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John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005

FLAME ON !!. John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005. FLAME OFF ! John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005. HEY!. Objectives. Burn classification Causes of burns

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John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005

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  1. FLAME ON !! John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005

  2. FLAME OFF! John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine December 15, 2005 HEY!

  3. Objectives • Burn classification • Causes of burns • Treatment regimens • Complications

  4. Epidemiology(from http://www.ameriburn.org/pub/BurnIncidenceFactSheet) • More than 1 million burn injuries per year • 4,500 fire and burn deaths per year • 45,000 hospitalizations per year • half to burn centers and half to other hospitals • 700,000 annual emergency department visits

  5. Epidemiology • 3rd leading cause of death in childhood • Morbidity is 3x mortality • >$1 billion/year in medical costs • 80% minor scalds, 3-5% life threatening • 13% flames and smoke inhalation, 2-3% electricity and chemical • Causes of burns vary with age

  6. Skin Anatomy • Preserves body fluids • Temperature regulation • Infection barrier From Advances in Skin & Wound Care 2005, 18 (6): 323-332

  7. Pre-Hospital Care of Burns • Stop the burn • Dissipate/cool the heat • DON’T… • Use ice or extreme cold • Use other emollients, eg peanut butter, butter, grease

  8. Superficial Burns • 1st degree burns • Redness, mild inflammation • No significant edema and vesicle • Painful • 3-5 days to heal, usually without scar From American Family Physician 2000, 62 (9): 2016

  9. Superficial Burn From American Family Physician 2000, 62 (9): 2016

  10. Treatment for Superficial Burns • Moisturize burn area with bland emollients • Anti-pruritics • Pain relief: Tylenol, NSAIDs • Protect from sun for at least a year

  11. Superficial Partial Thickness Burn • Superficial 2nd degree burn • Pink-red, moist • Blisters and edema • Painful with exposed nerve roots • Heals in 2 weeks, with minimal scar From American Family Physician 2000, 62 (9): 2016

  12. Superficial Partial Thickness Burn From American Family Physician 2000, 62 (9): 2016

  13. Treatment for Superficial Partial Thickness Burns • Clean with mild soap and water or 1/4 strength povidone-iodine or NS • Wipe away dead tissue • Leave bullae alone, unless they are very large or in an area where will burst • Petrolatum gauze if <2% BSA • Topical antibiotics • Change dressing BID and re-evaluate in 1-2 days

  14. Superficial Partial Thickness Burns: Other Considerations • Clean technique for dressing changes • Wash hands • Clean the bathroom! • Signs and symptoms of infection • Hypertrophic scarring • Massage (with moisturizer) • Pressure garment dressings • Silicone gel sheets • Hyperpigmentation

  15. From American Journal of Clinical Dermatology 2002, 3 (8): 533

  16. Bacteria in Burns • Gram + colonization  Gram -  fungi • Signs of infection: increased redness, pain, swelling to edges, exudate, fever, deteriorating burn status • Cover for MRSA, Pseudomonas, Strep • No role for prophylactic antibiotics • Td immunization

  17. Topical Antibiotics • Silver sulfadiazene (Silvadene) (1%) • Covers Gram - (E. coli, Enterobacter, Pseudomonas), Gram + (S. aureus) and yeast • May interfere with wound-healing • Adverse Reactions: leukopenia, kernicterus • DON’T use if have Sulfa allergy • DON’T use with preemies, <2 mo, or on pregnant women

  18. Topical Antibiotics (cont’d) • Bacitracin ointment • Covers Gram + cocci and bacilli • Inhibits cell wall synthesis, stimulates PMNs • Rare reactions: hypersensitivity, rash (if used on healed wounds) • Resistance rare

  19. Topical Antibiotics (cont’d) • Neomycin ointment • Covers Gram - (E. coli, Enterobacter) and Gram + bacteria • Inhibits replication (bind ribosomal subunit) • Rare reactions: hypersensitivity, ototoxicity, nephrotoxicity (dose related) • Resistance rare

  20. Topical Antibiotics (cont’d) • Mafenide acetate (0.5%) cream • Methylated sulfonamide • Bacteriostatic against Gram - and +, but not yeast • May impair wound healing • Penetrates areas with limited blood supply well, eg eschars, ears • Adverse reactions: metabolic acidosis

  21. HONEY(American Journal of Clinical Dermatology 2001, 2 (1): 13-19) • Create layer so dressing doesn’t stick • Moist environment • Antibacterial (main ingredient, H2O2) • Activates immune system (B/T cells, PMNs) • Anti-inflammatory • Stimulate angiogenesis, fibroblasts and epi cells • Debriding effect

  22. Burn Zones • Coagulation • Stasis • Hyperemia From BMJ 2004, 328 (7453): 1427

  23. Burn Zones Zone of stasis Zone of hyperemia Zone of coagulation From BMJ 2004, 328 (7453): 1427

  24. Deep Partial Thickness Burns • Deep 2nd degree burn • Pale, dry, speckled from thrombosed vessels • Less painful • Can progress to full thickness • Heals in weeks, with scar • Often needs skin grafts From American Family Physician 2000, 62 (9): 2017

  25. Deep Partial Thickness Burn From American Family Physician 2000, 62 (9): 2017

  26. Full Thickness Burn • 3rd degree burn • Pale, charred, leathery • Non-tender in area of burn • Heals from periphery, needs skin graft From American Family Physician 2000, 62 (9): 2017

