Burn Care in the Burn Care in the 2121s ts t Century CenturyJames H. Holmes IV, MDJames H. Holmes IV, MD

Director, WFUBMC Burn CenterDirector, WFUBMC Burn CenterAssistant Professor of SurgeryAssistant Professor of Surgery

Wake Forest University School of MedicineWake Forest University School of Medicine

EpidemiologyEpidemiology• ~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

• LDLD50 50 > 70% TBSA …… vs. ~30% in 1970> 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 < 8 yoa scalds scalds all others all others flame burns flame burns work work chemical/electrical/molten chemical/electrical/molten

Burn LDBurn LD5050 & Advances in Care & Advances in Care

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1940 1950 1960 1970 1980 1990 2000

Burn size(%TBSA)

Year

Penicillin

Broad spectrum antibiotics

Modern fluid management

Early excision& grafting

Skin substitutes ?

A.B.A. Referral GuidelinesA.B.A. Referral Guidelines• PT burns > 10% TBSAPT burns > 10% TBSA• Any FT burnsAny FT burns• Burns involving the face, hands, feet, genitalia, Burns involving the face, hands, feet, genitalia,

perineum, or major jointsperineum, 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 Burns in patients with preexisting medical

conditions that may complicate managementconditions that may complicate management• Burns in patients who will require special social, Burns in patients who will require special social,

emotional, or long-term rehabilitative interventionemotional, or long-term rehabilitative intervention

BURNS = TRAUMABURNS = TRAUMA

Remember ABC’sRemember ABC’s(with a twist)(with a twist)

AAirway & irway & BBreathingreathing• Inhalation Injury (~7% of patients in NBR)Inhalation Injury (~7% of patients in NBR)

HX: closed space fire, meth lab explosion, or HX: closed space fire, meth lab explosion, or petroleum product combustion petroleum product combustion

Upper airway injury: Upper airway injury: acute mortalityacute mortality facial/intraoral burns, naso/oropharyngeal soot, sore throat, facial/intraoral burns, naso/oropharyngeal soot, sore throat,

abnormal phonation, stridorabnormal phonation, stridor

Lower airway injury: Lower airway injury: delayed mortalitydelayed mortality dyspnea, wheezing, carbonaceous sputum, dyspnea, wheezing, carbonaceous sputum, COHb, COHb,

PaO2/FiO2PaO2/FiO2

Will increase resuscitation volumesWill increase resuscitation volumes

• Clinical dx - Clinical dx - NONO NPL, bronchoscopy +/- NPL, bronchoscopy +/-• Intubate EARLY!!! Intubate EARLY!!! OrotrachealOrotracheal• Surgical airway uncommonSurgical airway uncommon

CCalculate burn sizealculate burn size

• The “TWIST”The “TWIST”

• Burn depthBurn depth Superficial Superficial Partial-thickness (PT)Partial-thickness (PT) Full-thickness (FT)Full-thickness (FT) IndeterminateIndeterminate

• Only partial-thickness (2Only partial-thickness (2ndnd degree), degree), indeterminate, & full-thickness (≥3indeterminate, & full-thickness (≥3rdrd degree) injuries count towards %TBSAdegree) injuries count towards %TBSA

Estimating Burn Estimating Burn Depth/SeverityDepth/Severity

3 Zones of Thermal Injury3 Zones of Thermal Injury

Coagulation

Stasis

Hyperemia

Burn DepthBurn Depth

““Superficial”Superficial”

• Formerly “1st-degree”Formerly “1st-degree”

• Essentially a sunburnEssentially a sunburn• PinkPink• PainfulPainful• NONO blisters blisters• Will heal in < 1 weekWill heal in < 1 week

““Partial-thickness”Partial-thickness”

• Formerly “2nd-degree”Formerly “2nd-degree”

• PinkPink• MoistMoist• Exquisitely painfulExquisitely painful• BlisteredBlistered• Typically heals in < 2-3 Typically heals in < 2-3

weeksweeks

““Full-thickness”Full-thickness”

• Formerly “3rd-degree”Formerly “3rd-degree”

• DryDry• LeatheryLeathery• White to charredWhite to charred• InsensateInsensate• Will require E&GWill require E&G

““Indeterminate”Indeterminate”

