New Approaches in Burn Management New Concepts in the Management of Thermal Injuries


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New Approaches in Burn Management


New Concepts in the Management of Thermal Injuries

  • Objectives

    • Smoke inhalation--who can be sent home?
    • What really predicts intubation in smoke inhalation?
    • RSI in smoke inhalation
    • Whose palm is it anyway?
    • Is the rule of nines really the rule?
    • Challenging the Parkland formula
    • New imaging for burn depth
    • Blister management
    • Hands


Prehospital Care

  • Pain Management by EMS

    • EMS personnel hesitate to give an appropriate amount of pain medication to burn patients
  • Airway Management

    • EMS personnel are concerned about the airway NOT about making it to the regional burn center.
    • so these patients show up in your ED


Know the Burn Depth “Lingo” For the Consultants



Know the Burn Depth “Lingo” For the Consultants

  • Plastic Surgeons

    • 3 Zones
    • Partial Thickness
    • Full Thickness


Epidemiology as Easy as Two-Three

  • 2/3 male

  • 2/3 white

  • 2/3 drunk

  • 2/3 have flammable liquid

  • 2/3 reduction in death due

  • to smoke detectors

  • 23 mean age



Mechanisms

  • Six groups based on mechanism of injury

    • Scalds 30%
    • Contact burns 30%
    • Fire 30%
    • Chemical 3%
    • Electrical 5%
    • Radiation 1%
  • Flash Burns



Chemistry Flash Backs

  • Tar Burns

    • “Likes dissolve likes”
    • Excellent removal with butter
  • Wet Cement

    • CaOH-
    • Treat like an ocular alkali burn
  • Hydrofluoric Acid Burn

    • Dissolve 10% calcium gluconate solution in 3 times the volume of a water-soluble lubricant.
    • For burns to the fingers, retain gel in a latex glove.


Chemistry Flash Backs

  • Microwaves cause “superheating”

    • Heating a liquid to a temperature above its normal boiling point, making it unstable.
  • Microwave energy burns are based on the water content of tissue

  • Muscle burns more than fat

  • Delay between time of injury and signs of skin damage or pain



Just Admit Him for Syncope?

  • Fireman has sudden collapse at a house fire

    • His firefighter partner called it a “Knock Down Fire”
    • This is classic presentation of CN
    • CO requires longer exposure for symptoms


Smoke Inhalation Who Can We Discharge Home?

  • Arterial blood gases, chest radiography and carboxyhemoglobin estimation rarely influence immediate management.

  • Bottom Line

    • Patients presenting with normal vital signs and examination and short smoke exposure may be safe to discharge from the emergency department without further investigation.
  • Mushtag,F, et al, Discharge from the accident and emergency department after smoke inhalation: influence of clinical factors and emergency investigations. J Emerg Med. 2004 Jun;11(3):141-4.



Factors that Predict the Need for Intubation in Patients with Smoke Inhalation Injury

  • No statistically significant correlation was found between intubation and any of the “classic symptoms” of smoke inhalation:

    • stridor
    • hoarseness
    • drooling
    • dysphagia (all p = 1.0)
  • Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke Inhalation Injury Ear Nose Throat J. 2006 Apr ;85(4):278-80



Factors that Predict the Need for Intubation in Patients with Smoke Inhalation Injury

  • Intubation positively correlates with the physical examination findings of

    • soot in the oral cavity (p < 0.001)
    • facial burns (p = 0.025)
    • body burns (p = 0.025)
  • Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke Inhalation Injury Ear Nose Throat J. 2006 Apr;85(4):278-80



Factors that Predict the Need for Intubation in Patients with Smoke Inhalation Injury

  • Conclusion

    • Patients with
      • soot in the oral cavity,
      • facial burns, or
      • body burns
    • have a higher likelihood of laryngeal
    • edema and the need for intubation.
    • Madnani DD, et al, Ear Nose Throat J. 2006 Apr;85(4):278-80


Intubation and Smoke Inhalation

  • “Take it early” as it never gets better !

  • Prevent a “DOA”

    • Developing Obstructed Airway due to progressive edema
    • First attempt is best attempt - This is for the most experienced intubator NOT a junior resident


Three Factors of Smoke Inhalation That Produce a Difficult Airway

  • Thermal damage – Upper airway takes the brunt and causes edema due to the poor conductivity of air and the high amount of dissipation that occurs in the upper airways.

