Niknam Eshraghi, M.D., F.A.C.SGeneral and Burn Surgery; The Oregon ClinicDirector; Oregon Burn Center, Legacy Emanuel Medical CenterAffiliate Professor of Surgery, Oregon Health Sciences University

Update on Burn Care and Resuscitation

Objectives

Identify the components for initial evaluation of a burn victimBe able to estimate surface area involvedDistinguish the different depths of burn injuryUnderstand the American Burn Association criteria for referral to a burn unit.

Financial disclosure

None

Topics to be covered

Burn epidemiology and outcomesInitial evaluation and managementBurn injury classification

Burn typeBurn sizeBurn depth

ResuscitationWound care

Burn Epidemiology and Outcomes

Burn EpidemiologyWorld Wide

millions of people are burned each year1/3 of these are in childrenGreater than 80% of these burns are preventableMore than 200,000 die of their injuries each year

Burn injuries receiving medical treatment: 450,000 per yearFire and burn death: 3,400 per yearPatients hospitalized: 40,000 total with

30,000 in burn centers

Burn EpidemiologyUnited States

American Burn Association, 2013

Burn Centers

127 burn centers with about 1700 beds, admitting an average of 200 patients per year.Other 4500 hospitals each admit 3 per yearOregon Burn Center admits close to 300 patients with burn or skin disorders.

What Are the Causes?

Majority of burn injuries are caused by:

Lack of knowledgePoor judgment

Very few are true accidents

Causes of death from major burn injuries:Early

Burn shock

Failure of resuscitation

Delayed

Wound sepsis

Multi-organ failure

Respiratory insufficiency

Burn Impact; Mortality

Historical PerspectiveBurns a depressing field until the later part of 20th centuryPercent of total body surface area burn for expected 50% mortality (1952)

Age (years) %TBSA0-14 4915-44 4645-64 27>65 10

Bull et al.Ann Surg 1954;139:269

• Effects of burn injury– Early

• Pain• Major illness• Prolonged hospitalization

– Delayed• Long recovery• Disfigurement, and loss of function• Psycho-social impact

Burn Impact; Morbidity

Initial Evaluation and Management

Initial Evaluation

First Forget the skinDo not get overwhelmed by the looks or the smell of the burnThink systematically and remain objective

Initial Evaluation

Next do the Primary Survey

Airway

Breathing

Circulation

Disability

Exposure

Initial Evaluation

AirwayEvaluate Control for

Unstable victim, Inhalation injury, large burn, ……

Protect the cervical spineOral tracheal intubation is preferred.Largest appropriate endo-tracheal tube that can be safely inserted should be used

Initial Evaluation

BreathingListenAdminister high flow oxygenMonitor quality and depth of breathing

Initial Evaluation

CirculationEvaluate blood pressure and pulseEstablish IV access

Two large bore IV’ in unburned areasIntra osseous OK but be aware.

Intra-osseous Infusion Initial Evaluation

Disability-If not alert and oriented consider;Associated Injuries?CO poisoning?Substance abuse?Hypoxia?Pre-existing medical condition

Initial Evaluation

Exposure Remove all clothing and jewelryKeep patient warm

Warm roomKeep patient covered; dry sheets, blanketsWarm IV fluids

Secondary Survey

After resuscitation efforts are well established.Do a head-to-toe evaluation Obtain history & physical exam.Radiographic & laboratory studies

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Get Information

Gather and record as much information as possible

PatientFamilyFirst respondersTransport team

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Burn Evaluation

Classify the type of burn injuryEstimate the extent of burn injuryEstimate the depth of burn injury

ABA Transfer Criteria2nd degree burns > 10 %Burns to hands, face, feet, genitals, major joints3rd degree burnsElectrical burnsChemical burnsInhalation injuriesBurns with pre-existing medical conditionBurns accompanied by trauma where the burn is the greater risk to lifeBurns to children in hospitals without pediatric servicesPatients with special social, emotional or rehabilitative needs

Types of Burn Injury

Types of Burn Injury

ThermalElectricalChemicalInhalation

Burn Injury Classification

Flame Burn

Scald BurnContact burns

Electrical Burns

Hidden Damage

Chemical Burns

Nitric acid Hydrofluoric Acid

Alkali

Frost biteFlame Facial Burn

5 Hours Later

Depth of Burn Injury Burn Depth

SuperficialPartial thicknessFull thickness Deep into underlying tissue

Your Skin It's Got You Covered! Superficial Burn

Intact skinRed appearance PainfulBurn depth within epidermisUsually heals in 5-10 days

