Burn Management

Lynn Kemp, R.N. Trauma Coordinator St. Barnabas Hospital

Incidence
Approx. one million burn patients/annually

in the United States 3-5% cases are life-threatening 60,000 hospitalized / 5,000 die Fires are the 5th most common cause of death from unintentional injury Deaths are highest among children < 5 yr. and adults > 65 yr.

Functions
Skin is the largest organ of the body
Essential for:

Thermoregulation Prevention of fluid loss by evaporation Barrier against infection Protection against environment provided by sensory information

Types of burn injuries

Thermal: direct contact with heat

(flame, scald, contact) Electrical A.C. alternating current (residential) D.C. direct current (industrial/lightening) Chemical Frostbite

Epidermis
Outermost layer, composed of cornified

epithelial cells.
Outer surface cells are dead and sloughed

off.

Dermis
Middle layer, composed primarily of

connective tissue.
Contains capillaries that nourish the skin,

nerve endings and hair follices

Hypodermis
Layer of adipose and connective tissue

between the skin and underlying tissues.

Classification
Burns are classified by depth, type and

extent of injury
Every aspect of burn treatment depends on

assessment of the depth and extent

First degree burn

Involves only the

epidermis Tissue will blanch with pressure Tissue is erythematous and often painful Involves minimal tissue damage Sunburn

Second degree burn

Referred to as partial-

thickness burns Involve the epidermis and portions of the dermis Often involve other structures such as sweat glands, hair follicles, etc. Blisters and very painful Edema and decreased blood flow in tissue can convert to a full-thickness burn

Third degree burn

Referred to as full-

thickness burns Charred skin or translucent white color Coagulated vessels visible Area insensate patient still c/o pain from surrounding second degree burn area Complete destruction of tissue and structures

Fourth degree burn

Involves

subcutaneous tissue, tendons and bone

Burn extent
% BSA involved morbidity

Burn extent is calculated only on individuals with second and third degree burns Palmar surface = 1% of the BSA

Measurement charts
Rule of Nines: Quick estimate of percent of burn Lund and Browder: More accurate assessment tool Useful chart for children takes into account the head size proportion.
Rule of Palms: Good for estimating small patches of burn wound

Lab studies
Severe burns: CBC Chemistry profile ABG with carboxyhemoglobin Coagulation profile
U/A
Type and Screen CPK and urine

myoglobin (with electrical injuries) 12 Lead EKG

Imaging studies
CXR
Plain Films / CT scan: Dependent upon

history and physical findings

Criteria for burn center admission

Full-thickness > 5% BSA
Partial-thickness > 10% BSA Significant chemical injury,

Circumferential burns of

thorax or extremities

Any full-thickness or partial-

thickness burn involving critical areas (face, hands, feet, genitals, perineum, skin over major joint)
Children with severe burns

electrical burns, lightening injury, co-existing major trauma or significant preexisting medical conditions
Presence of inhalation injury

Initial patient treatment

Stop the burning process
Consider burn patient as a multiple trauma

patient until determined otherwise

Perform ABCDE assessment Avoid hypothermia! Remove constricting clothing and jewelry

Details of the incident

Cause of the burn Time of injury Place of the occurrence (closed space,

presence of chemicals, noxious fumes) LOC upon arrival to scene Likelihood of associated trauma (MVA / explosion) Pre-hospital interventions

Airway considerations
Maintain low threshold for Prior to intubation attempt:

intubation and high index of suspicion for airway injury

Swelling is rapid and

have smaller sizes of ETT available

Prepare for cricothyrotomy

progressive first 24 hours

Consider RSI to facilitate

for tracheostomy
Utilize ETCO2 monitoring

intubation cautious use of succinylcholine hours after burn due to K+ increase

pulse oximetry may be inaccurate or difficult to apply to patient.

Airway considerations
Upper airway injury (above the glottis): Area buffers the heat of smoke thermal injury is usually confined to the larynx and upper trachea.
Lower airway/alveolar injury (below the glottis): - Caused by the inhalation of steam or chemical

smoke. - Presents as ARDS often after 24-72 hours

Criteria for intubation

Changes in voice Wheezing / labored Assume inhalation injury

respirations Excessive, continuous coughing Altered mental status Carbonaceous sputum Singed facial or nasal hairs Facial burns Oro-pharyngeal edema / stridor

in any patient confined in a fire environment Extensive burns of the face / neck Eyes swollen shut Burns of 50% TBSA or greater

Pediatric intubation
Normally have smaller airways than adults Small margin for error If intubation is required, an uncuffed ETT should be placed Intubation should be performed by experienced individual failed attempts can create edema and further obstruct the airway

AGE 4

ETT size

Ventilatory therapies
Rapid Sequence Intubation
Pain Management, Sedation and Paralysis PEEP High concentration oxygen Avoid barotrauma

Hyperbaric oxygen

Ventilatory therapies
Burn patients with ARDS requiring

PEEP > 14 cm for adequate ventilation should receive prophylactic tube thoracostomy.

Circumferential burns of the chest

Eschar - burned,

inflexible, necrotic tissue

Compromises ventilatory

motion
Escharotomy may be

necessary
Performed through non-

sensitive, full-thickness eschar

Carbon Monoxide Intoxication

Carbon monoxide has a binding affinity for hemoglobin which is 210-240 times greater than that of oxygen.
Results in decreased oxygen delivery to tissues, leading to cerebral and myocardial hypoxia.

