Transcript Management Of Burns - NH-TEMS

MANAGEMENT OF
BURNS
CPT Allen Proulx, MPAS, PA-C
OBJECTIVES
Describe the differences between partial
and full-thickness burns.
Describe how to estimate the size of a
burn.
Describe initial care of burns.
Describe follow-up care of partial
thickness burns.
References for photos
 Advanced Burn Life Support Course,
American Burn Association, 1994
 Textbook of Military Medicine, Part I, Vol 5
Conventional Warfare, OTSG, 1991
 Textbook of Surgery, Sabiston, editor
W. B. Saunders, 1986
 SESAP VI,
American College of Surgeons, 1988
 Burn care product info
Depth of burn
Partial thickness
burn =
involves epidermis
Deep partial
thickness =
involves dermis
Full thickness =
involves all of skin
Partial thickness burns
 Sunburn is a very superficial burn.
 Expect blistering and peeling in a few days.
 Maintain hydration orally.
 Heals in 3-6 days- generally no scaring
 Topical creams provide relief.
 No need for antibiotics
Deeper partial thickness
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Blisters are typical of partial thickness burns.
Don’t be in a hurry to break the blisters.
Heals in 14-21 days
Blisters provide biologic dressing and comfort.
Once blisters break, red raw surface will be very painful.
Full thickness burn
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Yellow, “leathery” appearance; or charred
Often have no sensation (nerve endings destroyed)
Outer edges might be partial thickness.
Initial management same as partial thickness.
Later will need skin grafts.
Mixed partial and full thickness
 Central yellow area might be full thickness.
 Outer edges are probably partial thickness.
 Initial management is the same.
 Later will need skin grafts for the full thickness
areas.
Zones of Burn Wounds
 Zone of Coagulation
 devitalized, necrotic, white, no
circulation
 Zone of Stasis ‘circulation sluggish’
 may covert to full thickness,
mottled red
 Zone of Hyperemia
 outer rim, good blood flow, red
Wound
excision until
fine punctate
bleeding
occurs
Estimate the size of the
burn
The patient’s own palm is about 1%
of his body surface area.
“Rule of Nines”
Rule of 9s
ABA
American Burn Assoc
says send these to a burn center
 Partial thickness burns >10% BSA
 Burns involving the face, hands, feet, genitalia,
perineum, or major joints
 full thickness/3 degree burn
 Electrical, Chemical, and Inhalation burns
 In combat, all but the most superficial
burn should be evacuated
Burn care products
 < 20% TBSA 2nd degree – Silvadene (SVC)
Cream BID
 Any > 20% TBSA-SVC and Sulfamylon
(SMC) alt BID
 3rd degree burn – SVC and SMC alt BID
 *SMC only to the ears
* Bacitracin
Opth to face
Care of small burns
What can YOU do?
Care of small burns
 Clean entire limb with
soap and water (also under nails).
 Apply antibiotic cream
(no PO or IV antibiotic).
 Dress limb in position of function,
and elevate it.
 No hurry to remove blisters unless infection occurs.
 Give pain meds as needed (PO, IM, or IV)
 Rinse daily in clean water; in shower is very practical.
 Gently wipe off with clean gauze.
Blisters
 In the pre-hospital setting, there is no
hurry to remove blisters.
 Leaving the blister intact initially is less
painful and requires fewer dressing
changes.
 The blister will either break on its own,
or the fluid will be resorbed.
Blisters break on their own
Upper arm burn day 1
day 2
Burn “looks worse” the next day because of
blisters breaking and oozing
Upper arm
burn
121
 Blisters show probable partial thickness burn.
 Area without blister might be deeper partial
thickness.
Debride blister using simple instruments
Medic debriding blister
After debridement
Before and after debridement
 Removing the blister leaves a weeping, very
tender wound, that requires much care.
Silver sulfadiazene
Arm burn 4 days
Arm burn 7 days – note the exudate
Foot burn
debridement
Before debriding
and applying
cream,
clean entire foot
(including
toes and nails).
Silver- impregnated dressings
(Silverlon)
 Apply wet silver dressing
directly on the burn.
 Creams or dressings
under the silver dressing
impede the antimicrobial action.
 Keep it moist!
 Remove it, rinse it out, replace it on the
burn.
Steps in using silver-impregnated
dressings
 Clean the burn and surrounding area.
 Soak silver-impregnated dressing and gauze in
STERILE WATER or BOTTLED DRINKING
WATER
 Apply silver-impregnated dressing
(over-lapping edges are best).
