Thermal Burns

Burn Protocols from Jeff Guy

An app to calculate body surface area by Mersey Burns

Burn mortality prediction: J Trauma Acute Care Surg. 2012 Jan;72(1):251-6.

Burn Severity/Age

Children

Adults

Elderly

Minor

<10% TBSA

<15% TBSA

<10% TBSA

Full-thickness <2% TBSA

Moderate

10-20% TBSA

15-25% TBSA

10-20% TBSA

Full-thickness <10% TBSA (non-critical areas)

Severe

> 20% TBSA

> 25% TBSA

>20% TBSA

Full-thickness >10% TBSA

Burns in critical areas*

Complicated 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 patients palm (not counting the fingers) covers approximately 1% of the TBSA.

Fluids

Parkland Formula

Parkland formula for first 24 hours post burn (Half to be administered in first 8 hours post burn):

4 mls per % of body surface area burnt x body weight (kg) using LR

+ normal fluid requirements

+ blood from traumatic loss.

This should be reassessed hourly. A urine catheter must be inserted to assess urine output. Urine output should be no less than 0.7ml/kg/hr. If urine output is inadequate, increase infusion by 200ml next hour.

The hourly rate for the first 8 hours is: (% burn x kg)/4

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 wont 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 Ringers 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-thicknessburns to 1 of 2 treatment groups.3 The groups were similarin gender, mean age, mechanism of injury, and burn surface area.Twenty-five patients were treated with pure, unprocessed, undilutedhoney, and 25 patients were treated with SSD-impregnated gauze.Dressings were changed daily, and the wounds were inspectedevery 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 showedclinical granulation and epithelialization of the wound byday 7, and 100% showed such progress by day 21. In the SSD-treatedgroup, wound healing was evident in 72% by day 7 and in only84% by day 21, although these differences were not statisticallysignificant. By day 21, wound healing was complete in all ofthe patients in the honey-treated group and in only 21 of the25 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 Subrahmanyamrandomly assigned 104 patients with less than 40% TBSA partial-thicknessburns to 1 of 2 groups. Fifty-two patients were treated withhoney, and 52 patients were treated with SSD. Biopsy specimensfor culture and sensitivity determination were taken on admission,day 7, and day 21. Honey was superior to SSD cream for preventingbacterial growth in the burn wound and for wound healing (p= 0.05). Although Subrahmanyam’s studies were not conductedin an outpatient setting, and the TBSA of partial-thicknessburns was as much as 40%, these results suggest that honeymay be a simple, inexpensive, alternativeand probablysuperiordressing to use when treating minor burns.

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]
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

Cone JB. What’s new in general surgery: burns and metabolism. J Am

Coll Surg 2005;200:607-615.

This article is an excellent concise review of all significant advances in

burn injury and burn care over the last 12 months. Subjects include initial

ED and burn unit evaluation, resuscitation, and stabilization; aggressive

airway management with liberal flexible bronchoscopy and instillation of

various agents to try to reduce airway blockage by mucus and sloughed

epithelium; ventilator management; new skin substitutes; modulation of

the hypercatabolism of burns; and chemical burns, with a focus on

hydrofluoric acid.

Escharotomy

Article on Out-of-hospital Escharotomy

by Chris Nickson of lifeinthefastlane.com

A 35 year-old man was involved in a house fire and sustained extensive severe burns, particularly affecting his trunk and upper limbs. The patient is shown undergoing a procedure:

Click to enlarge

Questions

Q1. Describe the appearance of the skin on the patients chest?

Show answer

The skin has been severely burned. It has a leathery appearance consistent with the coagulated dead skin of a full thickness burn.

This is called eschar.

In a full thickness burn epidermis and dermis are destroyed, and the burn may penetrate more deeply into underlying structures. The sensory nerves in the dermis are destroyed, so pinprick sensation will be absent.

Q2. What procedure is being performed?

Show answer

Escharotomy

Although this rarely needs to be performed in the ED, studies have shown that a reluctance to perform escharotomies means nearly half of all pediatric burns patients have inadequately released burns prior to arrival at a tertiary burns centre.

Q3. When should this procedure be performed?

Show answer

Once eschar formation occurs the skin loses its expansibility and becomes restrictive. Progressive edema due to capillary leak, especially following fluid resuscitation, can have dire consequences. An escharotomy may be needed to release the burn and allow expansion.