  27. Leathery Skin George Hamilton

  28. Full Thickness burn From American Family Physician 2000, 62 (9): 2017 From BMJ 2004, 329 (7457): 103

  29. Treatment of Deep Partial and Full Thickness Burns • Irrigate with sterile saline • Wipe away loose tissue • Cover loosely with clean sheets • ABC’s, fluid resuscitation, monitor temperature • Early excision and grafting (autograft, allograft, xenograft, artificial skin), negative pressure dressings • Escharotomy, Doppler studies

  30. Escharotomy From BMJ 2004, 329 (7457): 102

  31. From Advances in Skin & Wound Care 2003, 16 (4): 178-187

  32. Admission Factors • Admit kids <2 y/o • Kids that family won’t be able to care for wounds at home • >10% BSA partial thickness burns, consider burn center if >20% BSA • >2 % BSA full thickness burns • >1% BSA on face, perineum, hand, feet, across joints, or circumferential burns • Inhalational injury or associated trauma

  33. Burn Center Criteria Chart

  34. Burn Algorithm Example From BMJ 2004, 329 (7458): 160

  35. Case 1: The Roof Is On Fire 6 y/o boy is brought to you by EMS. He was in a house fire and caught on the second floor. During the rescue, he and the fire fighter fell to the first floor. They both reek of burned plastic.

  36. Case 1: Exam • T 38.5C HR 120 RR 38 BP 100/60 SaO2 95% Wt 30 kg • General: crying, lying on stretcher • HEENT: burnt hair, oral mucosal erythema, black sputum • CV: tachycardic, RR • Pulm: tachypneic, wheezes • Abdomen/Ext/Neuro: unremarkable • Derm: burns noted to all extremities and trunk What would you like to do?

  37. Labs and XRays • CBC: anemia, thrombocytopenia • CMP: renal function, electrolytes, albumin • CPK: rhabdomyolysis • T&S • PT/PTT: coagulopathy • Chest XR: evidence of inhalational injury

  38. Estimation of Burn Surface Area • Wallace rule of 9’s • NOT accurate in children • Palmar surface area • Area of an adult palm, including fingers, is 0.8% for males and 0.7% for females • Area of a pediatric palm, including fingers, is 1% • May have to alter estimate if BMI > 31 • Lund and Browder chart

  39. Wallace Rule of Nines From BMJ 2004, 329 (7457): 101

  40. Lund and Browder Chart From AACN Clinical Issues 2003, 14 (4): 429-441

  41. Fluid Calculations • Parkland formula • 4 mL/ kg/ %BSA (partial and full thickness burns) • 1/2 over first 8 hours, half over next 16 hours • Add in maintenance fluids for <5 y/o • Carvajal formula • 5000 mL/ m2/ %BSA (partial and full thickness burns) • 1/2 over first 8 hours, half over next 16 hours • 2000 mL/ m2/ day for maintenance • Galveston formula • 5000 mL/m2 BSA + 1500 mL/m2 BSA (for maintenance) in first 24 hours

  42. Fluid + Colloid Calculations • Theory: if add back colloids, use less crystalloid overall • Adding back colloids, eg albumin • Brooke Army formula • Evans formula • Guegniaud et al

  43. Sedation & Analgesia • Hyperalgesic state • Lower thresholds • Exposed nerve roots • Primary (injury site) vs secondary pain (injury and adjacent sites) • Hypermetabolic state, ergo altered pharmacokinetics • Background vs procedure-related pain • IV/IO is best route. Intranasal is an option.

  44. Sedation & Analgesia (cont’d) • Opioids: Morphine, Fentanyl, Oxycodone, Methadone, Remifentanil, Alfentanil • Opioid Agonist/Antagonist: Nubain, Pentazocine • Benzodiazepines: Versed, Valium, Ativan • Dissociative drugs: Ketamine • Non-opioid analgesics: NSAIDs, Tramadol, Tylenol

  45. Sedation & Analgesia (cont’d) • Gases: Nitrous oxide, Sevoflurane • Sedative-Hypnotics: barbiturates, chloral hydrate • Neuroleptics: Haldol, Risperdol, Neurontin, Zyprexa, Ziprasidone, Clonidine • Stimulants and Antidepressants: Ritalin, tricyclics (as adjuvants for pain control) • Other: Etomidate, Propofol, Lidocaine, hypnosis, distraction, behavioral techniques, etc.

  46. Case 1: He’s getting more agitated • HR 100s RR 44 BP 100/60 SaO2 97% • Upper airway disperses heat • Damage to lower airway usually chemical: cell and surfactant damage, inflammation (ARDS)

  47. CXR of Smoke Inhalation

  48. Inhalational Injury • Place on 100% O2 • Check ABG • Acidosis, hypoxemia, hypercarbia • Carboxyhemoglobin • Intubate with RSI • DON’T use succinylcholine! • May need higher than usual doses of meds • Ventilate with high frequency, CPAP • Frequent suctioning • Consider bronchodilators (nebs or IV) • Consider heparin/acetylcystine nebs

  49. Beware Facial Burns From BMJ 2004, 328 (7455): 1555

  50. Carbon Monoxide Poisoning • CO binds to hemoglobin and cytochromes • In non-smoker, carboxyHgb < 1% • Causes metabolic acidosis through hypoxia, possible cerebral edema • “Cherry red” skin color • Rhabdomyolysis from pressure  ARF • Delayed neuropsychologic sequelae (DNS)

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