 Wrap with the moist gauze.
 Secure with mesh, gauze, or tape.
 Keep it moist with WATER, every 12h or so
More frequent in hot arid environments
pics
Soak silver dressings and gauze
in WATER (not saline).
Apply the
silver dressing.
Wrap with moist gauze.
Secure with mesh, gauze, or tape.
First few days
 Moisten dressing with WATER every 12h or so.
 Remove outer gauze and silver dressing every
day.
Inspect the burn.
Rinse exudate off burn.
 Rinse exudate off silver dressing with WATER.
 Return same silver dressing to the burn.
 Apply new outer gauze moistened with
WATER.
pics
Moisten well
to remove it each day.
Rinse it out, and put it
back on the burn.
Moisten with WATER
q12h or so.
After several days
 Replace silver dressing
every 2 - 5 days
depending on amount of exudate,
cellular debris
 First wet the silver dressing before removing
it.
 Don’t pull on it if it’s stuck – moisten it more.
 Apply new moist silver dressing and gauze.
QUESTIONS ABOUT
SMALL BURNS?
SUMMARY
 Describe the differences between partial and
full-thickness burns.
 Describe how to estimate the size of a burn.
 Describe initial care of small burns.
 Describe follow-up and post-burn care.
NEXT TOPIC - BURNS OF SPECIAL AREAS
Burns of special areas
of the body
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Face
Mouth
Neck
Hands and feet
Genitalia
Face
 Be VERY concerned for the airway!!
 Eyelids, lips and ears often swell
alarmingly.
 In fact, they look even worse the next day.
 But they will start to improve daily after
that.
 Cleanse eyes with warm water or saline.
 Apply antibiotic ointment or liquid tears
until lids are no longer swollen shut.
 Bacitracin cream/ointment will serve
Hands and feet
This is rather deep
and might require
grafting.
But initial
management is basic.
Dressings should not impede
circulation.
Leave tips of fingers exposed.
Keep limb elevated.
Hands and feet
 Allow use of the hands in dressings by day.
 Splint in functional position by night.
 Keep elevated to reduce swelling.
Hands and feet
 Fingers might develop
contractures if active
measures are not taken
to prevent them.
Genitalia
 Shower daily, rinse off old cream, apply new cream.
 Insert Foley catheter if unable to urinate due to swelling.
Large Burns
Causes of death in burn
patients
Airway
Facial edema, and/or airway
edema
Breathing
Toxic inhalation (CO, +/- CN)
Respiratory failure due to smoke
injury or ARDS
Edema Formation
 Amount of edema can be
immense (even without
facial burns)
 Depression of mental
status can worsen problem
 Edema peaks at 12 to 24
hours
 Pediatric patients even
more concerning
Causes of death in burn
patients
Circulation: “failure of resuscitation”
Cardiovascular collapse, or acute
MI
Acute renal failure
Other end organ failure
Missed non-thermal injury
Patients with larger burns
First assess
CBA’s
“Disability” (brief neuro exam)
Expose
Later
Examine rest of patient
Calculate IV fluids
Treat burn
Airway?
 “Flash” burns may refer to
those that suddenly flare up,
then die down quickly.
 Patients may have burnt
facial hair and carbon on
lips.
 Patients with this kind of
facial burn will probably
NOT need an artificial
airway.
 Give humidified oxygen
while under close
observation.
Circulation
 Record vital signs.
 Check distal pulses and nail beds.
Keep him warm!
Loss of skin impairs ability to retain heat
and fluids.
Being cold will cause vasoconstriction.
 Monitor urine output (in larger burns, insert Foley
catheter for hourly urine output). 30/50cc/hr
 Monitor at least HCT and urine specific gravity.
 When available, monitor electrolytes.
Neuro status
 The burn itself does not alter the level of
consciousness.
 If patient is not alert, think of other causes:
hypovolemia
carbon monoxide
head injury
 Don’t allow swollen eyelids to prevent you from
examining the pupils.
 Test sensation and motion in burned extremities.
Expose
 Undress the patient to examine
the whole body.
 But burned patients lose body
heat quickly, so keep them
warm.
 To keep warm, use whatever
means available:
blankets
heating lamps
bed frame
large box covered with
blankets
Head to toe exam
Obtain history and examine rest of body.
Ask about allergies, meds, medical
conditions.
Look for other injuries.
Calculate fluid requirements
wt in kg
x
% burn
x
2 - 4cc / kg / %
100 kg patient with 50% TBSA burn:
100 x 50 x 2 = 10,000cc = 10 liters RL
This is calculated for the first 24 hours post-burn.
