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The Burn PatientThe Burn Patient

E . James Radin , MDE . James Radin , MD

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ObjectivesObjectives

•• Describe the types of burnsDescribe the types of burns•• Population at riskPopulation at risk

•• ABA guidelines for transport to burn centerABA guidelines for transport to burn center•• Signs of inhalationSigns of inhalation

•• Assessment of surface involvedAssessment of surface involved•• Burn formulasBurn formulas

•• Evaluation and managementEvaluation and management

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EpidemiologyEpidemiology

•• 2 million burns per year2 million burns per year•• 30 , 000 admissions a year30 , 000 admissions a year•• all age groups at riskall age groups at risk

•• Mortality increases with ageMortality increases with age•• Males predominateMales predominate

•• Inhalation , Thermal , Chemical , ElectricalInhalation , Thermal , Chemical , Electrical•• Scenes are not always safe for providersScenes are not always safe for providers

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Estimates of Involved SurfaceEstimates of Involved Surface

•• Rule of Nines . . . . . . . . .Rule of Nines . . . . . . . . .

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Degree of BurnDegree of Burn

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First DegreeFirst Degree

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Second DegreeSecond Degree

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Third DegreeThird Degree

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Facial BurnsFacial Burns

•• SurfaceSurface•• OcularOcular•• AirwayAirway

•• Singed Nasal HairsSinged Nasal Hairs•• Airway edemaAirway edema•• Glossal SwellingGlossal Swelling•• Epiglottic edemaEpiglottic edema•• Glottic edemaGlottic edema

•• Rapidly progressive deteriorationRapidly progressive deterioration

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Ocular BurnsOcular Burns

•• Often chemicalOften chemical•• Contact lenses need to be removedContact lenses need to be removed

•• Copious irrigationCopious irrigation•• Sterile dressingsSterile dressings

•• Notify ED ASAP to arrange Notify ED ASAP to arrange Opthamology EvaluationOpthamology Evaluation

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Pulmonary BurnsPulmonary Burns

•• Closed spaceClosed space•• Facial involvementFacial involvement•• Carbonaceous sputumCarbonaceous sputum•• Singed nasal hairsSinged nasal hairs•• Lip edemaLip edema•• ThermalThermal•• ChemicalChemical

•• Foreign debrisForeign debris•• Rapidly progressive deteriorationRapidly progressive deterioration

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Pulmonary BurnsPulmonary Burns

•• ABC’sABC’s•• Definitive control of the airwayDefinitive control of the airway

•• Humidified OxygenHumidified Oxygen•• Prevent HypoxiaPrevent Hypoxia•• Assist VentilationAssist Ventilation

•• NG / Oral Gastric tubesNG / Oral Gastric tubes

•• DoDo NotNot DelayDelay TransportTransport toto aa BurnBurnCenterCenter forfor DiagnosticDiagnostic TestsTests

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Circumferencial BurnsCircumferencial Burns

•• Fluid replacement causes edemaFluid replacement causes edema•• Capillary leaks / tighten the extremityCapillary leaks / tighten the extremity

•• Compartment pressures can go above arteriolarCompartment pressures can go above arteriolar

•• Monitor . . . . . . . .Monitor . . . . . . . .•• PulsesPulses

•• Doppler flowDoppler flow•• Tightness / Compartment pressuresTightness / Compartment pressures

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Electrical BurnsElectrical Burns

•• CNS injuryCNS injury•• Peripheral nerve injuryPeripheral nerve injury•• Cardiac arrhythmiasCardiac arrhythmias•• Occult injuryOccult injury

•• Low / high resistance tissuesLow / high resistance tissues•• Low / high voltage < 1000 volts >Low / high voltage < 1000 volts >•• Muscle injury / MyoglobinemiaMuscle injury / Myoglobinemia

•• Renal injury / direct electrical / myoglobinRenal injury / direct electrical / myoglobin•• Entry and Exit woundsEntry and Exit wounds

•• AC / DCAC / DC

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Electrical BurnsElectrical Burns

