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

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

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

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

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

6. Sup 2nd degree

7. 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

8. Deep dermal

11. 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

12. Full-thickness

14. Etiology

15. Types of burns

16. Where do burns occur

17. Circumstances of injury

18. Admissions by age

19. % of admissions vs. burn size

20. Inhalation injury diagnosis Closed-space fire Face burns

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

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

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

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

25. 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

26. 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

27. Reduction of CO

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

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

30. Resuscitation

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

32. Rule of Nines

33. Lund and Browder Chart

34. 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

35. 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

36. 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.

37. 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

38. 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

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

45. Zones of burn injury

46. Pain control

47. 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

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

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

50. Summary Airway Circulation/Resuscitation Pain control

51. Questions?