1. Burn Care in the 21 s t Century James H. Holmes IV, MD Director, WFUBMC Burn Center Assistant Professor of Surgery Wake Forest University School of Medicine

2. Epidemiology ~500,000 pts/yr seek medical care for burns~500,000 pts/yr seek medical care for burns 40,000 require hospital adm (avg <15% TBSA)40,000 require hospital adm (avg <15% TBSA) >90% preventable; ~50% d/t substance abuse>90% preventable; ~50% d/t substance abuse ~4000 die …... vs. ~15,000 deaths in 1970~4000 die …... vs. ~15,000 deaths in 1970 LD 50 > 70% TBSA …… vs. ~30% in 1970LD 50 > 70% TBSA …… vs. ~30% in 1970 >50% return to pre-burn functioning>50% return to pre-burn functioning Mechanism is age-related & situational:Mechanism is age-related & situational:  < 8 yoa  scalds  all others  flame burns  work  chemical/electrical/molten

3. Burn LD 50 & Advances in Care

4. A.B.A. Referral Guidelines PT burns > 10% TBSAPT burns > 10% TBSA Any FT burnsAny FT burns Burns involving the face, hands, feet, genitalia, perineum, or major jointsBurns involving the face, hands, feet, genitalia, perineum, or major joints Electrical burnsElectrical burns Chemical burnsChemical burns Inhalation injuryInhalation injury Burns with concomitant non-thermal traumaBurns with concomitant non-thermal trauma Burns in patients with preexisting medical conditions that may complicate managementBurns in patients with preexisting medical conditions that may complicate management Burns in patients who will require special social, emotional, or long-term rehabilitative interventionBurns in patients who will require special social, emotional, or long-term rehabilitative intervention

5. BURNS = TRAUMA Remember ABC’s (with a twist)

6. A irway & B reathing Inhalation Injury (~7% of patients in NBR)Inhalation Injury (~7% of patients in NBR)  HX: closed space fire, meth lab explosion, or petroleum product combustion  Upper airway injury: acute mortality  facial/intraoral burns, naso/oropharyngeal soot, sore throat, abnormal phonation, stridor  Lower airway injury: delayed mortality  dyspnea, wheezing, carbonaceous sputum,  COHb,  PaO2/FiO2  Will increase resuscitation volumes Clinical dx - NO NPL, bronchoscopy +/-Clinical dx - NO NPL, bronchoscopy +/- Intubate EARLY!!!  OrotrachealIntubate EARLY!!!  Orotracheal Surgical airway uncommonSurgical airway uncommon

7. C alculate burn size The “TWIST”The “TWIST” Burn depthBurn depth  Superficial  Partial-thickness (PT)  Full-thickness (FT)  Indeterminate Only partial-thickness (2 nd degree), indeterminate, & full-thickness (≥3 rd degree) injuries count towards %TBSAOnly partial-thickness (2 nd degree), indeterminate, & full-thickness (≥3 rd degree) injuries count towards %TBSA

8. Estimating Burn Depth/Severity

9. 3 Zones of Thermal Injury Coagulation Stasis Hyperemia

10. Burn Depth

11. “Superficial” Formerly “1st-degree” Essentially a sunburn Pink Painful NO blisters Will heal in < 1 week

12. “Partial-thickness” Formerly “2nd-degree” Pink Moist Exquisitely painful Blistered Typically heals in < 2-3 weeks

13. “Full-thickness” Formerly “3rd-degree” Dry Leathery White to charred Insensate Will require E&G

14. “Indeterminate” Unsure as to whether PT or FT Observe for conversion b/t days 3-7 May or may not require E&G Can unpredictably increase LOS

15. C alculate burn size Determine burn depthDetermine burn depth Only PT (2 nd degree), indeterminate, & FT (≥3 rd degree) countOnly PT (2 nd degree), indeterminate, & FT (≥3 rd degree) count Estimate %TBSAEstimate %TBSA  Palmar surface of pts hand = 1% TBSA  Age-appropriate diagrams (e.g.- Berkow)  Rule of Nines

16. Berkow Diagram

17. Rule of Nines Body divided into fractions of 9%  Head = 9%  Ant thorax = 18%  Post thorax = 18%  Each UE = 9%  Each LE = 18%  Genitalia = 1% Not reliable in kids!!!