•• Arrhythmia when they occur usually at time of Arrhythmia when they occur usually at time of injury , not delayedinjury , not delayed•• Bone and skin are high resistance , occult injury Bone and skin are high resistance , occult injury

very commonvery common•• Look for entry and exit wounds , all tissue Look for entry and exit wounds , all tissue

between is at extreme surgical riskbetween is at extreme surgical risk•• Myoglobinemia from muscle injury can shut down Myoglobinemia from muscle injury can shut down

kidneyskidneys•• AC is more dangerous than DCAC is more dangerous than DC•• Duration of shock determines extent of injuryDuration of shock determines extent of injury

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Burns can be by direct contact or by arcing

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Chemical BurnsChemical Burns

•• Treatment Specific . . . . . . . .Treatment Specific . . . . . . . .•• Hydrofluoric : Irrigate , Calcium GluconateHydrofluoric : Irrigate , Calcium Gluconate•• HCL / Sulfuric : Bicarbonate irrigationHCL / Sulfuric : Bicarbonate irrigation

•• Phenol : No irrigationPhenol : No irrigation•• White Phosphorous : Ignites with irrigationWhite Phosphorous : Ignites with irrigation

•• Sample or container to hospital ! ! !Sample or container to hospital ! ! !

•• Treatment Kits at Industrial Sites ! ! !Treatment Kits at Industrial Sites ! ! !

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Fluid ResuscitationFluid Resuscitation

•• Rapid volume depletionRapid volume depletion•• Diffuse capillary leaksDiffuse capillary leaks

•• > 15 % , Edema even where there is no > 15 % , Edema even where there is no burnburn

•• Aggressive fluids are not needed for short Aggressive fluids are not needed for short triptrip

•• Do not waste scene time for IV if under 15 Do not waste scene time for IV if under 15 minutes to the burn centerminutes to the burn center

•• Fluids critical for the long flight ! ! !Fluids critical for the long flight ! ! !

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Fluid ResuscitationFluid Resuscitation

•• Large bore IV (s)Large bore IV (s)•• Non Non -- burn site if possibleburn site if possible•• Best tool , Urine Output . . . . Best tool , Urine Output . . . . •• 0 . 5 cc / kg / hr adult0 . 5 cc / kg / hr adult

•• 1 . 0 cc / kg / hr child [ < 30 kg ]1 . 0 cc / kg / hr child [ < 30 kg ]

•• Too much fluids can be just as bad as too little ! ! !Too much fluids can be just as bad as too little ! ! !

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Parkland FormulaParkland Formula

••% BSA x Kg x 4 cc = 24 hour total % BSA x Kg x 4 cc = 24 hour total needneed

•• 1 / 2 over the first eight hours1 / 2 over the first eight hours•• 1 / 2 over the next sixteen hours1 / 2 over the next sixteen hours

•• Lactate Ringers is the fluid of choice !Lactate Ringers is the fluid of choice !

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Modified Brooke FormulaModified Brooke Formula

••% BSA x Kg x 2 cc = 24 hour total % BSA x Kg x 2 cc = 24 hour total needneed

•• 1 / 2 over the first eight hours1 / 2 over the first eight hours

•• 1 / 2 over the next sixteen hours1 / 2 over the next sixteen hours

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Wound CareWound Care

•• After the initial resuscitationAfter the initial resuscitation•• Remove smoldering clothingRemove smoldering clothing•• Do not remove adherent clothingDo not remove adherent clothing

•• Compensate for loss of thermoregulationCompensate for loss of thermoregulation•• Provide comfort and pain controlProvide comfort and pain control•• Dry linen dressings , not gauzeDry linen dressings , not gauze

•• Do not cool wound , can advance the Do not cool wound , can advance the degree of burndegree of burn

•• Regulate ambient temperatureRegulate ambient temperature

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Burn Center Transport Guidelines Burn Center Transport Guidelines

•• Partial thickness over 15 %Partial thickness over 15 %•• Full thickness over 5 %Full thickness over 5 %

•• Involvement of hands , perineum , face , Involvement of hands , perineum , face , feetfeet

•• InhalationInhalation•• All high voltageAll high voltage•• All chemicalAll chemical

•• Patients with significant pre Patients with significant pre -- existing existing diseasedisease

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