with concomitant non-thermal trauma Burns in patients with preexisting medical conditions that may complicate management Burns in patients who will require special social, emotional, or long-term rehabilitative intervention

5. BURNS = TRAUMARemember ABC�s(with a twist)

6. Airway & Breathing Inhalation Injury (~7% of patients in NBR) HX: closed space fire, meth lab explosion, or petroleum product combustion Upper airway injury: acute mortality facial/intraoral burns, naso/oropharyngeal soot, sore throat, abnormal phonation, stridor Lower airway injury: delayed mortality dyspnea, wheezing, carbonaceous sputum, ?COHb, ?PaO2/FiO2 Will increase resuscitation volumes Clinical dx - NO NPL, bronchoscopy +/- Intubate EARLY!!! ? Orotracheal Surgical airway uncommon

7. Calculate burn size The �TWIST� Burn depth Superficial Partial-thickness (PT) Full-thickness (FT) Indeterminate Only partial-thickness (2nd degree), indeterminate, & full-thickness (=3rd degree) injuries count towards %TBSA

8. Estimating Burn Depth/Severity

9. 3 Zones of Thermal Injury

10. Burn Depth

11. �Superficial� Formerly �1st-degree� Essentially a sunburn Pink Painful NO blisters Will heal in < 1 week

12. �Partial-thickness� Formerly �2nd-degree� Pink Moist Exquisitely painful Blistered Typically heals in < 2-3 weeks

13. �Full-thickness� Formerly �3rd-degree� Dry Leathery White to charred Insensate Will require E&G

14. �Indeterminate� Unsure as to whether PT or FT Observe for conversion b/t days 3-7 May or may not require E&G Can unpredictably increase LOS

15. Calculate burn size Determine burn depth Only PT (2nd degree), indeterminate, & FT (=3rd degree) count Estimate %TBSA Palmar surface of pts hand = 1% TBSA Age-appropriate diagrams (e.g.- Berkow) Rule of Nines

16. Berkow Diagram

17. Rule of Nines Body divided into fractions of 9% Head = 9% Ant thorax = 18% Post thorax = 18% Each UE = 9% Each LE = 18% Genitalia = 1% Not reliable in kids!!!

18. Calculate burn size Determine burn depth Only PT (2nd degree), indeterminate, & FT (=3rd degree) count Estimate %TBSA Palmar surface of pts hand = 1% TBSA Age-appropriate diagrams (e.g.-Berkow) Rule of Nines Burn experience ? accuracy in determining burn size & severity

19. Circulation Typically burns ?20% require IVF resuscitation Resuscitate w/ LACTATED RINGER�S Adult ? Baxter/Parkland Formula = 4 cc/kg/% burn 1/2 over 1st 8 hr from time of burn 1/2 over subsequent 16 hr Child (<20 kg) ? 3 cc/kg/% burn + D5 MIVF Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids) Peripheral IV access -- NO cut-downs Do NOT bolus !!! NO normal saline!!!

20. Resuscitation Fine Points More is NOT better!!! Crystalloid � NOT colloid & only LR Goal is normotensive, perfused, urinating pt. < 4 cc of LR /kg/%TBSA ? central monitoring Escharotomies ACS is unacceptable!!!

21. Disability(from other injuries) Primary & secondary surveys are important!!! R/O non-thermal trauma � ~5% have concomitant non-thermal injury Management of non-thermal trauma typically supercedes burn management, except for the resuscitation.

22. Everything else No IV antibiotic prophylaxis!!! Vascular access: PIV is preferable Analgesia = IV opiates Conservative & judicious sedatives, prn only Wood�s lamp eye exam for flash burns to face Escharotomies Early enteral nutrition (= 20% TBSA)

23. Escharotomies

24. Indications Circumferential FT extremity burns with threatened distal tissue Diminished or absent distal pulses via doppler Any S/S of compartment syndrome Circumferential FT thoracic burn Elevated PIP or Pplateau Worsening oxygenation or ventilation Nearly impossible to resuscitate patient with restrictive eschar needing release Fasciotomies rarely needed

25. Technique ANATOMIC POSITION!! Med & lat lines of extremities, over lumbricals on dorsal hands, ant or mid axillary lines on chest, & lateral neck lines Thru eschar only -- RELEASE Use cautery (knife OK) Not a sterile procedure Digits are controversial

26. After�

27. Initial Wound Management No IV antibiotics!!! Analgesia = IV opiates Wound care ? keep it simple Moist dressings (smaller burns) Dry non-adherent dressings (larger burns) �burn sheet�, cellophane, etc� Topical antibiotics only if delay in transfer Silvadene Bacitracin +/- blister removal Defer to burn center protocols, if uncertain

28. Excision & Grafting

29. Tangential Excision (TE) Done �early� (w/in 7 d) Various adjustable knives Sequentially remove only non-viable tissue Standard burn operation BLOODY!!! Tourniquets on extremities Speed is essential

30. Fascial Excision (FE) Done �early� (w/in 7 days) Done w/ Bovie Used for deep FT w/ dead subQ tissue Excise to fascia �Inferior� cosmesis (?) Blood loss < TE

31. Split-thickness Autograft (STAG) Skin is currently the only way to definitively �close� a burn wound. STAG typically 0.010 - 0.012 inches thick Meshed or sheet (location) Limited quantity Donor site issues & complications

