EMCrit.org

Thermal Burns

* Critical areas include face, hands, feet, perineum

** Complications include inhalation injury, high-voltage electrical burns, associated major trauma, infants, elderly, and comorbid medical problems (e.g., diabetes mellitus)

(Emergency Medical Practice)

management

burn flow chart

 The extent of injury is best described using the percentage of the total body surface area (TBSA) that is burned. When calculating the TBSA, only second- and third-degree burns are included. For patients older than 10, the "rule of nines" may be used to estimate the TBSA.  For small or patchy burns, it is helpful to remember that in the adult, the patient’s palm (not counting the fingers) covers approximately 1% of the TBSA.

Fluids

Parkland Formula

Burns are multisystem injury regardless of area involved.  They sharply raise body metabolism, predispose to thermal and evaporative loss, and are an invitation to infection.

ABCs

·        Airway-intubate before the onset of swelling.  If patient can not manage their secretions, they get a tube.  If they won’t allow themselves to be laid down, tube them.  Use a large bore size to tube to facilitate toilet.  Secure tube above and below ears

·        Breathing-eschar may restrict breathing.  Consider high-frequency percussive ventilation which increases oxygenation by “shaking” the O2 molecules and sends secretions upwards to orophraynx

·        Circulation-Two 14 or 16 gauge IV lines.  You can place lines through burns.  Consider suturing in place to prevent decannulation.  Be meticulous with disinfection as burn patients are predisposed to suppurative thrombophlebitis (fatal if not treated.)

Secondary Management

·        Stop Burn Process, never use ice, only room temp water

·        Pain Control

·        Remove jewelry and clothes. 

·        Estimate Burn Size

·        Start fluid resuscitation:

Parkland-Lactated Ringer’s 4 mL x %TBSA burn x kg.  Give half of calculated needs in first eight hours, the rest over 16 hours or (Kg x TBSA Burned)/4=rate per hour for first 8 hours.  Monitor fluids by urine output (pink urine=muscle destruction

Consider escharotomies, consider fasciotomies

Smoke Inhalation

Leading cause of death in building fires.  Signs are confusion, agitation or aggression, singed eyebrows or nasal hair, soot in the sputum, hoarseness, loss of voice, inability to manage secretions, or stridor.  If bronch shows soot below the vocal cords, you have inhalation injury.  Patients will do well for first day or so until the cilia become damaged then predisposed to pneumonia which kills these patients.

Use HFOV ventilation for its increased ability to mobilize secretions.  Nebulized heparin and acetylcystine may have a role.

Burn Unit Referral Criteria.

·        Partial-thickness burns greater than 10% TBSA

·        Burns that involve the face, hands, feet, genitalia, perineum, or major joints

·        Third-degree burns in any age group

·        Electrical burns, including lightning injury

·        Chemical burns

·        Inhalation injury

·        Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality

·        Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality

·        Burned children in hospitals without qualified personnel or equipment for the care of children

·        Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention

<10 % burns, transfer with wet dressings.  >10% dry dressings

Electrical/Lightning Burns

Honey, an inexpensive, simple, and natural substance, has been used since ancient times to treat burn wounds. In 1998, Subrahmanyam randomly assigned 50 patients with less that 40% TBSA partial-thickness burns to 1 of 2 treatment groups.³ The groups were similar in gender, mean age, mechanism of injury, and burn surface area. Twenty-five patients were treated with pure, unprocessed, undiluted honey, and 25 patients were treated with SSD-impregnated gauze. Dressings were changed daily, and the wounds were inspected every 2 days until healed. Biopsy specimens for analysis and culture were taken from the wounds on presentation, day 7, and day 21. In the honeytreated group, 84% of the patients showed clinical granulation and epithelialization of the wound by day 7, and 100% showed such progress by day 21. In the SSD-treated group, wound healing was evident in 72% by day 7 and in only 84% by day 21, although these differences were not statistically significant. By day 21, wound healing was complete in all of the patients in the honey-treated group and in only 21 of the 25 patients in the SSD-treated group (p < 0.05).

Results of another study suggest that honey has antibacterial properties that are superior to those of SSD.⁴ Subrahmanyam randomly assigned 104 patients with less than 40% TBSA partial-thickness burns to 1 of 2 groups. Fifty-two patients were treated with honey, and 52 patients were treated with SSD. Biopsy specimens for culture and sensitivity determination were taken on admission, day 7, and day 21. Honey was superior to SSD cream for preventing bacterial growth in the burn wound and for wound healing (p = 0.05). Although Subrahmanyam's studies were not conducted in an outpatient setting, and the TBSA of partial-thickness burns was as much as 40%, these results suggest that honey may be a simple, inexpensive, alternative—and probably superior—dressing to use when treating minor burns.

