burns & escharotomy

Burns & EscharotomyBurns & Escharotomy

ByBy

Don Hudson, D.O. Don Hudson, D.O. FACEP/ACOEPFACEP/ACOEP

LifeFlight Medical DirectorLifeFlight Medical Director

BurnsBurns

In the USA over 2.2 million/year In the USA over 2.2 million/year Major burns have a significant risk of Major burns have a significant risk of morbidity & death.morbidity & death.The pre-hospital care is a major The pre-hospital care is a major contributor to patients final out come.contributor to patients final out come.

BurnsBurns

The skin is the largest organ in the bodyThe skin is the largest organ in the bodyIt provides Thermal regulation & It provides Thermal regulation & prevention of fluid loss by evaporation.prevention of fluid loss by evaporation.Hermetic barrier to infection.Hermetic barrier to infection.Contains sensory receptors that provide Contains sensory receptors that provide information about the environment.information about the environment.

Skin AnatomySkin Anatomy

The skin is divided into 3 layersThe skin is divided into 3 layersEpidermis- outer layer of cornified Epidermis- outer layer of cornified epithelial cells.epithelial cells.Dermis- the middle layer, mostly Dermis- the middle layer, mostly connective tissue. Contains capillaries, connective tissue. Contains capillaries, nerve endings, & hair follicles.nerve endings, & hair follicles.Hypodermis- a layer of fat & connective Hypodermis- a layer of fat & connective tissue between skin & underlying tissuetissue between skin & underlying tissue

Approach to Burn PatientApproach to Burn Patient

AgeAgeHistoryHistoryDuration of exposureDuration of exposureType of fireType of fireTetanus statusTetanus statusConsider Abuse in pediatricsConsider Abuse in pediatricsDetermine depth, type & extent of injuryDetermine depth, type & extent of injury

For ReviewFor Review

Consider AbuseConsider Abuse

Important PointsImportant Points

AA- Allergies- AllergiesMM- Medications even OTC- Medications even OTCPP- Past medical Hx/previous illness- Past medical Hx/previous illnessLL- Last meal or fluids consumed- Last meal or fluids consumedEE- Events leading up to injury/Hx present- Events leading up to injury/Hx present illness illness

Burn PatientsBurn Patients

Burn patients need lots of medical skillBurn patients need lots of medical skillYou must identify the amount of burnYou must identify the amount of burnYou must define degree of burnYou must define degree of burnYou must identify associated injuriesYou must identify associated injuriesYou must establish events preceding the You must establish events preceding the injuryinjuryEstablish basic care firstEstablish basic care first

Airway, Fluids & UrineAirway, Fluids & Urine

TreatmentTreatment

Airway- establish earlyAirway- establish earlyFluids- Two (2) big bore IV’sFluids- Two (2) big bore IV’sConsider Foley for fluid managementConsider Foley for fluid managementProtect from further injuryProtect from further injuryConsultConsultNotify dispatch of findingsNotify dispatch of findingsArrange appropriate referral &/or treatmentArrange appropriate referral &/or treatment

Studies NeededStudies Needed

CBS & Chemistry profileCBS & Chemistry profileABGABGCO levelCO levelCoagulation profileCoagulation profileUAUAType & screenType & screenCPK & urine myoglobin (especially in electrical CPK & urine myoglobin (especially in electrical injuries)injuries)CXRCXR

FluidsFluids

(4 ml crystalloid) X (% BSA burn) X (body wt in Kg)(4 ml crystalloid) X (% BSA burn) X (body wt in Kg)

Ex a man weighting 70 Kg with 30% BSA would Ex a man weighting 70 Kg with 30% BSA would require (30) X (4ml) X 70 = 8400 ml in 1require (30) X (4ml) X 70 = 8400 ml in 1stst 24 hr. 24 hr.

Half of the fluid is given in the first 8 hr. with the Half of the fluid is given in the first 8 hr. with the balance given in the next 16 hr.balance given in the next 16 hr.

Maintain urine output at 1 ml/kg/hourMaintain urine output at 1 ml/kg/hour

EscharotomyEscharotomyNeeded when there is a full thickness burn Needed when there is a full thickness burn involving the extremities or chest.involving the extremities or chest.The eschar acts like a tourniquet.The eschar acts like a tourniquet.Edema forming in the middle layer pushes Edema forming in the middle layer pushes out ward & the eschar restricts further out ward & the eschar restricts further motion.motion.This compromises the vascular flowThis compromises the vascular flow

ProcedureProcedurePerform along lateral aspect of extremityPerform along lateral aspect of extremityIncision should go completely through the Incision should go completely through the eschar.eschar.Be prepared for the subq fat to bubble up Be prepared for the subq fat to bubble up through the incisionthrough the incisionOnce the incision is made some bleeding Once the incision is made some bleeding will occur.will occur.

Incision LinesIncision Lines

ProcedureProcedureDo not forget chest, it may also need a Do not forget chest, it may also need a procedureprocedure

Don’t forget Don’t forget PAIN MEDSPAIN MEDSDon’t forget, clean, bandage, Universal Don’t forget, clean, bandage, Universal Precautions about blood products & Precautions about blood products & potential for hypothermiapotential for hypothermia

VisualsVisuals

ReviewReview

AnatomyAnatomy

First DegreeFirst Degree

Second DegreeSecond Degree

Second & Third DegreeSecond & Third Degree

One Hour DifferenceOne Hour Difference

30 Min After Procedure30 Min After Procedure

Note: Chest IncisionsNote: Chest Incisions

Fat BulgingFat Bulging

ChestChest

FootFoot

LegLeg

REMEMBERREMEMBERBe earlyBe earlyBe aggressive in TxBe aggressive in TxAirway ControlAirway ControlIV’s, adequate fluidsIV’s, adequate fluidsFoleyFoleyConsider other injuriesConsider other injuriesSplintsSplintsEscharotomyEscharotomyTemperature controlTemperature control

THE ENDTHE END