Presentation on theme: "CPT Allen Proulx, MPAS, PA-C"— Presentation transcript:
1CPT Allen Proulx, MPAS, PA-C MANAGEMENT OF BURNSCPT Allen Proulx, MPAS, PA-C1
2OBJECTIVESDescribe 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.
3References for photos Advanced Burn Life Support Course, American Burn Association, 1994Textbook of Military Medicine, Part I, Vol 5Conventional Warfare, OTSG, 1991Textbook of Surgery, Sabiston, editorW. B. Saunders, 1986SESAP VI,American College of Surgeons, 1988Burn care product info
4Depth of burn Partial thickness burn = involves epidermis Deep partial thickness =involves dermisFull thickness =involves all of skin
5Partial 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 scaringTopical creams provide relief.No need for antibiotics
6Deeper partial thickness Blisters are typical of partial thickness burns.Don’t be in a hurry to break the blisters.Heals in daysBlisters provide biologic dressing and comfort.Once blisters break, red raw surface will be very painful.
7Full thickness burn 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.
8Mixed 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.
9Zones of Burn Wounds Zone of Coagulation devitalized, necrotic, white, no circulationZone of Stasis ‘circulation sluggish’may covert to full thickness, mottled redZone of Hyperemiaouter rim, good blood flow, red
10Wound excision until fine punctate bleeding occurs
11Estimate the size of the burn The patient’s own palm is about 1% of his body surface area.“Rule of Nines”
13American Burn Assoc says send these to a burn center Partial thickness burns >10% BSABurns involving the face, hands, feet, genitalia, perineum, or major jointsfull thickness/3 degree burnElectrical, Chemical, and Inhalation burnsIn combat, all but the most superficial burn should be evacuatedNew ABA criteria dated Dec 2004
14Burn care products< 20% TBSA 2nd degree – Silvadene (SVC) Cream BIDAny > 20% TBSA-SVC and Sulfamylon (SMC) alt BID3rd degree burn – SVC and SMC alt BID*SMC only to the ears * Bacitracin Opth to faceS. Aureus, E.coli, Klebsiella,Pseudomonus, Proteus, and Candida
16Care 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.
17BlistersIn 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.
18Blisters break on their own Upper arm burn day day 2Burn “looks worse” the next day because of blisters breaking and oozing
19Upper arm burn Blisters show probable partial thickness burn. 121Blisters show probable partial thickness burn.Area without blister might be deeper partial thickness.
20Debride blister using simple instruments Pull off the blisters using simple instruments.Even a suture removal set can be used.Only the edges of the blister will be painful.
21Medic debriding blister Medic has no particular training other than bedside coaching by the surgeon.Simple instruments are used.Patient is in no distress.
27Foot burn debridement Before debriding and applying cream, clean entire foot(includingtoes and nails).
28Silver- impregnated dressings (Silverlon) Apply wet silver dressingdirectly on the burn.Creams or dressingsunder the silver dressingimpede the antimicrobial action.Keep it moist!Remove it, rinse it out, replace it on the burn.
29Steps in using silver-impregnated dressings Clean the burn and surrounding area.Soak silver-impregnated dressing and gauze inSTERILE WATER or BOTTLED DRINKING WATERApply 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
30pics Soak silver dressings and gauze in WATER (not saline). Apply the Wrap with moist gauze.Secure with mesh, gauze, or tape.
31First 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.
32pics Moisten with WATER q12h or so. Moisten well to remove it each day.Rinse it out, and put it back on the burn.Make more frequent in hot, arid environment
33After several days every 2 - 5 days Replace silver dressingevery daysdepending on amount of exudate, cellular debrisFirst 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.
34QUESTIONS ABOUT SMALL BURNS? SUMMARYDescribe 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
35Burns of special areas of the body FaceMouthNeckHands and feetGenitalia
36Face 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
37Hands 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.
38Hands and feet Allow use of the hands in dressings by day. Splint in functional position by night.Keep elevated to reduce swelling.