32. Allograft Only temporary Ultimately rejected Always requires STAG Uses: temporary closure to allow donor healing & re-cropping STAG overlay test excision bed

33. Wound Closure Advances Dermal substitutes Integra? (bilaminate, collagen-chondroiton-6-SO4) Alloderm (cryopreserved allogeneic dermis) Dermagraft (neonatal FB on Biobrane) allow formation of autogenous �neodermis� utilize ultra-thin STAG (0.006 - 0.008 in) superior cosmesis & fxn vs. standard E&G Cultured epithelial autografts (CEA) Epicel? (cultured skin from patient) fragile, limited overall burn experience, $$$$

35. Integra?

36. The Template FDA approved in �96 Bilaminate membrane Applied to excised wound Engrafts in ~ 14 days (~7 days with VAC?) Ultra-thin STAG (�EAG�) Superior cosmesis & fxn, decreased LOS Drawbacks: Learning curve At least 2 operations

37. Operation #1 (Application) Procedure #1 In Procedure #1, the burn injury is excised and INTEGRA template is applied. Excised Wound Bed: Top left illustration depicts excision to viable tissue. Top right photo shows a fascial excision. Fascia, fat and dermis are all suitable wound beds if the following conditions are met: free from contamination and infection, adequate vascular supply, dry with no signs of bleeding, uniform and flat. Surgical Application: INTEGRA template is applied to the wound bed and attached by staples or sutures. Procedure #1 In Procedure #1, the burn injury is excised and INTEGRA template is applied. Excised Wound Bed: Top left illustration depicts excision to viable tissue. Top right photo shows a fascial excision. Fascia, fat and dermis are all suitable wound beds if the following conditions are met: free from contamination and infection, adequate vascular supply, dry with no signs of bleeding, uniform and flat. Surgical Application: INTEGRA template is applied to the wound bed and attached by staples or sutures.

38. Operation #2 (EAG) Procedure #2 In Procedure #2, the silicone is removed and a thin epidermal graft is placed on the neodermis. The top left illustration and top right photo show silicone removal as part of the second procedure at about day 21. The silicone layer is removed when sufficient donor sites are available and neodermis has formed. Silicone removal is atraumatic and should come off easily if neodermis is mature. The bottom left illustration and bottom right photo show the application of a thin epidermal autograft. Thin epidermal autografts are taken at approximately 0.006 inches (or 0.15 mm), with 0.004�0.008 inches (or 0.10�0.20 mm) being an acceptable range. Grafts may be meshed and expanded 3:1. Epidermal autografts are more fragile than conventional split-thickness grafts and should be cared for like a thick sheet graft. Procedure #2 In Procedure #2, the silicone is removed and a thin epidermal graft is placed on the neodermis. The top left illustration and top right photo show silicone removal as part of the second procedure at about day 21. The silicone layer is removed when sufficient donor sites are available and neodermis has formed. Silicone removal is atraumatic and should come off easily if neodermis is mature. The bottom left illustration and bottom right photo show the application of a thin epidermal autograft. Thin epidermal autografts are taken at approximately 0.006 inches (or 0.15 mm), with 0.004�0.008 inches (or 0.10�0.20 mm) being an acceptable range. Grafts may be meshed and expanded 3:1. Epidermal autografts are more fragile than conventional split-thickness grafts and should be cared for like a thick sheet graft.

39. Integra? Results

40. Chemical Burns Decontaminate patient prior to transport or transfer Acids/alkalis Meth labs Petroleum products �Industry� H2O� H2O� H2O� H2O Irrigation for =30 min No formal antidotes (exothermic rxns), except for HF Keep patient warm, if at all possible

41. Electrical Injuries/Burns High (>1000 V) & Low (<1000 V) voltage Remove patient from current source Dysrhythmias, SZ, FX, etc�.. Electrical & thermal components to injury Holmes� IVF rule of thumb: �double the calculated IVF rate (or volume) for a given estimated TBSA� Always more injury than is apparent

42. Modern Burn Care Model

43. Beyond the OR Wound care & healing are PAINFUL Long-term opiates are the rule PT/OT is long-term� lifelong to a degree Revisions & reconstructions are common w/ larger burns, >30% TBSA Burn care is expensive!!! NBR mean hospital charges for survivors ~$56,200/admission & ~$4075/d WFUBMC�. ~$4090/d

44. Beyond Acute Hospitalization PT/OT is lifelong, to some degree Long-term neuropsych & psychosocial issues are pervasive Burn survivor support groups & peers are essential S.O.A.R. Victim 2 Victor

45. Outcomes: What to expect Goal = LOS of 1 day/% TBSA burned Reality: NBR = 1.7 and WFUBMC = 1.3 RTW: ??? �� NBR = ? WFUBMC > 50% return to pre-burn fxn Disposition goal is ultimately home & independent�.. NBR = ? WFUBMC = 88% D/C�d home & 6% rehab PTSD & other neuropsych sequelae are COMMON

46. WFUBMC Burn Center Transfers or Referrals �Open-door� policy for ANY burn - NO CALL P.A.L. ? 800-277-7654 Ask for Trauma/Burn Attending on-call age, hx, %TBSA of PT/FT, UOP, airway & HD status LR for resuscitation transport (BMC AirCare ground or helicopter, 24-7) Do not directly call the WFUBMC Emergency Dept or Burn Center Dedicated Burn Clinic every MON & WED

47. WFUBMC Burn Team