BLASTS AND BURNS: Don’t Feel The Heat!

1. BLASTS AND BURNS: Don’t Feel The Heat! Susan Marie Baro, DO, FACOS Associate Trauma and Surgical Critical Care Associate Director Surgical Critical Care Physician Director Blood Conservation Program

2. OBJECTIVES • Understand the injuries that result from explosions and review current management and treatment of Blast Injuries • Review Burn Injury Classifications and Standard Treatments • Calculate % TBSA in Burns • Calculate IV Fluid Requirements in Burns

3. AMERICAN BURN ASSOCIATIONBurn Injury Severity Grading System • Minor Burn • 15% TBSA (Total Body Surface Area) or less in adults • 10% TBSA or less in children and the elderly • 2% TBSA or less full thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet or perineum

4. AMERICAN BURN ASSOCIATIONBurn Injury Severity Grading System • Moderate Burn • 15 – 25% TBSA in adults with less than 10% full thickness burn • 10 – 20% TBSA partial thickness burn in children < 10 and adults > 40 years of age with less than 10% full thickness burn • 10% TBSA or less full thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet, or perineum

5. AMERICAN BURN ASSOCIATIONBurn Injury Severity Grading System • Major Burn • 25% TBSA or greater • 20% TBSA in children <10 and adults > 40 years of age • 10% TBSA or greater full thickness burn • All burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment

6. AMERICAN BURN ASSOCIATIONBurn Injury Severity Grading System • Major Burn (cont.) • All high voltage electrical burns • All burn injury complicated b y major trauma or inhalation injury • All poor risk patients with burn injury

8. CLASSIFICATION OF BURNS • Thermal • Cold Exposure • Chemical • Electrical Current • Inhalation • Radiation

9. CLASSIFICATION BASED ON DEPTH OF TISSUE INJURY • 1st Degree – Superficial or Epidermal • 2nd Degree – Partial Thickness • 3rd Degree – Full Thickness • 4th Degree – burns extending beneath the subcutaneous tissues involving the fascia, muscle, and /or the bone

11. SUPERFICIAL BURN • Epidermal layer (ex, sunburn) • No Blisters • Red, painful, and dry • Epidermal layer peels away • Blanches with pressure • Subsides over 2 – 3 days and heals within 6 days without scarring

13. PARTIAL THICKNESS: SUPERFICIAL • Between the epidermis and the dermis • Forms blisters within 24 hours • Painful, red, weeping • Blanches with pressure • Pigment changes can occur • Usually heals in 7 – 21 days • Scarring unusual

15. PARTIAL THICKNESS:DEEP • Extends deep into the dermis • Damages hair follicles and glandular tissue • Painful to pressure only • Almost always blisters • Wet, waxy, or dry • Variable mottled coloration (Patchy cheezy white to red)

16. PARTIAL THICKNESS:DEEP (cont). • Does not blanch • Heals in 3 – 9 weeks if no grafting required • Causes hypertrophic scarring • If involves the joint, expect dysfunction even with aggressive physical therapy • Hard to differentiate from Full Thickness burn

18. FULL THICKNESS • Extends through and destroys all layers of the dermis and often injures underlying subcutaneous tissue • Burn eschar and denature dermis usually intact • Eschar compromises viability of limb and torso if circumferential • Anesthetic or hypoesthetic

19. FULL THICKNESS (cont.) • Skin waxy white to leathery gray to charred and black • Dry and inelastic • Does not blanch • No vesicles or blisters

20. FULL THICKNESS (cont.) • Eschar usually separates from the underlying tissue and reveals an unhealed bed of granulation tissue • Without surgery – they heal by wound contracture with epithelialization around the edges • Scarring is severe with contractures

22. FOURTH DEGREE • Deep • Potentially life threatening • Extend through the skin to underlying structures

24. TOTAL BODY SURFACE AREA • Size is usually underestimated • Results in under resuscitation • Lund-Browder • Most accurate for both children and adults • Takes into account the relative % of body surface area affected by growth • Kids have larger heads and smaller extremities

27. TOTAL BODY SURFACE AREA (cont). • Rule of Nines (adults) • Each leg represents 18% TBSA • Each arm represent 9% TBSA • Anterior and Posterior Trunk each represent 18% TBSA • Head represents 9 % TBSA

29. TOTAL BODY SURFACE AREA (cont). • Palm Method • Used when the burn is irregular and/or patchy • Utilizes the surface area of the patients palm • Palm, excluding extended fingers = 0.5% patients TBSA • Palm, extending fingers = 1% of patients TBSA

30. INITIAL MANAGEMENT • Essentially ATLS • Special attention to respiratory distress and smoke inhalation • Remove clothing promptly • Consider early transfer to Burn Center • History is important • Materials, chemicals, open vs closed space, explosion or blast involvement, associated trauma

31. AIRWAY • Inhalation injury remains a leading cause of death in the adult burn victim • Present in 2/3’s of patient with burns > 70% TBSA • Supplemental oxygen, maintain airway • Upper airway edema occurs rapidly