39Hands and feetFingers might develop contractures if active measures are not taken to prevent them.
40Genitalia Shower daily, rinse off old cream, apply new cream. Insert Foley catheter if unable to urinate due to swelling.
42Causes of death in burn patients AirwayFacial edema, and/or airway edemaBreathingToxic inhalation (CO, +/- CN)Respiratory failure due to smoke injury or ARDS
43Edema FormationAmount of edema can be immense (even without facial burns)Depression of mental status can worsen problemEdema peaks at 12 to 24 hoursPediatric patients even more concerning
44Causes of death in burn patients Circulation: “failure of resuscitation”Cardiovascular collapse, or acute MIAcute renal failureOther end organ failureMissed non-thermal injury
45Patients with larger burns First assessCBA’s“Disability” (brief neuro exam)ExposeLaterExamine rest of patientCalculate IV fluidsTreat burn
46Airway?“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.
47Circulation Keep him warm! 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/hrMonitor at least HCT and urine specific gravity.When available, monitor electrolytes.
48Neuro status hypovolemia carbon monoxide head injury The burn itself does not alter the level of consciousness.If patient is not alert, think of other causes:hypovolemiacarbon monoxidehead injuryDon’t allow swollen eyelids to prevent you from examining the pupils.Test sensation and motion in burned extremities.
49Expose 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:blanketsheating lampsbed framelarge box covered with blankets
50Head to toe exam Obtain history and examine rest of body. Ask about allergies, meds, medical conditions.Look for other injuries.
51Calculate fluid requirements wt in kg x % burn x cc / kg / %100 kg patient with 50% TBSA burn:100 x x = 10,000cc = 10 liters RLThis 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
52Calculate fluid requirements Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initiallyHow do we know if this is too much fluid, or too little?Monitor at least:urine output - in adults, around 50 cc / hrDecreasing urine output = need for more fluids.
53Burn size in small children The head accounts for about 18% (instead of 9%).The legs account for about 13% (instead of 18%).
54Fluid 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 fluids20 kg - about 60 cc / hr30 kg - about 70 cc / hrExpected urine output for child: 1 cc / kg /hrfor infant: 2 cc/ kg / hr
55Fluids requirements in children 20 kg child with 30% burn:20 (kg) x 30(%) x 2 (cc/kg/%) = cc in 24 hrHalf of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially75 cc / hr for burn loss + normal 60 cc / hr maintenance =135 cc / hr initiallyHow do you know if the patient is getting too much fluid,or too little?Check urine output, urine specific gravity, HCT
56Be 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.
58Circumferential 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 tissuePressure inside limb gradually increases.Eventually, pressure inside limb exceeds arterial pressure.This requires escharotomy to relieve the pressure.
59Escharotomy - 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.
60Escharotomy - complications Bleeding: might require ligation of superficial veinsInjury to other structures: arteries, nerves, tendonsNOT 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.
61Escharotomy Eschar = burned skin Escharotomy = cut burned skin to relieve underlying pressureSimilar to bivalving a tight cast.Cut along inside and outside of limb from good skin to good skinKnife can be used, or cautery.Use local or no anesthesia.(Full-thickness burn should have no sensation, but underlying tissues do!)
62Escharotomy of forearm Incise along medial and/or lateral surfaces.Avoid bony prominences.Avoid tendons, nerves, major vessels.
63Escharotomy Patient had escharotomy of both legs. Incisions will heal. They will not be closed by DPC.These large burns are oftentreated by the “open” technique,that is, without dressings.
64Electrical burn Outer skin might not appear too bad. But heat was conductedalong the bone.Causes the most damage.Burns from inside out.Usually requires fasciotomy
65Fasciotomy 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.
66PhosphorusParticles of phosphorus must be removed from under the skin.Pick them off with forceps.Must apply wet dressing to prevent re-igniting.
67QUESTIONS? SUMMARYDescribe 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.
68BURN DOWN & DIRTY Educate your Task Force! proper technique for burning waste, wear of clothingDo 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 ?