burns

Question 1

immediate management

Answer 1

-ABCs
-Begin CPR if needed
-Establish adequate airway (RSI or cricothyrotomy)
-Consider early ET intubation when:
-Severe burns to lower face & neck
-Full-thickness chest wall burns, especially if circumferential -> eschar formation -> restriction
-Burn size >60%, including face

-Support ventilation & oxygenation
-Oxygen 2-12 L/min via NC or face mask
-With smoke inhalation, give 100% O2 -> give 100% to all of these pts…we dont know who has smoke inhalation injuries
-Monitor pulse oximetry and CO level

-EKG
-NGT
-tetanus prophylaxis
-remove any jewelry!!!!

Question 2

injuries associated with burns

Answer 2

-Fractures: 45-64%
-Complex soft tissue injuries: 36-52 %
-TBI: 17-26%
-Thoracic and abdominal injuries: 4-24 %
-mortality- 3-55%

Question 3

burn center referral criteria

Answer 3

comorbidities
-do it early

Question 4

criteria for ICU admission

Answer 4

-too unstable to be transferred
-Mechanical ventilation (inhalation injury, massive fluid resuscitation)
-Require cardiac or other hemodynamic monitoring - fluid shifts
-Have risk factors for multisystem organ failure

Question 5

when does a pt need IV access

Answer 5

-Deep burns covering >15% of BSA
-Clinical findings suggesting shock or volume depletion
-Use 2 large-bore peripheral IV lines, preferably in nonburned skin
-Central line only if peripheral access is impossible

Question 6

obtain labs

Answer 6

-ABG analysis
-Carboxyhemoglobin level
-CBC, lytes, urine myoglobin
-CXR and ECG
-cyanide
-tox screen

-musculoskeletal / internal injury -> CT scan

Question 7

factors that affect rate of IV transfusion

Answer 7

-flow rate=
-length of tubing
-viscosity (blood > colloids > crystalloid)
-radius- bore
-pressure- pressure adding systems for IVs

Question 8

nutrition

Answer 8

-all have NG tube inserted
-decompress to prevent -> ileus from severe burns -> no GI motility
-have very high caloric requirements too
-sudden hypotension -> may be gastric distention -> kink on IVC in T8

-deep burns >20% of BSA -> develop ileus -> vomit -> give NG tube
-prevents aspiration

Question 9

fluid resuscitation!!!!!!

Answer 9

-loss of large volumes of intravascular fluid, electrolytes and proteins
-Fluid loss maximal during first 6-8 hrs
-!Fluid resuscitation: crystalloid (LR or NS) on day #1
-normal saline is avoided bc of hyperchloremic acidosis it creates

-Fluid resuscitation formulas
-Parkland (Baxter): 4ml/kg per % of BSA burned
-when did the pt get the burns?
-70kg pt, 30% burn, 6:00AM-> get to hospital at 8:00AM -> 30(70)= 2100(4) = 8400cc of fluids
-since two hours have already gone by -> do 8400/2 = 4200/6 = 700cc per hour for first 8 hours
-4200/6 = 260cc for the next 16 hrs

-Modified Brooke:
-Adult: 2ml/kg per % of BSA burned
-Child: 3ml/kg per % of BSA burned

-½ of calculated volume given in first 8 hours; the remainder is given over the next 16 hours

Question 10

eval for any other possible injuries

Answer 10

-Especially the patient burned in MVA, explosion, or after jumping from a burning building
-Search for fractures or injuries to the hands, c-spine, chest and abdomen

Question 11

indwelling catheter

Answer 11

-Insert indwelling urinary catheter to monitor UO
-MOST IMPORTANT MONITORING DEVICE IN A BURN PT
-IV infusion rates adjusted to maintain UO of 0.5-1.0 mL/kg/h (adults) & 1.0 mL/kg/h (peds <10kg)
-UA and urine myoglobin

