1. Initial Burn Care Lee D. Faucher, MD FACS Director UW Burn Center Professor of Surgery & Pediatrics

2. Objectives Burn Care: From where we came Initial Burn Patient Evaluation Pediatric Considerations Burn Center Definition

3. Objectives Burn Care: From where we came Initial Burn Patient Evaluation Pediatric Considerations Burn Center Definition

4. September 11, 2001 8:20am –American Airlines Flight 77 Departed Washington Dulles at 8:20am –58 passengers, crew of 6 9:38am –A 757-200 crashes into the Pentagon

5. Washington Hospital Center Located in Northwest DC –Areas largest trauma center and regional burn center

6. Code Orange: This is not a drill! Medical response –8 trauma surgeons –6 trauma residents –7 intensivists and their teams –All others Anesthesia, lab, blood bank, radiology, RT, security

7. Patients begin to arrive 3 patients in first 30 minutes –1 smoke only, 2 burns Then all air traffic grounded –4 more by ground

8. Patient Admissions Patient #Gender% TBSAArrival 1F0<1 hour 2F21<1 hour 3M22<1 hour 4F66<1 hour 5M49<1 hour 6F68<1 hour 7M417 hours 8M4210 hours 9M3228 hours 10M 31 hours

9. Post-Burn Weeks

10. Products consumed IV Fluids141 Liters Silvadene cream950 Jars Burn Dressing Gauze2006 packs 4X4 gauze18,490 Kerlix gauze3108 rolls Ace Bandages2111 Allograft26,700 sq cm Synthetic “skin”30,365 sq cm Autograft22,087 sq cm PRBCs269 units

11. Outcomes Patient #Gender% TBSA Age + TBSA Mortality Risk Outcome 1F032N/ASurvived 2F217411Survived 3M22614Survived 4F6611562Survived 5M4910041Survived 6F6810944Died 7M418015Survived 8M42719Survived 9M32631Survived 10M 8223Survived

12. Final numbers 189 deaths –125 in Pentagon –64 on Flight 77 106 injured –50 admitted to 9 area hospitals –9 serious burns

13. Objectives Burn Care: From where we came Initial Burn Patient Evaluation Pediatric Considerations Burn Center Definition

14. Medics Airway Assess for other injuries Start IV with LR, in burn OK –< 6 years = 125mL/hr – 6-13 years = 250mL/hr – >13 years = 500mL/hr 100% O 2 if closed space fire Transport to closest hospital

15. History Source of burn Enclosed space –Signs of smoke inhalation Circumstances surrounding injury Previous medical problems First-aid done

16. Reduction of CO

17. Medics - Electrical Do not become victim –Turn off power Initiate CPR –If < 1000 volt, ventricular fibrillation –If > 1000 volt, cardiac standstill and respiratory paralysis

18. Medics - Chemical Remove involved clothing Flush with water Flush with more water Then flush with more water When you think you are done, flush with more water NO NEUTRALIZATION

19. Cold DOES NOT –Reverse temperature –Inhibit destruction –Prevent edema DOES –Delay edema –Reduce pain

20. Case presentation EMS responds with Fire to structure fire with reported trapped occupants On arrival, see two bystanders dragging person out the front door.

21. Medic evaluation Airway –Moving air, moaning, unresponsive, entire head, face, neck, and chest burned

22. Medic evaluation Breathing –Equal bilateral breath sounds Circulation –Palpable distal pulses

23. Medic evaluation What else should be done at the scene? Where should this patient be taken?

24. Medic Report to ED 47 y/o male, extricated from structure fire, burns over head, chest, back, bilateral upper extremities and legs, intubated with one peripheral IV in place running LR at 500mL/hr Vitals: HR 130, BP 150/90, Sat 100%

25. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

26. Smoke inhalation assessment Flame burns Enclosed space Burns to face, mucosal membranes Singed eyelashes, nasal hairs Carbonaceous sputum

27. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

28. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

29. Rule of Nines

30. Lund and Browder Chart

31. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

32. IV access < 15% TBSA – oral resuscitation 15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s IV’s should be in the upper extremities Suture IV’s started through burns

33. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

34. Crystalloid solution Ringer’s Lactate –[Na + ] 130 mEq (serum 140 mEq) –Osmolality 272 mOsm (serum 300mOsm) Advantages of crystalloid –Effective in maintaining perfusion –Costs less than colloids –Can be mobilized with a diuretic

35. Resuscitation first 24 hours Baxter formula –4 mL/kg/% TBSA burned Give ½ the volume in first 8 hours and other ½ over next 16 hours.

