Transcript Burn

Initial Burn Care
Lee D. Faucher, MD FACS
Director UW Burn Center
Professor of Surgery & Pediatrics
Objectives
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Burn Care: From where we came
Initial Burn Patient Evaluation
Pediatric Considerations
Burn Center Definition
Objectives
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Burn Care: From where we came
Initial Burn Patient Evaluation
Pediatric Considerations
Burn Center Definition
September 11, 2001
• 8:20am
– American Airlines
Flight 77 Departed
Washington Dulles at
8:20am
– 58 passengers, crew
of 6
• 9:38am
– A 757-200 crashes
into the Pentagon
Washington Hospital Center
• Located in
Northwest DC
– Areas largest trauma
center and regional
burn center
Code Orange: This is not a drill!
• Medical response
– 8 trauma surgeons
– 6 trauma residents
– 7 intensivists and
their teams
– All others
• Anesthesia, lab,
blood bank, radiology,
RT, security
Patients begin to arrive
• 3 patients in first 30
minutes
– 1 smoke only, 2
burns
• Then all air traffic
grounded
– 4 more by ground
Patient Admissions
Patient #
Gender % TBSA Arrival
1
F
0
<1 hour
2
F
21
<1 hour
3
M
22
<1 hour
4
F
66
<1 hour
5
M
49
<1 hour
6
F
68
<1 hour
7
M
41
7 hours
8
M
42
10 hours
9
M
32
28 hours
10
M
10
31 hours
Post-Burn Weeks
35
30
OR Hours
# Operations
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Products consumed
IV Fluids
141 Liters
Silvadene cream
Burn Dressing Gauze
4X4 gauze
Kerlix gauze
950 Jars
2006 packs
18,490
3108 rolls
Ace Bandages
Allograft
Synthetic “skin”
2111
26,700 sq cm
30,365 sq cm
Autograft
PRBCs
22,087 sq cm
269 units
Outcomes
Patient #
Gender
%
TBSA
1
F
0
2
F
3
Age +
TBSA
Mortality
Risk
Outcome
32
N/A
Survived
21
74
11
Survived
M
22
61
4
Survived
4
F
66
115
62
Survived
5
M
49
100
41
Survived
6
F
68
109
44
Died
7
M
41
80
15
Survived
8
M
42
71
9
Survived
9
M
32
63
1
Survived
10
M
10
82
23
Survived
Final numbers
• 189 deaths
– 125 in Pentagon
– 64 on Flight 77
• 106 injured
– 50 admitted to 9 area
hospitals
– 9 serious burns
Objectives
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Burn Care: From where we came
Initial Burn Patient Evaluation
Pediatric Considerations
Burn Center Definition
Medics
• Airway
• Assess for other injuries
• Start IV with LR, in burn OK
– < 6 years = 125mL/hr
– 6-13 years = 250mL/hr
– >13 years = 500mL/hr
• 100% O2 if closed space fire
• Transport to closest hospital
History
• Source of burn
• Enclosed space
– Signs of smoke inhalation
• Circumstances surrounding injury
• Previous medical problems
• First-aid done
Reduction of CO
80
Room Air
100% Oxygen
3 ATM
% CO
60
40
20
0
0
20
40
Time in Minutes
60
80
Medics - Electrical
• Do not become victim
– Turn off power
• Initiate CPR
– If < 1000 volt,
ventricular fibrillation
– If > 1000 volt, cardiac
standstill and
respiratory paralysis
Medics - Chemical
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Remove involved clothing
Flush with water
Flush with more water
Then flush with more water
When you think you are done, flush with
more water
• NO NEUTRALIZATION
Cold
• DOES NOT
– Reverse temperature
– Inhibit destruction
– Prevent edema
• DOES
– Delay edema
– Reduce pain
Case presentation
• EMS responds with Fire to structure fire
with reported trapped occupants
• On arrival, see two bystanders dragging
person out the front door.
Medic evaluation
• Airway
– Moving air, moaning, unresponsive, entire
head, face, neck, and chest burned
Medic evaluation
• Breathing
– Equal bilateral breath sounds
• Circulation
– Palpable distal pulses
Medic evaluation
• What else should be done at the scene?
• Where should this patient be taken?
Medic Report to ED
• 47 y/o male, extricated from structure fire,
burns over head, chest, back, bilateral
upper extremities and legs, intubated with
one peripheral IV in place running LR at
500mL/hr
• Vitals: HR 130, BP 150/90, Sat 100%
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
Smoke inhalation assessment
• Flame burns
• Enclosed space
• Burns to face, mucosal
membranes
• Singed eyelashes, nasal
hairs
• Carbonaceous sputum
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
Rule of Nines
Lund and Browder Chart
Area
0-1
yr.
Head
19
Neck
2
Ant. Thorax
13
Post. Thorax 13
R. Buttock
2½
L. Buttock
2½
Genitalia
1
R. U. Arm
4
L. U. Arm
4
R. L. Arm
3
L. L. Arm
3
R. Hand
2½
L. Hand
2½
R. Thigh
5½
L. Thigh
5½
R. Leg
5
L. Leg
5
R. Foot
3½
L. Foot
3½
1-4
yr.
17
2
13
13
2½
2½
1
4
4
3
3
2½
2½
6½
6½
5
5
3½
3½
5-9 10-14
yr.
yr.