Give half of this in first 8 hours.
Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially
Calculate fluid requirements
Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially
How do we know if this is too much fluid, or too little?
Monitor at least:
urine output - in adults, around 50 cc / hr
Decreasing urine output = need for more fluids.
Burn size in small children
 The head accounts for about 18% (instead of 9%).
 The legs account for about 13% (instead of 18%).
Fluid requirements in children
 Use same formula for fluids to replace loss from
burns.
 In children, add this amount to normal maintenance
rate:
10 kg - about 40 cc / hr maintenance fluids
20 kg - about 60 cc / hr
30 kg - about 70 cc / hr
 Expected urine output for child: 1 cc / kg /hr
for infant: 2 cc/ kg / hr
Fluids requirements in children
20 kg child with 30% burn:
20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr
Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially
75 cc / hr for burn loss + normal 60 cc / hr maintenance =
135 cc / hr initially
 How do you know if the patient is getting too much fluid,
or too little?
Check urine output, urine specific gravity, HCT
 Be sure the patient’s airway, breathing and
circulation are secure.
 Then treat the burn wound itself.
 In patients with large burns, do not initially
spend much time carefully calculating fluids.
 Instead, start an IV and start giving fluids
rather rapidly while exam is being performed.
DO NOT BOLUS! 500cc/hr is a good rule.
 Later do the calculations.
Special types of burn
 Circumferential burn
 Burn requiring escharotomy
 Electrical burn
 Chemical burn
Circumferential burn
 Limb is burned all the way around.
 Soft tissues under the skin always swell with
burns
(due to capillary leak of fluids in first day or so).
 There is a loss of skin expansion due to the loss
of turgor/elasticity in burned tissue
 Pressure inside limb gradually increases.
 Eventually, pressure inside limb exceeds arterial
pressure.
 This requires escharotomy to relieve the
pressure.
Escharotomy - indications
 Circulation to distal limb is in danger due to
swelling.
Progressive loss of sensation / motion in hand /
foot.
Progressive loss of pulses in the distal extremity
by palpation or doppler.
 In circumferential chest burn, patient might not be
able to expand his chest enough to ventilate,
and might need escharotomy of the skin of the
chest.
Escharotomy - complications
COMPLICATIONS
 Bleeding: might require ligation of superficial
veins
 Injury to other structures: arteries, nerves,
tendons
NOT every circumferential burn requires
escharotomy.
 In fact, most DO NOT need escharotomy.
 Repeatedly assess neuro-vascular status of the
limb.
 Those that lose circulation and sensation need
escharotomy.
Escharotomy
 Eschar = burned skin
 Escharotomy = cut burned skin to
relieve underlying pressure
 Similar to bivalving a tight cast.
 Cut along inside and outside of
limb from good skin to good skin
 Knife can be used, or cautery.
 Use local or no anesthesia.
(Full-thickness burn should have
no sensation, but underlying
tissues do!)
Escharotomy of forearm
 Incise along medial
and/or lateral
surfaces.
 Avoid bony
prominences.
 Avoid tendons,
nerves, major
vessels.
Escharotomy
 Patient had escharotomy of
both legs.
 Incisions will heal.
 They will not be closed by
DPC.
 These large burns are often
treated by the “open”
technique,
that is, without dressings.
Electrical burn
 Outer skin might
not appear too bad.
 But heat was conducted
along the bone.
 Causes the most damage.
 Burns from inside out.
 Usually requires fasciotomy
Fasciotomy
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Fascia = thick white covering of muscles.
Fasciotomy = fascia is incised (and often overlying skin)
Skin and fascia split open due to underlying swelling.
Blood flow to distal limb is improved.
Muscle can be inspected for viability.
Phosphorus
 Particles of
phosphorus must be
removed from under
the skin.
 Pick them off with
forceps.
 Must apply wet
dressing to prevent reigniting.
QUESTIONS?
SUMMARY
Describe how to estimate the body
surface area of burn.
Describe how to calculate initial fluid
requirements in a patient with a large
burn.
Describe intial management of a patient
with a large burn.
Discuss indications and complications
of escharotomy.
BURN DOWN & DIRTY
Educate your Task Force!
proper technique for burning waste,
wear of clothing
Do not hesitate to evacuate.
Burns other than inhalation generally
don’t kill at point of injury- Bleeding and
breathing injuries do!
Oral Abx if managing burn at BAS ?