Grand Rounds

November 10, 2010

Burns: the First 24 Hours

Jeffrey R. Cole, MD
 Question

1. The minimal TBSA for burn center referral:

A. 5%
B. 10%
C. 15%
D. 20%
E. 25%
 Question

2. 70yo male with PMHx of severe COPD in ED with

possible carbon monoxide poisoning.
A. No Oxygen Supplementation
B. Nasal Cannula Only
C. 100% Face Mask
D. Intubate Patient Immediately
E. Make Patient Comfort Care
 Question

3. 4yo male presents in the emergency department

suffering 30% TBSA flame burn and is febrile:
A. Keep the patient warm with clean blankets
B. Place Ice packs on the patient
C. Place Ice packs on the patient
D. Place Ice packs on the patient
E. Place Ice packs on the patient
 Question

4. Deficiency of which of the following

can result in impaired collagen
synthesis secondary to deficient
hydroxylation of lysine and proline?
A. Zinc
B. Iron
C. Selenium
D. Ascorbic Acid
E. Chitterlings
 Outline:

 Epidemiology  Escharotomies
 Pathophysiology  Other Types of Burns
 Early Management  Wound Management
 Inhalational Injuries  Nutritional Support
 Resuscitation  UK Burn Practices
 Epidemiology

 ~1.1 million pts/yr seek care for burns

 ~45,000 require hospital adm (avg <15% TBSA)
 ~4,500 of these will die
 >90% preventable; ~50% due to substance
abuse
 Before WWII… hypovolemia⇨ARF⇨death
 Rialto Theater, 1921 & Coconut Grove, 1942
 Deaths occur in a bimodal distribution
 Immediately after fire or weeks later from MOFS.
 Epidemiology

 ~4,500 die …… vs. ~15,000 deaths in 1970

 LD50 > 70% TBSA …… vs. ~30% in 1970
 >50% return to pre-burn functioning in 12-24
months
 Goal today is long-term function and appearance
 ~50% suffer concomitant inhalation injury
 Mechanism is age-related & situational:
 < 8 yo → scalds
 all others → flame burns
 work → chemical/electrical/molten metals
 100

90

80 Skin substitutes ?

70 Early excision
Modern fluid & grafting
management
60
Burn size Broad spectrum
antibiotics
(%TBSA) 50

Penicillin
40

30

20

10
1940 1950 1960 1970 1980 1990 2000

Year
Overall: Flame 33%
Scald 30%
Contact 15%
Flash 10%
Electrical 15%
Time to Transfer???
 ABA Guidelines for Burn
Center Referral
1. >10% total body surface area (TBSA)
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
3. Full thickness burns in any age group
4. Any Electrical burns
5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with preexisting medical disorders that could
complicate management, prolong recovery, or affect mortality
8. Any patients with burns and concomitant trauma (such as fractures)
9. Burned children in hospitals without qualified personnel or equipment for the
care of children
10. Burn injury in patients who will require special social, emotional, or long-
term rehabilitative intervention

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.
 Pathophysiology

1. Effects every organ system - SIRS

2. SIRS w/ infection, sepsis syndrome
• Hypermetabolism – REE may ↑ 100%
• ↑heat loss & ↑β-adrenergic stimulation
• ↑ cellular, endothelial, and epithelial permeability⇨edema

3. Propranolol- ⇩REE & ⇩O2 consumption

4. Oxandrolone- anti-catabolic
5. Mediators during early phase edema
• Histamine – early, disrupts tight junctions
• Serotonin
• Eicosanoids – lead to PGE2 and PGI2
 Pathophysiology

1. 3 Zones of thermal
injury:
A. Zone of Coagulation
B. Zone of Stasis
C. Zone of Hyperemia
 Early Management

Pre-Hospital Care:
1. STOP THE BURNING PROCESS
2. CHECK AIRWAY
3. CHECK FOR OTHER INJURIES
 Rule of Thumb while in transit: START LR if >15%
TBSA:
 15-25% TBSA = 500 ml per hour
 25-50% TBSA = 750 ml per hour
 > 50% TBSA = 1 Liter per hour
4. Keep patient warm ⇨ ICE
BURNS = TRAUMA
Burn patients are “trauma”
patients until all life-
threatening, non-thermal
injuries are ruled-out…..
Initial Assessment = 1° Survey
 FORGET ABOUT THE BURN!!!
 Follow ATLS protocols until life-threatening,
non-thermal injuries are R/O’d or initially
addressed, then transition to ABLS
protocols… The ABC’s with a twist.
 All the burn injury requires for treatment in
the 1st 6-12 hours is an appropriate LR
resuscitation.
Remember ABC’s
(with a twist)
 Airway & Breathing
• Inhalation Injury
 Get a good hx- Classically associated with
closed-space fires and/or flame burns to
the face
 ~30% of patients with burns requiring burn
center admission carry the diagnosis
 Mortality ~25 - 30% in hospitalized patients
 An ABA criterion for burn center referral
 Inhalational Injuries…