Superficial Burn Partial Thickness Burn

Burn through the epidermis and into the dermisBlistered but this may be delayedLoose or sloughed epidermisMoist, red to non-blanching and white appearanceSubcutaneous edema may be present

Partial Thickness BurnFull Thickness Burn

Burned through epidermis, dermis, and subcutaneous tissueDry appearanceMay be red, white, black, or brown in colorLeathery in appearance

Full Thickness Burn

Burn Beyond Skin

Burned through epidermis, dermis, subcutaneous tissue, muscle, and boneCharred appearanceMay appear cracked Immobility of area

Burn Beyond Skin

Extent of Injury Estimation

Burn Size Estimation

Lund and BrowderDeveloped their burn diagram in 1944

SG&O 1944; 79:352

Knaysi proposed the rule of nineNY presentation 1967

Burn Size Estimation, What Is New?

Computerized estimation systems

Sage II provides reproducible age-specific burn diagram

(www.sagediagram.com)3-D Burn Vision provides a three dimensional rotating model

(Electric power research institute, concord CA)

Surface laser scanning

Treatment of Burns

Inhalation Injury

Present in >20% of burn victims with flame burns.Causes

Hot air or steam upper airway burn Carbon monoxide (CO) Toxic substances, and smoke particles

IncreasesICU stayFluid resuscitation requirement (2x)Mortality (2X)

Total N=121,930 (Excludes Unknown/Missing)

National Burn Repository 2005 report © American Burn Association 2006.

Inhalation Injury Inhalation Injury Diagnosis

History:Closed space injuryObtunded patient at the sceneSuspected inhalation of steam or smoke

Exam:Facial burns, sooth on face and airwaySinged hairHoarseness or wheezing

Findings:Early

Upper airway edemaBronchospasm

LateSloughed endobronchial liningSmall airway obstructionAlveolar floodingPulmonary fibrosis

Inhalation Injury Diagnosis

TestsBronchoscopyBronchoalveolar lavageXenon-133 or t-99 scanning

Labs:

carboxyhemoglobin level

Pao2/fio2

A-a gradient

PFT

None can predict clinical course

Inhalation Injury TreatmentChemical

Ketorolac, surfactantPerflubron liquid ventilationDimethyl sulfoxideHeparin, Antithrombine III, nitric oxide

MechanicalProne positioningPercussive, and oscillatory ventilationECMOLow volume pressure controlled ventilation

Supportive Care

Volumetric Diffusive Respirator (VDR)

Resuscitation

Burn shock is hypovolemic and cardiogenicDecreased Cardiac output up to 24 hrs.Extra cellular fluid reduction due to leak from injured skinTotal body capillary permeability with max edema 8-24 hr. post injury, Decreased plasma volumeMany mediators implicated including histamine and bradykinin

Resuscitation

GoalsInitial assessment and stabilizationReplace the lost intravascular volume with crystalloidMaintain adequate tissue perfusion and organ functionMinimize complications from organ failure and over-resuscitation

Resuscitation

Resuscitation History

From Cholera to “Fluid Creep”: A Historical Review of Fluid Resuscitation of the Burn Trauma PatientHansen SL, Wounds 2008, 20(7)

Baxter and Shires proposed the Parkland formulaInterstitial and intracellular edemaDisruption of NA-K pump

Ann NY Acad Sci 1968;150:874

2-4 ml LR x TBSA(%) x weight (kg) /hr2 x 8

Short version TBSA(%) x weight (kg) ml/hr

4

Resuscitation History

Will lead to increase fluid needs to catch upOrgan dysfunction

Renal failureBurn injury progression and wound conversion

Under Resuscitation ResuscitationGoal

Maintain tissue perfusion and organ function while avoiding inadequate or excessive fluid therapy

Pulmonary edema and respiratory failureBody edema, organ dysfunction

Gut dysmotilityCompartment syndromes

Over ResuscitationAlso known as intra-abdominal hypertensionA constellation consisting of cardiovascular, pulmonary, and renal compromise produced by increased intra-abdominal pressureDefinition

Pressure >25 mmHgTense abdomenDecreased pulmonary complianceOliguria

Abdominal Compartment Syndrome

CrystalloidLR most commonMajority of patients need more than what is calculated by the formula