3. Subrahmanyam M. A prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns 1998;24: 157 -161.[Medline]
4. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991;78: 497 -498.[Medline]

If you follow-up your own burn patients, you can still send them to physical and occupational therapy, and get them whirlpool debridement.

Burn dressings

Its most important quality is the ability to absorb and control the fluids oozing from the wound.  The best material is plain non-sterile gauze.  The gauze should be thick and fluffy to absorb as much fluid as possible.  Use multiple 4x4s wrapped with kerlix or kling.  Home dressing changes are fine, but give the patient only enough supplies to last until the follow-up.  Give patient silvadene and tongue depressors in addition to dressings.

The first dressing change should probably be by a health care provider in the clinic or hospital.  It is very difficult to grade a burn on the first day.  Dressing changes should be once a day if using a cream, if dry dressings with adaptec, then only every 3-4 days is necessary.  Probably need a recheck every 5-7 days.

Topicals don't really help out-patient burns, they were designed for burn center inpatients. 

Silvadene is the topical of choice.  It is water soluble making for easy dressing changes.  For the face, some use neosporin but the neomycin might sensitize the skin, so bacitracin is probably better.  The manufacturer of silvadene denies any claims that it causes hypopigmentation. 

Have patient remove dressing, get is shower and wash off all burn cream using a soft gauze.  They can wash with a mild soap.  The area is then dried and a thin layer of cream is put on with a tongue depressor.  Place fluffed up gauze on wound and then secure qith a gauze wrap.

If a burn becomes infected, use penicillin or clindamycin.

Blister removal

they probably should be left intact for at least a few days as it is an ideal burn dressing.  Necrotic or sluffed skin should be removed.  Give a good slug of analgesia and then grip the blister with a dry gauze pad and rip it off in one motion.  Do not shave minor burns.  Outpatients will need pain control as well.  Elevation is probably the most important thing they can do on extremities. 

Honey and Aloe are probably better than silvadene.

Tar Burns

usually 2nd degree

Tar can be removed with neosporin cream or neomycin cream, ointments are not as effective.  Have the patient change their dressing twice a day using a generous amount of the cream. 

Cement Burns

Produces caustic damage secondary to alkali burns, but it does so insidiously.  The patient may not know they have been exposed until hours after the exposure.  Full thickness burns can result after only an hour of exposure.  When water is added to cement, calcium hydroxide forms, this causes the burns.  The cement should be washed off as soon as possible.  It may require 15-30 minutes of copious irrigation. 

Hydrocarbon

Can causes burns as well as the problems of systemic absorption of the substance.

Hand Burns

Sunburn

UVa=photosensitive rashes and aging

UVb=sunburn and skin cancer

If your shadow is shorter than you are, get out of the sun.

SPF is a multiplicative amount of time in sun before burn.

Reapply every 40-80 minutes to match FDA testing

SPF is total day of exposure with reapplication, not each application

1 oz should cover entire body.

So 8 0z. bottle should only last 1 week.

SPF doesn't apply to UVa

Best is probably Parsol 1789

Titanium dioxide is fantastic

ICU Care of the Burn Patient

loss of plasma up to crits of 70%

decreased cardiac output out of proportion to plasma loss

followed by hypermetabolic state with increase cardiac output

In healthy adults, use modified brooke 2 cc /kg/% burned over 1st 24 hours

all formulae are based on time of injury, not of resuscitation

consider PAWP if pt is still oliguric with increased fluids.  consider Mannitol 12.5 g added to each liter

In 2nd 24 hours, albumin diluted 0.3-0.4 cc / kg / % burned

Use high frequency interrupted flow positive pressure ventilation (HFIFPPV)

nebulized heparin 5000 u alternating with aerosolized  acetylcysteine Q2 hrs

Suppurative thrombophlebitis-from prolonged iv placement, dreaded complication, changing catheter site every three days may benefit

Burn Management
Col. Lee Cancio, MD, Surgeon and Clinical Trials Program Manager of the Trauma Division at the US Army Institute of Surgical Research, Brooke Army Medical Center, San Antonio, Texas, presented an interesting discussion on burn management, with a special emphasis on burn mass-casualty scenarios relating to his recent military experience in Iraq.

He described the different phases of resuscitation of burn patients. Clearly, the phases overlap increasingly because excision and grafting often begin on the immediate post-burn day. The ABCs (airway, breathing, circulation) are applied with special attention to the physiology of burn patients. In addition, because of a burn patient's risk for hypothermia and insensitive fluid losses, particular attention to fluid management and temperature control are paramount. Cancio recommends prophylactically intubating patients with burns greater than 40% of total body surface area, obvious inhalational injury, or deep facial burns to minimize the risk of loss of airway due to facial edema.

