CPT Allen Proulx, MPAS, PA-C MANAGEMENT OF BURNS CPT Allen Proulx, MPAS, PA-C 1

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 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 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 New ABA criteria dated Dec 2004

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 S. Aureus, E.coli, Klebsiella,Pseudomonus, Proteus, and Candida

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 Blisters show probable partial thickness burn. 121 Blisters show probable partial thickness burn. Area without blister might be deeper partial thickness.

Debride 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.

Medic debriding blister Medic has no particular training other than bedside coaching by the surgeon. Simple instruments are used. Patient is in no distress.

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 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 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

After several days every 2 - 5 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 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 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/hr Monitor at least HCT and urine specific gravity. When available, monitor electrolytes.

Neuro 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: 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 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 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 re-igniting.

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 ?