Burn Care in the 21 s t Century

1. Burn Care in the 21s t Century James H. Holmes IV, MD Director, WFUBMC Burn Center Assistant Professor of Surgery Wake Forest University School of Medicine

2. Epidemiology • ~500,000 pts/yr seek medical care for burns • 40,000 require hospital adm (avg <15% TBSA) • >90% preventable; ~50% d/t substance abuse • ~4000 die …... vs. ~15,000 deaths in 1970 • LD50 > 70% TBSA …… vs. ~30% in 1970 • >50% return to pre-burn functioning • Mechanism is age-related & situational: • < 8 yoa  scalds • all others  flame burns • work  chemical/electrical/molten

3. Burn LD50 & Advances in Care

4. A.B.A. Referral Guidelines • PT burns > 10% TBSA • Any FT burns • Burns involving the face, hands, feet, genitalia, perineum, or major joints • Electrical burns • Chemical burns • Inhalation injury • Burns with concomitant non-thermal trauma • Burns in patients with preexisting medical conditions that may complicate management • Burns in patients who will require special social, emotional, or long-term rehabilitative intervention

5. BURNS = TRAUMARemember ABC’s(with a twist)

6. Airway & Breathing • Inhalation Injury (~7% of patients in NBR) • HX: closed space fire, meth lab explosion, or petroleum product combustion • Upper airway injury: acute mortality • facial/intraoral burns, naso/oropharyngeal soot, sore throat, abnormal phonation, stridor • Lower airway injury: delayed mortality • dyspnea, wheezing, carbonaceous sputum, COHb, PaO2/FiO2 • Will increase resuscitation volumes • Clinical dx - NO NPL, bronchoscopy +/- • Intubate EARLY!!! Orotracheal • Surgical airway uncommon

7. Calculate burn size • The “TWIST” • Burn depth • Superficial • Partial-thickness (PT) • Full-thickness (FT) • Indeterminate • Only partial-thickness (2nd degree), indeterminate, & full-thickness (≥3rd degree) injuries count towards %TBSA

8. Estimating Burn Depth/Severity

9. 3 Zones of Thermal Injury Hyperemia Stasis Coagulation

10. Burn Depth

11. “Superficial” • Formerly “1st-degree” • Essentially a sunburn • Pink • Painful • NO blisters • Will heal in < 1 week

12. “Partial-thickness” • Formerly “2nd-degree” • Pink • Moist • Exquisitely painful • Blistered • Typically heals in < 2-3 weeks

13. “Full-thickness” • Formerly “3rd-degree” • Dry • Leathery • White to charred • Insensate • Will require E&G

14. “Indeterminate” • Unsure as to whether PT or FT • Observe for conversion b/t days 3-7 • May or may not require E&G • Can unpredictably increase LOS

15. Calculate burn size • Determine burn depth • Only PT (2nd degree), indeterminate, & FT (≥3rd degree) count • Estimate %TBSA • Palmar surface of pts hand = 1% TBSA • Age-appropriate diagrams (e.g.- Berkow) • Rule of Nines

16. Berkow Diagram

17. Rule of Nines • Body divided into fractions of 9% • Head = 9% • Ant thorax = 18% • Post thorax = 18% • Each UE = 9% • Each LE = 18% • Genitalia = 1% • Not reliable in kids!!!

18. Calculate burn size • Determine burn depth • Only PT (2nd degree), indeterminate, & FT (≥3rd degree) count • Estimate %TBSA • Palmar surface of pts hand = 1% TBSA • Age-appropriate diagrams (e.g.-Berkow) • Rule of Nines • Burn experience  accuracy in determining burn size & severity

19. Circulation • Typically burns 20% require IVF resuscitation • Resuscitate w/ LACTATED RINGER’S • Adult  Baxter/Parkland Formula = 4 cc/kg/% burn • 1/2 over 1st 8 hr fromtime of burn • 1/2 over subsequent 16 hr • Child (<20 kg)  3 cc/kg/% burn + D5 MIVF • Goal = UOP of 30 cc/hr (1 cc/kg/hr in kids) • Peripheral IV access -- NO cut-downs • Do NOT bolus !!! • NO normal saline!!!

20. Resuscitation Fine Points • More is NOT better!!! • Crystalloid … NOT colloid & only LR • Goal is normotensive, perfused, urinating pt. • < 4 cc of LR /kg/%TBSA •  central monitoring • Escharotomies • ACS is unacceptable!!!

21. Disability(from other injuries) • Primary & secondary surveys are important!!! • R/O non-thermal trauma … ~5% have concomitant non-thermal injury • Management of non-thermal trauma typically supercedes burn management, except for the resuscitation.

