GSACEP core man LECTURE series: Burn Management This Curriculum is designed to augment traditional didactic Emergency Medicine training, specific for military residents. Patrick Glynn MD, Capt, USAF Updated: 19Feb2013 1

Disclaimer Views and opinions expressed do not necessarily reflect those of GS-ACEP, The Department of Defense, the U.S. Government, the North American Continent, the Western Hemisphere, or Mother Earth. The opinions and practices that may be “off label: do not necessarily reflect the standard of care expected at U.S. “brick and mortar” facilities. Many of these techniques are due to the austere environment from which they were derived and should only be practiced in those circumstances. 2

Outline Anatomy Pathophysiology Burn Assessment Management Reasons for referral Prognosis 3

Skin Anatomy Largest organ system of the body Epidermis Dermis outer layer, varying thickness Dermis Thicker, hair follicles, nerve endings, blood vessels Subcutaneous Fat Muscle 4

Skin Anatomy 5

Burn Pathophysiology Burns alter capillary permeability fluid leaks out Volume loss, hypotension worst in lungs ARDS Electrolyte abnormalities 6

Thermoregulation Normal skin regulates body temperature Burned skin doesn’t function properly patients lose autoregulation leads to HYPOthermia Keep burned patients warm 7

Zones of Burn Injury Coagulation Stasis Hyperemia Irreversible destruction Stasis middle layer with Decreased blood flow Can be saved by adequate Resuscitation Hyperemia surrounding area Increased blood flow recovery likely 8

Estimating size (TBSA) Patient’s Palm=1% TBSA Rule of 9’s - percentage surface area Head = 9 Each Arm = 9 Each Leg = 18 Back = 18 Front = 18 Groin = 1% Kids: Head=18, each leg 13.5% 9

Age Older and Younger patients have thinner skin more prone to thermal injury 10

Burn Depth - Superficial Red skin Painful NO blisters heals in 3-7 days example: sunburn 11

Burn Depth - Partial Thickness Epidermis / Dermis Blisters Wet appearing PAINFUL Can convert to full thickness or heal in 2-3 weeks 12

Burn Depth - Full Thickness PAINLESS Waxy Charred Dry Requires surgery / grafting 13

Burn Depth 14

Assessment - Airway Inhalation Injury Aggressive, Early management Face / neck burns Hoarse voice Singed nasal / facial hairs Soot in sputum Aggressive, Early management Intubate BEFORE swelling Large ETT for Bronchoscopy 15

Assessment - Mental status Altered hypoxia CO poisoning Cyanide toxicity if surrounded by fire / smoke treat with supplemental Oxygen 16

Management Airway - Assess / Reassess & Intervene Dressings in Field 17

Pre-hospital care Airway Stop burning process ie: wash off chemicals Start Fluid resuscitation Transport to hospital Pain control Protect burn wound 18

Management - Fluids Urine output - 1mL /kg/hr LR or NS Parkland Formula TBSA x (weight kg) x (4 LR) = 24 hour requirement 1/2 in first 8 hours 1/2 over the next 16 hours Still need maintenance fluids Urine output - 1mL /kg/hr 19

Resuscitation Example 70 kg patient 20% partial and full thickness burns What is the 8 hour fluid requirement? 20

Resuscitation Example 70 kg x 20 x 4 = 5600 mL in 24 hours 2800 mL in 8 hours 21

Chemical Burns Acid - coagulation necrosis Alkali - liquefaction necrosis usually worse remove clothing Irrigate aggressively with water / saline 22

Refer to burn center Full thickness burns Inhalational Injury Electrical burns Chemical burns Circumferential burns Partial Thickness >15% Pediatric or Elderly >10% High Risk Locations genital, hands, feet, face, over joints 23

Compartment Syndrome Extremities Abdominal remove rings, jewelry, clothing Abdominal 24

Management Aggressive pain control Compartment syndrome: needs fasciotomy to release pressure Escharotomy - for circumferential burns Tetanus immunization Blisters - Controversial 25

Burn Prognosis Increase Risk of Death: Larger burn size Older age Inhalational Injury Female Pre-existing diseases 26

References Tintinalli’s Emergency Medicine 7th Edition, chapter 45 27