Transcript Burn Care in the 21st Century

Burn Care in the
s
t
21 Century
James H. Holmes IV, MD
Director, WFUBMC Burn Center
Assistant Professor of Surgery
Wake Forest University School of Medicine
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
Burn LD50 & Advances in Care
100
90
Skin substitutes ?
80
Early excision
& grafting
70
Modern fluid
management
60
Burn size
(%TBSA) 50
Broad spectrum
antibiotics
Penicillin
40
30
20
10
1940
1950
1960
1970
Year
1980
1990
2000
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
BURNS = TRAUMA
Remember ABC’s
(with a twist)
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
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
Estimating Burn
Depth/Severity
3 Zones of Thermal Injury
Hyperemia
Stasis
Coagulation
Burn Depth
“Superficial”
• Formerly “1st-degree”
•
•
•
•
•
Essentially a sunburn
Pink
Painful
NO blisters
Will heal in < 1 week
“Partial-thickness”
• Formerly “2nd-degree”
•
•
•
•
•
Pink
Moist
Exquisitely painful
Blistered
Typically heals in < 2-3
weeks
“Full-thickness”
• Formerly “3rd-degree”
•
•
•
•
•
Dry
Leathery
White to charred
Insensate
Will require E&G
“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
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
Berkow Diagram
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!!!
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
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 from time 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!!!
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!!!
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.
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)
Escharotomies
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
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
After…
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
Excision & Grafting
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
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
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
Allograft
•
•
•
•
Only temporary
Ultimately rejected
Always requires STAG
Uses:
temporary closure to
allow donor healing &
re-cropping
 STAG overlay
 test excision bed

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, $$$$

Integra
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
Operation #1 (Application)
Wound Bed
Excision
Application of
Integra
Operation #2 (EAG)
Removal
of the
Silicone Layer
Graft
Application

Integra
Results
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
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
Modern Burn Care Model
Nursing (33%)
Therapy
(33%)
Med/Surg
(33%)
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
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
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
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
WFUBMC Burn Team