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

• Epidermis only

• No blisters

• Erythema

• Mild to absent systemic response

• Heals in 3-4 days

Superficial partial thickness

• Papillary dermis• Blisters• Homogenous pink• Painful, hypersensitive• Blanches• Hair usually intact• Does not scar, may pigment differently

Sup 2nd degree

Deep partial thickness

• 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

• 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

• 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 P-

450

Reduction of CO

0

20

40

60

80

0 20 40 60 80

Time in Minutes

% C

O

Room Air100% Oxygen3 ATM

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 ChartAArreeaa 00--11

yyrr.. 11--44 yyrr..

55--99 yyrr..

1100--1144 yyrr..

1155 yyrr..

AAdduulltt 22 33 TToottaall

HHeeaadd 1199 1177 1133 1111 99 77 NNeecckk 22 22 22 22 22 22 AAnntt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 PPoosstt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 RR.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ GGeenniittaalliiaa 11 11 11 11 11 11 RR.. UU.. AArrmm 44 44 44 44 44 44 LL.. UU.. AArrmm 44 44 44 44 44 44 RR.. LL.. AArrmm 33 33 33 33 33 33 LL.. LL.. AArrmm 33 33 33 33 33 33 RR.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ RR.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ LL.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ RR.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 LL.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 RR.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ LL.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½

TToottaall

IV access

• < 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?