Burns Flashcards
Define 1st degree burns and state if these should be included in the TBSA and what fluid management these burns require
Do not penetrate through the dermis
Sunburn/superficial thermal injury
Do not include in parklands calculation
What are the characteristics of a superficial partial burn and what is the treatment
- Erythematous
- Moist
- Homogenous
- Blisters
- Painful and hypersensitive to touch
- Blanch readily
Rx:
ABCDE
Parklands (3ml x kg x TBSA in the first 24 hours and then add maintenance 4:2:1
Burn shield –> flammazine q24 –> will re-epitheliaze without functional/cosmetic defects or hypertrophic scars
Indeterminante depth burns
Reticulated surface: red/white blotches and dry surface may blister. CRT sluggish.
Wound pain ± = discomfort (no hypersensitivity)
Healing time and hypertrophic scarring variable
Graft if wound not healing in 2 weeks
What are the defining characteristics of full thickness burns
- No spontaneous healing
- Cosmetic and functional impairment
- Hypertrophic scarring
- Early eschar excision and skin graft
- Leathery to palpation and no sensation
When is fluid replacement therapy indicated in burns
When TBSA > 20% with superficial partial thickness burns
± Skin graft
Describe the unique hemodynamic response induced by > 20% TBSA superficial partial burns
1st 48 hours: Massive vasoconstriction - 50% reduction in CO
> 48 hours: hyperdynamic physiology
> 20% TBSA –> massive vasoconstriction –> Decline in Cardiac Output by 50% –>normovolaemic hypoperfusion (burn shock) –> survival depends on restoration of circulating volume
If intense fluid therapy is provided –> cardiac function returns to normal within 48 hrs then changes to a hyperdynamic physiology as the healing process proceeds
What fluid management is preferred in burns and how does this contrast to fluid management for blunt and penetrating trauma
Crystalloid fluid therapy is favored
–> Modified Ringers Lactate is best
Hypertonic Saline –> kidney failure
Blood t/f –> higher mortality associated
Name the two formulas that are used to guide burn injury fluid resuscitation
Parklands formula
modified Brooke
What is the Parkland formula
FIRST 24 hours:
1. 4ml/kg/% TBSA given in the first 24 hours
- 1st 8 hrs: Give half total volume
- last 16 hours: Give half total volume
2. Use Urine output as a guide
Slow infusion if urine output is >1.0 ml/kg/hr
Faster infusion if urine output is < 0.5 ml/kg/hr
SECOND 24 hours
1. Give half the total volume given in first 24 hours and target UO 0.5 - 1.0 ml/kg/hr
How does the Parklands formula differ for children and infants
USE THE SAME FORMULA but adjust the UO targets:
- Children < 30 kg: UO target is 1.0 ml/kg/hr
- Infant < 1 year: UO target is 1 - 2 ml/kg/hr
What is the difference between the PArklands and the modified Brooke protocols and which one does GSH use?
Parklands: 4 ml/kg/%TBSA in first 24 hrs
Modified Brooke: 2 ml/kg/%TBSA in first 24 hrs
GSH: 3 ml/kg/TBSA in first 24 hours
What is ‘fluid creep’ and what are the consequences of this phenomenon
Fluid administration may exceed the intended volumes as calculated by the Parklands/modified Brooke
- Incorporation of 1st degree burns into calculation
- Prolonged use of sedative infusions –> Rx of hypotension with fluid
Consequences
- Abdominal compartment syndrome
- Pulmonary complications
= Resuscitation morbidity
In which patients is abdominal compartment syndrome a risk
- Receiving > 6 ml/kg/%TBSA
- Circumferential burns
- Children
How can intra-abdominal pressure be determined when abdominal compartment syndrome is suspected and what pressure confirms that abdominal compartment syndrome is present?
Intraluminal bladder pressure using foleys catheter transducer.
3-way stopcock: ZERO at pelvic brim –> instill 20 ml of fluid into bland to distend it –> take pressure 60 s after fluid is instilled
Intra-abdominal pressures exceeding 20 mmHg warrant abdominal cavity decompression
(Caution: intra-abdominal pseudomonas infection if laparotomy incision is close to burn tissue)
What pulmonary complications result from ‘fluid creep’ in burns patients
- Pneumonia
- Resuscitation induced pulmonary oedema
- Decreased tracheal ciliary activity
- Reduced immunocompetence
- ETT
- Abdominal compartment syndrome effect FRC
