1. Christopher P. Brandt M.D. Associate Professor of Surgery Case Western Reserve University BURNS Initial Evaluation & Management

2. Joseph B.  Your patient is brought to the E.D. by the EMS service.  He is a 14 year-old male who was involved in a house fire

3. History What other points of history do you want to know? What other points of history do you want to know?

4. History, Joseph B.  Neighbors heard an explosion  Patient found confused, outside of the house  Cannot remember what occurred  Denies shortness of breath  Transport time of twenty minutes  PMH of ADHD  Tetanus – up to date

5. Physical Examination What would you look for? What would you look for?

6. Physical Examination  VS T=96.5 P=140 R=24 BP=90/60  Awake; No hoarseness or stridor  Soot in mouth  Clear breath sounds  Burns involving face, neck, trunk, arms and upper legs (see photos)  Doppler pulses in all extremities

9. Physical Examination  How do you determine the extent and depth of the burn injuries?  What findings suggest inhalation injury?

10. 1818 Extent of burn % total body surface area

11. Burn Depth  Color  Moistness  Capillary refill/Blanching  Sensation  Blistering

12. Superficial Second Degree Deeper second degree Third Degree

13. Inhalation injury  Occurred in closed space  Cough, dyspnea, wheezing, hoarseness, stridor  Facial burns / Singed facial hair  Carbonaceous sputum  Hypoxia Indicators

14. Labs What would you obtain? What would you obtain?

15. Lab Results  CBC - WBC-12.0 Hct-49%  Electrolytes -Na-147 Cl-100 K-4.5 BUN-12  ABG - 7.31/35/125 on 50%VM  Carboxyhemoglobin- 21%  Tox. Screen - Negative  U/A - Normal

16. Interventions at this point?

17. ­Assess airway; Intubation ? ­Oxygen ­Fluid resuscitation ­Foley Catheter ­NG tube ­Wound care ­Pain medication

18. Interventions ­Why is fluid resuscitation important? ­How do you estimate fluid requirements? ­How do you monitor response to initial fluid therapy? ­What complications can occur from over- or under- resuscitation?

19. Fluid Management ­Edema formation  Systemic inflammatory response  Capillary leak/ Increased vascular permeability  Loss of skin barrier ­Zones of injury ­Parkland formula  Crystalloid 4 x %TBSA x wt (kg)  ½ of total in first eight hours  Goal of ½ - 1 cc/kg/hr U.O.

20. Studies What further studies/tests would you want at this time? What further studies/tests would you want at this time?

21. Studies  CXR – Basilar atelectasis  EKG – Sinus tachycardia  ? Bronchoscopy

22. Management  Low urine output  Loss of Doppler signals in the hands  Inadequate ventilation with high airway pressures? What would you do in the following scenarios?

23. Management Escharotomy

24. Management  What are the principles of management of the inhalation injury?  What will be the basic strategies for management of the burn wounds?

25. Questions?

26. Acknowledgment ASSOCIATION FOR SURGICAL EDUCATION The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials we welcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com