1. 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

2. 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

3. Outline Anatomy Pathophysiology Burn Assessment Management
Reasons for referral
Prognosis 3

4. 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

5. Skin Anatomy 5

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

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

8. 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

9. 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

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

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

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

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

14. Burn Depth 14

15. 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

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

17. Management Airway - Assess / Reassess & Intervene Dressings in Field17

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

19. 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

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

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

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

23. 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

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

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

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

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