GEMC: Introduction to Burns: Resident Training

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Information about GEMC: Introduction to Burns: Resident Training
Education

Published on March 2, 2014

Author: openmichigan

Source: slideshare.net

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This is a lecture by Dr. Robert Preston from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

Project: Ghana Emergency Medicine Collaborative Document Title: Introduction to Burns Author(s): Robert Preston, MD License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

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Introduction to Burns Robert Preston, MD Division of Emergency Medicine Division of Burn, Trauma, and Critical Care University of Utah Robworldwide@Gmail.com Enlarge, Wikimedia Commons 3

HPI •  9 year old with no significant medical history •  He lit his shirt on fire in his room •  He was able to extinguish the flames on his shirt, but larger fire started in his room •  Neighbor/Ambulance staff rescued him from bedroom, no longer on fire himself but confused and with obvious burns to much of his body •  Initial Vitals: •  T 37.2 HR 121 BP 155/78 RR 24 S 92%ra *** 4

Physical Face Anterior thorax Right arm, anterior and posterior, upper ½ Left arm, anterior aspect, entire limb Face Source Undetermined 5

ABCs •  •  •  •  •  General: Shaking, moaning A: Verbal, but confused. B: Crackles at bases. C: Thready, rapid, regular pulses D: Opens eyes to pain; Localizes to pain (crossing midline) 6

Physical •  VS: 155/78 P122 T 37.2 RR 24 Sat% 92% ra •  Gen: Shaking, moaning. •  Neuro: GCS 12; No FND •  HEENT: PERRL. Soot in nose. •  Resp: Tachypenic. Crackles at bases bilaterally •  CV: Regular, rapid rate. No r,m,g. Burns to anterior chest •  Abd: Tender to palpation due to burns. Not distended. •  Skin: Burns to torso, front and back, as well as to upper anterior right arm, upper anterior and posterior left arm; •  Extremities: Pulses 2/4 throughout in all extremities *** 7

LABS •  WBC: 13; Hgb: 15 Platelets: 390 141 106 8 4.0 25 0.5 101 8

Chest Xray Source Undetermined 9

Critical Actions ü  ü  ü  ü  ü  ü  A-B-C approach Pain control offered, provided Tetanus status assessed Identify probable inhalation injury and proceed with intubation Estimate TBSA of burn (Rule of 9s or suitable other method) Initiate adequate initial fluid resuscitation (Parkland formula or or suitable other method) 10

Webaware, Wikimedia Commons 11

First degree burn  Bejinhan, Wikimedia Commons Jmh649, Wikimedia Commons 12

Superficial partial-thickness (2nd) 1Veertje, Wikimedia Commons 13

Deep partial-thickness (2nd) Westchaser, Wikimedia Commons 14

Deep partial-thickness (2nd) Source Undetermined 15

Full Thickness (3rd) Source Undetermined Source Undetermined 16

The initial evaluation and management of burn injury It’s never just a burn! 17

Step 1: Decontamination •  Flame and Scald injuries –  Remove clothing and use cool water/cloth to cool •  Electrical injury –  C-spine precautions –  Assess for myocardial injury •  Chemical –  Dilute, dilute, dilute –  Don’t waste time initially looking for specific antidoes* 18

Step 2: Primary Survey & Airway Management •  The burn patients is a multi-trauma patient •  A: Airway –  Facial and oropharyngeal swelling progresses 24 –  Succinylcholine (?) •  B: Breathing –  Assess for inhalation injury •  C: Circulation –  Evaluate for circumferential burns –  Assess pulses frequently 19

Inhalation injury •  Responsible for most deaths from fires •  Hot gases and chemicals in the smoke •  Signs and symptoms –  –  –  –  Burns to face or oropharynx Singed nasal/facial hair Carbonaceous sputum Typical resp symptoms: cough, tachypnea, wheeze, stridor, excessive secretion/sputum production –  Dysphonia –  Changed in mental status/LOC 20

Three types of Inhalation Injury •  Carbon Monoxide Poisoning •  Upper Airway •  Pulmonary 21

Carbon Monoxide Poisoning •  Not a pulmonary toxin – rather, a circulatory problem –  Hgb unable to transport oxygen •  Symptoms –  Progressive mental status deterioration with confusion, somnolence, can lead to coma and seizures. •  Diagnose with ABG not pulse-ox •  Treatment – Oxygen, Oxygen, Oxygen –  FiO2 1.0 reduces T ½ from 2.5 hrs to 40 min 22

Upper Airway •  A THERMAL burn to the face/mouth/oropharynx. •  Symptoms primarily caused by SWELLING: Hoarseness, stridor, airway obstruction. •  Can occur from non-flame injuries (scalds, chemicals). •  Remember that edema is PROGRESSIVE over 24 hours: re-evaluate patients frequently. 23

