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Initial Burn Care Lee D. Faucher, MD FACS Director UW Burn Center Associate Professor of Surgery & Pediatrics Objectives • Discuss burn pathophysiology • Outline treatment modalities • Understand why some treatments better than others What is a burn? • Cutaneous injury caused by heat, electricity, chemicals, friction, or radiation. First Degree Burns • • • • • Epidermis only No blisters Erythema Mild to absent systemic response Heals in 3-4 days Superficial partial thickness • • • • • • • Papillary dermis Blisters Homogenous pink Painful, hypersensitive Blanches Hair usually intact Does not scar, may pigment differently Sup 2nd degree Deep partial thickness • • • • • • • Reticular dermis Mottled red and white Not painful to pinprick or pressure Does not blanch Heals > 3 weeks Usually scars Need to excise and graft Deep dermal Full thickness burns • • • • • • • Into fat or deeper Red, white, brown, black, etc. Diminished sensation Dry, may be leathery Depressed Heals only from the periphery Always excise and graft Full-thickness Etiology Types of burns Where do burns occur Circumstances of injury Admissions by age % of admissions vs. burn size Inhalation injury diagnosis • Closed-space fire • Face burns Terminology • Inhalation injury “nonspecific” – Thermal injury • Upper airway – Local chemical irritation • Throughout airway – Systemic toxicity • CO Clinical diagnosis • History and physical – Exposure – Duration – Enclosed space • Diagnostic studies Other signs and symptoms • • • • • • • Lacrimation Cough Hoarseness Dyspnea Disorientation Anxiety Wheezing • Conjunctivitis • Carbonaceous sputum • Singed hairs • Stridor • Bronchorrhea Poison management = CO • 500 unintentional deaths each year • Persistent Neurologic Sequelae – May improve over time • Delayed Neurologic Sequelae – Relapse later Poison management = CO • Treatment – CO level means nothing to predict outcome – Length of hypoxia is the determining factor – Oxygen – HBO • No studies show benefit in treatment Pathophysiology • The main factor responsible for mortality in thermally injured patients • Carbon monoxide the most common toxin – 200 times greater affinity – Competitive inhibition with cytochrome P450 Reduction of CO 80 Room Air 100% Oxygen 3 ATM % CO 60 40 20 0 0 20 40 Time in Minutes 60 80 Objective data • Bronchoscopy – Edema – Infraglottic soot – Hyperemia – Mucosal sloughing • Sensitivity near 100% under IDEAL circumstances Grading of injury • No reliable indicators of progressive respiratory failures • No studies have found any correlation with initial findings and clinical outcomes and progress Resuscitation Field resuscitation • Start IV with LR, in burn OK – < 6 years = 125mL/hr – 6-13 years = 250mL/hr – >13 years = 500mL/hr Rule of Nines Lund and Browder Chart Area 0-1 yr. Head 19 Neck 2 Ant. Thorax 13 Post. Thorax 13 R. Buttock 2½ L. Buttock 2½ Genitalia 1 R. U. Arm 4 L. U. Arm 4 R. L. Arm 3 L. L. Arm 3 R. Hand 2½ L. Hand 2½ R. Thigh 5½ L. Thigh 5½ R. Leg 5 L. Leg 5 R. Foot 3½ L. Foot 3½ 1-4 yr. 17 2 13 13 2½ 2½ 1 4 4 3 3 2½ 2½ 6½ 6½ 5 5 3½ 3½ 5-9 10-14 yr. yr. 13 11 2 2 13 13 13 13 2½ 2½ 2½ 2½ 1 1 4 4 4 4 3 3 3 3 2½ 2½ 2½ 2½ 8 8½ 8 8½ 5½ 6 5½ 6 3½ 3½ 3½ 3½ 15 Adult 2 3 Total yr. 9 7 2 2 13 13 13 13 2½ 2½ 2½ 2½ 1 1 4 4 4 4 3 3 3 3 2½ 2½ 2½ 2½ 9 9½ 9 9½ 6½ 7 6½ 7 3½ 3½ 3½ 3½ Total IV access • • • • • < 15% TBSA – oral resuscitation 15 – 40% TBSA – one large bore IV > 40% -- two large bore IV’s IV’s should be in the upper extremities Suture IV’s started through burns Crystalloid solution • Ringer’s Lactate – [Na+] 130 mEq (serum 140 mEq) – Osmolality 272 mOsm (serum 300mOsm) • Advantages of crystalloid – Effective in maintaining perfusion – Costs less than colloids – Can be mobilized with a diuretic Resuscitation first 24 hours • Baxter formula – 4 mL/kg/% TBSA burned • Give ½ the volume in first 8 hours and other ½ over next 16 hours. If < 20kg • Same Baxter formula for LR • Add 4mL/kg of D5 ¼ NS – Infuse at constant rate, increase LR if needed for adequate urine output Monitor urine output • Place foley if > 20% TBSA • Urine output goal – 2 mL/kg/hr very young – 1 mL/kg/hr child – 0.5 mL/kg/hr adult • Diuretics are NEVER used to increase urine output • Increase urine output to > 100mL/hr if pigment present How to do this • Maintain continuous IV fluid replacements • AVOID boluses • Only bolus IV fluids if hypotensive Zones of burn injury Pain control Non-medication methods • Cover burns with plastic wrap – Wet dressings will stick and cause more pain – Other burn dressings are expensive and not necessary – Quik Clot is expensive and will not provide any patient benefit Ice Pack-----DO NOT USE EVER • DOES NOT – Reverse temperature – Inhibit destruction – Prevent edema • DOES – Delay edema – Reduce pain Medication • Medications – Opioids – Narcotics – Pain medications – IV Analgesia Summary • Airway • Circulation/Resuscitation • Pain control Questions?