EMED- Burn Management (1)
IV fluid therapy
(2nd degree burn or higher.. usually you are getting fluids) - May be required in patients with 2nd burn >20% - may be required in pt with 3rd burn >10% - Large bore peripheral IV (14g or 16g) (normal IV size: 18-20) little old lady: 22 - (that size isn't appropriate for resuscitation but it may be the only thing you can get in) (maybe try to throw in another IV or a central line or IO - whatever needed to get the fluid in) - Foley to monitor urine output - Estimate fluid need based on weight and percentage burned **
Initial injury (Ischemia Induced Injury)
(either you don't have good perfusion (d/t an atherosclerotic ds) ... or d/t: - Vascular thrombosis/vasoconstriction: (vasoconstriction: due to fight or flight response, or you may not have that volume, you loose water & with SA: evaporation of water) - Systemic hypovolemia, impairment of perfusion: (body tries to preserve the core, but not the periphery so you have that lack of blood supply there) (also with eschar / edema: causing constriction - produces the same effect) ( EX: chest injury: they can't breathe and inability to inspire)
Infants
(harden to get an IV ... use IO access= Intraosseous infusion into the long bone = vascular) 1 Maintenance fluids 2 Pulmonary/Cerebral Edema 3 Hypoglycemia ** 4 Hypo Na+/K+ ** 5 Fluid losses proportionally greater e.g normal blood volume A-70ml/kg C-80 I-85-90 6 *Access-IO frequently regurided* 7 Short delays in resuscitation (eg 30) min -> possible profound shock due to small circulating BV (infants have high electrolyte abnormalities after burn- impt to get more fluid into them faster) (really all she said about this slide) *(use an IO- larger bore needle to get fluids in faster)*
Initial injury (Ischemia Induced Injury) (just what she said)
(if not a good blood supply: then early debridement- cutting away dead tissue w/ no blood supply, removing eschar to get more blood supply) (sometimes we make that injury worse in order to promote healing) (scrape thru dead tissue to get to area with blood supply - we also do this for peripheral arterial ds with dry gangrene to find some blood supply) (need blood supply to heal)
Thromboxane A2 & B2
(inflammation) - Decrease blood flow, increase ischemia - Wound conversion deeper
Triage criteria (#2) *******TQ*******
(maybe we wouldn't necessarily keep you, but now we are gonna keep you....) - Burn w/ *suspected abuse or neglect* - Electrical burns including lightning injuries - 2 or 3 degree associated with major trauma (any trauma = staying) - Burn with inhalation injury (for 24hr observation at least) - Patients with pre-existing medical problems which can adversely effect patient outcome - TEN = (*Toxic Epidermal Necrolysis*) with > 30% sloughing of skin (due to dehydration- they need fluids)
Difficult Resuscitation-- If HYPOTENSIVE
(once way to raise BP is to give volume, another way = vasopressors) - *Vaso* 0.04 units/min drip (if your afraid of giving too much fluid due to pt co-morbidities then we can add pressers to cut down on the fluid we are adding) (she didn't say any of this Vvvvvvvv) - Cvp ↓ ↑ fluids - Cvp - 10- 12 ADD LEVO 2-20ug/min - Possible PA catheter -↓ check for associated injuries - At goal add Dobutamine - Consider EPI or NEO as last resort
Catecholamines
(released b/c you are in shock --> *fight/flight*) - Massive release - Probably only work on non burned tissue to limit edema - Vasoconstrictor effects increase ischemia (worsening it)
Triage criteria (priorities) #1 *******TQ*******
