1. Burns… Back to Basics 2009 Dr. Jennifer Clow, CCFP (EM)

2. Case: 45 y. o. male, working in shed 45 y. o. male, working in shed Wood-burning stove for heat… Wood-burning stove for heat… –Thinks stove is cold – adds more wood, then pours lighter fluid on top –Stove explodes Patient and shed on fire!!! Patient and shed on fire!!! Brought in by paramedics to your ER… Brought in by paramedics to your ER…

3. Case, cont’d What do you want to do??? What do you want to do??? –Airway –Breathing –Circulation –Disability –Exposure What other information do you need? What other information do you need?

4. Case, cont’d History… History… –Wood-burning stove –Door open at time of exposure –Flash caught patient’s clothing on fire –Patient ran from burning shed immediately –No toxic chemicals in shed PMHx PMHx Meds/Social Meds/Social

5. Case, cont’d Physical Examination Physical Examination –Hemodynamic stability? –Depth and extent of burns – TBSA? –Any facial burns? –Signs of inhalational injury? –Circumferential burns? –Any associated traumatic injuries? –Signs of poisoning

6. The info…

7. Causes of burns… Thermal – flame, flash, contact, scald Thermal – flame, flash, contact, scald Electrical – high/low voltage, lightning Electrical – high/low voltage, lightning Chemical – acid, alkali Chemical – acid, alkali Radiation – UV, therapeutic Radiation – UV, therapeutic

8. Clinical Evaluation of Burns Clinical Evaluation of Burns

9. Burn Depth 1 st degree – just epidermis 1 st degree – just epidermis 2 nd degree – dermis 2 nd degree – dermis –Superficial –Deep 3 rd degree – full thickness 3 rd degree – full thickness 4 th degree – involves muscles, bones, deep organs 4 th degree – involves muscles, bones, deep organs

10. Burn depth…. Figure 43-3. Layers of the skin, showing depth of first-, second-, and third- degree burns. (Reproduced, with permission, from Way LW [editor]: Current Surgical Diagnosis & Treatment, 9th ed. Appleton & Lange, 1991.)

11. First degree Skin is red, tender, dry Skin is red, tender, dry No blister formation No blister formation e.g. sunburn e.g. sunburn Usually heals within 7-10 days Usually heals within 7-10 days Does not scar Does not scar

12. First Degree Burn

13. Second Degree Superficial Partial Thickness Superficial Partial Thickness –Blisters, very painful –Dermis exposed – red, moist, good capillary refill –Heals within 2-3 weeks –Minimal scar formation

14. Second Degree Burn

16. Second Degree, cont’d Deep Partial Thickness Deep Partial Thickness –Skin is white/yellow –Minimal pain – difficult to differentiate from third degree by inspection –Cap. Refill, pain sensation absent –Pressure felt, 2 point discrimination decreased –Healing takes 1-3 months –Usually scars, may need grafting

17. Third Degree Full thickness of skin (epidermis, dermis and subcutaneous tissue) Full thickness of skin (epidermis, dermis and subcutaneous tissue) Skin white or black, may be charred Skin white or black, may be charred No dermal elements remain, therefore will not heal independently – require surgical intervention and skin grafts No dermal elements remain, therefore will not heal independently – require surgical intervention and skin grafts Significant scarring Significant scarring

18. Third Degree Burn

20. Fourth Degree Extends through skin and subcutaneous tissue to involve muscle, bones, tendons or deeper tissues Extends through skin and subcutaneous tissue to involve muscle, bones, tendons or deeper tissues Requires extensive surgical repair Requires extensive surgical repair May necessitate amputation May necessitate amputation

21. Fourth Degree Burn

22. Burn Depth… Comparison Table 43-5. Characteristics of burns of different depth. Depth of BurnAppearanceSkin TextureCapillary Refill SensationHealing First-degreeSuperficial epidermisRedNormalYes 5-10 days; no scar Second-degreeSuperficial partial- thickness Red; may be blistered EdematousYes 10-21 days; no or minimal scar Deep partial-thicknessPink to whiteThickPossibly 25-60 days; dense scar Third-degreeFull-thicknessWhite, black, or brown LeatheryNo No spontaneous healing Fourth-degreeInvolves underlying subcutaneous tissue, tendon, or bone Variable No No spontaneous healing

23. TBSA??? Total Body Surface Area Total Body Surface Area Only applies to area with second and third degree burns Only applies to area with second and third degree burns “Rule of Nines” “Rule of Nines” May use palm of patient’s hand to signify 1% TBSA May use palm of patient’s hand to signify 1% TBSA

24. Rule of Nines…

25. Rule of Nines Table 43-4. Rule of nines (rapid means of estimating body surface area burned in adult patients) and rule of lives (rapid means of estimating body surface area burned in infants and children.) Percentage AreaAdultInfantChild Head and neck92015 Arm Right910 Left910 Torso Front1820 Back1820 Leg Right181015 Left181015 Genitalia and perineum1... Total100 = 100

26. Adults vs. Children

27. Inhalational Injury?? Signs of Inhalational Injury Signs of Inhalational Injury –Singed nasal hairs, soot around nares –Carbonaceous sputum, cough –Hoarse voice, stridor, respiratory distress –Carboxyhemoglobin > 10% Risk Factors Risk Factors –Burns sustained in a confined space –Flash burns, burns to face

