MANAGEMENT OF BURNS

CPT Allen Proulx, MPAS, PA-C

OBJECTIVES

Describe the differences between partial and full-thickness burns. Describe how to estimate the size of a burn. Describe initial care of burns. Describe follow-up care of partial thickness burns.

References for photos

Advanced Burn Life Support Course, American Burn Association, 1994 Textbook of Military Medicine, Part I, Vol 5 Conventional Warfare, OTSG, 1991 Textbook of Surgery, Sabiston, editor W. B. Saunders, 1986 SESAP VI, American College of Surgeons, 1988 Burn care product info

Depth of burn
Partial thickness burn = involves epidermis Deep partial thickness = involves dermis

Full thickness = involves all of skin

Partial thickness burns

Sunburn is a very superficial burn. Expect blistering and peeling in a few days. Maintain hydration orally. Heals in 3-6 days- generally no scaring Topical creams provide relief. No need for antibiotics

Deeper partial thickness

Blisters are typical of partial thickness burns. Dont be in a hurry to break the blisters. Heals in 14-21 days Blisters provide biologic dressing and comfort. Once blisters break, red raw surface will be very painful.

Full thickness burn

Yellow, leathery appearance; or charred Often have no sensation (nerve endings destroyed) Outer edges might be partial thickness. Initial management same as partial thickness. Later will need skin grafts.

Mixed partial and full thickness

Central yellow area might be full thickness. Outer edges are probably partial thickness. Initial management is the same. Later will need skin grafts for the full thickness areas.

Zones of Burn Wounds

Zone of Coagulation devitalized, necrotic, white, no circulation Zone of Stasis circulation sluggish may covert to full thickness, mottled red Zone of Hyperemia outer rim, good blood flow, red

Wound excision until fine punctate bleeding occurs

Estimate the size of the burn

The patients own palm is about 1% of his body surface area. Rule of Nines

Rule of 9s

ABA

American Burn Assoc says send these to a burn center

Partial thickness burns >10% BSA Burns involving the face, hands, feet, genitalia, perineum, or major joints full thickness/3 degree burn Electrical, Chemical, and Inhalation burns

In combat, all but the most superficial burn should be evacuated

Burn care products

< 20% TBSA 2nd degree Silvadene (SVC) Cream BID Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID 3rd degree burn SVC and SMC alt BID *SMC only to the ears * Bacitracin Opth to face

Care of small burns

What can YOU do?

Care of small burns

Clean entire limb with soap and water (also under nails). Apply antibiotic cream (no PO or IV antibiotic). Dress limb in position of function, and elevate it. No hurry to remove blisters unless infection occurs. Give pain meds as needed (PO, IM, or IV) Rinse daily in clean water; in shower is very practical. Gently wipe off with clean gauze.

Blisters
In the pre-hospital setting, there is no hurry to remove blisters. Leaving the blister intact initially is less painful and requires fewer dressing changes. The blister will either break on its own, or the fluid will be resorbed.

Blisters break on their own

Upper arm burn day 1 day 2

Burn looks worse the next day because of blisters breaking and oozing

Upper arm burn

121

Blisters show probable partial thickness burn. Area without blister might be deeper partial thickness.

Debride blister using simple instruments

Medic debriding blister

After debridement

Before and after debridement

Removing the blister leaves a weeping, very tender wound, that requires much care.

Silver sulfadiazene

Arm burn 4 days

Arm burn 7 days note the exudate

Foot burn debridement

Before debriding and applying cream, clean entire foot (including toes and nails).

Silver- impregnated dressings (Silverlon)

Apply wet silver dressing directly on the burn. Creams or dressings under the silver dressing impede the antimicrobial action. Keep it moist! Remove it, rinse it out, replace it on the burn.

Steps in using silver-impregnated dressings

Clean the burn and surrounding area. Soak silver-impregnated dressing and gauze in STERILE WATER or BOTTLED DRINKING WATER Apply silver-impregnated dressing (over-lapping edges are best). Wrap with the moist gauze. Secure with mesh, gauze, or tape. Keep it moist with WATER, every 12h or so More frequent in hot arid environments

pics

Soak silver dressings and gauze in WATER (not saline).

Apply the silver dressing.

Wrap with moist gauze. Secure with mesh, gauze, or tape.

First few days

Moisten dressing with WATER every 12h or so. Remove outer gauze and silver dressing every day. Inspect the burn. Rinse exudate off burn. Rinse exudate off silver dressing with WATER. Return same silver dressing to the burn. Apply new outer gauze moistened with WATER.

pics

Moisten with WATER q12h or so.

Moisten well to remove it each day. Rinse it out, and put it back on the burn.

After several days

Replace silver dressing

every 2 - 5 days depending on amount of exudate, cellular debris

First wet the silver dressing before removing it. Dont pull on it if its stuck moisten it more. Apply new moist silver dressing and gauze.

QUESTIONS ABOUT SMALL BURNS?

SUMMARY

Describe the differences between partial and full-thickness burns. Describe how to estimate the size of a burn. Describe initial care of small burns. Describe follow-up and post-burn care.
NEXT TOPIC - BURNS OF SPECIAL AREAS

Burns of special areas of the body

Face Mouth Neck Hands and feet Genitalia

Face
Be VERY concerned for the airway!! Eyelids, lips and ears often swell alarmingly. In fact, they look even worse the next day. But they will start to improve daily after that. Cleanse eyes with warm water or saline. Apply antibiotic ointment or liquid tears until lids are no longer swollen shut. Bacitracin cream/ointment will serve

Hands and feet

This is rather deep and might require grafting. But initial management is basic.

Dressings should not impede circulation. Leave tips of fingers exposed. Keep limb elevated.

Hands and feet

Allow use of the hands in dressings by day. Splint in functional position by night. Keep elevated to reduce swelling.