13
11
2
2
13
13
13
13
2½ 2½
2½ 2½
1
1
4
4
4
4
3
3
3
3
2½ 2½
2½ 2½
8
8½
8
8½
5½
6
5½
6
3½ 3½
3½ 3½
15 Adult 2 3 Total
yr.
9
7
2
2
13
13
13
13
2½ 2½
2½ 2½
1
1
4
4
4
4
3
3
3
3
2½ 2½
2½ 2½
9
9½
9
9½
6½
7
6½
7
3½ 3½
3½ 3½
Total
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
IV access
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< 15% TBSA – oral resuscitation
15 – 40% TBSA – one large bore IV
> 40% -- two large bore IV’s
IV’s should be in the upper extremities
Suture IV’s started through burns
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
Crystalloid solution
• Ringer’s Lactate
– [Na+] 130 mEq (serum 140 mEq)
– Osmolality 272 mOsm (serum 300mOsm)
• Advantages of crystalloid
– Effective in maintaining perfusion
– Costs less than colloids
– Can be mobilized with a diuretic
Resuscitation first 24 hours
• Baxter formula
– 4 mL/kg/% TBSA burned
• Give ½ the volume in first 8 hours and other ½
over next 16 hours.
If < 20kg
• Same Baxter
formula for LR
• Add 4mL/kg of D5 ¼
NS
– Infuse at constant
rate, increase LR if
needed for adequate
urine output
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
Keep patient warm
Monitor urine output
• Place foley if > 20% TBSA
• Urine output goal
– 2 mL/kg/hr very young
– 1 mL/kg/hr child
– 0.5 mL/kg/hr adult
• Diuretics are NEVER used to increase
urine output
• Increase urine output to > 100mL/hr if
pigment present
Emergency room treatment
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Assess airway/breathing
Ensure source of heat removed
Estimate % TBSA
Obtain/ensure adequate IV access
Initiate/continue resuscitation
Closely monitor urine output
KEEP PATIENT WARM!!!!!
Next priorities
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Insert NG tube
Escharotomies
Medications
Wound care
Next priorities
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Insert NG tube
Escharotomies
Medications
Wound care
Escharotomies
• Only for leathery, circumferential, full-thickness
burns
• Rarely needed in transport < 12 hours
• Almost always done at the Burn Center
• Emergent indications:
– Unable to ventilate
– Pulseless, painful extremity
Escharotomy pic
Next priorities
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Insert NG tube
Escharotomies
Medications
Wound care
Medications
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Pain control
Pain control
More pain control
Tetanus immunization
NEVER need antibiotics
Next priorities
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Insert NG tube
Escharotomies
Medications
Wound care
Wound care
• Debridement and topical application is usually
done after transfer
• Can cover with plastic wrap
• Transport patient in DRY sheet and blanket
• If transport delayed > 12 hours,
– Debride loose tissue and clean with mild soap and
water
– Apply Silver Sulfadiazine and wrap loosely
Resuscitation 24 - 48 hours
• Continue maintenance fluids, watch serum
Na+
• May use albumin or plasma for volume
– Infuse 5 – 10mL/kg as needed
• Maintain adequate urine output
Objectives
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Burn Care: From where we came
Initial Burn Patient Evaluation
Pediatric consideration
Burn Center Definition
Burn Etiology
ABA National Burn Repository, 2012 Report
UWHC Admissions <18 years
Admissions to Burn Centers
ABA National Burn Repository, 2012 Report
Percent
Overall Burns and Mortality
40
35
30
25
20
15
10
5
0
0 to 2
5 to 16
2 to 5
Age
Lived
ABA National Burn Repository, 2012 Report
Died
16-20
Overall Mortality and TBSA
100
Percent
80
60
40
20
0
0 to 10 10 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 80 to 90
TBSA
0 to 2
ABA National Burn Repository, 2012 Report
2 to 5
5 to 16
16 - 20
> 90
Where Childhood Burns Occur
10
2
8
Home
Auto
Recreation
Other
80
ABA National Burn Repository, 2012 Report
A kid with a small burn
Why we do this
• An acute burn may not be completely
blistered
• Can’t do wound care in clinic
• Sedation easier when adequate pain
control
Appropriate wound care
• Silicone
• Foam
• Silver
What is Mepilex Ag
Then what do we do
• Dressing changed every 3 to 5 days
• Our length of stay drastically reduced
• Still same number of surgical procedures
Objectives
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Burn Care: From where we came
Initial Burn Patient Evaluation
Pediatric Considerations
Burn Center Definition
Burn Center Referral
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All children
Any burn > 10% TBSA
Any full-thickness burn
Burns to hands, face, feet or perineum
Any Electrical or Chemical burns
Other associated injuries, medical problems,
or inhalation injury
• Systemic disease
Excerpted from Guidelines for the Operations of Burn Units (pp. 55-62), Resources for Optimal
Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons
Outpatients Do Not include
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Special locations
Extremes of age
Associated injuries
Previous medical problems
Unusual etiologies
– Some chemical, some electrical
• Unstable social situations
Nurses
Residents
Physiatrists
Pediatricians
Burn Surgeons
Nurse Practitioner
Physical therapists
Physician Assistant
Child Life therapists
Health psychologists
Respiratory therapists
Recreational therapists
Occupational therapists
Social Worker
Pharmacists
Nutritionists
Administrators