Question 12

further evaluation

Answer 12

-Obtain hx: injury mechanism, possible presence of toxic combustibles, burn take place in open or enclosed space, PMH, tetanus status, allergies
-person passed out from smoke inhalation -> palms can be burned (usually people clench the hands) -> suspect inhalation injury

-Determine severity of injury (table on next slide)
-Crucial for deciding on hospital admission or transfer to burn center
-Guides initial fluid resuscitation & establishes prognosis

-In General:
-Minor burns – usually managed as outpatients
-Moderate uncomplicated burns – hospital admission
-Major burns – transfer to burn center

Question 13

determinants of burn severity

Answer 13

BURN SIZE
BURN DEPTH
BURN SITE
PRESENCE OF CIRCUMFERENTIAL BURNS- act like a tourniquet -> compartment syndrome, prevent breathing
INHALATION INJURY
ELECTRICAL INJURY
AGE OF PATIENT
ASSOCIATED INJURIES
MAJOR UNDERLYING MEDICAL PROBLEMS

Question 14

summary of american burn association burn severity categorizations

Answer 14

MAJOR BURN INJURY
-SECOND-DEGREE BURN >20% BSA IN ADULTS
-SECOND-DEGREE BURN >10% BSA IN CHILDREN
-THIRD-DEGREE BURN >5% BSA
SIGNIFICANT BURNS INVOLVING HANDS, FACE, EYES, EARS, FEET, PERINEUM, MAJOR JOINTS
-PATIENTS WITH: INHALATION INJURY, ELECTRICAL INJURY, BURN INJURY COMPLICATED BY OTHER MAJOR TRAUMA
-POOR-RISK PATIENTS WITH BURNS

MODERATE UNCOMPLICATED BURN INJURY
-SECOND-DEGREE BURN OF 10-20% BSA IN ADULTS
-SECOND-DEGREE BURN OF 5-10% BSA IN CHILDREN
-THIRD-DEGREE BURN OF 2-5% BSA

MINOR BURN INJURY
-SECOND-DEGREE BURN <10% BSA IN ADULTS
-SECOND-DEGREE BURN <5% BSA IN CHILDREN
-THIRD-DEGREE BURN <2% BSA

Question 15

classification of burns by depth of injury

Answer 15

-morphine
-fentanyl
-benzos
-for 2nd degree

Question 16

burn size

Answer 16

-Accurate measurement of burned area in % of body surface area (BSA)
-Can be estimated by using age-adjusted chart or “rule of 9s” for adults or “rule of 5s for infants and children
-Scattered small burns can be estimated by comparing them with the size of PTS HAND -> 1% of BSA
-Extent of all burns should be recorded on a drawing (front and back views) on the pt’s chart

Question 17

rule of nines

Answer 17

-head and neck- 9
-arm- 9 each
-torso front- 18
-torso back- 18
-leg- 18 each
-genitalia and perineum- 1

Question 18

burn depth

Answer 18

-First-degree –
-only epidermal layer
-red, painful, dry, and tender without blisters
-usually heals in about 7 days w/o scarring
-sunburn

-Second-degree –
-extends into dermis
-further classified into superficial or deep partial-thickness
-Superficial partial-thickness – blisters and very painful; exposed dermis is red and moist, with intact capillary refill; healing occurs in 2-3 weeks with little to no scarring
-Deep partial-thickness – white to yellow in color; pressure applied to skin is felt but 2-point discrimination is often diminished; capillary refill and pain sensation are absent; healing occurs in 3 weeks - 3 months and scarring is common

-Third-degree –
-aka full-thickness burns
-charred, pale, leathery, and painless
-do not heal spontaneously because all dermal elements are destroyed
-surgical repair and skin grafting are needed

-Fourth-degree – extend through SC fat, muscle and bone
-amputation or extensive reconstruction is required

Question 19

antibiotics

Answer 19

-always assume worst burn if you cant distinguish
-clean wounds, escharotomy, remove clothing
-anti-infection agents on the skin- bacitracin etc.
-IV antibiotics shouldnt be used unless active infection