28. Inhalational Injury… Mechanism Mechanism –Injury occurs due to heat exposure, chemical inhalation, particulate matter Injury Injury –Upper airway edema –Bronchospasm –Pulmonary edema

29. Tests ECG ECG CXR, other imaging as indicated CXR, other imaging as indicated CBC, electrolyes, glucose, renal fcn CBC, electrolyes, glucose, renal fcn ABG, carboxyhemoglobin ABG, carboxyhemoglobin ?tetanus status ?tetanus status

30. Management…

31. Minor Burns…

32. Treatment Includes all 1 st degree, and many superficial 2 nd degree burns Includes all 1 st degree, and many superficial 2 nd degree burns Can usually be managed as outpatients Can usually be managed as outpatients May or may not require specialized follow- up, or GP care May or may not require specialized follow- up, or GP care Many patients need significant reassurance Many patients need significant reassurance Ensure patients have a safe place to stay Ensure patients have a safe place to stay

33. Treatment Cooling Cooling Cleaning – mild antiseptic solution, or soap and water; limit rubbing Cleaning – mild antiseptic solution, or soap and water; limit rubbing Debride blisters if large, or over joints Debride blisters if large, or over joints Topical antibiotics Topical antibiotics Sterile dressings Sterile dressings Analgesia Analgesia

34. Major Burns…

35. ABC’s!!! Airway Airway –Intubate if any signs of airway injury, if significant TBSA burns, if altered LOC Breathing Breathing –100% O2 –Monitor SpO2, respiratory rate, WOB –Intubate Early!!!

36. ABC’s cont’d Circulation… Circulation… –2 large bore IVs –FLUIDS, FLUIDS, FLUIDS… –Parkland Formula Disability, Exposure Disability, Exposure –Cut off all clothing; may need soaking off –Evaluate other injuries

37. Parkland Formula Ringers lactate Ringers lactate 4 ml/kg/%TBSA over 24 hours 4 ml/kg/%TBSA over 24 hours –Half in 1 st 8 hours –Half in next 16 hours Titrate to urine output, BP, HR Titrate to urine output, BP, HR May need 40+ liters of fluid May need 40+ liters of fluid

38. Other Management Foley catheter Foley catheter Nasogastric tube Nasogastric tube Tetanus prophylaxis Tetanus prophylaxis Remove jewelry Remove jewelry Antibiotics Antibiotics Wound care Wound care Control pain – narcotics, amnestics Control pain – narcotics, amnestics

39. Special Situations Circumferential Burns Circumferential Burns –May need escharotomy, especially on neck, trunk, limbs Inhalational Injury Inhalational Injury –Require intubation, 100% O2 –May need hyperbaric oxygen Ocular Injury Ocular Injury –Need urgent ophthalmologic evaluation

40. Assessment of Severity Table 43-2. Determinants of burn severity. Burn size Burn depth Burn site Presence of circumferential burns Inhalation injury Electrical injury Age of patient Associated injuries Major underlying medical problems

41. Assessment of Severity… Table 43-3. Summary of American Burn Association burn severity categorization. Major burn injury Second-degree burn of > 25% body surface area in adults Second-degree burn of > 20% body surface area in children Third-degree burn of > 10% body surface area Most burns involving hands, face, eyes, ears, feet, or perineum Most patients with the following: Inhalation injury Electrical injury Burn injury complicated by other major trauma Poor-risk patients with burns Moderate uncomplicated burn injury Second-degree burn of 15-25% body surface area in adults Second-degree burn of 10-20% body surface area in children Third-degree burn of < 10% body surface area Minor burn injury Second-degree burn of < 15% body surface area in adults Second-degree burn of < 10% body surface area in children Third-degree burn of < 2% body surface area

42. Transfer to Burn Center? All “Major” Burns All “Major” Burns Any burn patients with associated major trauma Any burn patients with associated major trauma Suspected child abuse Suspected child abuse Anyone requiring surgical interventions Anyone requiring surgical interventions

43. Back to the case… 2 nd and 3 rd degree burns 2 nd and 3 rd degree burns –Chest and abdomen, full back –Both arms, hands –Anterior legs –Half of face ??TBSA ??TBSA

44. Rule of Nines…

45. Back to the case… Vitals Vitals –BP 170/100 –HR 130 –SpO2 – cannot obtain due to burned fingers –RR 30 –Temp 36 orally

46. Back to the case… Singed nasal hairs Singed nasal hairs Soot in mouth Soot in mouth Coughing Coughing Talking normally Talking normally Complains of severe pain over entire body Complains of severe pain over entire body

47. Back to the case… Now what?????? Now what?????? Sedate and intubate Sedate and intubate Keep sedated Keep sedated Foley, NG Foley, NG BIG IVs BIG IVs How much fluid??? How much fluid???

48. Back to the case… Parkland formula Parkland formula –Approximately 70% TBSA –Patient weighs 80 kg –4 ml/kg/%TBSA = 4 x 80 x 70 = 22400 ml –i.e. more than 22 liters of fluid… 11 over first 8 hours, then 11 over next 16… –Titrate to urine output and vitals

49. Back to the case… Circumferential burns to chest, arms, fingers Circumferential burns to chest, arms, fingers –Requires escharotomy to ensure chest is able to expand, and to limit chances of losing fingers! Needs a burn center!!! Needs a burn center!!!

50. Escharotomy

51. Severe Burn Case