(the worse they are.. may not be able to treat in your ED) - 2nd degree burns >20% at any age - 2 or 3rd degree burns >10% (in children <10 years or adults >50 years) - 3rd degree burns >10% at any age - 2 or 3rd degree burns to face, hands, feet, genitalia, perineum, and major joints (loss of mobility) - *Chemical burns* to face, hands, feet, genitalia, perineum, and major joints
Initial injury (Heat induced Injury)
*HEAT* - Depth dependent on depth of heat penetration (how far has that heat penetrated) - Rapid protein denaturation & cell damage (what does the heat do to the cells, maybe affects proteins but depends on how deep it is) - Dead skin tissue = eschar
Initial injury (Inflammatory Mediator Injury)
*Inflammatory response* (body knows its not okay and needs to fix it) - First to third day after injury (this doesn't happen immediately) - Tissue damage caused by toxic mediators of inflammation (cytokines come in to fix problem) - Increased permeability - Later wound conversion if excessive (this response can actually make the injury worse --> the skin gets weppy from burn injury) (immune response then happens and tries to fix it but it can't, things just wepp out since the dermis isn't there - so the immune response goes away)
Delayed Injury
*Ongoing inflammation = continued tissue damage* - body is trying to fix itself- but in doing so it creates more problems. - (i.e. increased neutrophils, proteolytic activity, deactivation of growth factors)
Acute Hemodynamic Changes
*hypovolemic shock* --> 1 Tachycardia-precedes 2,3 * 2 Depression of cardiac output precedes 3* -Circulating myocardial depressant factor 3 Decrease plasma volume 4 Increased SVR secondary to Catecholamines 5 Increased PVR* + hypoproteinemia = pulmonary edema 6 Desynchronization of R and L heart (not working well together) * * = only ones she mentioned
Most burn related deaths are due to *******TQ*******
*smoke inhalation*
For Difficult Resuscitation -->>
- *Add Albumin*** (colloid) - *Q4h bladder pressures* (how fast everything fills up) - *Urine < 30 consider cup catheter* CVP 10-12 SVO2 65-75% (didn't say this part) ((monitoring that urine output... if they are frail or babies who can't pee on demand- cath for strict I&O for these pts)) (if sudden incr in urine output- maybe need to cut down at the resuscitation- your volume overloading them) (didn't mention this part vvvvv) - Low on cvp-↑ fluids - If at goal-vaso 0.04 u/min or dobutamine 5ug/min (max 20ug)
Pathogenesis of Burn Injury
- *First = Initial injury* >> which includes: 1- *Heat Induced Injury* 2- *Inflammatory Mediator Injury* (cytokines start to try to fix problem) 3- *Ischemia Induced Injury* (lack of blood supply, the capillaries are deep in the dermis: so full-thickness burns you are worried about this) - *Then = Delayed injury* (ongoing inflammation)
Superficial/First Degree Burn *******TQ*******
- *Limited to the epidermis* - Heals in 7-10 days (good outcome) - Rarely admitted (Blistering can occur, yes) (usually without scarring- depending on how big, where it is, age of pt, if its treated, associated injuries) (for the most part - no residual scarring, goes away)
Fluid Resuscitation *******TQ*******
- *Parkland Formula* is most common in US (not for 1st degree) (said she wasn't going into it) - 4cc/kg/%TBSA burn of LR = Total volume in 24 hrs - First ½ of total volume - give in the first 8hrs from time of burn - Remaining ½ of total volume - give over the next 16 hrs (then you give your maintenance)...
