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GSACEP core man LECTURE series:

Burn Management

Patrick Glynn

MD, Capt, USAFUpdated: 19Feb2013

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Disclaimer

Views and opinions expressed do not necessarily reflect those of GS-ACEP, The Department of Defense, the U.S. Government, the North American Continent, the Western Hemisphere, or Mother Earth.

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Outline

Anatomy

Pathophysiology

Burn Assessment

Management

Reasons for referral

Prognosis

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Skin Anatomy

Largest organ system of the bodyEpidermis outer layer, varying thickness

Dermis Thicker, hair follicles, nerve endings,

blood vessels

Subcutaneous Fat Muscle

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Skin Anatomy

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Burn PathophysiologyBurns alter capillary permeability fluid leaks out

Volume loss, hypotension worst in lungs

ARDS Electrolyte abnormalities

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Thermoregulation

Normal skin regulates body temperature

Burned skin doesn’t function properly patients lose autoregulation leads to HYPOthermia

Keep burned patients warm 7

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Zones of Burn Injury

Coagulation Irreversible destruction

Stasis middle layer with Decreased blood flow Can be saved by adequate Resuscitation

Hyperemia surrounding area Increased blood flow recovery likely

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Estimating size (TBSA)Patient’s Palm=1% TBSA

Rule of 9’s - percentage surface area Head = 9 Each Arm = 9 Each Leg = 18 Back = 18 Front = 18 Groin = 1%

Kids: Head=18, each leg 13.5% 9

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Age

Older and Younger patients have thinner skin more prone to thermal injury

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Burn Depth - Superficial

Red skinPainfulNO blisters

heals in 3-7 daysexample: sunburn

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Burn Depth - Partial Thickness

Epidermis / DermisBlistersWet appearingPAINFUL

Can convert to full thickness

or heal in 2-3 weeks12

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Burn Depth - Full Thickness

PAINLESS

WaxyCharredDry

Requires surgery / grafting

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Burn Depth

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Assessment - AirwayInhalation Injury Face / neck burns Hoarse voice Singed nasal / facial hairs Soot in sputum

Aggressive, Early management Intubate BEFORE swelling

Large ETT for Bronchoscopy

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Assessment - Mental status

Altered hypoxia CO poisoning Cyanide toxicity if surrounded by fire /

smoke

treat with supplemental Oxygen16

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Management

Airway - Assess / Reassess & Intervene

Dressings in Field

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Pre-hospital care

Airway

Stop burning process ie: wash off chemicals

Start Fluid resuscitation

Transport to hospital

Pain control

Protect burn wound18

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Management - FluidsLR or NSParkland Formula TBSA x (weight kg) x (4 LR) = 24 hour

requirement 1/2 in first 8 hours 1/2 over the next 16 hours

Still need maintenance fluids

Urine output - 1mL /kg/hr19

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Resuscitation Example

70 kg patient

20% partial and full thickness burns

What is the 8 hour fluid requirement?

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Resuscitation Example

70 kg x 20 x 4 = 5600 mL in 24 hours

2800 mL in 8 hours

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Chemical Burns

Acid - coagulation necrosis

Alkali - liquefaction necrosis usually worse

remove clothingIrrigate aggressively with water / saline 22

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Refer to burn centerFull thickness burns

Inhalational Injury

Electrical burns

Chemical burns

Circumferential burns

Partial Thickness >15%

Pediatric or Elderly >10%

High Risk Locations genital, hands, feet, face, over

joints 23

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Compartment Syndrome

Extremities remove rings, jewelry, clothing

Abdominal

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Management

Aggressive pain control

Compartment syndrome: needs fasciotomy to release pressureEscharotomy - for circumferential burns

Tetanus immunization Blisters - Controversial

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Burn Prognosis

Increase Risk of Death: Larger burn size Older age Inhalational Injury Female Pre-existing diseases

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References

Tintinalli’s Emergency Medicine 7th Edition, chapter 45

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