• Unsure as to whether Unsure as to whether PT or FTPT or FT

• Observe for conversion Observe for conversion b/t days 3-7b/t days 3-7

• May or may not require May or may not require E&GE&G

• Can unpredictably Can unpredictably increase LOS increase LOS

CCalculate burn sizealculate burn size

• Determine burn depthDetermine burn depth

• Only PT (2Only PT (2ndnd degree), indeterminate, & FT degree), indeterminate, & FT (≥3(≥3rdrd degree) count degree) count

• Estimate %TBSAEstimate %TBSA Palmar surface of pts hand = 1% TBSA Palmar surface of pts hand = 1% TBSA Age-appropriate diagrams (Age-appropriate diagrams (e.g.e.g.- Berkow)- Berkow) Rule of NinesRule of Nines

Berkow DiagramBerkow Diagram

Rule of NinesRule of Nines

• Body divided into Body divided into fractions of 9%fractions of 9% Head = 9%Head = 9% Ant thorax = 18%Ant thorax = 18% Post thorax = 18%Post thorax = 18% Each UE = 9%Each UE = 9% Each LE = 18%Each LE = 18% Genitalia = 1%Genitalia = 1%

• Not reliable in kids!!!Not reliable in kids!!!

CCalculate burn sizealculate burn size

• Determine burn depthDetermine burn depth

• Only PT (2Only PT (2ndnd degree), indeterminate, & FT degree), indeterminate, & FT (≥3(≥3rdrd degree) count degree) count

• Estimate %TBSAEstimate %TBSA Palmar surface of pts hand = 1% TBSA Palmar surface of pts hand = 1% TBSA Age-appropriate diagrams (Age-appropriate diagrams (e.g.e.g.-Berkow)-Berkow) Rule of NinesRule of Nines

• Burn experience Burn experience accuracy in accuracy in determining burn size & severitydetermining burn size & severity

CCirculationirculation• Typically burns Typically burns 20% require IVF resuscitation20% require IVF resuscitation

• Resuscitate w/ Resuscitate w/ LACTATED RINGER’SLACTATED RINGER’S Adult Adult Baxter/Parkland Formula = Baxter/Parkland Formula = 44 cc/kg/% burn cc/kg/% burn

1/2 over 1st 8 hr 1/2 over 1st 8 hr fromfrom time of burntime of burn 1/2 over subsequent 16 hr1/2 over subsequent 16 hr

Child (<20 kg) Child (<20 kg) 33 cc/kg/% burn + D cc/kg/% burn + D55 MIVF MIVF

Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids)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!!!

Resuscitation Fine PointsResuscitation Fine Points

• More is NOT better!!!More is NOT better!!!• Crystalloid … NOT Crystalloid … NOT

colloid & only colloid & only LRLR• Goal is normotensive, Goal is normotensive,

perfused, urinating pt.perfused, urinating pt.• < 4 cc of LR /kg/%TBSA< 4 cc of LR /kg/%TBSA central monitoringcentral monitoring• EscharotomiesEscharotomies• ACS is unacceptable!!!ACS is unacceptable!!!

DDisabilityisability(from other injuries)(from other injuries)

• Primary & secondary surveys are Primary & secondary surveys are important!!!important!!!

• R/O non-thermal trauma … ~5% have R/O non-thermal trauma … ~5% have concomitant non-thermal injuryconcomitant non-thermal injury

• Management of non-thermal trauma Management of non-thermal trauma typically supercedes burn management, typically supercedes burn management, except for the resuscitation.except for the resuscitation.

EEverything elseverything else

• NoNo IV antibiotic prophylaxis!!! IV antibiotic prophylaxis!!!

• Vascular access: PIV is preferableVascular access: PIV is preferable

• Analgesia = IV opiatesAnalgesia = IV opiates

• Conservative & judicious sedatives, Conservative & judicious sedatives, prnprn only only

• Wood’s lamp eye exam for flash burns to faceWood’s lamp eye exam for flash burns to face

• EscharotomiesEscharotomies

• Early Early enteralenteral nutrition (≥ 20% TBSA) nutrition (≥ 20% TBSA)

EscharotomiesEscharotomies

IndicationsIndications

• Circumferential FT extremity burns with Circumferential FT extremity burns with threatened distal tissuethreatened distal tissue Diminished or absent distal pulses via dopplerDiminished or absent distal pulses via doppler Any S/S of compartment syndromeAny S/S of compartment syndrome

• Circumferential FT thoracic burnCircumferential FT thoracic burn Elevated PIP or PElevated PIP or Pplateauplateau

