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Burns…. Back to Basics 2010 Dr. Jennifer Clow, CCFP (EM). Case:. 45 y. o. male, working in shed Wood-burning stove for heat… Thinks stove is cold – adds more wood, then pours lighter fluid on top Stove explodes Patient and shed on fire!!! Brought in by paramedics to your ER….
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Burns… Back to Basics 2010 Dr. Jennifer Clow, CCFP (EM)
Case: • 45 y. o. male, working in shed • Wood-burning stove for heat… • Thinks stove is cold – adds more wood, then pours lighter fluid on top • Stove explodes • Patient and shed on fire!!! • Brought in by paramedics to your ER…
Case, cont’d • What do you want to do??? • Airway • Breathing • Circulation • Disability • Exposure • What other information do you need?
Case, cont’d • History… • Wood-burning stove • Door open at time of exposure • Flash caught patient’s clothing on fire • Patient ran from burning shed immediately • No toxic chemicals in shed • PMHx • Meds/Social
Case, cont’d • Physical Examination • Hemodynamic stability? • Depth and extent of burns – TBSA? • Any facial burns? • Signs of inhalational injury? • Circumferential burns? • Any associated traumatic injuries? • Signs of poisoning
Causes of burns… • Thermal – flame, flash, contact, scald • Electrical – high/low voltage, lightning • Chemical – acid, alkali • Radiation – UV, therapeutic
Burn Depth • 1st degree – just epidermis • 2nd degree – dermis • Superficial • Deep • 3rd degree – full thickness • 4th degree – involves muscles, bones, deep organs
Burn depth…. Figure 43-3. Layers of the skin, showing depth of first-, second-, and third-degree burns. (Reproduced, with permission, from Way LW [editor]: Current Surgical Diagnosis & Treatment, 9th ed. Appleton & Lange, 1991.)
First degree • Skin is red, tender, dry • No blister formation • e.g. sunburn • Usually heals within 7-10 days • Does not scar
Second Degree • Superficial Partial Thickness • Blisters, very painful • Dermis exposed – red, moist, good capillary refill • Heals within 2-3 weeks • Minimal scar formation
Second Degree, cont’d • Deep Partial Thickness • Skin is white/yellow • Minimal pain – difficult to differentiate from third degree by inspection • Cap. Refill, pain sensation absent • Pressure felt, 2 point discrimination decreased • Healing takes 1-3 months • Usually scars, may need grafting
Third Degree • Full thickness of skin (epidermis, dermis and subcutaneous tissue) • Skin white or black, may be charred • No dermal elements remain, therefore will not heal independently – require surgical intervention and skin grafts • Significant scarring
Fourth Degree • Extends through skin and subcutaneous tissue to involve muscle, bones, tendons or deeper tissues • Requires extensive surgical repair • May necessitate amputation
TBSA??? • Total Body Surface Area • Only applies to area with second and third degree burns • “Rule of Nines” • May use palm of patient’s hand to signify 1% TBSA
Inhalational Injury?? • Signs of Inhalational Injury • Singed nasal hairs, soot around nares • Carbonaceous sputum, cough • Hoarse voice, stridor, respiratory distress • Carboxyhemoglobin > 10% • Risk Factors • Burns sustained in a confined space • Flash burns, burns to face
Inhalational Injury… • Mechanism • Injury occurs due to heat exposure, chemical inhalation, particulate matter • Injury • Upper airway edema • Bronchospasm • Pulmonary edema
Tests • ECG • CXR, other imaging as indicated • CBC, electrolyes, glucose, renal fcn • ABG, carboxyhemoglobin • ?tetanus status
Treatment • Includes all 1st degree, and many superficial 2nd degree burns • Can usually be managed as outpatients • May or may not require specialized follow-up, or GP care • Many patients need significant reassurance • Ensure patients have a safe place to stay
Treatment • Cooling • Cleaning – mild antiseptic solution, or soap and water; limit rubbing • Debride blisters if large, or over joints • Topical antibiotics • Sterile dressings • Analgesia
ABC’s!!! • Airway • Intubate if any signs of airway injury, if significant TBSA burns, if altered LOC • Breathing • 100% O2 • Monitor SpO2, respiratory rate, WOB • Intubate Early!
ABC’s cont’d • Circulation… • 2 large bore IVs • FLUIDS, FLUIDS, FLUIDS… • Parkland Formula • Disability, Exposure • Cut off all clothing; may need soaking off • Evaluate other injuries
Parkland Formula • Ringers lactate • 4 ml/kg/%TBSA over 24 hours • Half in 1st 8 hours • Half in next 16 hours • Titrate to urine output, BP, HR • May need 40+ liters of fluid
Other Management • Foley catheter • Nasogastric tube • Tetanus prophylaxis • Remove jewelry • Antibiotics • Wound care • Control pain – narcotics, amnestics
Special Situations • Circumferential Burns • May need escharotomy, especially on neck, trunk, limbs • Inhalational Injury • Require intubation, 100% O2 • May need hyperbaric oxygen • Ocular Injury • Need urgent ophthalmologic evaluation
Transfer to Burn Center? • All “Major” Burns • Any burn patients with associated major trauma • Suspected child abuse • Anyone requiring surgical interventions
Back to the case… • 2nd and 3rd degree burns • Chest and abdomen, full back • Both arms, hands • Anterior legs • Half of face • ??TBSA
Back to the case… • Vitals • BP 170/100 • HR 130 • SpO2 – cannot obtain due to burned fingers • RR 30 • Temp 36 orally
Back to the case… • Singed nasal hairs • Soot in mouth • Coughing • Talking normally • Complains of severe pain over entire body
Back to the case… • Now what?????? • Sedate and intubate • Keep sedated • Foley, NG • BIG IVs • How much fluid???
Back to the case… • Parkland formula • Approximately 70% TBSA • Patient weighs 80 kg • 4 ml/kg/%TBSA = 4 x 80 x 70 = 22400 ml • i.e. more than 22 liters of fluid… 11 over first 8 hours, then 11 over next 16… • Titrate to urine output and vitals
Back to the case… • Circumferential burns to chest, arms, fingers • Requires escharotomy to ensure chest is able to expand, and to limit chances of losing fingers! • Needs a burn center!!!