 3 main classifications:
 CO poisoning
 Thermal injury
 Smoke inhalation

 “It is better to extubate an alive

patient than to try to intubate a dead
one.”
 Carbon Monoxide Poisoning

 Affinity 240x >O2

1. Prevents reversible displacement of O2
2. shifts curve to the left
3. Binds to cytochrome a3, resulting in less effective
intracellular respiration
4. Direct toxicity to skeletal & cardiac muscle
5. Neurologic symptoms
 >20% ⇨ sx include headache, N/V
 >30% ⇨ weak, confused, lethargic
 >40-50% ⇨ coma, death
 Most deaths occur at the scene w/COHgb>60%
 100% FiO2 reduces the T ½ from 4 hrs to 40 min
 Thermal inhalation injury…
 Upper airway/supraglottic injury
 direct thermal injury to mucosa
 loss of airway patency due to edema
 Intubate at first suspicion of injury… “if you
think about intubation, chances are that the
tube should have already been in place…”
 Lower airway/subglottic injury
 Super heated steam inhalation
 Prophylactic steroids are ineffective &
contraindicated w/ a concomitant burn
− Robinson, et al. J Trauma 1982; 22:876-9.
− Levine, et al. J Trauma 1978; 18:188-93.
 Smoke Inhalation…

 Combines CO & Hydrogen

cyanide toxicity
 Incidence has decreased
due to the use of smoke
detectors
 Exam:
 Face/mouth/oropharynx
 Hoarseness
 Stridor
 Edema
 Neurologic deficits
 Carbonaceous sputum
 Diagnosis of Inhalational Injuries…

 Assess the P:F ratio (arterial oxygen pressure,

PaO2:percentage of inspired oxygen, FiO2)
 P:F ratio of 400-500 is normal
 P:F ratio of <300 is characteristic of impending
doom
 P:F ratio of <250 is an indication for intubation
 Diagnosis of Inhalational Injuries…

 Fiberoptic bronchoscopy (FOB) is the “gold-

standard” for the definitive diagnosis of a lower
airway inhalation injury (carbonaceous debris;
mucosal pallor, erythema, or ulcerations;
endobronchial slough)
− biopsies/cytology are impractical & have risks
Bronchoscopy
 Treatment of Inhalational Injuries…

 High-frequency techniques (HFOV &

HFPV) offer no outcome benefits in any
age group
− Cartotto, et al. Crit Care Med 2005; 33 Supp: S175-81.
− Salim, et al. Crit Care Med 2005; 33 Supp: S241-5.

 “Lung-protective” strategy (Pplat ≤ 30 – 35

cmH2O or VT = 6 - 8 cc/kg with optimal
PEEP) in ventilator mode of choice
 Treatment of Inhalational Injuries…
 Airway Pressure Release Ventilation
(APRV) -- ?????
 ECMO -- ?????
− Thompson, et al. JBCR 2005; 26:62-6.

 Prone positioning -- ?????

 Inhaled nitric oxide – contraindicated (?)
− Soejima, et al. Am J Resp Crit Care Med; 163: 745-52.

 Early trach -- ?????

 Calculate burn depth
 The “TWIST”
 Only partial-thickness (2nd degree) &
full-thickness (≥3rd degree) injuries
count towards %TBSA
 Burn depth
 Superficial
 Partial-thickness (superficial & deep) (PT)
 Full-thickness (FT)
Estimating Burn
Depth/Severity
(look at the wound)
“Superficial”

 Formerly “1st-degree”

 NO blisters
 Essentially a sunburn
 Pink
 Painful
“Partial-thickness”

 Formerly “2nd-
degree”
 Superficial Partial Thickness
 Dermal involvement
 Blisters/weeping
 Painful
 Heal 2-4 wks
 Deep Partial Thickness
 Red, patchy
 No blanching
 Less Sensate
 Needs Grafting
“Full-thickness”

 Formerly “3rd-
degree”

 Dry
 Leathery
 White to charred
 Insensate
Superficial
Superficial & Deep Partial Thickness
Full Thickness or 3rd Degree
 Calculate burn size
 Determine burn depth
 Only PT (2nd degree) & FT (≥3rd
degree) count
 Estimate %TBSA
 Palmar surface of pts hand = 1% TBSA
 Age-appropriate diagrams (e.g.-Berkow)
 Rule of Nines
Rule of Nines