22. Everything else • No IV antibiotic prophylaxis!!! • Vascular access: PIV is preferable • Analgesia = IV opiates • Conservative & judicious sedatives, prn only • Wood’s lamp eye exam for flash burns to face • Escharotomies • Early enteral nutrition (≥ 20% TBSA)

23. Escharotomies

24. Indications • Circumferential FT extremity burns with threatened distal tissue • Diminished or absent distal pulses via doppler • Any S/S of compartment syndrome • Circumferential FT thoracic burn • Elevated PIP or Pplateau • Worsening oxygenation or ventilation • Nearly impossible to resuscitate patient with restrictive eschar needing release • Fasciotomies rarely needed

25. Technique • ANATOMIC POSITION!! • Med & lat lines of extremities, over lumbricals on dorsal hands, ant or mid axillary lines on chest, & lateral neck lines • Thru eschar only -- RELEASE • Use cautery (knife OK) • Not a sterile procedure • Digits are controversial

26. After…

27. Initial Wound Management • No IV antibiotics!!! • Analgesia = IV opiates • Wound care  keep it simple • Moist dressings (smaller burns) • Dry non-adherent dressings (larger burns) • “burn sheet”, cellophane, etc… • Topical antibiotics only if delay in transfer • Silvadene • Bacitracin • +/- blister removal • Defer to burn center protocols, if uncertain

28. Excision & Grafting

29. Tangential Excision (TE) • Done “early” (w/in 7 d) • Various adjustable knives • Sequentially remove only non-viable tissue • Standard burn operation • BLOODY!!! • Tourniquets on extremities • Speed is essential

30. Fascial Excision (FE) • Done “early” (w/in 7 days) • Done w/ Bovie • Used for deep FT w/ dead subQ tissue • Excise to fascia • “Inferior” cosmesis (?) • Blood loss < TE

31. Split-thickness Autograft (STAG) • Skin is currently the only way to definitively “close” a burn wound. • STAG typically 0.010 - 0.012 inches thick • Meshed or sheet (location) • Limited quantity • Donor site issues & complications

32. Allograft • Only temporary • Ultimately rejected • Always requires STAG • Uses: • temporary closure to allow donor healing & re-cropping • STAG overlay • test excision bed

33. Wound Closure Advances • Dermal substitutes • Integra (bilaminate, collagen-chondroiton-6-SO4) • Alloderm (cryopreserved allogeneic dermis) • Dermagraft (neonatal FB on Biobrane) • allow formation of autogenous “neodermis” • utilize ultra-thin STAG (0.006 - 0.008 in) • superior cosmesis & fxn vs. standard E&G • Cultured epithelial autografts (CEA) • Epicel (cultured skin from patient) • fragile, limited overall burn experience, $$$$

35. Integra

36. The Template • FDA approved in ‘96 • Bilaminate membrane • Applied to excised wound • Engrafts in ~ 14 days (~7 days with VAC) • Ultra-thin STAG (“EAG”) • Superior cosmesis & fxn, decreased LOS • Drawbacks: • Learning curve • At least 2 operations

37. Operation #1 (Application) Wound Bed Excision Application of Integra

38. Operation #2 (EAG) Removal of the Silicone Layer Graft Application

39. Integra Results

40. Chemical Burns • Decontaminate patient prior to transport or transfer • Acids/alkalis • Meth labs • Petroleum products • “Industry” • H2O… H2O… H2O… H2O • Irrigation for ≥30 min • No formal antidotes (exothermic rxns), except for HF • Keep patient warm, if at all possible

41. Electrical Injuries/Burns • High (>1000 V) & Low (<1000 V) voltage • Remove patient from current source • Dysrhythmias, SZ, FX, etc….. • Electrical & thermal components to injury • Holmes’ IVF rule of thumb: “double the calculated IVF rate (or volume) for a given estimated TBSA” • Always more injury than is apparent

42. Modern Burn Care Model Nursing (33%) Therapy (33%) Med/Surg (33%)

43. Beyond the OR • Wound care & healing are PAINFUL • Long-term opiates are the rule • PT/OT is long-term… lifelong to a degree • Revisions & reconstructions are common w/ larger burns, >30% TBSA • Burn care is expensive!!! • NBR mean hospital charges for survivors ~$56,200/admission & ~$4075/d • WFUBMC…. ~$4090/d

44. Beyond Acute Hospitalization • PT/OT is lifelong, to some degree • Long-term neuropsych & psychosocial issues are pervasive • Burn survivor support groups & peers are essential • S.O.A.R. • Victim 2 Victor

45. Outcomes: What to expect • Goal = LOS of 1 day/% TBSA burned • Reality: NBR = 1.7 and WFUBMC = 1.3 • RTW: ??? …… NBR = ? • WFUBMC > 50% return to pre-burn fxn • Disposition goal is ultimately home & independent….. NBR = ? • WFUBMC = 88% D/C’d home & 6% rehab • PTSD & other neuropsych sequelae are COMMON

46. WFUBMC Burn Center Transfers or Referrals • “Open-door” policy for ANY burn - NO • CALL P.A.L.  800-277-7654 • Ask for Trauma/Burn Attending on-call • age, hx, %TBSA of PT/FT, UOP, airway & HD status • LR for resuscitation • transport (BMC AirCare ground or helicopter, 24-7) • Do not directly call the WFUBMC Emergency Dept or Burn Center • Dedicated Burn Clinic every MON & WED

47. WFUBMC Burn Team