Transcript Slide 1

Burn Injury… triage & assessment
Burns constitute a major global problem and are a
leading cause of trauma deaths in children. Minor burns,
if poorly treated, cause devastating complications with
lifelong morbidity.
Understanding how burns cause tissue damage and how
the skin heals is vitally important in ensuring that the right
diagnosis is made and the right treatment given.
Bradley J. Phillips, MD
UNM Burn Center
Adults & Pediatrics
Typical burns from hot
water in a child
from tragedy… hope!
Modern Burn Care…
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Injury
Covers the entire spectrum of injury
Covers all age groups
Efficient & protocol-driven care
Multidisciplinary team
Acute Care
Functional Releases
Long-term
Reconstruction
Acute-MD & Plastics
Acute-MD &
Plastics
Plastics
In-Pt: admission
Discharge
1-2 yrs.
ICU
Med-Surg
Life…
Out-Pt: clinic
Burn Demographics & Incidence…
• As of the early 1990’s, the rate of reportable burn injuries in the U.S. had
declined from about 10/10,000 to 4.2/10,000.
• 45,000 hospitalizations per year, about half to 125 specialized burn
treatment centers and half to the nation’s 5,000 other hospitals.
• 700,000 annual emergency department visits @1.2 per injury. (Burn center
hospitals average 200 burn admissions a year, other hospitals less than five.)
• The average size of a burn injury admitted to a burn center is about 14%
of total body surface area (% TBSA). (1991-93)
• Burns of 10% TBSA or less account for 54% of burn center admissions,
while burns of 60% TBSA or more account for 4% of admissions.
The Basis…
Admissions
• 4.2 per 10,000 burn injuries
(projected)
– ~ 2 million people in New Mexico
– ~ 1.2 million people in the general referral area
• ~ 504 burn injuries per yr.
– 54%, less than 10% TBSA
– 42%, between 10 – 60% TBSA
– 4%, greater than 60% TBSA
:
:
:
272 pts 211 pts 20 pts -
~ 140
~ 200
~ 10
~ 1/3 of pts will be less than age 18…
(based on ABC numbers)
* Should lead to ~ 350
actual admissions per yr.
~ 235 adults/yr.
~ 115 kids/yr.
UNM Hospital: Burn Admissions
ICD9 Codes
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2000:
2001:
2002:
2003:
2004:
2005:
2006:
406
361
360
395
399
354
359
Actual Admissions
~ 200
~ 160
~ 160
~ 190
~ 200
~ 150
~ 160
Anatomy of skin
Epidermis
basement
membrane
Dermis
Subcutaneous
layer
The skin is made up of two layers, the outer layer (epidermis) and inner layer (dermis).
Between the epidermis and dermis is the basement membrane which is semi permeable
and acellular. It provides support, flexibility and regulates the transfer of substances across
the dermal-epidermal junction.
Under the skin is the subcutaneous layer which allows the skin to be loosely attached to
the underlying fascia. It increases mobility and is especially important over joints.
Local effects of burn injury
Local effects:
– Cell death/disturbed function
– Release of inflammatory mediators
– Increased capillary permeability
– Microvascular thrombosis
Due to differences in skin thickness with age, at 55C,
severe damage occurs after 10 seconds in a child and
30 seconds in an adult.
Skin thickness is also reduced in older people and in
certain conditions (e.g. steroid therapy).
Cell Death… the zones
Local effects (cont.)
Zone of Hyperemia
Zone of Stasis
RISK FACTORS FOR WOUND CONVERSION
LOCAL
Impaired Blood Flow
Zone of Coagulation
increased inflammation
(infection, open wound, irritants)
surface desiccation
SYSTEMIC
Septicemia
hypovolemia
excess catabolism
surface exudate buildup
chronic illness
mechanical trauma
(dressing changes, shearing)
hyperglycemia
chemical trauma - topical agents
--
from tragedy… hope!
Local effects (cont.)
Increased capillary permeability
When capillaries are damaged, they leak protein-rich fluid which results in edema.
Normal skin; normal
capillary permeability
Burn wound edema with
increased capillary permeability
and protein leakage
Local effects (cont.)
Microvascular Thrombosis
Release of thrombogenic factors such as thromboxane, together with a hypovolemic state
cause sludging in the smallest blood vessels. This in turn leads to further tissue ischemia,
increased cell death and can cause extension of the depth and surface area of the burn.
Area of burn
increases due to
sludging in blood
vessels and
ischemia
Systemic effects of burn injury
When a burn is large (>20% of total body surface area), in addition to
the local response, there is also a systemic response
With large burns, the loss of
circulating blood volume will
Loss of
circulating
blood
Ischemia
rapidly lead to
HYPOVOLEMIC SHOCK,
unless resuscitation is started
Vascular
permeability
Vasoactive substances are released that act not just locally in the burned
tissue, but in non-burned tissue as well.
Assessing total burn surface area
(TBSA)
The area of this burn is about 8% of
total body surface area.
How much of the body
surface area is burnt?
a.
2%
b.
8%
c.
18%
d.
25%
e.
I have no idea what you are talking about
There are several ways to assess the size of a burn. They all consider the burnt area as
a percentage of the total body surface area and are supported by mapping the
burnt area on a diagram. In the next couple of slides, we will be looking at the
following methods of assessment:
1.
The rule of 9’s
2.