Question 20

blisters

Answer 20

-do not pop them
-if they do pop do it in a sterile manner -> do not deroof -> acts as a physiologic bandage
-infection risk
-2nd degree

Question 21

major burns

Answer 21

-Burns areas considered as major injuries:
-Hands and feet – deep burns can result in scarring leaving the pt with permanent disability
-Face – sever scarring can result in profound physical and emotional impact; often associated with inhalation injuries and compromised airway
-Eyes – corneal scarring and eyelid dysfunction may ultimately lead to blindness
-massive periorbitial edema -> examine eyes before they swell short
-Ears – deep burns predispose to the development of pressure deformity and infection
-Perineum – more susceptible to infection

Question 22

circumferential burns

Answer 22

-major burn
-Neck - may cause lymphatic & venous obstruction that leads to laryngeal edema & airway obstruction
-Extremities – compartment syndrome
-Chest – respiratory failure

Question 23

inhalation injury

Answer 23

-Burned sustained in confined space
-singed nasal hairs
-facial burns
-soot in nose or mouth
-hoarseness
-carbonaceous sputum
-wheezing
-CO level >10%

Question 24

electrical injury

Answer 24

-Damage may be extensive, even if outward signs are minimal
-arrhythmias - EF drops
-renal failure may occur
-transient -> pts can recover on their own well

Question 25

risks for major burn

Answer 25

-Age of pt
-Mortality rates increase with very young (<5 yo) or very old (>55 yo) patients

-Associated injuries
-Burns occurring with other injuries such as fractures or internal injuries due to MVAs, falls or explosions

-Major underlying medical problems
-Morbidity & mortality increased in patients with hx of MI, angina, significant pulmonary disease, DM, renal failure, alcohol or substance abuse

Question 26

pain control

Answer 26

-Minor burns, especially of the extremities, can be relieved by immersing in cool water
-Oral, subcutaneous, or intramuscular narcotics may be used for outpatient therapy
-IV Morphine, Meperidine or Hydromorphone should be used to control pain in patients with moderate or major burns
-benzos
-fentanyl
-Be careful with the patient with compromised respiration!!!
-cool them down -> but not too much -> hypothermia -> coagulation

Question 27

tx and wound care (minor burns)

Answer 27

-Treated on an outpatient basis
-Clean with mild soap & water or a dilute antiseptic solution
-Large blisters >2 cm or involving mobile joints should be drained or debrided
-Small blisters on nonmobile areas should be left intact

-Topical antibiotics –
-1% silver sulfadiazine cream (Silvadene) -> not for face or sulfa allergies
-bacitracin, neomycin, polymixin B
-Analgesics - NSAIDs -> careful if they require surgery

Question 28

tx and wound care (moderate and major burns)

Answer 28

-Gently remove clothing, dirt, & other debris adhering to burn
-irrigation with sterile saline may help
-Don’t scrub wounds or use harsh detergents
-Little or no debridement of moderate or major burns should be performed in the ER -> sterile burn unit
-Redundant skin from ruptured blisters of minor superficial partial thickness burns may be removed -> dont want to remove viable skin
-Avoid ointments & complex dressings on pts being transferred -> use simple nonadherent dressing -> vasaline and pregmented gauze
-Pain control- don’t use systemic antibiotics

Question 29

pts transferred to burn center

Answer 29

-When pt with serious burn is first evaluated -> closest burn center should be contacted immediately -> they give recommendations and plans -> transfer
-With quick transfer, early escharotomy may be performed and can prevent complications of circumferential burns
-Fluid resuscitation and all other supportive measures should be continued during transport
-Keep patient warm during transfer- they will lose heat

Question 30

escharotomy

Answer 30

-surgical incision(s) used to treat full-thickness circumferential burns
-Indications for emergent escharotomy:
-Vascular compromise of extremities or digits -> ischemia bowel
-Suspected abdominal compartment syndrome- urine output decrease
-measure bladder pressure -> >40 dx, >20 suspect
-Impending or established respiratory failure
-decreases pressure -> increase perfusion -> gapping is seen

