assessment and initial care of burn patients
TRANSCRIPT
Assessment and initial care of
burn patients
Robert Riviello, MD, MPH
University Teaching Hospital, Kigali
Brigham and Women’s Hospital, Boston
Burn patient is a trauma…
• Stop burn process
• A-B-C
• Primary/secondary
survey
• History
History
• How did the burn
occur ?
• Inside vs outside
• Did the clothes catch
on fire ?
• Temperature of the
liquid
• How much liquid
• Was cloth removed
• Abuse ?
• What was the agent ?
• Duration of contact
• What decontamination
occurred
• What kind of electricity
was involved, voltage ?
• Pathway of voltage
• LOC, CPR ?
Flame/Scald Chemical/Electric
Severity of Burn
• Extent of burn
– Rule of 9s
– Scattered burns
• Depth of burn
– Temperature
– Duration of contact
– Thickness of the dermis
– Blood supply
• Comorbidities
• Age
1% Estimation (palm + fingers)
Burn Center Referral Criteria
• Partial thickness burns >10% TBSA
• Burns of face, hands, feet, genitalia, perineum, over major joints.
• 3rd degree burn in any age group
• Electric burns including lightening
• Chemical burns
• Inhalation injury
• Any patient with concomitant trauma in which the burn posses the greatest risk of morbidity or mortality
• Children
• Burn injury to patients who will require special social, emotional or long-term rehabilitative intervention.
Management Principles
• Start fluid resuscitation
• Monitor extremity perfusion
• Continuous airway assessment
• Pain management
Fluid Resusitation
• Parkland Formula for >20% TBSA burns
• LR = fluid of choice
• Parkland Formula:
4cc x TBSA burn x wt (Kg) = total fluid amt
Example: 4cc x 50 x 85kg = 17,000
Replace ½ (8500) in first 8hr = 1,062/hr x 8 hrs
Replace next ½ (8500) in next 16hr = 530cc x 16hr
Inhalation injury
• Carbon monoxide
poisoning
• Inhalation injury
above the glottis
• Inhalation injury
below the glottis
Carbon monoxide poisoning
• CO binds to hemoglobin 200x more than
oxygen tissue hypoxia
• CO T1/2 = 4h on room air, can be decreased to
1h on 100% oxygen
• Cherry discoloration
• Absent tachypnea or cyanosis
• O2 sat normal
Carbon monoxide poisoning
• CO levels
– 5-10% present in smokers, people exposed to heavy
traffic
– 15-20% headache, confusion
– 20-40% disorientation, fatigue, nausea, visual
changes
– 40-60% hallucinations, combativeness, coma,
obtundation and LOC
– >60% mortality > 50%
Inhalation injury above the glottis
• Thermal or chemical
• Except of rare occasions, thermal injury is
limited to above glottis
– Nasopharynx, oropharynx, larynx
• Swelling – may start after fluid resuscitation
Intubate early
Succinyl choline (rapid sequence) is safe
• 4 y.o. male with facial
burn following a house
fire
• Singed eyebrows,
eyelashes and facial
burns
• Lips swollen
• Carbonaceous sputum
Inhalation injury below the glottis
• Almost always chemical
– Aldehydes, sulfur oxides, phosgenes
• Smaller airways, terminal bronchi
• Resulting injury causes:
– Impaired ciliary activity
– Inflammation/edema/increased blood flow
– Hypersecretions
– Ulcerations
– Spasm
– Impaired immune response
Inhalation injury management
• 100% Oxygen
• Intubate if
– Decreased level of consciousness
– Stridor, retraction, respiratory distress
– Progressive hoarseness
– Carbonaceous/pink, frothy sputum
– High CO
– Clue: enclosed space injury
Cyanide Poisoning
• Similar s/s to CO poisoning
• Inhalation/toxicity 2/2 burning nitriles, polurethane,
formaldehyde, wool, silk
• Found in pesticides, tobacco, almonds, cassava, apple
seeds, apricot
