Burns in the Emergency Department

1. Burns in the Emergency Department Nicole Coyne, MBS, MMS, PA-C Arizona Burn Center

2. Learning Objectives • Understand the parameters of burn injury • Properly evaluate burns • Recognize the need for early referral • Appropriately manage the burn and other system abnormalities that occur as a result of burns

3. The Basics • Skin Anatomy • Epidermis • 10% skin’s thickness • Acts as barrier • Dermis • 90% skin’s thickness • Contains accessory structures • Collagen, elastin • Mechanoreceptors

4. The Basics • Skin Functions • Protection • Sensation • Heat regulation • Barrier to fluid loss • Storage • Absorption • Water resistance

5. Evaluation of burn depth

6. Superficial Burns • Only epidermis involved • Red, painful, no blisters • EX: sunburn • Heal within 7 days without scarring

7. Superficial Burn

8. Superficial Burn

9. Partial Thickness Burns • Extends partially into dermis • Divided in to superficial and deep • Superficial: • EX: hot water scald • Pink, moist, blisters, painful • Deep: • EX: hot grease scald • Pale pink to white, decreased cap refill, may be less painful • Most will heal without grafting in 7-21 days • Minimum to severe scars

10. Superficial Partial Thickness Burn

11. Superficial Partial Thickness Burn

12. Deep Partial Thickness Burn

13. Indeterminate Partial Thickness Burn

14. Full Thickness Burn • AKA third degree burn • Epidermis and full thickness dermis involved • Hard, leathery, insensate • Flame burn is a good example • Only small burns will heal • Almost always requires surgery

15. Full Thickness Burn

16. Full Thickness Burn

17. Full Thickness Burn

18. Beyond Full Thickness • Involvement of: • Muscle • Tendon • Bone • Blood vessel • Nerve

19. More than skin deep…

20. Initial evaluation of burns

21. ABCs • Airway • Does mechanism suggest airway compromise? • Will the patient require large amounts narcotics? • Only give IV • Volume of distribution disrupted by burn shock • Breathing • 100% oxygen non-rebreather • Circulation • 2 large bore IVs, preferably in unburned skin • Need to resuscitate? • Calculate TBSA to determine

22. Airway Management • Intubate if: • History suggests airway compromise • Closed space injury • Carbonaceous sputum • Facial burns • COHb>5 • Hoarse voice • Singed facial hair • Patient unable to protect airway due to trauma or large doses of narcotics • Pulse ox not reliable • Carbon monoxide has 100x higher affinity for Hb, oximeter reads as O2

23. Airway Management • Intubate?: • 63 year old male with COPD, smoking with nasal cannula 1/6/12 NO!

24. Airway Management • Same patient… • 7/24/12

25. Breathing • All patients should be placed on 100% oxygen by non-rebreather • Better to intubate early and not need it than wait and have a difficult airway

26. Circulation • Large bore IVs, through unburned skin if possible • Parkland resuscitation for burns 20% or greater

27. Circulation: Calculating TBSA • Rule of Nines

28. Circulation: Calculating TBSA • Lund-Browder

29. Circulation: Resuscitation • Patients with >20% TBSA at highest risk for burn shock • Magnitude influenced by: • Depth and extent of burn • Pre-existing illness • Presence of inhalation injury

30. Circulation: ResuscitationBurn Shock Pathophysiology • Edema forms rapidly after injury • Peaks at 12 hours post burn • Increased perfusion to injured area • Increased capillary permeability • Release of histamine, prostaglandins, kinins • Causes edema in non-burned tissues • Decreased oncotic pressure (Starling) • Leakage of proteins into interstitial • Decreased cell transmembrane potential • Cellular swelling due to influx of sodium

31. Circulation: Resuscitation Goals • Maintain adequate tissue perfusion to end organs • End point: urine output • Adults: 0.5 mL/kg/hr • Children: 1 mL/kg/hr • Electrical burns: 1-2mL/kg/hr • Diuretics not indicated in acute setting • Use foley catheter to monitor

32. Circulation: Resuscitation Formula • Parkland Formula • Burns 20% TBSA and greater • 4mL LR x Weight in kg x TBSA = 24 hour post burn total • Half of volume given in first 8 hours post burn • Rest given in remaining 16 hours • Use of colloid • Rescue vs. standard protocol

33. Circulation: Resuscitation Formula • Example: • 70 kg male with flash burn to face, chest, abdomen and volar surfaces of BUE • TBSA? • 31%: ~4% face, 18% chest and abdomen, 4.5% each upper extremity • Resuscitation? • YES! • (4mL)(70kg)(31% TBSA)=8680 in 24 hrs • 542.5 mL/hr for first 8 hours • 271.25 mL/hr next 16 hours

34. Circulation: Resuscitation • Factors influencing fluid requirements: • Burn depth • Inhalation injury • Can increase needs by 30-50% • Delay in resuscitation • Compartment syndrome • Electrical burns • Myoglobinuria

35. Under-Resuscitation • Intravascular volume depletion • Hemoconcentration: elevated hematocrit • Suboptimal tissue perfusion • End organ failure • Death

36. Over-Resuscitation • Results in resuscitation morbidity • Abdominal compartment syndrome • Decreased renal blood flow, leading to renal failure • Intestinal ischemia • Respiratory failure—increased peak airway pressure • Airway obstruction • Extremity compartment syndrome • Pulmonary edema

37. Referral to a burn center

38. In Arizona… • Only one nationally verified burn center • 450,000 burn injuries yearly require treatment nationally (2011 data) • 45,000 require hospitalization • 3,500 deaths per year (approx 8%) • 70% Patients male • Arizona Burn Center 2010 • 947 admissions • 9 deaths (less than 1%) • Over 5500 outpatient visits

39. ABA Referral Criteria • Partial-thickness burns of greater than 10% of the total body surface area • 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 • 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 rehabilitative intervention

40. Complicated injuries

41. Need for Specialized Care • Chemical burns • Electrical burns • Circumferential burns

42. Chemical Burns • Can be from acids or bases • May not appear to be as deep initially • Must be copiously irrigated with WATER • Delay transport for decon • Do not try to neutralize

43. Electrical Burns • Good history important • Monitor for cardiac abnormalities • Injuries may be much worse than they appear • Risk of rhabdomyolysis

44. Circumferential Burns • Compartment Syndrome • Circumferentially burned extremities at highest risk • Clinical diagnosis vs. measured compartment pressures • 6 P’s: • Pain • Paresthesia • Pallor • Paralysis • Poikliothermia • Pulselessness • Escharotomy • Incision through burned skin to underlying subcutaneous tissue • Fasciotomy • Incision through the fascia overlying muscle compartments of an extremity

45. Escharotomy/Fasciotomy • Extend incisions through unburned tissue proximally and distally if possible • Incisions made mid-medial and mid-lateral on extremity • Shield escharotomy used in patients with circumferential torso burns to improve ventilation • Do at bedside if patient unstable

46. Escharotomy vs Fasciotomy Escharotomy Fasciotomy

47. Summary • Depth of injury determined largely by mechanism • Early referral to a specialized burn center improves both morbidity and mortality • Other system abnormalities may occur as a result of burns and require specialized treatment

48. Thank You! • Questions? • Contact information: Nicole Coyne, PA-C Arizona Burn Center 602-344-5726 Nicole_Coyne@dmgaz.org