THERMAL BURNS

Question 1

MAJOR BURN MANAGEMENT

Answer 1

EMS HANDOVER

Time of injury
Mechanism of burn:
Burning agents
Chemicals
Duration of exposure
Open or closed space
Inhalation injury
Concomitant injuries
First aid Provided

AIRWAY

PROMPT INTUBATION IF SIGNS OF AIRWAY INJURY OR DISTRESS:
Worsening throat pain
Change in phonation
Stridor
Neck pain / edema
Wheezing
Facial burns
Mucosal Burns
OR
TBSA > 20%

BREATHING

1. CONFINED SPACE: assess for Carbon Monoxide or Cyanide
2. CHEST COMPARTMENT SYBDROME: Assess for full-thickness/circumferential burns to the torso in addition to difficulty with ventilation or bagging the patient
3. VENTILATION:

Humidified oxygen (100%)
Intubation / Ventilation
Bronchodilators
Pulmonary Toilet
Monitor pulmonary edema from fluid resuscitation, inhalation injury

CIRCULATION

Cardiopulmonary Monitoring
2 large bore IVs

1. 500 ml bolus LR
2. ADULT PARKLAND FORMULA
   LR 4 ml x weight (kg) x % TBSA over initial 24 hr
   Half over the first 8 hrs from the time of burn
   Other half over subsequent 16 hrs
   Target U/O: 0.5 - 1.0 ml / kg / hr
3. PEDIATRIC PARKLAND
   LR 3 ml x weight (kg) x % BSA over initial 24 hr plus maintenance
   Half over the first 8 hrs from the time of burn
   Other half over subsequent 16 hrs
   Target U/O: 1 ml / kg / hr
   Add 5% dextrose in maintenance fluids for children < 20 kg
4. CIRCUMFERENTIAL BURNS
   Assess circulation distal to burn with Doppler if needed
   Perform ESCHAROTOMY PRN

DISABILITY

1. PAIN

Toradol 10 mg IM. Avoid in renal disease, PUD, history of gastrointestinal bleed.

Ketamine 0.3 mg / kg slow IV push

Morphine 1-4 mg IV up to 10 mg q 4 hrs

Hydromorphone 0.2-0.5 mg IV up to 1 mg q 4 hrs

2. ALTERED MENTAL STATUS
   Consider Carbon Monoxide or Cyanide if profound acidosis or unexplained cardiovascular
   OR
   Head Trauma

EXPOSURE

1. REMOVE ALL CLOTHING
2. SECONDARY SURVEY / TRAUMA SURVEY
   Do head to toe PHYSICAL EXAM
3. Burn size
4. Burn depth
5. Circumferential burns
6. Specific body parts: hands, face, genitalia, major joints
7. Neurovascular Status
8. Concomitant Injuries
9. WOUND CARE

Moist saline soaked dressing
AND
Clean Dry Sheets

INVESTIGATIONS
CBC
Lytes
BUN / Cr
Blood Glucose
VBG’s with carboxyhemoglobin levels if inhalation injury is suspected
CK
U/A for Myoglobin, B-HcG, Toxicology, Diabetics
CXR for intubated patients
Bronchoscopy in suspected inhalation injury
ECG if electrical burn or pre-existing cardiac problems
Type and Cross

ADJUNCTS
1. Placement of foley catheter
2. Insertion of nasogastric tube for partial thickness burns > 20%
3. tetanus booster

MONITORING
1. Continuous cardiopulmonary and capnography
2. Volume Status to avoid fluid overlead
3. Frequent Neurovascular Checks
4. If Hydrofluric Acid Exposure- monitor hypocalcemia, hypomagnesemia, hyperkalemia

Question 2

DOCUMENTATION

Answer 2

HISTORY
Time of injury
Mechanism of burn:
Burning agents
Chemicals
Duration of exposure
Open or closed space
Inhalation injury
Concomitant injuries
First aid Provided

Ask about:
headache
loss of consciousness
nausea
altered mental status

PHYSICAL EXAM
1. BURN SIZE
Rule of Nines (Adult)
head = 9%
Torso = 18% (front), 18% (back)
Arm = 9% (each)
Leg = 18% (each)
Genital = 1%

Do not include superficial burns

Rule of Nines (Pediatric)
Head = 18%
Torso = 18 % (front), 18% (back)
Arm = 9 % (each)
Legs = 14% (each leg)
OR
Area of patient’s back of hand ~ 1% of TBSA

2. BURN DEPTH
   SUPERFICIAL: (1st degree)
   Like a sunburn
   Red
   Painful
   No blisters
   Area blanches
   Heals in 7 d

SUPERFICIAL PARTIAL THICKNESS: (superficial second degree)
Epidermis and superficial dermis (papillary layer)
Red
very painful
Blisters
Exposed dermal layer is red and moist
Area blanches
14-21 d, no scar

DEEP PARTIAL THICKNESS: (deep second degree)
Epidermis and deep dermis (reticular layer)
sweat glands, and hair follicles damaged
Exposed dermis
Red to pale white and yellow
Blisters, very painful
Burned area does not blanch 0 cap refill
3-8 wk, permanent scar

FULL-THICKNESS: (third degree)
Entire epidermis and dermis
charred, pale, leathery; no pain
Months, severe scarring, skin grafts necessary

3. CURCUMFERENTIAL BURN
   Neurovascular status distal to the burn
4. SPECIFIC BODY PARTS:
   hands
   face
   genitalia
   major joints
5. NEUROVASCULAR STATUS
6. CONCOMITANT INJURIES

Question 3

DISPOSITION

Answer 3

CRITERIA FOR TRANSFER TO BURN CENTER

Third-degree (full-thickness) burns in any age group.

Partial thickness burns greater than 10% total body surface area (TBSA.)

Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

Electrical burns, including lightening injury.

Chemical burns.

Inhalation injury.

Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.

Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality.

Burned children in hospitals without qualified personnel or equipment for the care of children.

Burn injury in patients who will require special social, emotional or rehabilitative intervention.

DISCHARGE HOME
Minor Burns