32. AIRWAY (cont.) • RSI with Succinylcholine acceptable in the first 72 hours but no later secondary to the risk of severe hyperkalemia • Significant % develop ARDS

33. SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY • Persistent cough, stridor, or wheezing • Hoarseness • Deep facial or circumferential neck burns • Nares with inflammation or singed hair • Carbonaceous sputum or burnt matter in the nose or mouth • Blistering or edema of the oropharynx

34. SIGNS OF SIGNIFICANT SMOKE INHALATION INJURY (cont.) • Depressed mental status • Respiratory distress • Hypoxia or Hypercapnia • Elevated Carbon Monoxide and/or Cyanide levels • Inhalation injury from hot gasses usually occurs above the vocal cords

35. CARBON MONOXIDE AND CYANIDE • Check Carboxyhemaglobin level in all patients with moderate to severe burns • Standard Pulse-Ox not reliable • Treatment with high flow oxygen alone effectively removes CO • Hyperbaric Oxygen Treatment if increased CO or if treatment for Cyanide poisoning places patient at risk for hypoxemia

36. CARBON MONOXIDE AND CYANIDE (cont.) • Check Methemaglobin if Cyanide poisoning suspected • Consider Cyanide toxicity in severe burn patients with unexplained lactic acidosis and declining EtCO2 • Treatment: Hydroxocobalamin

37. TREATMENT • Supplemental Oxygen and Airway Protection • Bronchodilators when bronchospasm present • Avoid Corticosteroids • Fluid resuscitation with aggressive monitoring

38. TREATMENT (cont.) • Vent Settings: low tidal volumes to minimize airway pressures and to reduce incidents of Ventilator Associated Acute Lung Injury (ALI) • Inhaled Nitric Oxide – may increase hypoxic vasoconstriction • Aerosolized Heparin and N-Acetylcysteine(NAC) – may help to remove broncho-pulmonary casts

39. FLUID RESUSCITATION • Burn Shock – occurs within 24 – 48 hours • Characterized by myocardial depression and increased capillary permeability • Results in large fluid shifts and depletion of intravascular volume • Rapid, aggressive fluid resuscitation helps to reconstitute the intravascular volume and maintain end organ perfusion

40. FLUID RESUSCITATION (cont.) • A-line • Foley for accurate urine outputs • Over-resuscitation leads to ARDS, pneumonia, MSOF, and compartment syndromes (including abdomen, limb, and orbit) • Any patient with > 15% TBSA, nonsuperficial burns (2nd/3rd Degree) should receive formal fluid resuscitation

41. FLUIDS • IV Crystalloid – typically Ringer’s Lactate • helps to reduce incidence of hyperchloremic acidosis associated with large volumes of isotonic saline (NS) • Colloid and Hypertonic Saline for initial resuscitation not found to show any improvement in outcomes, are more expensive, and possibly increase renal failure and death

42. FLUIDS (cont.) • Following initial resuscitation IV fluids need to meet baseline fluid needs and maintain Urine outputs • IF UO < 0.5 ml/kg/hr – bolus with 500 to 1000 ml fluid and increase rate by 20 – 30% • If adequate resuscitation and patient stabilizes, change to D5 ½ NS with 20 mEqKCl per liter at maintenance to keep UO > 0.5 ml/kg/hr

43. ESTIMATING INITIAL FLUID REQUIREMENTS • Parkland Formula – utilized in initial 24 hrs • Includes partial and full thickness burns • 4 ml/kg for each % of TBSA burned over 15% TBSA • ½ volume given in 1st 8 hours and the remaining volume given over the next 16 hours

44. ESTIMATING INITIAL FLUID REQUIREMENTS (cont.) • Modified Brooke Formula • Given over initial 24 hours • 2 ml/kg for each % TBSA • Likely reduces the overall volume

45. BLOOD TRASFUSION • Avoid if possible • Associated with increased mortality • Only if Hemoglobin < 8 gm/dL unless patient with acute coronary syndrome • If at risk for ACS – transfuse to 10 gm/dL

46. IMMEDIATE BURN CARE • Remove clothing • Cool burned area immediately using cool water or saline soaked gauze • can minimize the zone of injury in small burns • Monitor cor body temp to prevent hypothermia, especially if >10% TBSA • Avoid temps below 35o C/95o F • Aggressive Pain control with Morphine and Benzo’s for anxiety

48. CHEMOPROPHYLAXIS • Extensive burns cause immunosuppression on basis of altered neutrophil activity, T lymphocyte dysfunction, and imbalance in production of cytokines • Bacterial colonization of the burn eschar site can result • Burns destroy physical barrier to tissue invasion • Permits spread of bacteria to the dermis and through the lymphatics along the fibrous septae

49. CHEMOPROPHYLAXIS (cont.) • Once invasion occurs – organisms can invade the blood vessels producing secondary bacteremia • Topical antibiotics are given to all patients with nonsuperficial burns

50. TETANUS • Update for any burns deeper than superficial • Tetanus Immune Globulin – if patient did not receive complete set of primary immunizations