  • Air inhaled at 142°C - by the time it reaches the carina it will have cooled to 38°C.

  • Asphyxiation – Tissue hypoxia alone - with CO or CN??

  • Pulmonary irritation – Particulate matter causes a decrease in all lung volumes and lung compliance





RSI in Burn Patients

  • Don’t take away what they already have

      • Should be your thought before pushing any paralytic
  • Why a 7.5 ETT ?

  • What is your plan B ?





Hypotension Post Intubation in a Burn Patient

  • Now the patient is intubated but your bagging is becoming an isometric exercise.

  • And the patient is developing hypotension.

  • Why?

  • Is this burn shock?

  • Is the vent setting wrong?

  • What else might the patient need?



Escharotomy

  • “SNAP, CRACKLE, POP”



The Palm and the Assessment of TBSA #1 Problem

  • The area of the palm alone is

      • 0.5 percent TBSA in males
      • 0.4 percent TBSA in females
  • Whereas the area of the palm plus the palmar surface of the five digits is

      • 0.8 percent BSA in males
      • 0.7 percent BSA in females
  • Therefore, if a hand alone is used to assess

  • the size of a burn, the percent BSA is overestimated.

  • Rossiter ND et al. How big is a hand? Burns. 1996 May;22(3):230-1.



Palmar Estimation and BMI #2 Problem

  • The mean HSA diminishes significantly as BMI increases in both sexes (P<0.001).

  • This difference is more pronounced in women, particularly those with a BMI >31 kg/m2

  • Awareness of the potential for overestimation of burn surface area using this method alone may improve the accuracy of burn area estimation.

  • Berry MG et al. The influence of body mass index on burn surface area

  • estimated from the area of the hand. Burns. 2001 Sep;27(6):591-4.



The Rule of Nines Isn’t Always the Rule



The Rule of Nines Isn’t Always the Rule

  • The Rule of Nines provides reasonable estimates of body surface area for patients ranging from 10 to 80 kg.

  • For obese patients weighing more than 80 kg, a rule of fives is proposed:

      • 5% body surface area for each arm
      • 5 x 4 or 20% for each leg
      • 10 x 5 or 50% for the trunk
      • and 2% for the head
  • Livingston EH. Percentage of burned body surface area determination in obese and nonobese patients. J Surg Res. 2000 Jun 15;91(2):106-10





Fluids and Formulas

  • Lactated Ringer’s in all burn resuscitation

  • Burn resuscitation requires more fluid than trauma resuscitation.

  • Prevent hyperchloremic acidosis and buffer lactate



Fluids and Formulas

  • On the Horizon

    • Adjuvant administration of high-dose ascorbic acid
    • (66 mg/kg/hr) during the first 24 hours after thermal injury significantly reduces
      • resuscitation fluid volume requirements by 30%
      • wound edema
      • severity of respiratory dysfunction
    • Reduction of Resuscitation Fluid Volumes in Severely Burned Patients Using Ascorbic Acid Administration Arch Surg. 2000;135:326-331.


Fluids and Formulas

  • Formulas

    • Parkland LR 4 mL/kg per percent burn ????
    • Modified Brook LR 2 mL/kg per percent burn
    • Galveston LR 5000 ml/m² BSA burned/day plus
          • 2000 ml/m² BSA total/day
          • (also used in TEN)
    • Barret J.P et al. Survival of paediatric burns involving 100% total body surface area Ann Burns Fire Disasters 1999; 12:139.
    • Spies et al. Treatment of extensive toxic epidermal necrolysis in children Pediatrics 2001;108:1162-1168.


How Well Does the Parkland Formula Estimate Actual Fluid Resuscitation Volumes?

  • Despite its effectiveness, the Parkland formula underestimates the volume requirements in most adults with isolated cutaneous burns, especially in those with large full thickness burns.

  • New data suggest 5.5-6.0 ml/kg per TBSA%

  • Cartotto RC et. al. How well does the Parkland formula estimate actual fluid resuscitation volumes? Burn Care Rehabil. 2002 JulAug;23(4):258-65.

  • Mitra B et.al. Fluid resuscitation in major burns J Surg. 2006 Jan-Feb;76(1-2):35-8.



