burns initial evaluation & management

Christopher P. Brandt M.D.Christopher P. Brandt M.D.Associate Professor of SurgeryAssociate Professor of Surgery

Case Western Reserve UniversityCase Western Reserve University

BURNSBURNSInitial Evaluation & ManagementInitial Evaluation & Management

Joseph B.Joseph B.

Your patient is brought to the E.D. by the Your patient is brought to the E.D. by the EMS service.EMS service.

He is a 14 year-old male who was involved He is a 14 year-old male who was involved in a house firein a house fire

HistoryHistory

What other points of history do you What other points of history do you want to know?want to know?

History, Joseph B.History, Joseph B.

Neighbors heard an explosionNeighbors heard an explosion Patient found confused, outside of the housePatient found confused, outside of the house Cannot remember what occurredCannot remember what occurred Denies shortness of breathDenies shortness of breath Transport time of twenty minutesTransport time of twenty minutes PMH of ADHDPMH of ADHD Tetanus – up to dateTetanus – up to date

Physical ExaminationPhysical Examination

What would you look for?What would you look for?

Physical ExaminationPhysical Examination

VS T=96.5VS T=96.5 P=140 R=24 BP=90/60 P=140 R=24 BP=90/60 Awake; No hoarseness or stridorAwake; No hoarseness or stridor Soot in mouthSoot in mouth Clear breath soundsClear breath sounds Burns involving face, neck, trunk, arms and Burns involving face, neck, trunk, arms and

upper legs (see photos)upper legs (see photos) Doppler pulses in all extremitiesDoppler pulses in all extremities

Physical ExaminationPhysical Examination

How do you determine the extent and How do you determine the extent and depth of the burn injuries?depth of the burn injuries?

What findings suggest inhalation What findings suggest inhalation injury?injury?

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Extent of burn Extent of burn % total body % total body surface areasurface area

Burn DepthBurn Depth

ColorColor MoistnessMoistness Capillary refill/BlanchingCapillary refill/Blanching SensationSensation BlisteringBlistering

Superficial Second Degree

Deeper second degree

Third Degree

Inhalation injuryInhalation injury

Occurred in closed spaceOccurred in closed space

Cough, dyspnea, wheezing, hoarseness, Cough, dyspnea, wheezing, hoarseness, stridorstridor

Facial burns / Singed facial hairFacial burns / Singed facial hair

Carbonaceous sputumCarbonaceous sputum

HypoxiaHypoxia

IndicatorsIndicators

LabsLabs

What would you obtain?What would you obtain?

Lab ResultsLab Results

CBC - CBC - WBC-12.0 Hct-49%WBC-12.0 Hct-49% Electrolytes -Electrolytes -Na-147 Cl-100 K-4.5 BUN-12Na-147 Cl-100 K-4.5 BUN-12 ABG -ABG - 7.31/35/125 on 50%VM 7.31/35/125 on 50%VM Carboxyhemoglobin-Carboxyhemoglobin- 21% 21% Tox. ScreenTox. Screen - Negative - Negative U/AU/A - Normal - Normal

Interventions at this point?Interventions at this point?

Interventions at this point?Interventions at this point?

Assess airway; Intubation ?Assess airway; Intubation ?OxygenOxygenFluid resuscitationFluid resuscitationFoley CatheterFoley CatheterNG tubeNG tubeWound careWound carePain medicationPain medication

InterventionsInterventions

Why is fluid resuscitation important?Why is fluid resuscitation important?How do you estimate fluid requirements?How do you estimate fluid requirements?How do you monitor response to initial fluid How do you monitor response to initial fluid

therapy?therapy?What complications can occur from over- or What complications can occur from over- or

under- resuscitation?under- resuscitation?

Fluid ManagementFluid Management

Edema formationEdema formation Systemic inflammatory responseSystemic inflammatory response Capillary leak/ Increased vascular permeabilityCapillary leak/ Increased vascular permeability Loss of skin barrierLoss of skin barrier

Zones of injuryZones of injuryParkland formulaParkland formula

Crystalloid 4 x %TBSA x wt (kg)Crystalloid 4 x %TBSA x wt (kg) ½ of total in first eight hours½ of total in first eight hours Goal of ½ - 1 cc/kg/hr U.O.Goal of ½ - 1 cc/kg/hr U.O.

StudiesStudies

What further studies/tests would you What further studies/tests would you want at this time?want at this time?

StudiesStudies

CXRCXR – Basilar atelectasis – Basilar atelectasis

EKGEKG – Sinus tachycardia – Sinus tachycardia

? Bronchoscopy? Bronchoscopy

ManagementManagement

Low urine outputLow urine output

Loss of Doppler signals in the handsLoss of Doppler signals in the hands

Inadequate ventilation with high airway Inadequate ventilation with high airway

pressures?pressures?

What would you do in the following scenarios?What would you do in the following scenarios?

ManagementManagement

EscharotomyEscharotomy

ManagementManagement

What are the principles of management of What are the principles of management of the inhalation injury?the inhalation injury?

What will be the basic strategies for What will be the basic strategies for management of the burn wounds?management of the burn wounds?

Questions?Questions?

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