Burn Injury Manual2010

7/24/2019 Burn Injury Manual2010

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1

BURN INJURY

Initial Management of the BurnPatient

Burn Center Outpatient Appointments: 617-732-7715

24-Hour Transfer Arrangements: 617-732-5034


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Message from the Burn Director, Bohdan Pomahac, MD

I am pleased to provide you with this resource manual for pre-

hospital burn care. Burn patients can be one of the most

challenging, but also the most rewarding to take care of. At

Brigham & Womens Hospital, we are committed to providing ourpatients with the best possible functional and aesthetic outcome

following their burn injury.

I am personally attracted to burn care because of my background in

plastic surgery, but also the perceived need for more innovation in

this field. Burn care is a true team effort and you are a critical part

of that team. I am excited that together we can serve our patients and the community-at-

large.

Please feel free to contact my office if we can answer any questions or be of any

assistance to you.

Sincerely,

Bohdan Pomahac, M.D.Medical Director, Burn Service

Department of Surgery

TheBrighamandWomensHospitalBurnCenterisanaccreditedAmericanBurn

Association(ABA)burncenter.OurteamisalwaysavailabletoassistyouinthemanagementoftheburnpatientandiswillingtoprovideexpertassistanceinthetransferprocessasoutlinedbytheABA.

24-Hour Burn/Trauma Patient Transfer Number: 617-732-5034

Burn Trauma Program Contacts:

Out-patientBurnClinic 617-732-7715

Dr.PomahacMainOffice 617-732-7796Burn/TraumaProgramManager 617-732-7734

www.brighamandwomens.org/burntrauma
http://www.brighamandwomens.org/burntraumahttp://www.brighamandwomens.org/burntraumahttp://www.brighamandwomens.org/burntrauma


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Table of ontents

Section Title Page

Introduction 4

I. ManagingtheABCsintheBurnPatient:

Airway

Breathing

Circulation

5

II. BurnCenterTransferCriteria 15

III. InitialAssessmentandManagementofBurnInjury Skinfunctions

Burnassessment Initialmanagement Burnseverityandoutcome

16

IV. ChemicalBurns Generalprinciplesandmanagement Eyeinjury

Specificchemicalinjury

29

V. ElectricalBurns

Terminology

Initialassessmentandmanagement

Highvoltageinjury Lowvoltageinjury

36

VI. BurnstoHighRiskAreas: Hands,feet,perineum,face,ears

46

VII. Coldinjuries:HypothermiaandFrostbite 49


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Introduction

Anumberofadvancesintheearlymanagementofmajor,moderate,andminorburnshavesubstantiallyreducedthemortalityandmorbidityassociatedwithburn

injuryevents.Theseadvancesincludeapplicationofthemostcurrentscienceandevidencedirectlyrelatedtopainmanagement,infectionrates,andwoundcoverage.Thefocusofthisresourcemanualistheprovisionofcareforburnpatientsduringtwocriticalperiods:

Initialassessmentandtreatmentoflifethreateningconditions,specifically

relatedtoAirway,BreathingandCirculation.

Earlyrecognitionoftheburnseverity,depth,size.Currenttreatmentswillbediscussedtoroundoffthecompletepictureofearly

managementofburninjury.SequencesofEventsandPrioritiesinManagement:

StoptheBurningProcess ManagementofAirwayandPulmonaryProblems Restorationofhemodynamicstability TheBurnWound:

o Assessmento Initialmanagemento Determinedisposition

TransferCriteriatoBurnCenter

B CRITERI FOR P TIENT TR NSFER TO BURN CENTER

Partialthicknessburnsgreaterthan10%oftotalbodysurfacearea(TBSA);

Burnsinvolvingtheface,hands,feet,genitalia,perineum,ormajorjoints;

Thirddegreeburnsinanyagegroup; Electricburns,includinglightninginjury; Chemicalburns;

Inhalationinjury; Burninjuryinpatientswithpre-existingmedicaldisordersthatcould

complicatemanagement,prolongrecoveryoraffectmortality;

Anypatientswithburnsandconcomitanttrauma(suchasfractures)inwhichtheburnposesthegreatestriskofmorbidityormortality;

Burnedchildreninhospitalswithoutqualifiedpersonnelorequipmentforthecareofchildren;

Burninjuryinpatientswhowillrequirespecialsocial,emotionalorlong-termrehabilitativeintervention.