Inhalation and Fluid Requirements

  • Patients with flame burns and inhalation injury have a mean fluid requirement of

    • 2 ml/kg/% burn above patients with flame burns without inhalation injury for adequate resuscitation.
  • Dai NT et al. The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries. Burns 1998 Nov;24(7):671-5.



Early Fluid Resuscitation Improves Outcomes in the Pediatric Patient

  • The incidence of sepsis, renal failure, death due to cardiac arrest, and overall mortality is significantly higher in burned children receiving fluid resuscitation that was delayed >2 hr.

  • Fluid resuscitation, given within 2 hr of a thermal injury, may be one of the most important steps in the prevention of multi-organ failure and mortality.

  • Barrow RE et al. Early fluid resuscitation improves outcomes in

  • severely burned children. Resuscitation. 2000 Jul;45(2):91-6.



Emergency Department Fluid Resuscitation of Burn Patients Transferred to a Burn Center

  • The average total body surface area (TBSA) estimated by the referring emergency department staff was 23.9%

  • Compared with the burn intensive care unit staff’s average estimation of 17.8%

  • More importantly 47% were underresuscitated.

  • Hagstrom M et al. A review of emergency department fluid resuscitation of burn

  • patients transferred to a regional, verified burn center. Ann Plast Surg. 2003;51:173-6.



Emergency Department Fluid Resuscitation of Burn Patients Transferred to a Burn Center

  • Bottom Line

  • Early communication permits review of estimated TBSA burn evaluation and permits cooperative calculations and optimal delivery of early fluid resuscitation.

  • Burn center practitioners can improve care of patients before arrival by appropriately guiding the referring physician.

  • Hagstrom M et al. A review of emergency department fluid resuscitation

  • of burn patients transferred to a regional, verified burn center.

  • Ann Plast Surg. 2003 Aug;51(2):173-6.



Advances in Modalities Used for the Assessment of Burn Wound Depth

  • Depth dictates prognosis

  • Although bedside clinical evaluation remains the most widespread and cost-effective method, it is accurate only 2/3 of the time and is limited by poor interrater reliability

  • New techonological modalities are now in use

    • Laser Doppler Imaging (LDI)


Burn Assessment by Laser Doppler Imaging

  • Noncontact scanning technique that measures the entire burn wound surface.

  • Color-coded perfusion map corresponds to varying burn depth.

  • Accuracy up to 99%

  • The latest, most accurate, most advanced modality of diagnosing burn depth



Management of Blisters in the Partial-Thickness Burn

  • Previously a controversial topic

    • Preservation: intact blister provides natural biological protection to the wound; blister fluid supports wound healing
    • Blister debridement and fluid evacuation; components of blister fluid are detrimental to wound healing


Management of Blisters in the Partial-Thickness Burn

  • Blisters do not indicate burn depth

    • Blisters typically signify the presence of a superficial partial- thickness wound.
    • We can get into trouble: they may occur over deeper dermal injuries that require excision and skin grafting.
    • It is imperative to accurately identify the depth, as it correlates with the risk of wound infection.


Visually Deceiving Burns

  • Many burn injuries involve various depths of burn.

  • Debridement of blisters aids in accurate wound depth identification by allowing direct visualization of the wound bed.



Management of Blisters in the Partial-Thickness Burn

  • Infection

    • 3 Zones of Injury
      • Coagulation
        • central devitalized tissue
      • Stasis
        • marginally perfused
      • Hyperemia
        • outlying tissue


Management of Blisters in the Partial-Thickness Burn

  • Knowledge of these zones and the associated risk of conversion of partial-thickness to full-thickness injury requires ongoing assessment, especially during the first 48 hours.

  • Prevention of wound conversion is key.



Debridement of Burn Blisters

  • Protective to the fragile zone of stasis in the early stages of injury

  • Inflammatory mediators within blister fluid contribute to increasing size of the blister as the result of effect on microcirculation and increased capillary permeability

  • Mechanical pressure from the blister on ischemic tissue contributes to deepening the wound



Debridement of Burn Blisters

  • Prevention of wound conversion reduces the risk of infection.

