Initial Burn Care

Lee D. Faucher, MD FACSDirector UW Burn CenterProfessor of Surgery &

Pediatrics

Objectives

• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition

Objectives

• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition

September 11, 2001• 8:20am

– American Airlines Flight 77 Departed Washington Dulles at 8:20am

– 58 passengers, crew of 6

• 9:38am– A 757-200 crashes

into the Pentagon

Washington Hospital Center

• Located in Northwest DC– Areas largest

trauma center and regional burn center

Code Orange: This is not a drill!

• Medical response– 8 trauma surgeons– 6 trauma residents– 7 intensivists and

their teams– All others

• Anesthesia, lab, blood bank, radiology, RT, security

Patients begin to arrive

• 3 patients in first 30 minutes– 1 smoke only, 2

burns

• Then all air traffic grounded– 4 more by ground

Patient AdmissionsPatient # Gender % TBSA Arrival

1 F 0 <1 hour

2 F 21 <1 hour

3 M 22 <1 hour

4 F 66 <1 hour

5 M 49 <1 hour

6 F 68 <1 hour

7 M 41 7 hours

8 M 42 10 hours

9 M 32 28 hours

10 M 10 31 hours

Post-Burn Weeks

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14

OR Hours

# Operations

Products consumedIV Fluids 141 Liters

Silvadene cream 950 Jars

Burn Dressing Gauze 2006 packs

4X4 gauze 18,490

Kerlix gauze 3108 rolls

Ace Bandages 2111

Allograft 26,700 sq cm

Synthetic “skin” 30,365 sq cm

Autograft 22,087 sq cm

PRBCs 269 units

OutcomesPatient # Gender %

TBSAAge + TBSA

Mortality Risk

Outcome

1 F 0 32 N/A Survived

2 F 21 74 11 Survived

3 M 22 61 4 Survived

4 F 66 115 62 Survived

5 M 49 100 41 Survived

6 F 68 109 44 Died

7 M 41 80 15 Survived

8 M 42 71 9 Survived

9 M 32 63 1 Survived

10 M 10 82 23 Survived

Final numbers

• 189 deaths– 125 in Pentagon– 64 on Flight 77

• 106 injured– 50 admitted to 9 area

hospitals– 9 serious burns

Objectives

• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition

Medics• Airway• Assess for other injuries• Start IV with LR, in burn OK

– < 6 years = 125mL/hr– 6-13 years = 250mL/hr– >13 years = 500mL/hr

• 100% O2 if closed space fire

• Transport to closest hospital

History

• Source of burn• Enclosed space

– Signs of smoke inhalation

• Circumstances surrounding injury• Previous medical problems• First-aid done

Reduction of CO

0

20

40

60

80

0 20 40 60 80

Time in Minutes

% C

O

Room Air100% Oxygen3 ATM

Medics - Electrical

• Do not become victim– Turn off power

• Initiate CPR– If < 1000 volt,

ventricular fibrillation– If > 1000 volt, cardiac

standstill and respiratory paralysis

Medics - Chemical

• Remove involved clothing• Flush with water• Flush with more water• Then flush with more water• When you think you are done, flush

with more water• NO NEUTRALIZATION

Cold

• DOES NOT– Reverse temperature– Inhibit destruction– Prevent edema

• DOES– Delay edema– Reduce pain

Case presentation

• EMS responds with Fire to structure fire with reported trapped occupants

• On arrival, see two bystanders dragging person out the front door.

Medic evaluation

• Airway– Moving air, moaning, unresponsive,

entire head, face, neck, and chest burned

Medic evaluation

• Breathing– Equal bilateral breath sounds

• Circulation– Palpable distal pulses

Medic evaluation

• What else should be done at the scene?

• Where should this patient be taken?

Medic Report to ED

• 47 y/o male, extricated from structure fire, burns over head, chest, back, bilateral upper extremities and legs, intubated with one peripheral IV in place running LR at 500mL/hr

• Vitals: HR 130, BP 150/90, Sat 100%

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

Smoke inhalation assessment

• Flame burns• Enclosed space• Burns to face, mucosal

membranes• Singed eyelashes, nasal

hairs• Carbonaceous sputum

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

Rule of Nines

Lund and Browder ChartAArreeaa 00--11

yyrr.. 11--44 yyrr..

