Burn Management - Improving care in ED

Report
Burn Management
Burn Management
Kathryn Clark
Burn Management
Burn injuries in NZ
• ~1 million people per year in the US
seek medical care for burns
• ~ 1/3 of these in ED.
• 1311 adults/children admitted to
hospital with burn injuries in 2002-2003
• 33% from fire, flame, smoke
• 77% from scalds and contact with hot
objects
• 26% Maori, 10.5 % PI
• 66% Male
NZGG, Management of Burns and Scald in Primary Care 2007
Burn Management
Burn injuries in NZ
• Most burn injuries occur at home
• Children <5 years at greatest risk of
burn related hospitalization and death
• 50% scalds- hot drinks, fat, cooking oil,
water.
• >90% at home in developed countries
NZGG, Management of Burns and Scald in Primary Care 2007
Burn Management
• Mr F
• 53 year old candle maker on Waiheke
• Flown in by Westpac
• Candle making equipment in covered car port
caught fire in the night
• Mr F went out into the car port to move the
car
• Sustained burns to face, torso, arms, hands
Burn Management
Types of Burns
• Thermal: Heat/flame/contact
- scald burns most common children
- flame more common in adults
• Cold exposure (frostbite)
• Chemical: Acid/alkali
• Electrical Current Inhalation
• Radiation: Sunburn, radiation therapy
Burn Management
Other History
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Time of injury
First aid/pre-hospital treatment?
Other trauma
Inhalation injury
Non-accidental injury
Burn Management
Initial Assessment
• Airway at risk secondary to:
– Direct injury/trauma
– Fluid resuscitation
– Oedema from inflammatory response
• Airway
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Clear airway
Maintain cervical spine protection
Consider early intubation if airway compromised
ICU/anaesthetic/ENT r/v as required
Burn Management
• Breathing
– Apply supplemental oxygen
– Consider early mechanical ventilation
Burn Management
Inhalation Injury
• Upper airway injury
– Direct visualisation of posterior pharynx
– Scope cords
• Lower airway injury
– Consider bronchoscopy if uncertain
– ARDS
• Carbonmonoxide poisoning
– COHb level
– 100% O2
– Hyperbaric
Burn Management
To intubate or not to intubate…
• Signs of significant smoke inhalation
and potential need for intubation:
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Cough, stridor, wheeze, hoarseness
Deep facial or circumferential neck burns
Nares with inflammation or singed hair
Carbonaceous sputum/burnt matter in the
mouth/nose
Blistering, sloughing, edema of the
oropharynx
Depressed mental status (inc. drug/EtOH)
Respiratory distress
Hypoxia/hypercapnia
Elevated CO and/or CN-
Burn Management
• Circulation
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Establish IV access - 2 wide bore cannulae
Through unburnt tissue
IV Fluid bolus
Control any site of haemorrhage
Trauma - internal bleeding?
•Initial bloods
• Severe inflammatory reaction
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Capillary leak
Intravascular fluid loss
High fevers
Organ Malperfusion
ESOF
–FBC, Haematocrit,
– U&Es, COHb
Burn Management
Wound Assessment
• Burn depth
• Body surface area estimation
• Burn distribution
Burn Management
Burn Management
Burn Classification
• Epidermal:
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Dry, red, no blisters, epidermis only
Very superficial
May be painful
Heal within 7 days
No scarring
Burn Management
• Superficial dermal :
– Pale pink, with fine blisters, blanches with pressure
– Usually extremely painful
– Heals within 2 weeks
–Can have colour match defect
• Mid dermal:
– Dark
pink, large blisters, sluggish cap refill
– Less painful
– Heals 14-21 days, moderate risk hypertrophic scarring
Burn Management
• Deep dermal:
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Blotchy red/white, may blister, no cap refill
No sensation
Heals very slowly >21 days
Usually needs grafting
High risk of hypertrophic scarring
• Full thickness:
– White, waxy, charred, no blisters, no cap refill
– Insensate
– Grafting needed if <1 cm2, will scar
Burn Management
Burn Surface Area
The Rule of Nines and Lund–Browder Charts
Orgill D. N Engl J Med 2009;360:893-901
Burn Management
Fluid Resuscitation
• Required for:
– All adult burns >15% TBSA
– All paediatric burns >10% TBSA
• Modified Parkland Formula
– 3-4 x Wt(kg) x %TBSA = mL/24 hours
– 1/2 volume over 1st 8hrs
– 1/2 over next 16 hours from time of injury
Burn Management
Type of Fluid
• Lactated Ringers
• Hartmans
• Plasmalyte
• Avoid normal saline as large volumes
will result in a hypercholoraemic
metabolic acidosis.