Lund and Browder charts
3.
Palm of hand
4.
Unburnt area
Assessing TBSA - Rule of Nines
This method divides the body into areas each of which
equates to 9% of the total body surface area:
• the whole of one arm (anterior and posterior surfaces
including the hand) is 9%, therefore 2 arms = 18%
• the entire head including face, scalp and neck is 9%
• anterior trunk is 18%
• posterior trunk including buttocks is 18%
• the whole lower limb (anterior and posterior surfaces,
including the thigh, leg and foot) is 18%; therefore both lower
limbs = 36%.
This totals 99% with the perineum making the final 1%.
Assessing TBSA in children
Why might the “rule of 9’s”
be unreliable in children?
Body proportions change with age. In a child, the
head represents a much greater proportion of the
total body surface area.
Assessing TBSA - Palm size
Another useful way, especially for small
burns is to use the palm of the patient’s
hand (with fingers extended).
This equates to approximately 1% of
the body surface area.
In very large burns, it is often easier to
measure the area of skin that is not
burned and then subtract this from 100%.
Depth of burn
The depth of a burn determines its treatment and how long it takes to heal.
For this reason, it is important to be able to assess the depth as:
 Superficial………………………………………….
“1st Degree”
 Partial thickness…………………………………..
“2nd Degree”
• Superficial partial thickness
• Deep partial thickness
 Full thickness……………………………………...
“3rd Degree”
Depth of burn - Superficial (erythema)
Involves epidermis only:
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Painful
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Red
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No blistering
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Heals rapidly (reversible injury)
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No permanent scars
Erythema is NOT included when assessing TBSA!
Depth of Burn – superficial partial thickness
Typical hot water scald
Involves epidermis and upper dermis:
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Red
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Blistering, moist
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Painful
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Heals by epithelialization
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Healing complete within 14 days
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Minimal or no permanent scars
but can leave discolouration
Patches of skin
that would come
off on cleaning
Glistening moist
red/pink
appearance typical
of superficial injury
Depth of Burn - superficial partial thickness
Pin-point
bleeding
Pink surface;
blanches on pressure
Blister
from tragedy… hope!
Depth of Burn – deep partial thickness
Involves epidermis, upper dermis and varying
degrees of lower dermis:
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Pale, mottled appearance
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Fixed staining (no blanching)
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May be painful or insensate (depending
on depth)
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Heals by combination of epithilialization
and wound contracture
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May take weeks to heal
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Can leave significant scars and
contractures over joints depending on
time taken to heal
Deep dermal area, reddish with fixed staining
Depth of Burn – full thickness
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Involves all of epidermis and all of dermis
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Dry, leathery (white, dark brown or charred)
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Insensate
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Heals by contraction
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Delayed healing
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Hypertrophic or keloid scars
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Leads to contractures
Dry, leathery, charred
appearance of a full
thickness burn
Circumferential full thickness burn
Black, charred skin
Typical position of hand in full
thickness burns with
metacarpophalangeal joints
extended and interphalangeal
joints flexed
Depth of Burn – mixed thickness
(A)
Assess the depth
of the burn in
areas A, B and C
(B)
(C)
Depth of Burn – Mixed thickness
Full thickness,
dry white
leathery
appearance
Superficial partial
thickness showing
pink blanching
Deep dermal with pale pink and
white patches, non blanching
Classifying the patient…
* First you should assess the severity of the burn injury according to
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TBSA
depth
position
presence of infection
time since the burn
presence or absence of inhalation injury
* Combine this information with patient factors:
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age
associated injuries
other medical problems
nutritional status
* Finally consider social and family factors to classify the patient according
to how and where to provide treatment.
Remember…
• All Burn Patients are “Trauma Patients”, first!
• Airway… Breathing… Circulation
• FLUIDS – FLUIDS – FLUIDS
– Up to a point!........................How much fluid should be given?
– Pain Control!!
– Dressings: keep the wounds clean & dry!
– Transfer to the UNM Burn Center (criteria)
Remember the
Tetanus Shot!
Fluids… a guide
• Classic Parkland Formula
4cc per % TBSA BURNED per Kg
½ given over the first 8 hrs
Remaining ½ given over the next 16 hrs
Type of Fluid: LR
Inhalation Injury: INCREASE Rate to 6cc per % per kg!
ABA Transfer Criteria
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1. Partial thickness burns greater than 10 % total body surface area (TBSA)
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2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
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3. Third-degree burns of any size and any age group
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4. Electrical burns, including lightning injury
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5. Chemical burns
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6. Inhalation injury
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7. Burn injury in patients with preexisting medical disorders that could complicate management,
prolong recovery, or affect mortality
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8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses
the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate
risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.
Physician judgment will be necessary in such situations and should be in concert with the regional
medical control plan and triage protocols
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9. Burned children in hospitals without qualified personnel or equipment for the care of children
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10. Burn injury in patients who will require special social, emotional and/or long-term rehabilitative
interventions.
Questions…
one child burned, is one child too many!
Bradley J. Phillips, MD
UNM Burn Center
Adults & Pediatrics
from tragedy… hope!
The New Mexico Burn Corps
Call 1-888-UNM-PALS
to join our TEAM!
We need active VOLUNTEERS from all ages to help
us meet the needs of New Mexico!
Bradley J. Phillips, MD
[email protected]