55--99 yyrr..

1100--1144 yyrr..

1155 yyrr..

AAdduulltt 22 33 TToottaall

HHeeaadd 1199 1177 1133 1111 99 77 NNeecckk 22 22 22 22 22 22 AAnntt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 PPoosstt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 RR.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ GGeenniittaalliiaa 11 11 11 11 11 11 RR.. UU.. AArrmm 44 44 44 44 44 44 LL.. UU.. AArrmm 44 44 44 44 44 44 RR.. LL.. AArrmm 33 33 33 33 33 33 LL.. LL.. AArrmm 33 33 33 33 33 33 RR.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ RR.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ LL.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ RR.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 LL.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 RR.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ LL.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½

TToottaall

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

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

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

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

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm

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

Emergency room treatment

• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• KEEP PATIENT WARM!!!!!

Next priorities

• Insert NG tube• Escharotomies• Medications• Wound care

Next priorities

• Insert NG tube• Escharotomies• Medications• Wound care

Escharotomies

• Only for leathery, circumferential, full-thickness burns

• Rarely needed in transport < 12 hours• Almost always done at the Burn Center• Emergent indications:

– Unable to ventilate– Pulseless, painful extremity

Escharotomy pic

Next priorities

• Insert NG tube• Escharotomies• Medications• Wound care

Medications

• Pain control• Pain control• More pain control• Tetanus immunization• NEVER need antibiotics

Next priorities

• Insert NG tube• Escharotomies• Medications• Wound care

Wound care

• Debridement and topical application is usually done after transfer

• Can cover with plastic wrap• Transport patient in DRY sheet and

blanket• If transport delayed > 12 hours,

– Debride loose tissue and clean with mild soap and water

– Apply Silver Sulfadiazine and wrap loosely

Resuscitation 24 - 48 hours

• Continue maintenance fluids, watch serum Na+

• May use albumin or plasma for volume– Infuse 5 – 10mL/kg as needed

• Maintain adequate urine output

Objectives

• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric consideration• Burn Center Definition

Burn Etiology

ABA National Burn Repository, 2012 ReportABA National Burn Repository, 2012 Report

UWHC Admissions <18 years

Admissions to Burn Centers

ABA National Burn Repository, 2012 Report

Overall Burns and Mortality

05

10152025303540

0 to 2 2 to 5 5 to 16 16-20

Age

Pe

rce

nt

Lived Died

ABA National Burn Repository, 2012 Report

Overall Mortality and TBSA

0

20

40

60

80

100

0 to 10 10 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 80 to 90 > 90

TBSA

Perc

en

t

0 to 2 2 to 5 5 to 16 16 - 20

ABA National Burn Repository, 2012 Report

Where Childhood Burns Occur

80

8

10 2

Home

Auto

Recreation

Other

ABA National Burn Repository, 2012 Report

A kid with a small burn

Why we do this

• An acute burn may not be completely blistered

• Can’t do wound care in clinic• Sedation easier when adequate pain

control

Appropriate wound care

What is Mepilex Ag• Silicone• Foam• Silver

Then what do we do

• Dressing changed every 3 to 5 days• Our length of stay drastically

reduced• Still same number of surgical

procedures

Objectives

• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition

Burn Center Referral• All children• Any burn > 10% TBSA• Any full-thickness burn• Burns to hands, face, feet or perineum• Any Electrical or Chemical burns• Other associated injuries, medical

problems, or inhalation injury• Systemic diseaseExcerpted from Guidelines for the Operations of Burn Units (pp. 55-62), Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons

Outpatients Do Not include

• Special locations• Extremes of age• Associated injuries• Previous medical problems• Unusual etiologies

– Some chemical, some electrical

• Unstable social situations

NursesResidents

PhysiatristsPediatricians

Burn SurgeonsNurse PractitionerPhysical therapistsPhysician AssistantChild Life therapistsHealth psychologists

Respiratory therapistsRecreational therapistsOccupational therapists

Social Worker PharmacistsNutritionists

Administrators