18. C alculate burn size Determine burn depthDetermine burn depth Only PT (2 nd degree), indeterminate, & FT (≥3 rd degree) countOnly PT (2 nd degree), indeterminate, & FT (≥3 rd degree) count Estimate %TBSAEstimate %TBSA  Palmar surface of pts hand = 1% TBSA  Age-appropriate diagrams (e.g.-Berkow)  Rule of Nines Burn experience  accuracy in determining burn size & severityBurn experience  accuracy in determining burn size & severity

19. C irculation Typically burns  20% require IVF resuscitationTypically burns  20% require IVF resuscitation Resuscitate w/ LACTATED RINGER’SResuscitate w/ LACTATED RINGER’S  Adult  Baxter/Parkland Formula = 4 cc/kg/% burn  1/2 over 1st 8 hr from time of burn  1/2 over subsequent 16 hr  Child (<20 kg)  3 cc/kg/% burn + D 5 MIVF  Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids) Peripheral IV access -- NO cut-downsPeripheral IV access -- NO cut-downs Do NOT bolus !!!Do NOT bolus !!! NO normal saline!!!NO normal saline!!!

20. Resuscitation Fine Points More is NOT better!!! Crystalloid … NOT colloid & only LR Goal is normotensive, perfused, urinating pt. < 4 cc of LR /kg/%TBSA  central monitoring Escharotomies ACS is unacceptable!!!

21. D isability (from other injuries) Primary & secondary surveys are important!!!Primary & secondary surveys are important!!! R/O non-thermal trauma … ~5% have concomitant non-thermal injuryR/O non-thermal trauma … ~5% have concomitant non-thermal injury Management of non-thermal trauma typically supercedes burn management, except for the resuscitation.Management of non-thermal trauma typically supercedes burn management, except for the resuscitation.

22. E verything else No IV antibiotic prophylaxis!!!No IV antibiotic prophylaxis!!! Vascular access: PIV is preferableVascular access: PIV is preferable Analgesia = IV opiatesAnalgesia = IV opiates Conservative & judicious sedatives, prn onlyConservative & judicious sedatives, prn only Wood’s lamp eye exam for flash burns to faceWood’s lamp eye exam for flash burns to face EscharotomiesEscharotomies Early enteral nutrition (≥ 20% TBSA)Early enteral nutrition (≥ 20% TBSA)

23. Escharotomies

24. Indications Circumferential FT extremity burns with threatened distal tissueCircumferential FT extremity burns with threatened distal tissue  Diminished or absent distal pulses via doppler  Any S/S of compartment syndrome Circumferential FT thoracic burnCircumferential FT thoracic burn  Elevated PIP or P plateau  Worsening oxygenation or ventilation Nearly impossible to resuscitate patient with restrictive eschar needing releaseNearly impossible to resuscitate patient with restrictive eschar needing release Fasciotomies rarely neededFasciotomies rarely needed

25. Technique ANATOMIC POSITION!! Med & lat lines of extremities, over lumbricals on dorsal hands, ant or mid axillary lines on chest, & lateral neck lines Thru eschar only -- RELEASE Use cautery (knife OK) Not a sterile procedure Digits are controversial

26. After…

27. Initial Wound Management No IV antibiotics!!!No IV antibiotics!!! Analgesia = IV opiatesAnalgesia = IV opiates Wound care  keep it simpleWound care  keep it simple  Moist dressings (smaller burns)  Dry non-adherent dressings (larger burns)  “burn sheet”, cellophane, etc…  Topical antibiotics only if delay in transfer  Silvadene  Bacitracin  +/- blister removal  Defer to burn center protocols, if uncertain

28. Excision & Grafting

29. Tangential Excision (TE) Done “early” (w/in 7 d) Various adjustable knives Sequentially remove only non-viable tissue Standard burn operation BLOODY!!! Tourniquets on extremities Speed is essential

30. Fascial Excision (FE) Done “early” (w/in 7 days) Done w/ Bovie Used for deep FT w/ dead subQ tissue Excise to fascia “Inferior” cosmesis (?) Blood loss < TE

31. Split-thickness Autograft (STAG) Skin is currently the only way to definitively “close” a burn wound. STAG typically 0.010 - 0.012 inches thick Meshed or sheet (location) Limited quantity Donor site issues & complications

32. Allograft Only temporary Ultimately rejected Always requires STAG Uses:  temporary closure to allow donor healing & re-cropping  STAG overlay  test excision bed