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5

I. Managing the ABCs in the Burn Patient

Caption1:Houseorhomedwellingfirescontinuetobethenumberonesourceofburn

injuries.

Caption2:Burnpatientsufferingfacialandinhalationinjuries.Modulecomponents:

StoptheBurningProcess

Carbonmonoxidetoxicity

Airwayinjuryfromsmoke

Pulmonaryproblemsfromsmoke

Chestwallrestriction

Burn-inducedplasmashift

FluidresuscitationBloodflowrestrictionfromcompression

Stop the Burning Process

a.FlameSource-Eliminateanyongoingburning,(i.e.fromburningclothes).

-Syntheticsinclothescanretainheatwhichneedstobeneutralized.

-CoverthepatientwithDRYCLEANsheets.

b. ChemicalSource

-Chemicalscontinuetoburnifincontactwithskin.-Removechemicallycontaminatedclothing.Continuousflushingwithwater


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6

Management of Airway and Pulmonary Conditions

Smokeinhalationisamajorcauseofmorbidityandmortalityintheimmediatepostburnperiod.These,oftenlifethreatening,effectsofsmokeinhalationmustberecognizedandaggressivelymanaged.Thedegreeoflungdamageisusuallynotevidentforseveralhours.

EarlytransfertoaBurnCenterishighlyrecommended,ifsmokeinjuryissuspected.

Thethreeinjuryprocesses,resultingfromsmokeexposure,arepresentedintheorderinwhichpeaksymptomsoccur:*CarbonMonoxideToxicity

-Immediate*UpperAirwayInjurywithPotentialObstruction

-Canbedelayedforanhourormore*LowerAirwayInjurywithImpairedGasExchange

-CanbedelayedforhoursCarbon M onoxide Toxicity Pathophysiology

CarbonMonoxidebindstothehemoglobinmoleculedisplacingoxygentherebydecreasingtheoxygendeliverytotissue.Over99%oftissueoxygenisprovidedbytheoxygencarriedonhemoglobin.

-RiskFactors Anyexposuretosmoke Anyexposuretofumes-DiagnosisHaveahighindexofsuspicioninanyfirevictimwithahistoryofsmokeexposure.Acarboxyhemoglobinlevelexceeding10%total(morbidityisrelatedtothepeaklevelatthescene--notthefirstvalueobtained).Beespeciallyconcernedofcasesinwhichthereisanunexplainedmetabolicacidosis.SeethetablebelowforhemoglobinlevelsasrelatedtothedegreeofCOintoxication.

Carbon Monoxide Intoxication

*CO Hgb Level Symptoms

0-5 Normalvalue

15-20 Headache,Confusion

20-40 Disorientation,fatigue,nausea,visualchanges

40-60 Hallucination,combativeness,coma,shock,shockstate

60orabove Cardio-pulmonaryarrest,Death

*COHgB=Carboxyhemoglobin


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7

Endpointsoflevelofconsciousness(LOC)inrelationtotreatments:

AWAKE OBTUNDED

Highflowbymaskoxygen(FiO2100%)untilCOHgb


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8

-CyanideToxicityCyanideisalsofoundinsmoke,especiallyfromburningpolyurethane.Plasmacyanidelevelsaredifficulttoobtainsotreatmentisusuallybasedonahighindexofsuspicion,usuallyduetoanunexplainedsevermetabolicacidosisnotcorrectedbyoxygenandfluids.Ingeneral,forcyanidepoisoning,cardiopulmonarysupportis

usuallysufficienttreatmentsincetheliver,viatheenzymerhodenase,willclearcyanidefromthecirculation.Sodiumnitriteisused(300mgIVover5-10minutes)inseverecases,especiallyinthosepatientsinwhichthediagnosisismadebybloodcyanidelevels.Thenitrite,inturn,bindswiththecyanide.Ordinarily,thiosulfateisalsogiven,whichinturnbindsthecyanidetoformthiocyanate.Onemustbereasonablysureofthediagnosisofcyanidetoxicitybeforegivingsodiumnitriteasasideeffectistheproductionofmethhemyoglobin.