Worsening oxygenation or ventilationWorsening oxygenation or ventilation

• Nearly impossible to resuscitate patient Nearly impossible to resuscitate patient with restrictive eschar needing releasewith restrictive eschar needing release

• Fasciotomies rarely neededFasciotomies rarely needed

TechniqueTechnique

• ANATOMIC POSITION!!ANATOMIC POSITION!!• Med & lat lines of extremities, Med & lat lines of extremities,

over lumbricals on dorsal over lumbricals on dorsal hands, ant or mid axillary lines hands, ant or mid axillary lines on chest, & lateral neck lineson chest, & lateral neck lines

• Thru eschar only -- RELEASEThru eschar only -- RELEASE• Use cautery (knife OK)Use cautery (knife OK)• Not a sterile procedureNot a sterile procedure• Digits are controversialDigits are controversial

After…After…

Initial Wound ManagementInitial Wound Management

• No IV antibiotics!!!No IV antibiotics!!!• Analgesia = IV opiatesAnalgesia = IV opiates• Wound care Wound care keep it simplekeep it simple

Moist dressings (smaller burns)Moist dressings (smaller burns) DryDry non-adherent dressings (larger burns) non-adherent dressings (larger burns)

““burn sheet”, cellophane, etc…burn sheet”, cellophane, etc… Topical antibiotics only if delay in transferTopical antibiotics only if delay in transfer

SilvadeneSilvadene BacitracinBacitracin

+/- blister removal+/- blister removal Defer to burn center protocols, if uncertainDefer to burn center protocols, if uncertain

Excision & GraftingExcision & Grafting

Tangential Excision (TE)Tangential Excision (TE)

• Done “early” (w/in 7 d)Done “early” (w/in 7 d)• Various adjustable knivesVarious adjustable knives• Sequentially remove only Sequentially remove only

non-viable tissuenon-viable tissue• Standard burn operationStandard burn operation• BLOODY!!!BLOODY!!!• Tourniquets on Tourniquets on

extremitiesextremities• Speed is essentialSpeed is essential

Fascial Excision (FE)Fascial Excision (FE)

• Done “early” (w/in 7 Done “early” (w/in 7 days)days)

• Done w/ BovieDone w/ Bovie• Used for deep FT w/ Used for deep FT w/

dead subQ tissuedead subQ tissue• Excise to fasciaExcise to fascia• ““Inferior” cosmesis (?)Inferior” cosmesis (?)• Blood loss < TEBlood loss < TE

Split-thickness Autograft (STAG)Split-thickness Autograft (STAG)

• Skin is currently the only Skin is currently the only way to definitively “close” way to definitively “close” a burn wound.a burn wound.

• STAG typically 0.010 - STAG typically 0.010 - 0.012 inches thick 0.012 inches thick

• Meshed or sheet (location)Meshed or sheet (location)

• Limited quantityLimited quantity• Donor site issues & Donor site issues &

complicationscomplications

AllograftAllograft

• Only temporaryOnly temporary• Ultimately rejectedUltimately rejected• Always requires STAGAlways requires STAG• Uses:Uses:

temporary closure to temporary closure to allow donor healing & allow donor healing & re-croppingre-cropping

STAG overlaySTAG overlay test excision bedtest excision bed

Wound Closure AdvancesWound Closure Advances• Dermal substitutesDermal substitutes

IntegraIntegra (bilaminate, collagen-chondroiton-6-SO(bilaminate, collagen-chondroiton-6-SO44))

Alloderm (cryopreserved allogeneic dermis)Alloderm (cryopreserved allogeneic dermis) Dermagraft (neonatal FB on Biobrane)Dermagraft (neonatal FB on Biobrane)

allow formation of autogenous “neodermis”allow formation of autogenous “neodermis” utilize ultra-thin STAG (0.006 - 0.008 in)utilize ultra-thin STAG (0.006 - 0.008 in) superior cosmesis & fxn vs. standard E&Gsuperior cosmesis & fxn vs. standard E&G

• Cultured epithelial autografts (CEA)Cultured epithelial autografts (CEA) EpicelEpicel (cultured skin from patient)(cultured skin from patient)

fragile, limited overall burn experience, $$$$fragile, limited overall burn experience, $$$$