• Think w/ neurological side effects and metabolic acidosis
Cyanide symptoms
• LOW LEVEL
• Lethargy
• Headache
• vertigo
• Confusion
• LONG STANDING LOW
LEVELS
• Paralysis
• Hypothyroidism
• Miscarriages
High level Cyanide
• Onset: seconds to
minutes
• Apnea, seizures, LOC,
coma, pulmonary
edema, cardiac arrest
• High exposure could
mean convulsions and
death within 1-15
minutes
Cyanide Signs
• Metabolic acidosis
• Venous O2 above normal
• Hypotension
• Pink coloration
• Bitter almond odor
Testing/Treatment
• ABG
• Serum cyanide
• Urine thiocyanate
• Treat before testing if
clinical suspicion
• 100% O2 face mask
• Intubation if indicated
• Amyl nitrate (inh)
• Na Nitrite IV
• Hydroxycobalamine
70 mg/kg IV
(typical adult dose 5g)
Compartment Syndrome
• * Pain (PROM)
• Paraesthesias
• Pallor
• Poikilothermia
• Pulselessness
Chest/Abdomen Compartment
Syndrome
Chest/Abdomen shield
The skin functions altered by burn
• Protection from desiccation
• Protection from bacterial invasion
• Protection from toxins
• Fluid balance: avoiding evaporation
• Neurosensory
• Social-interactive
• Protection from
trauma due to
elasticity, durability
• Fluid balance via
regulation of blood
flow
• Thermoregulation thru
control of skin blood
flow
• Growth factors,
epidermal regeneration
Epidermis Dermis
• Wash
• Debride blisters/loose skin
• Closed dressing / Xeroform
• Temporary skin substitute (biobrane)
• Pain control
• Clinic 1-2 days
• Heals in 2 weeks
2nd Degree
Superficial 2nd degree
Deep 2nd degree Wash
Debride blisters/loose skin
Closed dressing
Clinic 3-4 days
Heals in 4 weeks +/-
Consider grafting
Deep 2nd degree
Conversion
(pre)
Conversion
(post)
• Wash, remove char
• Silver sulfadiazine BID, closed
dressings
• Early excision and grafting
• Prophylactic IV Abx not
indicated
3rd Degree
Deep 3rd Degree
3rd Degree
3rd – Graft - Final Outcome
• Tendon
• Muscle
• Bone
• Frequent need for
amputations
4th Degree burn
4th Degree burn
Chemical burns
• Alkalis
• Acids
• Organic compounds
• Concentration
• Volume
• Duration of contact
• Mechanism of action of the agent
Cement burn
Alkalis or acid
• Protein denaturation
• Tan to gray surface discoloration
• Extreme pain
• Treatment
– Vigorous water lavage (50min-avoiding
hypothermia)
Gasoline immersion
• Superficial skin injury – erythema
• Systemic injury from absorbed hydrocarbons • Kidney - Lipid degenerative changes in prox tubules
• Lungs – surfactant denaturation atelectasis, lipoid
pneumonia
• CNS – edema, seizures, coma
• Liver – lipid degenerative changes, hepatitis
• Treatment
– Water immersion
– Hydration + pulmonary support
Hydrofluoric Acid
• Deep skin burn (deceiving – may look benign !)
• Systemic effects due to hypocalcemia, calcium
binds to fluoride ion
• 1% TBSA burn may be lethal (dysrythmias)
• Treatment
– Water lavage
– Calcium gluconate – gel in glove, injection, …
Acid Burn
Lithium burns/explosions
• Lithium commonly used in batteries for laptops, cellphones, button batteries (ie singing greeting cards)
• Also used in nuclear weapons, 7Up, and colas!
• Can overheat, overcharge causing extremely high currents = short circuit = shock equal to a stun gun
Lithium
• Alkali
• Flammable
• Reactive to water
• MSDS sheets: irrigate with water for eyes, skin. If particles evident rinse off with mineral oil.
• Emergency optho consult
• Ingestion: damage to esophagus/lung
Tar Burns
• Contact burn
• No systemic effects, non-
toxic
• Treat by initially cooling,
then immerse in greasy
agent (aquaphor, vaseline,
mineral oil, triple
antibiotic) then peel off.