36. If < 20kg Same Baxter formula for LR Add 4mL/kg of D5 ¼ NS –Infuse at constant rate, increase LR if needed for adequate urine output

37. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output Keep patient warm

38. Monitor urine output Place foley if > 20% TBSA Urine output goal –2 mL/kg/hr very young –1 mL/kg/hr child –0.5 mL/kg/hr adult Diuretics are NEVER used to increase urine output Increase urine output to > 100mL/hr if pigment present

39. Emergency room treatment Assess airway/breathing Ensure source of heat removed Estimate % TBSA Obtain/ensure adequate IV access Initiate/continue resuscitation Closely monitor urine output KEEP PATIENT WARM!!!!!

40. Next priorities Insert NG tube Escharotomies Medications Wound care

41. Next priorities Insert NG tube Escharotomies Medications Wound care

42. Escharotomies Only for leathery, circumferential, full-thickness burns Rarely needed in transport < 12 hours Almost always done at the Burn Center Emergent indications: –Unable to ventilate –Pulseless, painful extremity

44. Escharotomy pic

45. Next priorities Insert NG tube Escharotomies Medications Wound care

46. Medications Pain control More pain control Tetanus immunization NEVER need antibiotics

47. Next priorities Insert NG tube Escharotomies Medications Wound care

48. Debridement and topical application is usually done after transfer Can cover with plastic wrap Transport patient in DRY sheet and blanket If transport delayed > 12 hours, –Debride loose tissue and clean with mild soap and water –Apply Silver Sulfadiazine and wrap loosely

49. Resuscitation 24 - 48 hours Continue maintenance fluids, watch serum Na+ May use albumin or plasma for volume –Infuse 5 – 10mL/kg as needed Maintain adequate urine output

50. Objectives Burn Care: From where we came Initial Burn Patient Evaluation Pediatric consideration Burn Center Definition

51. Burn Etiology ABA National Burn Repository, 2012 Report

52. UWHC Admissions <18 years

53. Admissions to Burn Centers ABA National Burn Repository, 2012 Report

54. Overall Burns and Mortality ABA National Burn Repository, 2012 Report

55. Overall Mortality and TBSA ABA National Burn Repository, 2012 Report

56. Where Childhood Burns Occur ABA National Burn Repository, 2012 Report

57. A kid with a small burn

58. Why we do this An acute burn may not be completely blistered Can’t do wound care in clinic Sedation easier when adequate pain control

59. Appropriate wound care

60. What is Mepilex Ag Silicone Foam Silver

66. Then what do we do Dressing changed every 3 to 5 days Our length of stay drastically reduced Still same number of surgical procedures

67. Objectives Burn Care: From where we came Initial Burn Patient Evaluation Pediatric Considerations Burn Center Definition

68. Burn Center Referral All children Any burn > 10% TBSA Any full-thickness burn Burns to hands, face, feet or perineum Any Electrical or Chemical burns Other associated injuries, medical problems, or inhalation injury Systemic disease Excerpted from Guidelines for the Operations of Burn Units (pp. 55-62), Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons

69. Outpatients Do Not include Special locations Extremes of age Associated injuries Previous medical problems Unusual etiologies –Some chemical, some electrical Unstable social situations

70. Nurses Residents Physiatrists Pediatricians Burn Surgeons Nurse Practitioner Physical therapists Physician Assistant Child Life therapists Health psychologists Respiratory therapists Recreational therapists Occupational therapists Social Worker Pharmacists Nutritionists Administrators