Hands and feet

Fingers might develop contractures if active measures are not taken to prevent them.

Genitalia

Shower daily, rinse off old cream, apply new cream. Insert Foley catheter if unable to urinate due to swelling.

Large Burns

Causes of death in burn patients

Airway Facial edema, and/or airway edema

Breathing Toxic inhalation (CO, +/- CN) Respiratory failure due to smoke injury or ARDS

Edema Formation
Amount of edema can be immense (even without facial burns) Depression of mental status can worsen problem Edema peaks at 12 to 24 hours Pediatric patients even more concerning

Causes of death in burn patients

Circulation: failure of resuscitation Cardiovascular collapse, or acute MI Acute renal failure Other end organ failure Missed non-thermal injury

Patients with larger burns

First assess CBAs Disability (brief neuro exam) Expose Later Examine rest of patient Calculate IV fluids Treat burn

Airway?
Flash burns may refer to those that suddenly flare up, then die down quickly. Patients may have burnt facial hair and carbon on lips. Patients with this kind of facial burn will probably NOT need an artificial airway. Give humidified oxygen while under close observation.

Circulation
Record vital signs. Check distal pulses and nail beds.

Keep him warm! Loss of skin impairs ability to retain heat and fluids. Being cold will cause vasoconstriction.
Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr Monitor at least HCT and urine specific gravity. When available, monitor electrolytes.

Neuro status
The burn itself does not alter the level of consciousness. If patient is not alert, think of other causes:

hypovolemia carbon monoxide head injury

Dont allow swollen eyelids to prevent you from examining the pupils. Test sensation and motion in burned extremities.

Expose
Undress the patient to examine the whole body. But burned patients lose body heat quickly, so keep them warm. To keep warm, use whatever means available: blankets heating lamps bed frame large box covered with blankets

Head to toe exam

Obtain history and examine rest of body. Ask about allergies, meds, medical conditions. Look for other injuries.

Calculate fluid requirements

wt in kg x % burn x 2 - 4cc / kg / %

100 kg patient with 50% TBSA burn: 100 x 50 x 2 = 10,000cc = 10 liters RL

This is calculated for the first 24 hours post-burn. Give half of this in first 8 hours. Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

Calculate fluid requirements

Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially How do we know if this is too much fluid, or too little? Monitor at least: urine output - in adults, around 50 cc / hr Decreasing urine output = need for more fluids.

Burn size in small children

The head accounts for about 18% (instead of 9%). The legs account for about 13% (instead of 18%).

Fluid requirements in children

Use same formula for fluids to replace loss from burns. In children, add this amount to normal maintenance rate: 10 kg - about 40 cc / hr maintenance fluids 20 kg - about 60 cc / hr 30 kg - about 70 cc / hr

Expected urine output for child: 1 cc / kg /hr for infant: 2 cc/ kg / hr

Fluids requirements in children

20 kg child with 30% burn: 20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially 75 cc / hr for burn loss + normal 60 cc / hr maintenance = 135 cc / hr initially How do you know if the patient is getting too much fluid, or too little? Check urine output, urine specific gravity, HCT

 Be sure the patients airway, breathing and circulation are secure. Then treat the burn wound itself. In patients with large burns, do not initially spend much time carefully calculating fluids. Instead, start an IV and start giving fluids rather rapidly while exam is being performed. DO NOT BOLUS! 500cc/hr is a good rule. Later do the calculations.

Special types of burn

Circumferential burn Burn requiring escharotomy Electrical burn Chemical burn

Circumferential burn
Limb is burned all the way around. Soft tissues under the skin always swell with burns (due to capillary leak of fluids in first day or so). There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue Pressure inside limb gradually increases. Eventually, pressure inside limb exceeds arterial pressure. This requires escharotomy to relieve the pressure.

Escharotomy - indications
Circulation to distal limb is in danger due to swelling. Progressive loss of sensation / motion in hand / foot. Progressive loss of pulses in the distal extremity by palpation or doppler. In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.

Escharotomy - complications
COMPLICATIONS Bleeding: might require ligation of superficial veins Injury to other structures: arteries, nerves, tendons NOT every circumferential burn requires escharotomy. In fact, most DO NOT need escharotomy. Repeatedly assess neuro-vascular status of the limb. Those that lose circulation and sensation need escharotomy.

Escharotomy
Eschar = burned skin Escharotomy = cut burned skin to relieve underlying pressure Similar to bivalving a tight cast. Cut along inside and outside of limb from good skin to good skin Knife can be used, or cautery. Use local or no anesthesia. (Full-thickness burn should have no sensation, but underlying tissues do!)

Escharotomy of forearm
Incise along medial and/or lateral surfaces. Avoid bony prominences. Avoid tendons, nerves, major vessels.

Escharotomy
Patient had escharotomy of both legs. Incisions will heal. They will not be closed by DPC. These large burns are often treated by the open technique, that is, without dressings.

Electrical burn
Outer skin might not appear too bad. But heat was conducted along the bone.

Causes the most damage.

Burns from inside out. Usually requires fasciotomy

Fasciotomy

Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved. Muscle can be inspected for viability.

Phosphorus
Particles of phosphorus must be removed from under the skin. Pick them off with forceps. Must apply wet dressing to prevent reigniting.

QUESTIONS?
SUMMARY
Describe how to estimate the body surface area of burn. Describe how to calculate initial fluid requirements in a patient with a large burn. Describe intial management of a patient with a large burn. Discuss indications and complications of escharotomy.

BURN DOWN & DIRTY

Educate your Task Force! proper technique for burning waste, wear of clothing Do not hesitate to evacuate. Burns other than inhalation generally dont kill at point of injury- Bleeding and breathing injuries do! Oral Abx if managing burn at BAS ?