Bunn, et al. Cochrane systematic Review, 2004
Huang, et al. Ann Surg. 1995
Burn Management
• Monitor UO
– 0.5 mL/kg/hr adults
– 1.0 mL/kg/hr children
– IDC if IV resus required
• If haemochromagens present in urine
increase goal of UO to 1-2 mL/kg/hr
Burn Management
Wound Management
• Appropriate first aid
– Prevent further tissue damage
– Minimise wound complications
– Manage pain
– Prevent hypothermia
Burn Management
• 20 mins cool running water
– 8-25 deg C (aim for 15 deg)
– Immediately or within 3 hours of injury
– Continuous running water
• Cooling decreases incidence of needing
surgery, scarring and decreases costs
– Skinner, Peat, NZMJ 2002
• Avoid hypothermia
– Check patient’s temperature
– Ensure room is heated, doors closed
– Remove wet clothing
Burn Management
• Remove all non-adherent clothing and
jewelry, debris
• Apply cling film
– Longitudinal strips, do not wrap around
– Sterile guards may be placed over cling film for
comfort and security
Burn Management
• Manage swelling
– Elevation
– Elevate head of bed if facial/head burns
– Q1hly monitoring of circumferential burns
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Colour
Warmth
CRT
Pulse
– Deep circumferential burns may require early
escharotomy
Burn Management
Escharotomy Indications
• Circumferential burns
• Compartment syndrome - abdominal or extremity
• Difficulty with ventilation in chest burns
Burn Management
Burn Management
• Ensure adequate analgesia
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Entonox
Paracetamol + NSAIDs + Codeine or Tramadol
IV opioids
Supervised sedation/Ketamine
• Tetanus toxoid/immunoglobulins
• Antibiotics not usually indicated
Burn Management
• Debride loose skin
• Clean wounds with aqueous
chlorhexadine
• Blisters
– Leave small blisters intact
– Debride blisters over joints if restricting
movement
– Snip large, tense blisters
Australasian Cochrane Centre (2009)
Burn Management
• Apply cling film if will reach local burn unit
within 8 hours
• Apply simple non-adherent dressing if due for
transfer within 24 hours
• If transfer delayed more than 24 hours
commence silver dressing after consultation
with burns unit
NZ National Burn Service Guideline, 2011
Burn Management
Wound Dressings
• Prevent infection
• Promote healing
– Function
– Aesthetics
• Comfort -aim for patient to be pain free
• Ease of care
– All require 24 hr reassesment
– Easy to remove, cause no further injury
• Cost
Burn Management
Immediate Presentation
Skin intact/small blisters
Skin broken
Intrasite gel under cling film
Film dressing secured with hypafix or
bandage
Intrasite gel under cling film
Film dressing secured with hypafix or
bandage
Intrasite filled glove
Intrasite filled glove
If infection is a concern SSD cream
Hypafix directly onto a burn on day 1 is usually a bad idea.