Inhalation injury can involve injury at 3 different levels: above the vocal cords, below the vocal cords, or in the lung tissue. Pitfalls to be aware of when treating these patients include hypoxia and hypercarbia due to inhalational injury that can lead to ventilator-induced lung injury (acute respiratory distress syndrome [ARDS]). He advocates "gentle" mechanical ventilation, keeping peak inspiratory pressures less than 40 cm H2O, FiO2 less than 60% along with pH greater than 7.2, SaO2 greater than 90%, and permissive hypercapnia and frequent use of bronchodilators to limit bronchospasm.

Cancio described the importance of differentiating burn shock from other forms of shock in terms of pathophysiology and time of onset. In cases of burn shock, increased capillary permeability, hydrostatic pressure, and colloid oncotic pressure contribute to loss of plasma volume from the microvasculature into the interstitium, leading to hypovolemic shock and edema formation. This usually occurs within 48 hours following the initial burn. In addition, decreased myocardial contractility and increased afterload also occur. This combination of events reduces cardiac output, which makes it necessary to correct the volume problem gradually.

To correct this volume problem, Cancio recommends against the use of a "bolus," using a modified "Brooke Army" formula at 2 cc/kg/% burn in adults with adjustments to achieve a urinary output of 30-50 cc/hr. Urine output, mental status, and resolution of base deficit are regarded as his indicators of ongoing resuscitation. He noted that examining the character of the peripheral pulses, and monitoring pulse and blood pressure are important as well. In a patient with a normal mental status, palpable peripheral pulses, and measurable blood pressure, Cancio recommends initially giving 1 L/hour of lactated Ringers solution. He then calculates burn size and using the formula, updates his fluid orders. An exception to this recommendation is the patient who presents with profound hypotension, has preexisting signs of dehydration, or when there has been a delay in resuscitation. In this situation a rapid infusion is used to restore palpable radial pulses and mentation.

Burn Wound Care
Cancio then reviewed care of burns for civilians as well as mass-casualty situations that may occur too far from a burn center for immediate transport. For civilians who are burned and can be rapidly transported to a burn center (less than 24 hours), he states that there is no need for application of creams, debridement, or prophylactic antibiotics. The goal is to keep the burns dry, warm, and clean, covering the burns with a dry sheet. In a mass-casualty scenario, patient transfer to a burn center is often delayed sometimes for days, so application of creams and prophylactic antibiotics is not unreasonable. The generous use of pain medication to debride burned tissue and perform dressing changes is essential.

Silver sulfadiazine (Silvadene) cream or mafenide acetate (Sulfamylon) cream should be applied as a thick layer as opposed to a lotion. He recommends application of a layer up to 1/16th to 1/8th of an inch. Silver sulfadiazine is often less painful and may costs less, but gram-negative organisms may have some resistance to this cream. Mafenide acetate, on the other hand, penetrates eschar and cartilage more effectively, has excellent gram-negative coverage including Pseudomonas, but can be quite painful on application to partial-thickness burns.

As an alternative to silver sulfadiazine cream or mafenide acetate cream, Silverlon and Acticoat have emerged for the treatment of burns. The principal mechanisms of action for these products are the same as those for silver sulfadiazine, with slow release of silver ions from a sheet-like material along with an antimicrobial effect.

Cancio discussed the management of burn wound cellulitis as well as burn wound sepsis. In burn wound cellulitis, there is usually more than 2 cm of erythema surrounding the burn wound edges. The causative organism is usually Staphylococcus aureus or streptococci bacteria. In addition, a low-grade fever may develop. The treatment is penicillin, vancomycin, or a first-generation cephalosporin.

Burn-wound sepsis was the leading cause of death before the introduction of topical antimicrobial agents. It is rarely seen in the West today. However, sepsis or septic shock due to Pseudomonas or other gram-negative organisms can constitute a life-threatening emergency. The presence of skin-color changes including dark red, brown, or black discoloration of the eschar makes the diagnosis of burn wound sepsis more likely. A biopsy specimen of the burn wound may reveal bacteria in the subcutaneous fat. Treatment is with an IV aminoglycoside, and antipseudomonal semisynthetic penicillin, along with application of mafenide acetate cream and excision of the burn down to the fascia.

Advanced Burn Life Support

Intubate all patients >40% BSA b/c even if no inhalation injury, these patients get massive edema

elevate head

consider nebulized heparin 5000 Q4 or 10000 Q6 to reduce airway clots

Patients get immediate SIRS

decreased CO and increased SVR

all mediator related

120 bpm is the NORMAL HR in burn pts, 160 is tachy

these folks have same EBB/Flow

keep sugars normal and check for ETOH to allow you to use urine to assess

0.5 cc/kg/hr ~50cc/hr

place NGT for > 20% BSA

start Stree Ulcer proph in ED

Elevate burned extremities

for pain 0.25 mg/kg of ketamine

invasive wound infections change in look or smell of burns