33. Wound Closure Advances Dermal substitutesDermal substitutes  Integra  (bilaminate, collagen-chondroiton-6-SO 4 )  Alloderm (cryopreserved allogeneic dermis)  Dermagraft (neonatal FB on Biobrane)  allow formation of autogenous “neodermis”  utilize ultra-thin STAG (0.006 - 0.008 in)  superior cosmesis & fxn vs. standard E&G Cultured epithelial autografts (CEA)Cultured epithelial autografts (CEA)  Epicel  (cultured skin from patient)  fragile, limited overall burn experience, $$$$

35. Integra 

36. The Template FDA approved in ‘96 Bilaminate membrane Applied to excised wound Engrafts in ~ 14 days (~7 days with VAC  ) Ultra-thin STAG (“EAG”) Superior cosmesis & fxn, decreased LOS Drawbacks:  Learning curve  At least 2 operations

37. Wound Bed Excision Application of Integra  Operation #1 (Application)

38. Operation #2 (EAG) Removal of the Silicone Layer Graft Application

39. Integra  Results

40. Chemical Burns Decontaminate patient prior to transport or transferDecontaminate patient prior to transport or transfer  Acids/alkalis  Meth labs  Petroleum products  “Industry” H 2 O… H 2 O… H 2 O… H 2 OH 2 O… H 2 O… H 2 O… H 2 O  Irrigation for ≥30 min No formal antidotes (exothermic rxns), except for HFNo formal antidotes (exothermic rxns), except for HF Keep patient warm, if at all possibleKeep patient warm, if at all possible

41. Electrical Injuries/Burns High (>1000 V) & Low ( 1000 V) & Low (<1000 V) voltage Remove patient from current sourceRemove patient from current source Dysrhythmias, SZ, FX, etc…..Dysrhythmias, SZ, FX, etc….. Electrical & thermal components to injuryElectrical & thermal components to injury Holmes’ IVF rule of thumb: “double the calculated IVF rate (or volume) for a given estimated TBSA”Holmes’ IVF rule of thumb: “double the calculated IVF rate (or volume) for a given estimated TBSA” Always more injury than is apparentAlways more injury than is apparent

42. Modern Burn Care Model Nursing (33%) Therapy (33%) Med/Surg (33%)

43. Beyond the OR Wound care & healing are PAINFULWound care & healing are PAINFUL  Long-term opiates are the rule PT/OT is long-term… lifelong to a degreePT/OT is long-term… lifelong to a degree Revisions & reconstructions are common w/ larger burns, >30% TBSARevisions & reconstructions are common w/ larger burns, >30% TBSA Burn care is expensive!!!Burn care is expensive!!! -NBR mean hospital charges for survivors ~$56,200/admission & ~$4075/d -WFUBMC…. ~$4090/d

44. Beyond Acute Hospitalization PT/OT is lifelong, to some degreePT/OT is lifelong, to some degree Long-term neuropsych & psychosocial issues are pervasiveLong-term neuropsych & psychosocial issues are pervasive  Burn survivor support groups & peers are essential  S.O.A.R.  Victim 2 Victor

45. Outcomes: What to expect Goal = LOS of 1 day/% TBSA burnedGoal = LOS of 1 day/% TBSA burned Reality: NBR = 1.7 and WFUBMC = 1.3Reality: NBR = 1.7 and WFUBMC = 1.3 RTW: ??? …… NBR = ?RTW: ??? …… NBR = ?  WFUBMC > 50% return to pre-burn fxn Disposition goal is ultimately home & independent….. NBR = ?Disposition goal is ultimately home & independent….. NBR = ?  WFUBMC = 88% D/C’d home & 6% rehab PTSD & other neuropsych sequelae are COMMONPTSD & other neuropsych sequelae are COMMON

46. WFUBMC Burn Center Transfers or Referrals “Open-door” policy for ANY burn - NO“Open-door” policy for ANY burn - NO CALL P.A.L.  800-277-7654 CALL P.A.L.  800-277-7654 Ask for Trauma/Burn Attending on-callAsk for Trauma/Burn Attending on-call age, hx, %TBSA of PT/FT, UOP, airway & HD status age, hx, %TBSA of PT/FT, UOP, airway & HD status LR for resuscitation LR for resuscitation transport (BMC AirCare ground or helicopter, 24-7) transport (BMC AirCare ground or helicopter, 24-7) Do not directly call the WFUBMC Emergency Dept or Burn CenterDo not directly call the WFUBMC Emergency Dept or Burn Center Dedicated Burn Clinic every MON & WEDDedicated Burn Clinic every MON & WED

47. WFUBMC Burn Team