1 gsacep core man lecture series: burn management patrick glynn md, capt, usaf updated: 19feb2013
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GSACEP core man LECTURE series:
Burn Management
Patrick Glynn
MD, Capt, USAFUpdated: 19Feb2013
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Disclaimer
Views and opinions expressed do not necessarily reflect those of GS-ACEP, The Department of Defense, the U.S. Government, the North American Continent, the Western Hemisphere, or Mother Earth.
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Outline
Anatomy
Pathophysiology
Burn Assessment
Management
Reasons for referral
Prognosis
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Skin Anatomy
Largest organ system of the bodyEpidermis outer layer, varying thickness
Dermis Thicker, hair follicles, nerve endings,
blood vessels
Subcutaneous Fat Muscle
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Skin Anatomy
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Burn PathophysiologyBurns alter capillary permeability fluid leaks out
Volume loss, hypotension worst in lungs
ARDS Electrolyte abnormalities
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Thermoregulation
Normal skin regulates body temperature
Burned skin doesn’t function properly patients lose autoregulation leads to HYPOthermia
Keep burned patients warm 7
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Zones of Burn Injury
Coagulation Irreversible destruction
Stasis middle layer with Decreased blood flow Can be saved by adequate Resuscitation
Hyperemia surrounding area Increased blood flow recovery likely
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Estimating size (TBSA)Patient’s Palm=1% TBSA
Rule of 9’s - percentage surface area Head = 9 Each Arm = 9 Each Leg = 18 Back = 18 Front = 18 Groin = 1%
Kids: Head=18, each leg 13.5% 9
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Age
Older and Younger patients have thinner skin more prone to thermal injury
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Burn Depth - Superficial
Red skinPainfulNO blisters
heals in 3-7 daysexample: sunburn
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Burn Depth - Partial Thickness
Epidermis / DermisBlistersWet appearingPAINFUL
Can convert to full thickness
or heal in 2-3 weeks12
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Burn Depth - Full Thickness
PAINLESS
WaxyCharredDry
Requires surgery / grafting
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Burn Depth
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Assessment - AirwayInhalation Injury Face / neck burns Hoarse voice Singed nasal / facial hairs Soot in sputum
Aggressive, Early management Intubate BEFORE swelling
Large ETT for Bronchoscopy
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Assessment - Mental status
Altered hypoxia CO poisoning Cyanide toxicity if surrounded by fire /
smoke
treat with supplemental Oxygen16
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Management
Airway - Assess / Reassess & Intervene
Dressings in Field
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Pre-hospital care
Airway
Stop burning process ie: wash off chemicals
Start Fluid resuscitation
Transport to hospital
Pain control
Protect burn wound18
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Management - FluidsLR or NSParkland Formula TBSA x (weight kg) x (4 LR) = 24 hour
requirement 1/2 in first 8 hours 1/2 over the next 16 hours
Still need maintenance fluids
Urine output - 1mL /kg/hr19
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Resuscitation Example
70 kg patient
20% partial and full thickness burns
What is the 8 hour fluid requirement?
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Resuscitation Example
70 kg x 20 x 4 = 5600 mL in 24 hours
2800 mL in 8 hours
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Chemical Burns
Acid - coagulation necrosis
Alkali - liquefaction necrosis usually worse
remove clothingIrrigate aggressively with water / saline 22
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Refer to burn centerFull thickness burns
Inhalational Injury
Electrical burns
Chemical burns
Circumferential burns
Partial Thickness >15%
Pediatric or Elderly >10%
High Risk Locations genital, hands, feet, face, over
joints 23
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Compartment Syndrome
Extremities remove rings, jewelry, clothing
Abdominal
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Management
Aggressive pain control
Compartment syndrome: needs fasciotomy to release pressureEscharotomy - for circumferential burns
Tetanus immunization Blisters - Controversial
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Burn Prognosis
Increase Risk of Death: Larger burn size Older age Inhalational Injury Female Pre-existing diseases
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References
Tintinalli’s Emergency Medicine 7th Edition, chapter 45
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