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

Objectives Discuss burn pathophysiology Outline treatment modalities Understand why some treatments better than others

What is a burn? Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation.

First Degree Burns Epidermis only No blisters Erythema Mild to absent systemic response Heals in 3-4 days

Superficial partial thickness Papillary dermis Blisters Homogenous pink Painful, hypersensitive Blanches Hair usually intact Does not scar, may pigment differently

Sup 2nd degree

Deep partial thickness Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft

Deep dermal

Full thickness burns Into fat or deeper Red, white, brown, black, etc. Diminished sensation Dry, may be leathery Depressed Heals only from the periphery Always excise and graft

Full-thickness

Etiology

Types of burns

Where do burns occur

Circumstances of injury

Admissions by age

% of admissions vs. burn size

Inhalation injury diagnosis Closed-space fire Face burns

Terminology Inhalation injury “nonspecific” –Thermal injury Upper airway –Local chemical irritation Throughout airway –Systemic toxicity CO

Clinical diagnosis History and physical –Exposure –Duration –Enclosed space Diagnostic studies

Other signs and symptoms Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing Conjunctivitis Carbonaceous sputum Singed hairs Stridor Bronchorrhea

Poison management = CO 500 unintentional deaths each year Persistent Neurologic Sequelae –May improve over time Delayed Neurologic Sequelae –Relapse later

Poison management = CO Treatment –CO level means nothing to predict outcome –Length of hypoxia is the determining factor –Oxygen –HBO No studies show benefit in treatment

Pathophysiology The main factor responsible for mortality in thermally injured patients Carbon monoxide the most common toxin –200 times greater affinity –Competitive inhibition with cytochrome P- 450

Reduction of CO

Objective data Bronchoscopy –Edema –Infraglottic soot –Hyperemia –Mucosal sloughing Sensitivity near 100% under IDEAL circumstances

Grading of injury No reliable indicators of progressive respiratory failures No studies have found any correlation with initial findings and clinical outcomes and progress

Resuscitation

Field resuscitation Start IV with LR, in burn OK –< 6 years = 125mL/hr – 6-13 years = 250mL/hr – >13 years = 500mL/hr

Rule of Nines

Lund and Browder Chart

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

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

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.

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

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

How to do this Maintain continuous IV fluid replacements AVOID boluses Only bolus IV fluids if hypotensive

Zones of burn injury

Pain control

Non-medication methods Cover burns with plastic wrap –Wet dressings will stick and cause more pain –Other burn dressings are expensive and not necessary –Quik Clot is expensive and will not provide any patient benefit

Ice Pack-----DO NOT USE EVER DOES NOT –Reverse temperature –Inhibit destruction –Prevent edema DOES –Delay edema –Reduce pain

Medication Medications –Opioids –Narcotics –Pain medications –IV Analgesia

Summary Airway Circulation/Resuscitation Pain control

Questions?