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Initial Burn Care Lee D. Faucher, MD FACS Director UW Burn Center
Associate Professor of Surgery & Pediatrics
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Objectives Discuss burn pathophysiology Outline treatment modalities
Understand why some treatments better than others
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What is a burn? Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.
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First Degree Burns Epidermis only No blisters Erythema
Mild to absent systemic response Heals in 3-4 days
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Superficial partial thickness
Papillary dermis Blisters Homogenous pink Painful, hypersensitive Blanches Hair usually intact Does not scar, may pigment differently
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Sup 2nd degree
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Deep partial thickness
Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft
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Deep dermal
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Full thickness burns Into fat or deeper Red, white, brown, black, etc.
Diminished sensation Dry, may be leathery Depressed Heals only from the periphery Always excise and graft
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Full-thickness
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Etiology
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Types of burns
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Where do burns occur
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Circumstances of injury
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Admissions by age
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% of admissions vs. burn size
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Inhalation injury diagnosis
Closed-space fire Face burns
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Terminology Inhalation injury “nonspecific” Thermal injury
Upper airway Local chemical irritation Throughout airway Systemic toxicity CO
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Clinical diagnosis History and physical Diagnostic studies Exposure
Duration Enclosed space Diagnostic studies
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Other signs and symptoms
Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea
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Poison management = CO 500 unintentional deaths each year
Persistent Neurologic Sequelae May improve over time Delayed Neurologic Sequelae Relapse later
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Poison management = CO Treatment
CO level means nothing to predict outcome Length of hypoxia is the determining factor Oxygen HBO No studies show benefit in treatment
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Pathophysiology The main factor responsible for mortality in thermally injured patients Carbon monoxide the most common toxin 200 times greater affinity Competitive inhibition with cytochrome P-450
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Reduction of CO
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Objective data Bronchoscopy
Edema Infraglottic soot Hyperemia Mucosal sloughing Sensitivity near 100% under IDEAL circumstances
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Grading of injury No reliable indicators of progressive respiratory failures No studies have found any correlation with initial findings and clinical outcomes and progress
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Resuscitation
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Field resuscitation Start IV with LR, in burn OK
< 6 years = 125mL/hr 6-13 years = 250mL/hr >13 years = 500mL/hr
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Rule of Nines
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Lund and Browder Chart
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IV access < 15% TBSA – oral resuscitation
15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s IV’s should be in the upper extremities Suture IV’s started through burns
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Crystalloid solution Ringer’s Lactate Advantages of crystalloid
[Na+] 130 mEq (serum 140 mEq) Osmolality 272 mOsm (serum 300mOsm) Advantages of crystalloid Effective in maintaining perfusion Costs less than colloids Can be mobilized with a diuretic
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Resuscitation first 24 hours
Baxter formula 4 mL/kg/% TBSA burned Give ½ the volume in first 8 hours and other ½ over next 16 hours.
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If < 20kg Same Baxter formula for LR Add 4mL/kg of D5 ¼ NS
Infuse at constant rate, increase LR if needed for adequate urine output
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Monitor urine output Place foley if > 20% TBSA Urine output goal
2 mL/kg/hr very young 1 mL/kg/hr child 0.5 mL/kg/hr adult Diuretics are NEVER used to increase urine output Increase urine output to > 100mL/hr if pigment present
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How to do this Maintain continuous IV fluid replacements AVOID boluses
Only bolus IV fluids if hypotensive
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Zones of burn injury
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Pain control
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Non-medication methods
Cover burns with plastic wrap Wet dressings will stick and cause more pain Other burn dressings are expensive and not necessary Quik Clot is expensive and will not provide any patient benefit
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Ice Pack-----DO NOT USE EVER
DOES NOT Reverse temperature Inhibit destruction Prevent edema DOES Delay edema Reduce pain
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Medication Medications Opioids Narcotics Pain medications IV Analgesia
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Summary Airway Circulation/Resuscitation Pain control
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Questions?
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