Indications for escharotomy include:

circumferential burns of the chestthat increase chest wall rigidity and impair ventilation (e.g. increased peak airway pressures in the ventilated patient).
- children may have predominantly diaphragmatic breathing so an escharotomy may be required even if the burn is limited to the anterior chest and abdomen (non-circumferential).
constrictive circumferential neck burns that threaten the airway.
circumferential burns of the extremitiesresulting in circulatory embarrassment/ compartment syndrome.
- The escharotomy should be permed once there is evidence of decreased circulation to the extremity, but before there pulses are lost (e.g. using doppler ultrasound, or SaO2<90% on pulse oximetry of the affected limb)).

Q4. Describe how the procedure is performed.

Show answer

Preparation

The procedure should be performed in a sterile fashion. It usually takes place in an operating room, but it can be performed in the ED or the field in emergency situations.

Use a surgical marker to define the intended lines of incision with the limbs in anatomical position. The forearms will need to be supinated.

A and B are guides to the lines of incision when performing an escharotomy (from PrimarySurgery.org)

Anesthesia

Anesthesia is not essential as the eschar is insensate. Local anesthetic may be infiltrated at the edge of the burn where incisions will be extended into normal skin. Nevertheless, the patients are often intubated and sedated due to the severity of the burns or associated trauma.

Hemorrhage

Blood loss can be severe have artery forceps and ties, diathermy or topical hemostatics (such as calcium alginate) at the ready.

Escharotomy may be performed using cutting diathermy, and coagulative diathermy may help with hemostasis.

Incisions

The burned skin is incised down to the subcutaneous fat with a scalpel or cutting diathermy. They should be deep enough for obvious separation of the wound edges to occur. If in doubt, run a finger along the incision to detect any residual restrictive defects. The incisions should extend into normal skin by up to 1 cm.

Trunk

Longitudinal incisions along the anterior axillary lines to the costal margins, or upper abdomen if also burnt.

These longitudinal incisions are connected by convex upwards transverse incisions below the clavicles across the upper chest, and across the upper abdomen.

Limbs

Longitudinal incisions along the mid-axial lines between the extensor and flexoral surfaces. Incisions along the flexural creases of joints are avoided.

Lower limbs The medial incision should pass behind the medial malleolus to avoid the long saphenous vein and saphenous nerve. Lateral incisions are made in the midlateral line, avoiding the common peroneal nerve at the neck of the fibula.

Upper limbs The medial incision should pass anterior to the medial epicondyle to avoid the ulnar nerve at the elbow. On the medial aspect of the hand the incision may progress as far as the base of the little finger. On the lateral aspect of the hand the incision can progress to the proximal phalanx of the thumb. Sometimes an incision along one side of a limb is sufficient to preserve circulation.

Neck

usually performed laterally and posteriorly to decrease risk of damage to the carotid arteries and jugular veins.

Penis

midlateral incisions to avoid the dorsal vein.

The completed escharotomy

Q5. Which vulnerable areas require extreme caution?

Show answer

Structures immediately beneath the skin nerves and vessels are most vulnerable to damage during an escharotomy.

Structures particularly at risk of damage include:

the ulnar nerve (incision should pass in front of the medial epicondyle)
the peroneal nerve near (incision should not pass dover the neck of fibula)
the long saphenous vein and saphenous nerve (incision should pass behind the medial malleolus)

Transverse incisions on the limbs should be avoided.

Q6. what are the complications of escharotomy, including when it is inadequately performed?

Show answer

Escharotomy may be complicated by:

bleeding

infection

damage to underlying structures

Inadequate escharotomy may be complicated by:

local effects muscle necrosis, compressive neuropathy, amputation, inadequate ventilation, airway obstruction, abdominal compartment syndrome

systemic effects rhabdomyolysis (renal impairment, hyperkalemia, metabolic accidosis)

from (Prehosp Emerg Care 2010;14(3):349)

References

Emergency Management of Severe Burns (EMSB) Course Manual (11th edition). 2006; Australia and New Zealand Burns Association.

PrimarySurgery.org

Roberts JR and Hedges JR. Clinical Procedures in Emergency Medicine (5th edition). 2009; Saunders.

Antibiotics

BMJ. 2010 Feb 15;340:c241Prophylactic antibiotics for burns patients: systematic review and meta-analysis. Don’t use them

Airway Management of the Burn Patient

Intubate Early (http://www.ncbi.nlm.nih.gov/pubmed/25151328)

Inhalation Injury

http://www.ccforum.com/content/pdf/s13054-015-1077-4.pdf