Airway Injury from Sm oke

RISK FACTORS

Oral Burn:Rapidswellingoftongueandmucosacompromisingairwaypatency.Supraglottic Edema:Progressiontoobstruction.Cord and Infraglottic Edema:Progressiontoobstruction.

Techniquestodetermineriskfactorsincludelaryngoscopicassessmentforsmokeinhalation:-Diagnosis

Historyofsmokeexposure(orexposuretohightemperaturee.g.explosion).

Directlaryngoscopicevidenceofinjury.

Symptomsofstridor,dyspnea(oftendelayedinonset).

Edemaanderythemawithdecreasingairwaylumenisnotedoninitialassessment.

-Treatment: 100%oxygen AirwaySupport Earlyintubationmayberequired TransfertoBurnCenterifsmokeinhalationinjurysuspected

NOTES:


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9

Initial Assessment and Management of the Airway

Keysignsandsymptoms:

StridorRetraction

RespiratoryDistresspresent

DeepBurns:Face,Neck

If key signs or symptoms Present If key signs or symptoms Absent

*Intubatenow!*Useadequatesizetube*Humidifiedoxygen*Elevatehead*TransporttoBurnCenter

*Provide100%oxygen*Lookforsignsofairwayinjury:

Oropharyngealerythema Hoarseness Pulmonarystatus

*Canperformlaryngoscopy*Ifedemapresent,intubatenow

*TransfertoBurnCenterifhistoryorfindingsarepositiveforsmokeinhalationinjuryREMEMBER:Deteriorationisoftendelayedinonset.

Pulmonary Problems from Smoke

OnsetofsymptomsisoftendelayedEarlytransfertoBurnCenterifsuspectofsmokeinjury

Table:LungInjuryfromToxinsinSmoke

Compounds Source Effect Timing

AmmoniaSulfurDioxideChlorine

Clothing,Furniture,Wool,Silk

Mucousmembraneirritation,Bronchospasm,Bronchorrhea

Earlyonset(firstseveralhours

HydrogenChloridePhosgene

PolyvinylChloride,Furniture,(wallfloorcoverings)

Severemucosaldamage;Ulcers,Mucousplugging,Mucosalslough,Pulmonaryedema

Delayedoften1-2days

AcetylaldehydeFormaldehyde

Acrolein

Wallpaper,Lacquered

wood,Cotton,Acrylic

Severemucosaldamage;Ulcers,

Mucousplugging,Mucosalslough,Pulmonaryedema

Delayedoften1-2days

Cyanide Polyurethaneupholstery,

TissueHypoxia IMMEDIATE

CarbonMonoxide Anycombustiblesubstance

TissueHypoxia IMMEDIATE


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10

Chest W all Restriction

Afullthicknessburnoftheanteriorandlateralchestwallcanleadtosevererestrictionofchestwallmotion,especiallyasedemadevelopsbeneaththenonviabletissue(eschar),evenintheabsenceofacompletelycircumferentialburn.Chestwallescharotomymayberequiredtorelievetherestriction.

EscharotomyisbestdoneinaBurnCenterunlessventilationisseverelyimpaired.

Caption:Impairedbreathingfromdeepchestwallburn.

Therestrictiontoventilationisfurthercompromisedbytheabdominalburndiminishingthe

movementofthediaphragm.Theescharotomyincisionsareplacedalongtheanterior

axillarylineswithbilateralincisionsconnectedbyasubcostalincision(seenextphoto).The

incisionsmustextendcompletelythroughtheescharsothatthesub-escharspacecan

expandanddecreasetissuepressure.Inafullthicknessburn,nerveendingsaredestroyed

alongwiththeentireepidermisanddermis.Asaresult,analgesicsareusuallynot

necessaryforescharotomy.