-Contraindictaions:
-Pts with irreversible gangrene of the extremity or digit
-too much of a bleed risk

-Complications
-Excessive blood loss - blood = tissue
-Inadvertent fasciotomy into underlying viable tissus

Question 31

smoke inhalation

Answer 31

-Mechanisms of injury (3 categories):
-1. Thermal injury of the airways
-2. Chemical injury of airways & lung parenchyma
-3. Systemic chemical poisoning
-Many pts have a combination of above

Question 32

smoke inhalation: thermal injury

Answer 32

-Pts who have been trapped! in a fire in a confined space inhale superheated gases & may also have direct flame injury of the !face & neck!
-Exposure to water or steam in heated gas mixture may produce thermal damage in upper and lower airways
-Clinical Findings:
-Should be suspected in any pt in a fire within a confined space
-Pts with obvious face or neck burns
-Nasal soot!, soot-tinged sputum, burned nasal & facial hairs
-Dyspnea, stridor, drooling or dysphonia
-Dx confirmed by laryngoscopy or bronchoscopy!

Question 33

smoke inhalation: chemical injury

Answer 33

-Caused by noxious products of combustion of flammable materials; directly toxic to airways & lung parenchyma
-ex. burning of plastics
-materials include: Acrolein, Hydrochloric acid, Toluene diisocyanate, Nitrogen dioxide

-Clinical findings:
-Very difficult to dx in ER
-Direct laryngoscopy or flexible fiberoptic bronchoscopy may reveal mucosal friability & airway edema
-CXR is usually normal initially -> ARDS may develop hours after exposure
-CO created due to incomplete combustion

-above the vocal cords edema
-bc of affective exchange that occurs there
-edematous vocal cords
-may need criccoidthyrotomy or trach for ventilation

Question 34

sequelae of smoke inhalation: systemic chemical poisoning

Answer 34

-MC complication of smoke inhalation is CO poisoning
-CO binds to Hgb with an affinity that is 260x greater than O2, forms carboxyhemoglobin
-even small amounts of carboxyhemoglobin drastically alters
-Bound CO is not easily displaced from Hgb -> shifts oxyhemoglobin dissociation curve to left -> more difficult for Hgb to release O2 to tissues
-Net result is tissue hypoxia & lactic acidosis
-cyanide poisoning
-CO also binds to the cytochromes, interfering with intracellular energy production
-In high concentrations, CO is also bound to myoglobin & rhabdomyolysis, myoglobinuria, and acute renal failure may occur

-Clinical findings:
-Should be expected in every fire victim
-Cherry-red skin color is not a frequent or reliable findings
-ABGs and Pulse oximetry is not reliable
-New Carboxyhemoglobin oximetry is available
-Confirmed by measuring serum carboxyhemoglobin level
-MI or arrhythmias may occur!

-Carboxyhemoglobin levels:
-Non-smokers- about 1%
-Smokers- 4-6%
-Levels >10% indicate significant exposure)
-Pts may be asymptomatic with levels 10-15%
-Levels > 50-60% have a high incidence of coma & seizures
-Levels > 70% are usually fatal

Question 35

smoke inhalation: ED clinical workup, tx, and disposition

Answer 35

-ABCs apply to ALL pts
-Facial & neck burns treat as previously discussed
-Low threshold for early intubation (RSI)
-While waiting for ABG & carboxyhemobglobin levels
-give 100% oxygen via a tight-fitting reservoir mask or ET tube
-Obtain ECG, continuous cardiac monitoring, CXR, & UA
-Inhaled and parenteral bronchodilators to pts with clinical evidence of bronchospasm
-Supportive care & admit pt for at least 24 hrs
-hyperbaric chamber
-acetylcysteine or heparin -> aerosolized and put in lungs -> bloody casts in the lung -> break it up -> allow ventilation

Question 36

cyanide toxicity

Answer 36

-burning of furniture or plastics

-Initiate treatment in:
-Severe burn victims with……
-Unexplained lactic acidosis or……
-low or declining end tidal volume CO2level

-If parameters are unavailable treat (you dont have CO2)….
-Any pt with depressed LOC
-Cardiac arrest
-Cardiac decompensation.