Saffle et al J am Coll Surg 2003;196(2)267

Hypertonic salineComplicatedMay reduce volume of resuscitationNo consensus on the osmolarity of the solutionHigher mortality in some studies

Resuscitation Fluids

AlbuminThree schools

1.Should not be used because it leaks and makes edema worse2.Should be given from the beginning3.Should be given 8-12 hrs post burn

Albumin is used by majority of burn surgeons in 8-12 hours in large burns

Sheridan RL Crit care med 2002;30(11):s500

DextranGuarded initial favorable results

Resuscitation Fluids

The debate goes onWhich formula Which fluid, or combination of fluids

As both under resuscitation and over resuscitation are detrimental to patient, continuous titration of volume must be made according to the patient’s clinical response.

Resuscitation Fluids ResuscitationAmerican Burn Association Practice Guidelines,

2008Fluid resuscitation, regardless of solution type or estimated need, should be titrated to maintain a urine output

0.5–1.0 mL/kg/h in adults 1.0–1.5 mL/kg/h in children

Increased volume requirements can be anticipated in patients with full-thickness injuries, inhalation injury, and a delay in resuscitationHypertonic saline should be reserved to providers experienced in this approach. Plasma sodium concentrations should be closely monitored to avoid excessive hypernatremia.Option: the addition of colloid-containing fluid following burn injury, especially after the first 12 to 24 hours post burn may decrease overall fluid requirements.

Pham TN, Cancio LC, Gibran NS; American Burn Association. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29(1):257–266.

Burn injury less than 10% body surfaceOral fluids should be adequate

Burn injury 10%-15%Oral fluids plus maintenance intravenous fluids should be given

Burn injury >15%intravenous fluid resuscitation should be initiate

Indication for Resuscitation

Wound care

Blisters; To Remove or Not to Remove!

To remove The fluid has pro-inflammatory metabolitesIt adversely affects neutrophil chemotaxisMay provide a medium of growth for bacteriaTense blisters may impair movement

Not to remove Covered dermis less painfulIntact blisters rarely get infected

No consensus in management

Characteristics of a good dressingWell toleratedAllows drainageBarrier against environmentDoes not allow drying and desiccationEasy to removeSimple Inexpensive

Burn Wound Dressing

Petroleum gauzeBacitracin zinc / double antibiotic ointmentXeroformSilver sulfadiazine (Silvadene)Mafenide Acetate

Common topical agents and dressings

Silver Sulfadiazine (Silvadene)

Wound Care

Superficial burnLotion or Bacitracin applied frequently

Partial thickness and deeper burnsBacitracin – Xeroform especially on the faceSSD – gauze all areas except face

Wound Care

Large surface area burnsCover with dry dressingPrevent hypothermiaTransfer to emergency room / burn unit Topical Agents; What Is New?

Acticoat (Smith and Nephew)Silver nanocrystal technologyReleases silver ions when moistenedPain less and may reduce painVery good spectrum of activityCan be left for 3-7 days

Topical Agents; What Is New?Silver

Mepilex Ag (Molnlycke)foam dressing with Safetac®, silicone technology.Minimizes pain at dressing changesRapid and sustained antimicrobial activityGentle adherence, conformable and softDoes not slip under dressing retention and can be cut to size

Topical Agents; What Is New?

Aquacel Ag (Convatec)Hydrofiber that turns to gel with moistureExudate managementLower silver ion release than Acticoat Good spectrum of activityCan be left for 7 days

Topical Agents; What Is New?Silver

Other silver containing dressingsActicoat Flex, Mepitel AgSilvasorb & Arglaes (Medline)Actisorb (Johnson & Johnson)Silverlon (Argentum)

Topical Agents; What Is New?And More Silver

The high osmotic promotes outflow of wound fluidhelps soften and liquefy necrotic tissueAids in autolytic Low pH

Topical Agents; What Is New?Honey

Physicians, residents, Students and NP’sNursesPhysical and Occupational therapyPharmacy/DietitianSocial Worker/Chaplain servicesRehabilitation and PsychologyChild life and art therapy

Multidisciplinary Team

Burn Care

Other important factorsNutritional support and modification of hypermetabolismPain and anxiety management Scar management TherapyReconstruction and rehabilitationFunding and work force issues

Summary

Evaluate, stabilize, resuscitate, Use LRCall when you need usEasy dressings, keep warm

OBC

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