IntegraIntegra

The TemplateThe Template

• FDA approved in ‘96FDA approved in ‘96• Bilaminate membraneBilaminate membrane• Applied to excised woundApplied to excised wound• Engrafts in ~ 14 days (~7 Engrafts in ~ 14 days (~7

days with VACdays with VAC))• Ultra-thin STAG (“EAG”)Ultra-thin STAG (“EAG”)• Superior cosmesis & fxn, Superior cosmesis & fxn,

decreased LOSdecreased LOS• Drawbacks:Drawbacks:

Learning curveLearning curve At least 2 operationsAt least 2 operations

Wound Bed Excision

Wound Bed Excision

Application of Integra

Application of Integra

Operation #1 (Application)Operation #1 (Application)

Operation #2 (EAG)Operation #2 (EAG)

Removal of the

Silicone Layer

Removal of the

Silicone Layer

Graft Application

Graft Application

IntegraIntegra Results Results

Chemical BurnsChemical Burns

• Decontaminate patient Decontaminate patient prior to transport or prior to transport or transfertransfer Acids/alkalisAcids/alkalis Meth labsMeth labs Petroleum productsPetroleum products ““Industry”Industry”

• HH22O… HO… H22O… HO… H22O… HO… H22OO Irrigation for ≥30 minIrrigation for ≥30 min

• No formal antidotes (exothermic rxns), No formal antidotes (exothermic rxns), except for HFexcept for HF

• Keep patient warm, if at all possibleKeep patient warm, if at all possible

Electrical Injuries/BurnsElectrical Injuries/Burns

• High (>1000 V) & Low (<1000 V) voltageHigh (>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 Holmes’ IVF rule of thumb: “double the calculated IVF rate (or volume) for a given calculated IVF rate (or volume) for a given estimated TBSA”estimated TBSA”

• Always more injury than is apparentAlways more injury than is apparent

Modern Burn Care ModelModern Burn Care Model

Nursing (33%)

Therapy (33%)

Med/Surg (33%)

Beyond the ORBeyond the OR

• Wound care & healing are PAINFULWound care & healing are PAINFUL Long-term opiates are the ruleLong-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 Revisions & reconstructions are common w/ larger burns, >30% TBSAw/ larger burns, >30% TBSA

• Burn care is expensive!!!Burn care is expensive!!!- NBR mean hospital charges for survivors NBR mean hospital charges for survivors

~$56,200/admission & ~$56,200/admission & ~$4075/d~$4075/d- WFUBMC…. WFUBMC…. ~$4090/d~$4090/d

Beyond Acute HospitalizationBeyond Acute Hospitalization

• PT/OT is lifelong, to some degreePT/OT is lifelong, to some degree

• Long-term neuropsych & psychosocial Long-term neuropsych & psychosocial issues are pervasiveissues are pervasive Burn survivor support groups & peers are Burn survivor support groups & peers are

essentialessential S.O.A.R. S.O.A.R. Victim 2 VictorVictim 2 Victor

Outcomes: What to expectOutcomes: What to expect

• Goal = LOS of 1 day/% TBSA burnedGoal = LOS of 1 day/% TBSA burned

• Reality: NBR = 1.7 and Reality: NBR = 1.7 and WFUBMC = 1.3WFUBMC = 1.3

• RTW: ??? …… NBR = ?RTW: ??? …… NBR = ? WFUBMC > 50% return to pre-burn fxnWFUBMC > 50% return to pre-burn fxn

• Disposition goal is ultimately home & Disposition goal is ultimately home & independent….. NBR = ?independent….. NBR = ? WFUBMC = 88% D/C’d home & 6% rehabWFUBMC = 88% D/C’d home & 6% rehab

• PTSD & other neuropsych sequelae are PTSD & other neuropsych sequelae are COMMONCOMMON

WFUBMC Burn Center WFUBMC Burn Center Transfers or ReferralsTransfers or Referrals

• ““Open-door” policy for Open-door” policy for ANYANY burn - NO burn - NO

• CALL P.A.L. CALL P.A.L. 800-277-7654 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 statusage, hx, %TBSA of PT/FT, UOP, airway & HD status LRLR for resuscitation for resuscitation transport (BMC AirCare ground or helicopter, 24-7)transport (BMC AirCare ground or helicopter, 24-7)

• Do Do notnot directly call the WFUBMC Emergency directly call the WFUBMC Emergency Dept or Burn CenterDept or Burn Center

• Dedicated Burn Clinic every Dedicated Burn Clinic every MON & WEDMON & WED

WFUBMC Burn TeamWFUBMC Burn Team