Burn Management
• Glad Wrap
– Transparent
– Easy to put on/remove
– Non-adherent
– Traps moisture/reduce fluid loss
– Prevents contamination
– Traps heat
– Reduces hypersensitivity
Burn Management
Delayed Presentation
Skin intact/small blisters
Skin broken
Hypafix vs film dressing vs simple
moisturising cream
Increased risk of infection and delayed
healing/scarring
GP Review
SSD Cream or other silver based
products
Antibiotics generally not needed
Specialist nursing review
Consider NAI in at risk populations
Burn Management
SSD Cream
Intrasite Gel
$12.30/50 g
$3.14/8 g
Antimicrobial
Bacteriostatic
Expensive moisturiser if skin
intact
~95% water
Burn Management
Silver
• SSD
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Broad spectrum
Does not penetrate eschar very well
Avoid if sulfa allergy
Side effects: neutropenia/thrombocytopenia
• Silver antimicrobial products
– Acticoat Ag
– Mepilix Ag
– Aquacel Ag
Change every 3 (7) days
Moisten with water (NOT saline - inactivates the Ag)
Burn Management
Burn Management
Burn Management
Burn Management
Wound Management: Burn Excision
& Grafting
• Autograft
• Full-thickness skin grafts (FTSG)
• Split-thickness skin grafts (STSG) – epidermis/pt dermis,
more likely to survive
• Meshed vs. Sheet
• Allograft- temporary, replaced after 2 weeks
• Porcine xenograft – Deep partial thickness
• Dermal substitutes: Integra, expensive
Burn Management
Electrical Burns
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Low / high voltage < 1000 volts >
Lightning
AC / DC
Pathway
– Look for entry and exit wounds
– Low / high resistance tissues
• Duration
Burn Management
Electrical Burns
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Cardiac arrhythmias
CNS injury
Muscle injury / Myoglobinemia
Renal injury / direct electrical / myoglobin
Local and Occult injury - requires trauma
evaluation
• Risk of rhabdomyolysis, compartment
syndrome
• Peripheral nerve injury
• Late complications - cataracts, progressive
demyelinating neurologic loss
Burn Management
Chemical Burns
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End the exposure
ABCDE
Alkalis generally cause worse damage
Initial treatment Empiric: irrigation with
water
• Dry powder should be brushed off
Burn Management
• Systemic absorption of some chemicals
is life threatening.
• The clinical signs of severe chemical injury:
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altered mental status,
respiratory insufficiency,
cardiovascular instability,
period of unconsciousness or convulsions.
Burn Management
Chemical Burns
• Treatment Specific . . .
– Hydrofluoric : Irrigate , Calcium Gluconate
– HCL / Sulfuric : Bicarbonate irrigation
– Phenol : No irrigation
– White Phosphorous : Ignites with irrigation
• Sample or container to hospital
• Treatment Kits at Industrial Sites
Burn Management
Ocular Burns
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Often chemical
Steam/heat
Contact lenses need to be removed
Copious irrigation
Sterile dressings
Opthalmology Evaluation ASAP
Burn Management
When to Refer/Discuss with
Regional Burn Unit
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>10 % TBSA in adult
>5% TBSA in child
>5% TBSA full thickness
Special areas:
– Face, hands, feet,
perineum
• Electrical or Chemical burns
• Inhalation injury
• Circumferential
• Extremes of age (<2
yrs, >70 yrs)
• Associated trauma
• NAI
• Complicating comorbidities
• Failure to heal with
conservative
management after 2
weeks
Burn Management
Take Home
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Always start with ABCs
The airway is at risk in burn patients
Assess for trauma
Modified Parkland formula
Rule of Nines/Lund-Browder
Keep burns clean
Keep dressings simple
Early intervention saves lives
Burn Management
1. Management of Burns and Scalds in Primary Care. NZGG/ACC 2007.
2. Singer et. Al. Management of local burns in the ED. AJEM. 2007. 25. 666671
3. Tenenhaus. Local treatment of burns: Topical antimicrobial agents and
dressings UpTo Date. 2014.
4. Rice, Orgill. Classification of burns. UpToDate. 2014.
5. National Burn Centre Clinical Committee. National Burn Service Initial
Assessment Guideline. 2011.
6. New Zealand National Burn Service. Escarotomy guidelines.
7. Rice, Orgill. Emergency care of moderate and severe thermal burns in
adults. UpToDate. 2014.
8. Skinner, Peat, NZMJ 2002
9. Bunn, et al. Hypertonic versus near isotonic crystalloid for fluid
resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004;
10. Huang, et al. Hypertonic sodium resuscitation is associated with renal
failure and death. Ann Surg. 1995;221(5):543.
11. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol
Obstet 1944; 79:352.
12. Monafo WW. Initial management of burns. N Engl J Med 1996;
335:1581.

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