 Body divided into

multiples of 9%
 Head = 9%
 Ant thorax = 18%
 Post thorax = 18%
 Each UE = 9%
 Each LE = 18%
 Genitalia = 1%
 Not reliable in kids!!!
Berkow Diagram
 So far, ABC’s
(with a twist) include:

Airway
Breathing
Calculate Burn Size
Calculate Burn Depth…
 Circulation
 Typicallyburns ≥20% TBSA require
IVF resuscitation (≥15% TBSA at
extremes of age)
 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)
Resuscitation Fine Points

 M ore is NOT better!!!

 ACS
 Goal is normotensive,
perfused, urinating pt.
 Plasmapheresis
 Colloid resuscitation
1. No protein solutions given x 24 hours
2. Proteins + crystalloid = ok
3. After 12 hrs, protein can be given

 ∅ central monitoring
 Escharotomies
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/ventilation
 Nearly impossible to resuscitate patient
with restrictive eschar needing release
 Fasciotomies are rarely needed
Technique
 Use cautery (knife OK)
 Avoid neurovascular &
musculotendinous structures
 Mid-medial & mid-lateral
 Thru eschar only --
RELEASE
Other Types of
Burns…
 Burns of Abuse -- REPORT !!!
 Odd mechanism
 Inconsistent
history
 Sharply defined
borders
 Circumferential
 Chemical Burns
 Decontaminate patient prior to
transfer
 Acid- coagulative necrosis
 Alkali- liquefactive necrosis… alkali worse than acid
secondary to tissue penetration
 H2O… H2O… H2O… H2O
 Irrigation for ≥30 min
 Exception: Chemicals containing Aluminum
hydroxide should be swept from skin first
(i.e. concrete powder, lye)
 No formal antidotes (exothermic rxns)
 Exception: Hydroflouric acid
burns⇨Calcium
 Electrical Injuries/Burns

 High (>1000 V) & Low (<1000

V) voltage
 Electrical & thermal components
to injury
 Cardiac arrhythmias,
compartment syndromes,
rhabdomyolysis, SZ, FX, etc…..
 Always more injury than is
apparent
Wound Management
 Initial Wound Management

 No I V antibiotics!!!
 Pain Control…
 Superficial burn ⇨ mild pain
 Partial Thickness ⇨ exposed nerve
endings ⇨ even air hurts
 Full Thickness ⇨ deep aching pain
 Analgesia = IV opiates / NSAIDS
 Wound Management

 Silvadene (aka SSD or Thermazene)

 1% cream in 50gm or 400gm
 Caution in Sulfa allergies
 Antifungal & Antibacterial
 Transient leukopenia
 Relatively Less Expensive
 Can cause skin discoloration
 Not as good eschar
penetration
 Wound Management
C7H10N2O2S
 Sulfamylon aka Mafenide
Acetate
 Can cause a metabolic acidosis
by inhibition of carbonic
anhydrase
 Hurts going on
 About a $100 for 50gm
 Available in cream or solution
 Used for eschar penetration
 Wound Management

 Bacitracin
 Produced by
lichen and inhibits
cell wall formation
 Usually mixed C66H103N17O16S
w/Neomycin and
Polymyxin B
 Cheap
 Used for face
 BID & PRN
 Wound Management

 Acticoat
 3 Layer nanocrystalline
silver dressing in 3-day
and 7-day
 “Works” against MRSA,
VRE, Pseudomonas
 Wound Management

 Aquacel Ag
 Promoted as a 14 day
dressing
 “Works” against MRSA,
Pseudomonas, VRE
 Silver Hydrofiber that
absorbs drainage and
bacteria
 Wound Management

 Surgical Therapy: Early ex cision

and grafting offers best outcome
 Two types of excision
 Tangential excision: Better cosmetic
result, higher blood loss
 Fascial Excision: Poor cosmetic result,
reliable bed of known viability, less blood
loss
 Wound Management
 Integra - Porous matrix of cross-
linked collagen and
glycosaminoglycan.
 Acts as a scaffold for
dermal regeneration.
 Allows early wound
excision
 Immediate closure of the
wound
 Controls fluid loss
 Decreases hypertrophic
scarring
 Wound Management

 Wound Vac
 Short Term after
graft placement
 Shortens Integra
maturation on the
average patient
from 2 weeks to 1
week
 ⇩Edema
 Close large wounds
 Wound Management
 Grafting
 Autograft
 STSG – avoid meshing
over cosmetically
important areas
 Nutritional Support

 Hypermetabolic state
 Protein goal is 2gm/kg/day
 Supplements: Vit C, Glutamine
 TEN>TPN
UK Algorithms
 University of Kentucky Burn Service Care Algorithm
Burn-Injured Patient Arrives in ED

ED Evaluation Phase
Plastic Surgery Burn Resident
ED Attending

Criteria for ICU Admission?

