author(s): patrick carter, daniel wachter, rockefeller ......epidemiology of burns 1-1.5% of...

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Advanced Emergency Trauma Course

GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD

Burns

Presenter:CarlSeger,MD

Epidemiology of Burns

  1-1.5%ofpopulationseesMDforburns/yearinUS

  1.25-2.5millionburnseachyear  500,000EDvisits,50,000admits,5,000deaths

  Mostburnscoverlessthan5-10%ofbodysurfacearea

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Types of Burns

 Thermal Chemical Electrical

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Thermal Burns

  Contact  Flame  Heat  Scalding

Medscape

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Chemical Burns

  Bothacidsandbasescanbedefinedascaustics,whichcausesignificanttissuedamageoncontact.

  ACIDSproduceacoagulationnecrosisbydenaturingproteins,formingacoagulum(eg.eschar)thatlimitsthepenetrationoftheacid.

  BASEStypicallyproduceamoresevereinjuryknownasliquefactionnecrosis

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Chemical Burns

  Acids•  Toiletbowlcleaners,draincleaners,metalcleaners,automobilebatteryfluid,fertilizermanufacturing,rustremovers,tirecleaners,tilecleaners,glassetching,dentalwork,refrigerant,andhairwaveneutralizers

  Bases•  Draincleaners,bleach,ovencleaners,mortar,plaster,andcement

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Electrical Burns   LOW-VOLTAGE•  Electricburnsalmostexclusivelyinvolveeitherthehandsororalcavity.

  HIGH-VOLTAGE•  Inburnsfromanelectricarc,thecurrentcoursesexternaltothebodyfromthecontactpointtotheground•  Electriccurrentthatpassesbetweenthepowersourceandtheanatomicpointofcontact(entrancewound),andbetweenthepatient(exitwound)andthegroundingmechanism,causinghiddendestructionofdeepertissues

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

General Skin Anatomy and Physiology

  SkinLayers•  Epidermis•  Dermis

  SkinFunction•  Protection

  Pathogens  Waterloss

•  Tempregulation•  Sensation•  VitaminDSynthesis

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

NationalCancerInstitute,SEER

Classification

  TraditionalClassification•  1stdegree•  2nddegree•  3rddegree

  CurrentClassification•  Superficialpartialthickness•  Deeppartialthickness•  FullThickness

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Burn Classification

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

K.Aainsqatsi,Wikipedia

1st Degree

  Redness  Dryskin  Painfultotouch  Painlasts48to72hrs  Peelingskin

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

SourceUndetermined

2nd Degree; Partial Thickness

  Involvesthetoplayersofskin.

  Theskinisredandblistered.

  Usuallypainful.  Takesupto3-4weekstoheal.

  Mayscar.

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

SourceUndetermined

3rd degree; Full thickness burns

  Destroysalllaysofskinandunderlyingstructures.

  Maylookbrownorblackandtissueunderneathmaybewhite.

  Usuallynotpainful.

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

SourceUndetermined

Pathophysiology of Burns   Cellulardamageat>45°C  Dependentontemperatureandduration

•  Singeretal.AcadEmergMed2000;7:1

  Threezonesofinjury–  Centralzoneofnecrosis  Zoneofstasis(atriskofnecrosis)  Zoneofhyperemia•  JacksonBrJSurg1953;40:588BurnPathophysiology

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Pathophysiology of Burns   Thermalinjurytriggersintenseinflammatoryresponse•  Initialreleaseofhistamine,bradykinin•  Increasedcapillarypermeabilitywiththirdspacing•  ProgressivevascularocclusionbyPMN,RBCs•  Releaseoffreeradicals,proteases

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Clinical Evaluation

  History•  Historyofevents–closedspace,toxicfumes•  Evaluateforinconsistenciesorpatternssuggestingchildabuse(immersioninjuries)•  PMH:AMPLE,Tetanusimmunizationstatus

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Clinical Evaluation •  PhysicalExam

  Assessforinhalationinjury•  Signsnotalwayspresent•  Singednasalhair•  Carbonaceoussputum•  Cough•  Hoarseness•  Dyspnea•  AMS

•  AssessSeverityofInjuryGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Clinical Evaluation

  DetermineSeverityofInjury•  Size• Depth/Degree•  Location-

 Hands,face,genitals,feet,circumfrential• Ruleof9’s

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Rule of 9’s

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Burnsurgery.org

Initial Burn Management

  ABCs  Identifyandtreatassociatedinjuries  Removesource,protectrescue  Initialcoolingwithcoolwater(notcold)  Coverwithdressing,leaveblistersintact  Brushoffanymetalothermaterial  Irrigationforchemicalburns