Caption:Escharotomyincisionsalonganterioraxillaryline.


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11

Burn Induced Plasma S hift

1. Restoring loss of Plasma Volume

Hypovolemia)

Lossofplasmavolumeisrapidafteraburninjuryasfluidcollectsintheburntissue.Themagnitudeoflosscanbeeasilyunderestimatedasplasmaisnotvisiblylostfromthesurfacebutratherishiddenbeneaththeburn.

Earlyfluidresuscitationisrequiredforburnsexceeding20%ofbodysurfacearea.

-Assessment Lookforothertraumaticinjuries(falls,explosions,blunttrauma) Estimatepercentofbodysurfaceburnedinordertoestimateisotonic

fluidrequirementsRuleofNines. Useburnresuscitationformularememberingtoaddmorefluidorblood

forothertraumaticinjuries


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12

Estimating the size of the Burn as a percentage of the Total Body Surface Area TBSA)

Caption:Thisformuladividesthebodyintopartsconsideredtobe9%(arms,head)to18%(legs,front,back)of

totalbodyskinsurfaceinadults.Thesmallchildhasadifferentsurfaceareabreakdown.Theburnsize(as%of

total)canthenbeusedintheresuscitationformula.Remember that a formula is only an estimate and

adjustments need to be made based on patients status.

Fluid Resuscitation Protocol

*Establishandmaintainadequatecirculation

*Burns>20%TBSArequireinitialfluidresuscitation

*Useatleastonelargeboreintravenouscatheter.BeginRingersLactate.Estimateinitialrateaccordingtotheestimatedpercenttotalbodyskinsurfaceareaburned(%TBSA).


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Estimatedbodyweight(4cc/kg/%TBSAin24hoursgivinghalfoftheestimatewithin1-8hours.)

*Otherinterventionstomonitorintakeandoutput:

-Foleycatheter-Nasogastrictube

Parameterstomaintain:

SystolicBloodPressure>90mm Urineoutput0.5-1.0ml/kg/hr Pulse37C

Modifyyourprotocolinthepresenceofmassiveburns,inhalationinjury,shock,andinelderlypatientsapplyingthefollowingstrategies:

-Fluidrequirementsaregreatertopreventburnshock.-Includecolloid(eitherHespanorAlbumin)inthesepatientsfromthestart.-TransfertoBurnCenterifamajorburnormoderateburnlevelexceedslocalresources.

NOTES:


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14

Blood Flow Re striction from Tissue Com pression

Assubescharedemadevelopsundertheburntissue,tissuepressureincreases.Thisisofparticularconcerninextremitieswithacircumferentialburn.Increasingpressurecannotbedissipatedbynormalexpansionintoneighboringtissue.Thisincreasedpressureinitiallyimpedesvenousreturn,whichmarkedlyaccentuatesfurtheredemaproduction,raising

pressuretoalevelthatcompromisesarterialbloodflow.

Perfusiontothedistalextremitymustbecloselymonitored.

Painandcolorwillbeunreliableindicatorsofperfusioninthepresenceofaburntothearea.

Awarmextremityinvariablyindicatesgoodflowduringtheperiod,butcoolskindoesnotalwaysindicatethattheproblemisduetoproximalburnconstriction.Hypovolemiamaywellbetheproblem.

Caption1:Circumferentialburnimpairingcirculationtohand.Caption2:Releaseoftissuepressure

andrestorationofperfusion(PreferableperformedinaBurnCenter).

Stepsforthepreventionandtreatmentofimpaireddistalperfusion

Removeconstrictingobjects,suchasjewelry.

Immediateelevationofburnedextremities. MonitorperipheralcirculationbypulsepalpationandDoppler. Escharotomiesplannedforcircumferentialthirdorfourthdegreeburns, if

perfusion is impaired(preferablyperformedinaBurnCenter).

The monitoring of distal pulsatile flow by palpation and then by the use of a Doppler

flowmeteristhemostpracticalmethodofassessment.Pulsatileflowmustbepresent.


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Burn Injury Manual2010

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