30 minutes post-burn Source Undetermined 24

6 hours post-burn Source Undetermined 25

Pulmonary Injury •  The true inhalation Injury, it is actually a CHEMICAL injury to the tracheo-bronchial mucosa –  Loss of cilia action, sloughing, bronchiectasis, air trapping, consolidation, infection •  NOT an indication for intubation: Oxygen! •  May be absent for 72 hours before manifesting –  Hypoxia –  ARDS-like (not really, though) –  Infection (mimic or co-existant) •  Facilitates MODF (usual cause of death) •  Confirm with bronch 26

Step 3: Secondary Survey •  •  •  •  •  Head-to-toe exam looking for all injuries De-bride burns and assess extent and depth Document with diagrams if possible Keep patient warm Multiple trauma is common in burn patients –  An unconscious patient is unconscious for some other reasons until proven otherwise –  Consider abuse/assault –  Other care as per non-burn trauma patient •  Suture lacs, stabilize fractures etc 27

Step 4: Fluid Resuscitation Fluid Resuscitation is the Primary Objective of Initial Burn Treatment! 28

Step 4: Fluid Resuscitation •  Calculate Total Body Surface Area 29

Estimating Burn Size Adult Anatomic structure Surface area Anterior head 4.5% Posterior head 4.5% Anterior torso 18% Posterior torso 18% Anterior leg each 9% Posterior leg each 9% Anterior arm each 4.5% Posterior arm each 4.5% Genitalia/perineum 1% Child Anatomic structure Surface area Anterior head 9% Posterior head 9% Anterior torso 18% Posterior torso 18% Anterior leg each 6.75% Posterior leg each 6.75% Anterior arm each 4.5% Posterior arm each 4.5% Genitalia/perineum 1% 30

Calculating burn size 1.  Best done after debridement. 2.  First-degree (nonblistered) burns don’t count. 7mike5000, Wikimedia Commons 31

Step 4: Fluid Resuscitation •  •  •  •  Calculate Total Body Surface Area Estimate fluid requirement with formula Don’t forget maintenance requirements Parkland is most popular starting point –  4 ml/kg x %BSA – ½ over first 8 hours, then over 16 –  Titrate to patient response – urine output* •  If not making –  Time = 0 is time of burn, not ED arrival 32

Step 4: Fluid Resuscitation •  Example: 70 kg man with 40% TBSA Burns •  Parkland: 70kg x 4ml LR x 40% = 11.2 L over 24 hours •  Give half over first 8 hours, i.e. 5.6 L / 8 = 700 ml/hr + maintenance (125/hr) = 825 ml/hr •  Give the other half over 16 hours, i.e. 5.6 / 16 = 350 ml/hr + maintenance (125/hr) = 475 ml/hr •  Increase or decrease hourly based on urine output 33

Step 4: Fluid Resuscitation Expect extra requirements in: •  Very young –  Average 5.8 cc/kg x %TBSA •  •  •  •  Very deep burns Electrical injuries (‘tip of the iceberg’) Inhalation Delay before ED presentation 34

Step 4: Fluid Resuscitation Complications •  Facial/airway swelling –  Re-assess frequently for stridor, eyes swollen shut •  Limb swelling - Compartment Syndrome –  In both burned and unburned extremities •  Torso swelling –  Look for respiratory compromise –  Measure bladder pressures 35

Escharotomy Sites • Incise to subcutaneous level • Consider using a Bovie/cautery to minimize bleeding • Cut through entire length of eschar Original Image, Sjef, Wikimedia Commons Altered Image, Lena Carleton, University of Michigan 36

Limb Escharotomy Wikimedia Commons ,.‫ﺁآﺭرﻡمﯼیﻥن‬ 37

Torso Escharotomy Source Undetermined 38

Torso and Abdominal Escharotomy Source Undetermined 39

Step 5: Wound Care •  Debride blisters, dirt, old or non-professionallyapplied ointments. Shave adjacent hair •  Wrap fingers individually •  Avoid Occlusive dressings •  Use a non-stick gauze or leave open •  Use a non-sulfa containing silver product •  Change q12h 40

Burn Pearls •  Don’t soak/pack in ice/ice water: –  Frostbite and hypothermia are real risks –  Just cool – helps if performed immediately •  •  •  •  Keep them comfortable – Pain Control is key Make sure tetanus up to date Consider an NG tube if > 25% BSA Outpatient therapy may be appropriate –  Less than 10% BSA –  Pain is controlled on oral meds (and tolerating POs) –  Able to perform wound care AND therapy (encourage active range of motion) 41

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