Transcript Flame Off! - Emory University Department of Pediatrics

FLAME
ON !!
John Cheng, MD
PEM Fellows’ Conference
Emory University School of Medicine
December 15, 2005
FLAME OFF!
HEY!
John Cheng, MD
PEM Fellows’ Conference
Emory University School of
Medicine
December 15, 2005
Objectives
 Burn
classification
 Causes of burns
 Treatment regimens
 Complications
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
visits
annual emergency department
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
Skin Anatomy

Preserves body fluids
 Temperature
regulation
 Infection barrier
From Advances in Skin & Wound Care 2005, 18 (6): 323-332
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
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
Superficial Burn
From American Family Physician 2000, 62 (9): 2016
Treatment for Superficial
Burns

Moisturize burn area
with bland emollients
 Anti-pruritics
 Pain relief: Tylenol,
NSAIDs
 Protect from sun for
at least a year
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
Superficial Partial Thickness
Burn
From American Family Physician 2000, 62 (9): 2016
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 12 days
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
From American Journal
of Clinical Dermatology
2002, 3 (8): 533
Bacteria in Burns
+ 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
 Gram
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
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
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
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
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
Burn Zones

Coagulation
 Stasis
 Hyperemia
From BMJ 2004, 328 (7453): 1427
Burn Zones
Zone of
stasis
Zone of
hyperemia
Zone of
coagulation
From BMJ 2004, 328 (7453): 1427
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
Deep Partial Thickness Burn
From American Family Physician 2000, 62 (9): 2017
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
Leathery Skin
George Hamilton
Full Thickness burn
From American Family Physician 2000, 62 (9): 2017
From BMJ 2004, 329 (7457): 103
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
Escharotomy
From BMJ 2004, 329 (7457): 102
From Advances in Skin & Wound Care 2003, 16 (4): 178-187
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
Burn Center Criteria Chart
Burn Algorithm Example
From BMJ 2004, 329 (7458): 160
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.
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?
Labs and XRays
 CBC:
anemia, thrombocytopenia
 CMP: renal function, electrolytes, albumin
 CPK: rhabdomyolysis
 T&S
 PT/PTT: coagulopathy
 Chest XR: evidence of inhalational injury
Estimation of Burn Surface
Area

Wallace rule of 9’s


Palmar surface area




NOT accurate in children
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
Wallace Rule of Nines
From BMJ 2004, 329 (7457): 101
Lund and Browder Chart
From AACN Clinical Issues
2003, 14 (4): 429-441
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
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
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.
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
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.
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)
CXR of Smoke Inhalation
Inhalational Injury

Place on 100% O2
 Check ABG



Intubate with RSI



Acidosis, hypoxemia, hypercarbia
Carboxyhemoglobin
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
Beware Facial Burns
From BMJ 2004, 328 (7455): 1555
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)
Carboxyhemaglobinemia





0-10%: may impair judgment and fine motor
skills
10-20%: HA, nausea, dyspnea, confusion, visual
changes
20-40%: AMS (lethargy, drowsiness, confusion,
agitation), nausea, vomiting
40-60%: weakness, incoordination, memory
loss, imminent CV and neurologic collapse
>60%: coma, convulsions, death
CO Poisoning Treatment

Oxygen

T1/2= 4 hours at RA, 1 hour at 100% O2, 30 minutes
at hyperbaric O2 (2-3 atm)

Sodium Bicarbonate
 Consider other poisonings


Sulfur or Nitrogen  acids
Cotton or plastics  aldehydes
• Acrolein, polyvinylchloride, polyethylene, benzene


Polyurethane  cyanide
Fire retardants  phosgene
Case 2: Zap
 18
month old girl is brought in by mom
after she found her chewing on an
electrical cord. + LOC.
 Her
vital signs are normal. You note that
she has swelling and redness of her lips
and that she is drooling.
From Baum, Carl. Textbook of Pediatric Emergency Medicine, 4th ed.
Lippincott Williams & Wlikins, Philadelphia, 2000: Chap 89, p 961
What would you like to do?
Electrical Injury
 Factors






for injury severity:
Resistance (injury α 1/R)
Type of current (AC or DC)
Frequency of current
Intensity (voltage)
Duration of contact
Pathway of current
Electrical Injury (cont’d)
 thermal injury
 Pathway of current
 Arcing




Head or thorax: risk of arrest
Hand to hand: cardiac and spinal cord injury,
suffocation, 60% mortality
Hand to foot: cardiac arrhythmias, 20%
mortality
Foot to foot: rarely fatal
 Deceptively
small entry and exit wounds
Electrical Injury Work Up
 Labs:
CBC, CMP, PT/PTT, T&S, CPK,
cardiac enzymes, U/A, urine myoglobin
and electrolytes
 EKG
 XR: plain films, head CT
 Specialized exams: ophthalmology
Electrical Injury Management




Separate from current source!
Protect yourself!
Prolonged CPR
Be mindful of:





Arrhythmias and airway edema
CNS pathology: cerebral edema, ICH
SIADH, ARF from rhabdomyolysis
Compartment syndromes  fasciotomy, amputation
Td immunization and antibiotic prophylaxis for
oral injuries
 Excessive bleeding when eschar separates!
Chemical Burns

Acid vs alkali
 Treat with copious irrigation with water

Monitor pH

Consult Poison Center
 Specific chemicals:




Hydrofluoric acid  calcium gluconate in dimethyl
sulfoxide
Methamphetamine  benzodiazepines
White phosphorus  irrigate, monitor Ca and Phos,
Woods lamp exam
Cyanide  Lilly (two steps: nitrite and thiosulfate)
Take Home Points
 Stop
the burn!
 Assess burn surface area.
 Manage the fluids, pain, infection.
 Reassess burn frequently.
 Think about comorbities given history.
 Close follow up or transfer/admit.