burns Flashcards
immediate management
-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!!!!
injuries associated with burns
-Fractures: 45-64%
-Complex soft tissue injuries: 36-52 %
-TBI: 17-26%
-Thoracic and abdominal injuries: 4-24 %
-mortality- 3-55%
burn center referral criteria
comorbidities
-do it early
criteria for ICU admission
-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
when does a pt need IV access
-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
obtain labs
-ABG analysis
-Carboxyhemoglobin level
-CBC, lytes, urine myoglobin
-CXR and ECG
-cyanide
-tox screen
-musculoskeletal / internal injury -> CT scan
factors that affect rate of IV transfusion
-flow rate=
-length of tubing
-viscosity (blood > colloids > crystalloid)
-radius- bore
-pressure- pressure adding systems for IVs
nutrition
-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
fluid resuscitation!!!!!!
-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
eval for any other possible injuries
-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
indwelling catheter
-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
further evaluation
-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
determinants of burn severity
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
summary of american burn association burn severity categorizations
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
classification of burns by depth of injury
-morphine
-fentanyl
-benzos
-for 2nd degree
burn size
-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
rule of nines
-head and neck- 9
-arm- 9 each
-torso front- 18
-torso back- 18
-leg- 18 each
-genitalia and perineum- 1
burn depth
-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
antibiotics
-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
blisters
-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
major burns
-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
circumferential burns
-major burn
-Neck - may cause lymphatic & venous obstruction that leads to laryngeal edema & airway obstruction
-Extremities – compartment syndrome
-Chest – respiratory failure
inhalation injury
-Burned sustained in confined space
-singed nasal hairs
-facial burns
-soot in nose or mouth
-hoarseness
-carbonaceous sputum
-wheezing
-CO level >10%
electrical injury
-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
