assessment and initial care of burn patients
TRANSCRIPT
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Assessment and initial care of
burn patients
Robert Riviello, MD, MPH
University Teaching Hospital, Kigali
Brigham and Women’s Hospital, Boston
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Burn patient is a trauma…
• Stop burn process
• A-B-C
• Primary/secondary
survey
• History
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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
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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
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1% Estimation (palm + fingers)
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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.
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Management Principles
• Start fluid resuscitation
• Monitor extremity perfusion
• Continuous airway assessment
• Pain management
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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
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Inhalation injury
• Carbon monoxide
poisoning
• Inhalation injury
above the glottis
• Inhalation injury
below the glottis
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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
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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%
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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
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• 4 y.o. male with facial
burn following a house
fire
• Singed eyebrows,
eyelashes and facial
burns
• Lips swollen
• Carbonaceous sputum
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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
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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
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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
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Cyanide symptoms
• LOW LEVEL
• Lethargy
• Headache
• vertigo
• Confusion
• LONG STANDING LOW
LEVELS
• Paralysis
• Hypothyroidism
• Miscarriages
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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
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Cyanide Signs
• Metabolic acidosis
• Venous O2 above normal
• Hypotension
• Pink coloration
• Bitter almond odor
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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)
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Compartment Syndrome
• * Pain (PROM)
• Paraesthesias
• Pallor
• Poikilothermia
• Pulselessness
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Chest/Abdomen Compartment
Syndrome
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Chest/Abdomen shield
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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
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• Wash
• Debride blisters/loose skin
• Closed dressing / Xeroform
• Temporary skin substitute (biobrane)
• Pain control
• Clinic 1-2 days
• Heals in 2 weeks
2nd Degree
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Superficial 2nd degree
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Deep 2nd degree Wash
Debride blisters/loose skin
Closed dressing
Clinic 3-4 days
Heals in 4 weeks +/-
Consider grafting
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Deep 2nd degree
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Conversion
(pre)
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Conversion
(post)
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• Wash, remove char
• Silver sulfadiazine BID, closed
dressings
• Early excision and grafting
• Prophylactic IV Abx not
indicated
3rd Degree
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Deep 3rd Degree
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3rd Degree
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3rd – Graft - Final Outcome
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• Tendon
• Muscle
• Bone
• Frequent need for
amputations
4th Degree burn
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4th Degree burn
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Chemical burns
• Alkalis
• Acids
• Organic compounds
• Concentration
• Volume
• Duration of contact
• Mechanism of action of the agent
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Cement burn
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Alkalis or acid
• Protein denaturation
• Tan to gray surface discoloration
• Extreme pain
• Treatment
– Vigorous water lavage (50min-avoiding
hypothermia)
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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
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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, …
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Acid Burn
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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
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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
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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.
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Electrical Burns
• High voltage >1000
• Entrance – exit site
• Thermal, arc, flash
• Electrical current
pathway: organ/tissue
damage
• Associated trauma
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Electrical Injury
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Compartment Syndrome as
complication from Electrical Injury
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Electrical-complications
• Respiratory arrest
• Seizures, coma
• Muscle necrosis –
compartment
syndrome
• Ventricular fibrilation
• Hemolysis
• Retinal detachment
• Renal failure
(myoglobinuria)
• Limb loss
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Lightning Burn
• 80-100 deaths/yr
• 30% mortality
• Superficial fern-like
burns
• Immediate deep
polarization of
mycardium-asystole
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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
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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
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Topical Agents • Silver Sulfadiazene
• Manefate Acetate
• Bacitracin/Triplemix
• Betadine
• Acticoat
• Aquacel Ag
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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
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Silvadene
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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
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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
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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
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Full Thickness
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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
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Partial Thickness/ 2nd Degree
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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
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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
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Aquacel Ag
• Benefits of Silver on a hydrofiber
• Absorbent
• Partial Thickness (light second degree)
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Skin Substitutes
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Dermal Coverage options
Allograft
Xenograft
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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
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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
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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
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Allograft • Prevents wound desiccation
• Protects exposed tendons and vessels
• Epidermis will eventually reject
• Must be kept frozen
• Often difficult to obtain
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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
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Esthetic and functional
recovery
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Treatment — Reconstructive
Ladder
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When no tx available
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3rd Degree Need for skin grafting
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http://www.ilstraining.com/bmwd/
bmwd/bmwd_it_04.html
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Negative Pressure Wound
Therapy
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Negative Pressure Wound
Therapy
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