-In severe burn victims, use hydroxocobalamin

Question 37

in inhalation injury…primary attention to:

Answer 37

-supplemental O2
-airway protection strategies
-100% O2

Question 38

chemical burns

Answer 38

-Usually result from skin exposure to strong acids or alkalis (more dangerous bc lasts longer)
-Full development is slower than thermal burns
-initial size is usually underestimated during initial evaluation -> grows
-Clinical features depend on type of agent, concentration, volume, & duration of exposure
-Most acids produce coagulation necrosis due to desiccating action on superficial tissue proteins; superficial and full-thickness burns may result

-Hydrofluoric (HF) acid rapidly penetrates intact skin and can cause progressive pain & deep tissue destruction
-onset of pain may be delayed up to 12 hrs postexposure -> pt c/o pain with the absence of any presentation of burn!
-As progresses, skin may turn -> blue-gray appearance with surrounding erythema

-Alkalis cause liquefaction necrosis, which allows hydroxyl ions to penetrate into deep tissues
-Soft, gelatinous, friable, brownish eschars are produced
-Airbags deploy by ignition of a solid propellant (sodium azide) creating an exothermic reaction and certain corrosive byproducts (sodium hydroxide, nitric oxide, and ammonia) -> alkaline type burn
-Airbag! deployment may cause a combination of friction, thermal, and chemical burns

Question 39

chemical eye burns

Answer 39

-true ocular emergencies causing redness, pain, and tearing
-rinse rinse rinse
-call ophthalmologist
-injected all the way up to the limbus
-Acid ocular burns quickly precipitate proteins in the superficial eye structures -> “ground glass” appearance
-Alkali ocular burns cause deeper penetration secondary to liquefaction necrosis -> severe chemosis, blanched conjunctiva, & opacified cornea obscuring the view of the iris and lens can occur
-dilute acid quickly
-alkaline burns need significant dilution over a period of time

Question 40

chemical burns ED care and disposition

Answer 40

-First priority - terminate burning process; remove garments & copious skin irrigation
-Remove dry chemical particles manually before irrigation
-Elemental metals (Na+, lithium, Ca+, and Mg+) can ignite spontaneously when exposed to air
-water shouldn’t be used to extinguish burning particles because of the explosive exothermic reaction that results

-oxalic, hydrofluoric acid- hypocalcemia, hypomagnesium, hyperkalemia, arrythmia, death
-tannic, formic, chromic- hepatic necrosis nephrotoxicity,
-phenol, cresol- hemoglobin, massive hemolysis, multiple organ failure

-These metal particles should be covered with mineral oil or extinguished with a class D! fire extinguisher
-Systemic toxicity can result from topical exposure of certain chemical agents

Question 41

burn tx

Answer 41

-In ocular exposure to alkalis or acids, eye irrigation with 2 L NS via a Morgan lens (IV) for a min of 1 hr is needed
-With alkali or acid exposure, return of the pH to neutral -> endpoint for irrigation
-Visual acuity, check & pH testing should follow -> not precede irrigation
-HF acid burns often require calcium gluconate to bind fluoride and neutralize its toxic effects; applied topically, subcutaneous, intradermal injection
-Treat systemic toxicity similar to thermal burns (pain control, IVF, tetanus)

Question 42

long term complications of burn

Answer 42

-Depression
-PTSD
-Contractures
-Sensory Loss
-**Skin Cancer is NOT a risk

-BSA + age = if > 100 -> minimal chance of survivorship -> palliative care
-BSA% + age + 17 (for multiple organ failure) = >140-150 -> negligible chance of survivorship
-