Electrical Burns
• High voltage >1000
• Entrance – exit site
• Thermal, arc, flash
• Electrical current
pathway: organ/tissue
damage
• Associated trauma
Electrical Injury
Compartment Syndrome as
complication from Electrical Injury
Electrical-complications
• Respiratory arrest
• Seizures, coma
• Muscle necrosis –
compartment
syndrome
• Ventricular fibrilation
• Hemolysis
• Retinal detachment
• Renal failure
(myoglobinuria)
• Limb loss
Lightning Burn
• 80-100 deaths/yr
• 30% mortality
• Superficial fern-like
burns
• Immediate deep
polarization of
mycardium-asystole
Burn Dressings • To dress or not to dress? Open vs. closed
• Open technique allows for constant observation of wounds
• Good for PT/OT: better ROM
• Hypothermia
• Requires frequent reapplication of antimicrobials; painful
• Unaesthetic for visitors and patient
Burn Dressings
• Closed (occlusive)
– Retains body temperature and fluids
– QD or BID dressing changes; wound debridement by virtue of dressing removal
– Keeps grafts in place
– Aesthetically more acceptable
– Impedes ROM
– Labor-intensive
Topical Agents • Silver Sulfadiazene
• Manefate Acetate
• Bacitracin/Triplemix
• Betadine
• Acticoat
• Aquacel Ag
Silvadene • Silver Sufadiazene-Thermazene, the white cream
• For deeper 2nd degree, non-epitheliazing
• Allows for slow release of silver
• Low toxicity, moderate tissue penetration
• Softens the eschar to the point of liquefaction
• Continued use can impede epitheliazation
Silvadene
Silvadene (cont) • Effective against gm+ and gm- and some fungi,
Staph Aureus, Pseudomonas and Candida Albicans
• Transient leukopenia is attributed to bone marrow suppression, WBC <2 , but spontaneously resolves
• Yellow/green exudate can be misinterpreted as infection
Sulfamylon • Manefate Acetate-the other white cream, can also be
used as 5% solution
• Not a true sulfonamide-but those with a sulfa allergy may have a reaction
• Antibacterial spectrum similar to silvadene, but has better pseudomonas coverage
• Has better eschar penetration, more effective with thicker eschar
Sulfamylon (cont)
• Less macerating, delays eschar separation
• Pain can occur with application to areas of partial thickness
• Can lead to bicarbonate (HCO3) wasting causing metabolic acidosis resulting in tachypnea and metabolic alkalosis
Full Thickness
Bacitracin/Triplemix • Petroleum based for superficial second degree
• Effective against gm+
• Renal function should be monitored when used over large area
• Yeast overgrowth can occur
Partial Thickness/ 2nd Degree
Betadine • Povodine-Iodine
• Effective for gm+, gm-, fungi and yeast, less effective against pseudomonas than sulfamylon
• Occasional pain with application
• Does not penetrate eschar well, delays separation
• Slows the development of granulation and epithelial tissue
Acticoat
• 3 layer dressing incorporates a silver coated polyethylene mesh
• Protects the wound from bacteria by the release of silver ions to the wound site
• Can be left in place up to 3-5 days
• Must be kept moist with sterile water, use over large areas can cause hypothermia
Aquacel Ag
• Benefits of Silver on a hydrofiber
• Absorbent
• Partial Thickness (light second degree)
Skin Substitutes
Dermal Coverage options
Allograft
Xenograft
Xenograft
• Several types used throughout the years, frog skin used in Brazil
• Pigskin since the ‘60’s, most common xenograft in U.S.
• For use on clean wounds/granulating tissue
• Available frozen and meshed
Xenograft • Epidermis removed in processing, cannot
obtain blood supply from wound so will slough
• Can remain in place 3-6 days dependant upon the wound
Allograft
• Cadaver skin, amnion
• Popular since the 50’s for excised and granulation tissue
• Bi-layer allows for some re-vascularization and maintains viability and some incorporation of dermal layer
• promotes development of granulation tissue
Allograft • Prevents wound desiccation
• Protects exposed tendons and vessels
• Epidermis will eventually reject
• Must be kept frozen
• Often difficult to obtain
Biobrane
• By-laminar construction with silicone bonded to nylon fabric and collagen peptides from porcine dermal collagen
• Provides a barrier function and controls vapor loss
• Effective on excised wounds, donor sites and grafts
• Provides no anti-microbial coverage, but minimizes proliferation
• Decreases pain, allows for mobility especially with the glove
• Needs removal with signs of infection
Esthetic and functional
recovery
Treatment — Reconstructive
Ladder
When no tx available
3rd Degree Need for skin grafting
http://www.ilstraining.com/bmwd/
bmwd/bmwd_it_04.html
Negative Pressure Wound
Therapy
Negative Pressure Wound
Therapy