  • Partial thickness wounds

    • retain intact vascular supply and tissue viability
    • are therefore less susceptible to microbial invasion


CLINICAL PRACTICE GUIDELINES

  • Bottom line of blister management

    • Blisters should be debrided to
      • stop burn wound conversion
      • remove non-viable tissue
      • allow proper visualization of the wound bed
      • evacuate fluid that will increase the size of the blister
      • evacuate fluid that suppresses local and systemic immune function
    • Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review.
    • J Burn Care Res. 2006;27(1):66-81


Hand Burns

  • Disability

  • Edema hinders motion contraction compartment syndrome

  • Elevation is crucial

  • Evaluation of radial, ulnar, and palmar arch pulses by palpation/Doppler hourly

  • If they can’t make a fist, make it to a Burn Center.



Two Bedside Tests for the Detection of Developing Compartment Syndrome of a Digit

  • Use a pulse oximeter to detect extremity hypoxia.

    • <95% O2 saturation may require escharotomy
  • Place an 18-gauge needle on the pressure tubing used to monitor arterial pressure and insert the needle into the compartment.

    • Pressures >30 mmHg require escharotomy


Hand Burn Contractures

  • The typical contracture is an "intrinsic minus" position:

  • the MP joints are fixed in hyperextension and the PIP joints are fixed in flexion.

  • For this reason, positioning of the burned hand should place the MP joints at maximum flexion (90 degrees) to maximally stretch the collateral ligaments.



Hand Burn Devices

  • A vacuum-assisted closure device for treatment of hand burns is in prospective clinical trials.

  • This device reduces edema and provides an excellent method of splinting.



Synthetic Skin Substitutes

  • Biobrane® is a bilayer synthetic skin substitute

  • An outer epidermal analog is constructed of a thin silicone film that functions comparable to skin.

    • Small pores in the silicone allow exudate removal and permeability to topical antibiotics.
  • An inner dermal analog is composed of a three-dimensional irregular nylon filament weave to which type I collagen peptides are bonded.



Synthetic Skin Substitutes



Synthetic Skin Substitutes



Outpatient Management of Partial-Thickness Burns: Biobrane versus 1% Silver Sulfadiazine

  • Across multiple trials comparing rates of healing in partial-thickness wounds, Biobrane® significantly reduced healing time without increased infection rates compared with topical SSD.

  • When used on properly selected wounds, Biobrane therapy significantly decreases pain and total healing time without increasing the cost of outpatient burn care.

  • Gerding RI et al. Outpatient management of partial thickness burns. Biobrane versus 1% silver sulfadiazine. Ann Emerg Med 1990:19:121-124.



Sulfamylon

  • Mafenide acetate diffuses through devascularized tissue.

  • 80% is delivered to burned tissue over the first 4 hours following topical application.

  • Sulfamylon® exerts bacteriostatic action against many gram-negative and gram-positive organisms, including Pseudomonas aeruginosa and certain strains of anaerobes.



Silver Sulfadiazine SSD

  • The use of SSD in partial-thickness wounds delays healing.

  • Use of SSD requires dressing changes BID, which may cause trauma to the epidermal cellular bed.

  • Despite its availability, its soothing effects and ease of application make its use widespread.

  • Contraindicated

    • Pregnancy
    • Nursing mothers
    • Allergy to sulfa
    • Facial burns


 

  • The Fallout:

  • 'I Felt My Face Just Melting'

  • Burn units struggle to cope with the flow of meth users straining their resources.



Methamphetamine Burn Patients: What Makes Them Different?

  • Key points

    • Methamphetamine burns larger than 40% TBSA have a 100% mortality.
  • Warner P et al. The methamphetamine burn patient J Burn Care Rehabil. 2003;24:275-8.



Burns in Pregnancy

  • Clinical Challenges

    • Intravascular volume is increased by 50%
    • Fall in colloid pressure – increases extravasation
    • Increase in TBSA
    • Parkland formula is inaccurate
    • INCREASE IN FLUID LOSS VS NONPREGNANT
    • Third-trimester patients may require TWICE the Parkland formula for adequate resuscitation
    • Pacheoco LD. et al. Burns in Pregnancy Obstet Gynecol. 2005 106:1210-2.


Outcome and Changes in Survival Following Severe Burns (1985 to 2004)

  • Outcome was evaluated in relation to the presence of three major risk factors for death:

    • age 60 years or over
    • total burned surface area 40% or more
    • inhalation injury
    • When zero, one, two, or three risk factors were present, mortality was respectively 0.5%, 9.9%, 48.0%, and 90.5%.
  • Brusselaers N. et al. Outcome and changes over time in survival following severe burns from 1985 to 2004 Intensive Care Med. 2005;31(12):1648-53




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