Cardiac arrhythmias are the most common fatal occurrence.

Signs and Symptoms of Carbon Monoxide Intoxication

Usually symptoms not present until 15% of

the hemoglobin is bound to carbon monoxide rather than to oxygen.

Early symptoms are neurological in nature

due to impairment in cerebral oxygenation

Signs and Symptoms of Carbon Monoxide Intoxication

Confused, irritable, restless
Headache

Dilated pupils
Bounding pulse Pale or cyanotic

Tachycardia, arrhythmias or infarction Vomiting / incontinence

complexion Seizures Overall cherry red color rarely seen

Carboxyhemoglobin Levels/Symptoms
05 15 20 20 40
40 - 60 > 60
Normal value
Headache, confusion Disorientation, fatigue, nausea, visual changes Hallucinations, coma, shock state, combativeness Mortality > 50%

Management of Carbon Monoxide Intoxication

Remove patient from source of exposure.
Administer 100% high flow oxygen

Half life of Carboxyhemoglobin in patients: Breathing room air 120-200 minutes Breathing 100% O2 30 minutes

Circulation considerations
Formation of edema is the greatest initial volume loss Burns 30% or < Edema is limited to the burned region
Burns >30% Edema develops in all body tissues, including non-burned areas.

Circulation considerations
Capillary permeability increased
Protein molecules are now able to cross the membrane

Reduced intravascular volume

Loss of Na+ into burn tissue increases osmotic pressure this continues to draw the fluid

from the vasculature leading to further edema formation

Circulation considerations
Loss of plasma volume is greatest during

the first 4 6 hours, decreasing substantially in 8 24 hours if adequate perfusion is maintained.

Impaired peripheral perfusion

May be caused by mechanical compression, vasospasm or destruction of vessels Escharotomy indicated when muscle compartment pressures > 30 mmHg
Compartment pressures best obtained via ultrasound to avoid potential risk of microbial seeding by using slit or wick catheter

Fluid resuscitation
Goal: Maintain perfusion to vital organs
Based on the TBSA, body weight and

whether patient is adult/child

Fluid overload should be avoided

difficult to retrieve settled fluid in tissues and may facilitate organ hypoperfusion

Fluid resuscitation
Lactated Ringers - preferred solution
Contains Na+ - restoration of Na+ loss is

essential
Free of glucose high levels of circulating

stress hormones may cause glucose intolerance

Fluid resuscitation
Burned patients have large insensible fluid

losses
Fluid volumes may increase in patients

with co-existing trauma

Vascular access: Two large bore

peripheral lines (if possible) or central line.

Fluid resuscitation
Fluid requirement calculations for infusion

rates are based on the time from injury, not from the time fluid resuscitation is initiated.

Assessing adequacy of resuscitation

Peripheral blood pressure:

may be difficult to obtain often misleading

Heart rate: Valuable in early

post burn period should be around 120/min.

> HR indicates need for > fluids

Urine Output: Best indicator

unless ARF occurs

A-line: May be inaccurate due

or pain control
Invasive cardiac monitoring:

to vasospasm
CVP: Better indicator of fluid

status

Indicated in a minority of patients (elderly or pre-existing cardiac disease)

Parkland Formula
4 cc R/L x % burn x body ARF may result from

wt. In kg.
of calculated fluid is

myoglobinuria
Increased fluid volume,

administered in the first 8 hours

Balance is given over the

remaining 16 hours.
Maintain urine output at

mannitol bolus and NaHCO3 into each liter of LR to alkalinize the urine may be indicated

0.5 cc/kg/hr.

Galveston Formula
Used for pediatric L/R is used at 5000cc/m2

patients
Based on body surface

area rather than weight

More time consuming

x % BSA burn plus 2000cc/M2/24 hours maintenance. of total fluid is given in the first 8 hrs and balance over 16 hrs. Urine output in pediatric patients should be maintained at 1 cc/kg/hr.

Effects of hypothermia
Hypothermia may lead to acidosis/coagulopathy
Hypothermia causes peripheral vasoconstriction

and impairs oxygen delivery to the tissues

Metabolism changes from aerobic to anaerobic

serum lactate

serum pH

Prevention of hypothermia
Cover patients with a dry Remove wet / bloody

sheet keep head covered

Pre-warm trauma room

clothing and sheets

Paralytics unable to

Administer warmed IV

shiver and generate heat

Avoid application of

solutions
Avoid application of

antimicrobial creams
Continual monitoring of

saline-soaked dressings
Avoid prolonged

irrigation

core temperature via foley or SCG temperature probe

Pain management
Adequate analgesia imperative! DOC: Morphine Sulfate Dose: Adults: 0.1 0.2 mg/kg IVP Children: 0.1 0.2 mg/kg/dose IVP / IO Other pain medications commonly used: Demerol Vicodin ES NSAIDs

GI considerations
Burns > 25% TBSA subject to GI complications secondary to hypovolemia and endocrine responses to injury
NGT insertion to reduce potential for aspiration and paralytic ileus.

Early administration of H2 histamine receptor recommended

Antibiotics
Prophylactic

antibiotics are not

indicated
in the early postburn period.

Other considerations
Check tetanus status administer Td as

appropriate
Debride and treat open blisters or blisters

located in areas that are likely to rupture

Debridement of intact blisters is

controversial

Questions