Respiratory Failure
Inhalational Injury
Yes Burn ≥10% TBSA
Burn ICU Phase Shock Plastics/
Associated Injuries No Burn Service
Extremes of Age Disposition
Electrical Burn

Blue Surgery/
Surgical Critical Care
Consultation Burns to Hands/Feet/
Head/Neck/Perineum

Blue Surgery Writes

Admission Orders Burns to
Arms/Legs/Trunk
(excluding perineum)

Non-Burn Wound-Related
ICU Management
per Blue Surgery
Plan Excision and Grafting
(autograft or homograft)
as soon as physiologically appropriate
* (1st excision within 48 hours of burn)

Post Case as “Class B Emergency”

in Morning of First Appropriate Day,
Excision to Physiologic Tolerance

Excision and Grafting Complete? No

Yes

*Blue Surgery
Resident and Complete ICU Care and Rehab
Faculty Involvement
 Adult Fluid Resuscitation

Patients Admit Weight

Step One (hour one)

Begin Fluid Resuscitation using LR _______ml/hr Vital Unstable: HR > 140; BP < 90/60; SaO2 < 90%
Then measure urine output & Base deficit

Vital Signs Stable: HR <140; BP >90/60; SaO2 > 90% Call Plastic Surgery resident/chief
resident or Attending on call for initial
resuscitation

Urine Output < Urine Output Urine Output 30 Urine Output Urine Output Consider decreasing IV rate every ½
15mL 15 – 30 mL – 50 mL 50 – 200 mL > 200 mL hour by 10% or 100mL/hr, whichever is
greater. Be sure to assess patient’s
Increase IV Increase IV Leave IV at Decrease IV blood sugar, BP, HR, lactic acid, ABG,
rate by 20% rate by 10% current rate rate by 10% Myoglobin before decreasing IV rate.
or 200 mL/hr, or 100 mL/hr, or 100mL/hr, Consult with Blue Surgery first.
whichever is or whichever or whichever
greater is greater is greater
ALBUMIN PROTOCOL
If patient requires > calculated
Repeat Step One Every Hour Until: resuscitation or has complications
related to edema, consider albumin
Consider improving protocol
Base Deficit as
indicator to decrease Patient may need colloid
IV fluid resuscitation: CALL Blue Surgery
Calculate Maintenance Rate resident to discuss. Check foley
___________ mL/hr is reached and catheter, breath sounds, vital signs,
held for 2 hours AND patient is at bladder pressure
Urine Output < 15 mL/hr least 24 hrs post-burn
for 2 hours despite Infuse current IV rate consisting of:
increased fluid 1/3 rate as 5% albumin
2/3 rate as LR
(Example: If current rate = 900 mL,
Fluid resuscitation is complete: switch give 300 mL albumin + 600 mL LR)
patient to IV of D5/0.45 NaCl + 20
mEq/liter at calculated maintenance Repeat Step One, decreasing fluids
CALL Blue Surgery
rate as permitted, while maintaining 2:1
resident check foley,
ratio, until total fluid = calculated
assess breath sounds, maintenance rate
vital signs, bladder
pressure, consider
Switch to LR for total fluids. Repeat
albumin protocol Restart patient on LR at current and Step One until patient maintains
return to STEP ONE if patient again
urine output for hours at calculated
develops oliguria or hemodynamic maintenance rate
Lawrence et al. 2010, J Burn Care & instability, CALL Plastic Surgery
Research resident
 Key Points

 4cc/kg/%TBSA 2nd or 3rd Degree

 Resuscitation is a dynamic process
 Basic Dressings:
 Bacitracin to face burns
 Sulfamylon cream to ear burns
 Silvadene to everything else

 “It is better to extubate an alive patient than

to try to intubate a dead one.”
 References:

Gordon, T. Evidence Based Surgery, BC Decker Publishers,

2000.
Norton, J. Surgery Basic Science and Clinical Evidence.
Springer, 2000.
Schwartz, S. Principles of Surgery 8th Edition. McGraw-Hill
Publishers, 2005.
Tevar, A. Surgery Review Illustrated. McGraw-Hill Publishers,
2005.
Trunkey, D. Current Therapy of Trauma 4th Edition. Mosby,
1999.
American Burn Association, www.ameriburn.org
Questions?