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

  AirwayManagement•  Secureairwayearly•  Signsofimpendingairwayobstruction

  Hoarseness,Stridor,Facialedema•  EndotrachealintubationorsurgicalairwayifETnotpossible•  Give100%O2forsuspectedsmokeinhalation

Acute Management

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Chemical Burns

  Brushoffdrymaterialfirst

  Takeoffanyclothingthatcaneasilyberemoved

  Flushwithwaterforatleast20-30minutes

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

 FluidResuscitation• ParklandFormula• UrineOutput• PediatricConsiderations

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Acute Management

Parkland Formula

  4x(%bodysurfaceburned)xwtinKg  Thisequalstheamountoffluid(inml)toreplaceina24hrperiod

  Thefirsthalfinthefirst8hrs  Therestinthenext16hrs

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Acute management

 GeneralWoundCarePrinciples• BiologicalDressing• WoundDebridement

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Acute management

  TopicalAgents•  Silvadinecream• Coveringthewoundwithcleanlinens

 Analgesia• Oftenverypainfulandrequirelargeamountofpainmedication

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Do’s and Don’ts of Burn Care

  Do’s•  Brushoffdrychemicalwhileinaprotectivesuit•  Flushwithcoolwater•  Coverwoundwithdrydressing•  Keepvictimcomfortable

  Don’ts•  Applyice•  Touchtheburn•  Removepiecesofclothfromburnedarea•  Cleansevereburns•  Breakblisters•  Useointmentonsevereburns

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Acute management

  Escharotomy•  Deepcircumferentialburnsoverneck,chestlimbs•  CompromisedABC’s•  Maybelifeorlimbthreatening•  IncisionofeschartosubQfat•  Avoidmajorvesselsandnerves•  Anestheticsusuallynotrequired

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Escharotomy

MedscapeGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Acute management

  InhalationalInjuries• GeneralEvaluationandManagement• CarbonMonoxide

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Inhalational Injuries

  Responsibleformostdeaths  Evolutionmayrequireseveraldays  Exposureofairwaysandlungstotoxicchemicals

  Tracheobronchitis  Airwayobstruction  Pulmonaryedemawithin2-3days

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Inhalation Injury

  CarbonMonoxide•  HashigheraffinityforhemoglobinthanO2.•  COpoisoningcanleadtoAMS,myocardialischemia,andseverelongtermneurologicsequelae•  O2inhigherconcentrationsacceleratesCOelimination•  Canalsotreatwithamylnitrate,sodiumnitrite,sodiumthiosulfate

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Complications of Burn Care

 Infection AirwayConsiderations CircumferentialBurns

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Indications for Admission

  Adults>15%2°DegreeBurns  Children>10%2°DegreeBurns  3°burns>2%  Face,hands,feet,perineum  Seriousunderlyingdiseases  Socialconsiderations

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

When does Cold Injury Occur?   TheFactorsthatcontributetoColdInjury•  Temperature• Durationofexposure•  Immobilization• Moisture•  Vasculardisease• Openwounds

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Recognize local cold injuries

  Frostnip-Mildform,doesnotresultintissuedestruction,verypainful

  Frostbite-intracellularicecrystals,cangetreperfusioninjury,Classifiedbasedoffofdepth

Medscape

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Frostbite

Medscape

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Medscape

Treating cold injuries

  Donotdelay  Removeclothing  Warmedblankets  Rewarmfrozenpart  Preservedamagedtissue  Preventinfection  Elevatedexposedpart  Analgesics,tetanus,andantibiotics

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Recognize hypothermia

  Rapidorslowdropincoretemperatureto<35degreesC

  Elderlyandchildrenatgreaterrisk  Low-rangethermometerrequired

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Hypothermia clinical signs

  Temperature<35degreesC  DepressedLevelofconsciousness  Gray,cyanotic  Variablevitalsigns  Absenceofcardiorespiratoryactivity

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Treating Hypothermia

  ABCDE’s  Rewarm  Assessforassociateddisorders  Bloodanalyses,includingK+andC++

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Treating hypothermia

  Passiveexternalrewarming:Warmenviroment,blankets,IVfluids

  Activecorerewarming:surgicalrewarmingtechniques

  Notdeaduntilwarmanddead

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse

Questions?

Dkscully(flickr)

References   Schwartz,L.,Balakrishnan,C.ThermalBurns.inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1220-1226.

  Harchelroad,F.,Rottinghaus,D.ChemicalBurns,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1226-1231

  Fish,R.ElectricalInjuriesandLightningInjuries,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1231-1238

  AmericanCollegeofSurgeons.Injuriesduetoburnsandcold,inAdvancedTraumaLifeSupportforDoctors7thedition.2004.p.231-241.

GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse