Burn Care

A

Scalds

• 1.

  Most common type of burn injury

• 2.

  Usually from hot water

  • a.

    Exacerbated by overlying garments that prolong contact

• 3.

  Common burn injury seen in child abuse—distribution exhibits a “dip” line pattern

B

Flame

• 1.

  Second most common type of burn injury

• 2.

  Full-thickness burns—common given the flammability of overlying garments

C

Flash

• 1.

  Related to the explosion of flammable liquids and gases

D

Contact

• 1.

  Result from contact with heated or cooled objects

• 2.

  Seen frequently in industrial and trauma-related accidents

A

Outpatient Setting

• 1.

  Select burn cases can be managed as outpatients, usually those with less than 5% total body surface area (TBSA) injured.

• 2.

  Must be seen and examined by an experienced practitioner

• 3.

  Availability of close follow-up care

• 4.

  Adequate social support for wound care

• 5.

  Burn wounds greater than 5%–10% TBSA should be referred to a burn center for evaluation.

B

Burn Unit Setting

Referral to a burn center is indicated in the following situations based on the guidelines of the American Burn Association injury severity grading system:

• 1.

  Partial-thickness burns of more than 10% TBSA in all patients

• 2.

  Burns that involve the face, hands, feet, genitalia, or major joints

• 3.

  Full-thickness burns in any age group

• 4.

  Electrical, chemical, or inhalation injury

• 5.

  Burn injury in patients with preexisting medical conditions that may complicate management, prolong recovery, or affect mortality

• 6.

  Any patient with burns and concomitant trauma in which the burn injury poses the greatest risk or morbidity and mortality

• 7.

  Children in hospitals without qualified personnel or equipment for appropriate pediatric care

• 8.

  Patients who will require special social, emotional, or rehabilitation intervention, including victims of abuse or neglect

A

History

• 1.

  Ascertain the circumstances associated with the injury.

  • a.

    History of unconsciousness, arrest, and the report given by the first responders

    • (1)

      Avoid immediate concentration on the burn injuries alone.

• 2.

  Identify burn agent—flame, scald, chemical, electrical.

• 3.

  Open versus closed space—Assess the possibility of inhalation injury.

• 4.

  Time of burn is important for calculating adequate resuscitation.

• 5.

  Prehospital treatment administered and vital signs during transport—Patients are often found to be overresuscitated or underresuscitated.

• 6.

  Take medical history—allergies, immunizations, current medications, and concomitant medical problems.

B

Airway/Breathing

• 1.

  Ensure adequacy of the airway.

  • a.

    Prophylactic intubation/tracheostomy is indicated for the following conditions:

    • (1)

      Loss of consciousness or decreased mental status with inability to protect airway

    • (2)

      Extensive burns greater than 60% TBSA

    • (3)

      Increasing stridor or hoarseness

    • (4)

      Evidence of posterior pharyngeal burn or injury

  • b.

    Injury to the airway may be difficult to assess, often resulting in overaggressive intubation. The presence of singed nose hairs alone is not indicative of airway injury and does not necessitate intubation.

• 2.

  Inhalation injury is the major contributor to mortality.

  • a.

    Carbon monoxide (CO) poisoning—CO displaces oxygen and binds hemoglobin, forming carboxyhemoglobin. Results in poor oxygen delivery.

    • (1)

      Diagnosis—signs and symptoms of hypoxia (nausea, headache, confusion) and/or serum carboxyhemoglobin level greater than 10% (nonsmokers) or greater than 20% (smokers) are diagnostic.

    • (2)

      Levels of 40%–50% are not uncommon in survivors with aggressive care.

    • (3)

      Oxygen saturation levels are normal despite high levels of carboxyhemoglobin.

    • (4)

      Treatment—100% O ₂ reduces half-life of CO.

      • (a)

        Follow with carboxyhemoglobin levels and continue to treat until levels are 10%–15%.

      • (b)

        Persistent metabolic acidosis despite adequate volume resuscitation implies CO poisoning of cellular respiration.

    • (5)

      Carboxyhemoglobin levels greater than 50% are potentially lethal.

    • (6)

      CO has a 200-time greater affinity for hemoglobin than does oxygen.

  • b.

    Thermal injury

    • (1)

      Usually limited to upper airway due to heat absorptive capacity of oropharynx. Steam burns are the exception that may affect lower airways.

    • (2)

      Upper airway obstruction may occur up to 72 hours post injury. Maximal edema is seen between 12 and 24 hours.

  • c.

    Chemical pneumonitis

    • (1)

      Mucosal injury and pulmonary edema are caused by exposure to products of combustion and noxious gases.

    • (2)

      Tracheobronchial mucosal injury leads to decreased immune defenses, bronchoconstriction and obstruction, and loss of ciliary clearance mechanisms.

    • (3)

      Patients with chemical pneumonitis are at high risk of pneumonia, pulmonary edema, and acute respiratory distress syndrome (ARDS).

  • d.

    Diagnostic modalities

    • (1)

      Suspect inhalation injury if the following are present:

      • (a)

        Closed-space injury (e.g., house fire)

      • (b)

        Presence of facial burns, singed nasal hairs, bronchorrhea, carbonaceous sputum, wheezing and rales, tachypnea, progressive hoarseness, and difficulty clearing secretions

    • (2)

      Upper airway—Perform direct laryngoscopy looking for carbon deposits, airway edema, and oropharyngeal burns.

    • (3)

      Lower airway—Perform fiberoptic bronchoscopy looking for gross airway edema, carbon deposits in tracheobronchial tree, and mucosal erythema and necrosis.

  • e.

    Treatment—Implement immediate O ₂ supplementation, ventilatory assistance, aggressive pulmonary toilet, O ₂ saturation monitor, placement of an arterial line for serial arterial blood gases, bronchodilators, and bronchioalveolar lavage to remove debris.

C

Burn Evaluation

The patient should be totally exposed, and any burned clothing and constricting jewelry removed.

• 1.

  Depth of the burn wound

  • a.

    First degree—Only the epidermal layer is involved.

    • (1)

      Painful to palpation

    • (2)

      Pink in appearance without blistering

  • b.

    Second degree (partial thickness)—The dermal layer is only partially involved, classified as superficial and deep partial thickness.

    • (1)

      Painful to palpation

    • (2)

      White to pink in appearance; blebs and blisters may be present.

    • (3)

      Epithelialization occurs from epithelial cells surrounding hair follicles or sweat glands (skin appendages) and from the wound edges and is markedly delayed with deeper injury.

    • (4)

      Deeper burns result in the destruction of epidermal appendages in reticular dermis and often require excision.

      • (a)

        Spontaneous reepithelialization is markedly delayed (similar to third-degree injury).

  • c.

    Third degree (full thickness)—The entire dermal layer is affected.

    • (1)

      All dermal appendages destroyed

    • (2)

      Insensate area

    • (3)

      White, black, or red in appearance with a dry and leathery (inelastic) texture

  • d.

    Fourth degree—The underlying fascia, muscle, and/or bone is involved.

• 2.

  The estimate of the TBSA of the burn injury is the sum of second- and third-degree burns only.

• 3.

  Size estimation ( Fig. 19.1 ).

  • a.

    The “rule of 9s” approximates the size of the affected area.

    • (1)

      Head and neck: 9%

    • (2)

      Each upper extremity: 9%

    • (3)

      Each lower extremity: 18%

    • (4)

      Anterior trunk: 18%

    • (5)

      Posterior trunk: 18%

    • (6)

      Perineum: 1%

  • b.

    Children have a proportionally larger head and trunk with a smaller lower body (see Fig. 19.1 for percentages).

  

D

Fluid Resuscitation

• 1.

  Access

  • a.

    Initially, two large-bore (>18-gauge) peripheral catheters can be used even if the access site has been burned.

  • b.

    Central venous access is more suitable than peripheral catheters for long-term use and if vasopressors are needed for hemodynamic instability.

  • c.

    Central venous pressure or pulmonary catheters are used in patients with cardiac or pulmonary disease, questionable fluid status, or hemodynamic instability.

    • (1)

      Catheter sites should be changed routinely (every 3–7 days) to decrease the risk of infection.

• 2.

  Formulas for fluid resuscitation—Multiple formulas and resuscitation schemes have been devised; the Parkland formula is the most widely used. Other formulas include the modified Brook or the military Joint Theater Trauma Systems (JTTS) resuscitation.

  • a.

    Parkland formula: This resuscitation scheme uses lactated Ringer (LR) solution at 3–4 mL/kg/% burn, with half the total volume given over the first 8 hours (calculated from the time of burn), and the other half over the following 16 hours.

  • b.

    JTTS guidelines: LR at an initial hourly rate of 1–2 mL/kg per percentage of burn with subsequent adjustment based on physiologic response. May increase or decrease rate by 20% based on physiologic markers. Total volume of resuscitation after the first 24 hours should not exceed 6 mL/kg per percentage of burn.

  • c.

    No matter which formula is used, overall fluid status and resuscitation endpoints should be monitored hourly and fluids should be carefully adjusted to prevent overresuscitation and underresuscitation. Maintenance fluid requirements should also be added.

  • d.

    Placement of a pulmonary artery catheter should be considered in the case of severe burns to assist with assessment of volume status.

  • e.

    Initial K ⁺ supplementation is not required, although large amounts are needed during healing.

  • f.

    Colloid may be given as early as 12 hours after injury in large burns and usually consists of albumin infused at a constant rate. Fresh frozen plasma may be given if coagulation deficits are present.

  • g.

    Blood should not be used for initial resuscitation (unless the patient is anemic secondary to other injuries).

  • h.

    High-volume fluid boluses should be avoided, but intravenous (IV) rate can be adjusted as needed.

  • i.

    Resuscitation formulas serve only as a guideline for initial IV fluid administration.

    • (1)

      Adjust the IV rate based on physiologic response.

• 3.

  Goals of resuscitation—The endpoint of resuscitation is to maintain adequate tissue perfusion, which is difficult to quantify; however, the following parameters can be used:

  • a.

    Adequate urine output (UOP)—adults, 30 mL/h; children, 1–1.5 mL/kg per hour

  • b.

    Blood pressure—goal mean arterial pressure (MAP) ≥60 mm Hg

  • c.

    Normal mentation

  • d.

    Well-perfused extremities (warm, good capillary refill)

  • e.

    Normal arterial pH, lactate levels, and base excess

  • f.

    Mixed venous O ₂ saturations greater than 70%

  • g.

    Inadequate volume restoration—manifested by oliguria, tachycardia, and persistent or worsening base deficit

E

Initial Procedures

• 1.

  Foley catheterization—required for accurate UOP measurements during resuscitation in patients with more than 20% TBSA burns

• 2.

  Nasogastric tube—gastric ileus occurs frequently after burns; also a useful route for oral medications

• 3.

  Nasojejunal feeding tube—placed under fluoroscopy beyond the ligament of Treitz, with immediate initiation of enteral feedings

  • a.

    Early enteral feeding has been shown to decrease sepsis-related complications. All patients with greater than 20% TBSA burn should be considered for enteral feedings.

• 4.

  Escharotomies—may be required for burns to extremities and chest to prevent compartment syndrome and respiratory compromise

  • a.

    Compartment syndrome—The symptoms are the 5 P s ( p ain, p allor, p oikilothermia, p ulselessness, and p aresthesias) exhibited by loss of motor and sensory nerve function, diminished peripheral pulses, decreased capillary refill, pressure greater than 30 mm Hg by direct measurement (causes collapse of the capillary beds).

    • (1)

      Decompression is achieved by incising the lateral and medial aspects of the extremity while in anatomic position.

    • (2)

      If symptoms are unrelieved, then fasciotomy may be required to relieve compartment syndrome.

    • (3)

      Extremity burns should be managed with elevation of the affected extremity.

    • (4)

      Compartment syndrome is especially important to look for with electrical burns.

  • b.

    Circumferential chest burns reduce compliance of chest wall, but escharotomies are rarely needed.

    • (1)

      Escharotomies should be performed in the presence of increased peak pressures, increased partial pressure of carbon dioxide (Pa co ₂ ), and decreased compliance.

F

Initial Tests

• 1.

  Baseline weight

• 2.

  Laboratory tests—complete blood cell count, electrolytes, arterial blood gas with carboxyhemoglobin (for large burns or suspected inhalation injury), coagulation studies

• 3.

  Chest radiograph and electrocardiogram (history of cardiac problems or electrical burns)

• 4.

  Urinalysis

G

Medications

• 1.

  Tetanus prophylaxis—unless received booster within last 5 years

• 2.

  Ulcer prophylaxis—may use proton pump inhibitor or H ₂ blocker, should attempt at enteral administration as soon as is safe for the patient and a route for enteral administration has been established

• 3.

  Multivitamins (particularly vitamin C and the other antioxidants) in tube feedings

• 4.

  Hemoglobinuria/myoglobinuria— If myoglobinuria is present, aim for UOP greater than 100 mL/h for clearance and renal protection. If there is no improvement, may give mannitol 12.5 g IV, and alkalinize urine with 1 ampule NaHCO ₃ in IV fluids to keep urine pH greater than 7.0 to prevent precipitation. If not adequately treated, renal failure can occur. Watch K ⁺ levels as well.

• 5.

  Prophylactic antibiotics are contraindicated.

A

Edema

• 1.

  Maximal at 18–24 hours after the burn for the following reasons:

  • a.

    Generalized increase in microvascular permeability secondary to release of inflammatory mediators in affected tissue (histamine)—involves nonburned tissue if burns more than 20% TBSA

  • b.

    Generalized impairment in cell membrane function—increased intracellular volume drawn in by increased intracellular Na ⁺ with concomitant loss of K ⁺

B