Document

Report
Initial Burn Care
Lee D. Faucher, MD FACS
Director UW Burn Center
Associate Professor of Surgery & Pediatrics
Objectives
• Discuss burn pathophysiology
• Outline treatment modalities
• Understand why some treatments better
than others
What is a burn?
• Cutaneous injury caused by heat,
electricity, chemicals, friction, or
radiation.
First Degree Burns
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Epidermis only
No blisters
Erythema
Mild to absent systemic response
Heals in 3-4 days
Superficial partial thickness
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Papillary dermis
Blisters
Homogenous pink
Painful, hypersensitive
Blanches
Hair usually intact
Does not scar, may pigment differently
Sup 2nd degree
Deep partial thickness
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Reticular dermis
Mottled red and white
Not painful to pinprick or pressure
Does not blanch
Heals > 3 weeks
Usually scars
Need to excise and graft
Deep dermal
Full thickness burns
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Into fat or deeper
Red, white, brown, black, etc.
Diminished sensation
Dry, may be leathery
Depressed
Heals only from the periphery
Always excise and graft
Full-thickness
Etiology
Types of burns
Where do burns occur
Circumstances of injury
Admissions by age
% of admissions vs. burn size
Inhalation injury diagnosis
• Closed-space fire
• Face burns
Terminology
• Inhalation injury “nonspecific”
– Thermal injury
• Upper airway
– Local chemical irritation
• Throughout airway
– Systemic toxicity
• CO
Clinical diagnosis
• History and physical
– Exposure
– Duration
– Enclosed space
• Diagnostic studies
Other signs and symptoms
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Lacrimation
Cough
Hoarseness
Dyspnea
Disorientation
Anxiety
Wheezing
• Conjunctivitis
• Carbonaceous
sputum
• Singed hairs
• Stridor
• Bronchorrhea
Poison management = CO
• 500 unintentional deaths each year
• Persistent Neurologic Sequelae
– May improve over time
• Delayed Neurologic Sequelae
– Relapse later
Poison management = CO
• Treatment
– CO level means nothing to predict outcome
– Length of hypoxia is the determining factor
– Oxygen
– HBO
• No studies show benefit in treatment
Pathophysiology
• The main factor responsible for mortality
in thermally injured patients
• Carbon monoxide the most common
toxin
– 200 times greater affinity
– Competitive inhibition with cytochrome P450
Reduction of CO
80
Room Air
100% Oxygen
3 ATM
% CO
60
40
20
0
0
20
40
Time in Minutes
60
80
Objective data
• Bronchoscopy
– Edema
– Infraglottic soot
– Hyperemia
– Mucosal sloughing
• Sensitivity near 100% under IDEAL
circumstances
Grading of injury
• No reliable indicators of progressive
respiratory failures
• No studies have found any correlation
with initial findings and clinical
outcomes and progress
Resuscitation
Field resuscitation
• Start IV with LR, in burn OK
– < 6 years = 125mL/hr
– 6-13 years = 250mL/hr
– >13 years = 500mL/hr
Rule of Nines
Lund and Browder Chart
Area
0-1
yr.
Head
19
Neck
2
Ant. Thorax
13
Post. Thorax 13
R. Buttock
2½
L. Buttock
2½
Genitalia
1
R. U. Arm
4
L. U. Arm
4
R. L. Arm
3
L. L. Arm
3
R. Hand
2½
L. Hand
2½
R. Thigh
5½
L. Thigh
5½
R. Leg
5
L. Leg
5
R. Foot
3½
L. Foot
3½
1-4
yr.
17
2
13
13
2½
2½
1
4
4
3
3
2½
2½
6½
6½
5
5
3½
3½
5-9 10-14
yr.
yr.
13
11
2
2
13
13
13
13
2½ 2½
2½ 2½
1
1
4
4
4
4
3
3
3
3
2½ 2½
2½ 2½
8
8½
8
8½
5½
6
5½
6
3½ 3½
3½ 3½
15 Adult 2 3 Total
yr.
9
7
2
2
13
13
13
13
2½ 2½
2½ 2½
1
1
4
4
4
4
3
3
3
3
2½ 2½
2½ 2½
9
9½
9
9½
6½
7
6½
7
3½ 3½
3½ 3½
Total
IV access
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< 15% TBSA – oral resuscitation
15 – 40% TBSA – one large bore IV
> 40% -- two large bore IV’s
IV’s should be in the upper extremities
Suture IV’s started through burns
Crystalloid solution
• Ringer’s Lactate
– [Na+] 130 mEq (serum 140 mEq)
– Osmolality 272 mOsm (serum 300mOsm)
• Advantages of crystalloid
– Effective in maintaining perfusion
– Costs less than colloids
– Can be mobilized with a diuretic
Resuscitation first 24 hours
• Baxter formula
– 4 mL/kg/% TBSA burned
• Give ½ the volume in first 8 hours and other ½
over next 16 hours.
If < 20kg
• Same Baxter
formula for LR
• Add 4mL/kg of D5 ¼
NS
– Infuse at constant
rate, increase LR if
needed for adequate
urine output
Monitor urine output
• Place foley if > 20% TBSA
• Urine output goal
– 2 mL/kg/hr very young
– 1 mL/kg/hr child
– 0.5 mL/kg/hr adult
• Diuretics are NEVER used to increase
urine output
• Increase urine output to > 100mL/hr if
pigment present
How to do this
• Maintain continuous IV fluid
replacements
• AVOID boluses
• Only bolus IV fluids if hypotensive
Zones of burn injury
Pain control
Non-medication methods
• Cover burns with plastic wrap
– Wet dressings will stick and cause more
pain
– Other burn dressings are expensive and
not necessary
– Quik Clot is expensive and will not provide
any patient benefit
Ice Pack-----DO NOT USE EVER
• DOES NOT
– Reverse temperature
– Inhibit destruction
– Prevent edema
• DOES
– Delay edema
– Reduce pain
Medication
• Medications
– Opioids
– Narcotics
– Pain medications
– IV Analgesia
Summary
• Airway
• Circulation/Resuscitation
• Pain control
Questions?

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