Skin function ********TQ********
- *Protection* (MAIN thing- 1st line of defense) - Immunologic - Fluid Balance - Thermoregulation - Neurosensory - Social-interaction (how you interact: how your skin presents yourself to ppl) (sense of touch: human interaction - touch receptors) - Vit D Metabolism (the skin keeps you functioning)
Severity of Burn Injury:
- *Source of the burn injury* (MAIN thing to think about - thermal, chemical, or electrical - which will play into how we will treat it) - Length of contact or exposure (how long?) - Age of victim - Anatomical location (better locations than others - genital skin is different, worse) - Associated injuries (inhalation injury - will make everything worse) - Pre-existing medical conditions (venous/arterial insufficiency, DM --> all these decrease ability to heal)
difficult resuscitation method:
- 12-18h calculate projected requirements - If > 6ml/kg/%TBSA - Ivey Index- 250cc/kg body wt. over 24h (she didn't say this)
Shriners Galveston Pediatric - Body Surface Area Formula "won't test on this" *SKIPPED*
- 5000ml/m2 TBSA burned + 2000ml/m2 TBSA over 24h - Maintenance 2nd 24h 3750ml/m2 TBSA burned + 1500ml/m2 TBSA
Difficult Resuscitation- SHOCK-CATECHOLAMINE RESISTANT (skipped) ***
- ? Missed injury - Acidemia ph < 7.20 a --> Change vent pCO2 30 if fails b --> Add bicarb - Adrenal insuff-stimulation test vs. random cortisol start hydrocortisone 100mg q 8h √ calcium-maintain ionized > 1.1 (*she skipped this*)
when would you admit for 1st degree *******TQ*******
- Admitted when very young/very old --> kid with scolding butt-dipped in hot water- who you suspect may have been abused
Resuscitation Fluids *******TQ*******
- Colloid >> FFP, albumin, dextran, hetastarch (Albumin is great for volume and keeping it in the vessels but not adding too much volume- like someone with HD and low EF)(colloids are good for those with Heart disease to not fluid overload them) (colloids- have higher osmotic pressure so fluids don't flow as well?) - *Crystalloid* >> *Lactated Ringers or Normal Saline* ** *1st thing used* (she didn't mention these vvvvvv) - Hypertonic solutions 250 mEq Na (Monafo) 180 mEq Na (Warden) - Vitamin C
Once the pt is stable:
- Determine associated injuries - Determine inhalation injury - Evaluate for admission or transfer vs. out patient follow up (do they need level 1 trauma transfer) - Determine depth of burn - Cover with appropriate dressing (something that won't stick) (but sometimes you want it to stick, kind of debridement) (exposed body part out in the open? quickly assess degree of wound- unwrap quickly and determine SA and depth of burn and cover with appropriate dressing
Improvements In Burn Outcomes (2)
- Early debridement (escharotomies: cut thru it to help them breath and help reduce the pain) - Skin substitutes (skin grafting to help improve outcomes) - Passive positioning/early mobilization (with burn pts they get a lot of strictures: pts start contracting... we try to cut down the fibrosis on them, break down those adhesions that are forming and stretch things out* the earlier the better*)
Mortality is increased with: *******TQ*******
- Extremes of age (very young and very old) (they don't do well. geriatrics: skin is thinner. babies: SA - more compact, both groups have decreased functionalities) - Pre-existing medical problems
Evaluation in ER
- Follow *ABC's of trauma in appropriate cases* (pts with inhalation burn: dx by physical appearance -> intubate them (eventually swelling/edema will happen if you don't go in, and you don't trach in the ED) (so treat before edema, when they come in: *sedate them and intubate them as quickly as possible*) - *History and Physical* (so you did the ABCs... they are talking, no swelling, they appear stable and you don't know if inhalation burn yet) ask how long were you exposed, what happened, just smoke/chemical fire?
Temperature Control
- Heat loss - radiation, convection, conduction evaporation - Radiant heat - Covering burn wounds - *avoid wet dressings* (wet will dry and then its hard to rip off- but good for debriding) (use a zero form dressing with antimicrobial properties that never drys - it feels moist and easy to peel off w/out taking anything away (used with I&Ds, deeper wounds that you pack) - Warm IV solutions (don't want to drop their body temp - when they have a burn the body temp goes down)
Hematologic Response
- Hemolysis → hemoglobinuria - Increase RBC lipid peroxidation → fragmented cells - Decrease RBC survival - Decrease hematopoiesis - Increase WBC - Activation of clotting → *DIC* - Depletion of factors → *DIC* (you used up everything) *(only mentioned DIC here)
Improved survival due to:
- Improved fire fighting techniques - Emergency medical services (EMS gets them to hospital quick) - Increased use of smoke detectors at home (and flammable gas detectors. methane from stove = explosive) (we have new technology & treatments: Hyperbaric oxygen tubes) (We also have designated burn centers)
Partial Thickness/Superficial Second Degree *******TQ*******
- Involves epidermis and superficial layer of dermis (some capillaries affected - so increased bleeding or lack of bleeding) - Typical blistered burn - *Usually heals in 2-3 weeks*
Deep Partial Thickness/Deep Second Degree *******TQ*******
- Involves through to deep dermis - very few epithelial structures remain (epithelial structures include: hair, sebaceous glands) - Heals in > 3 weeks (deeper, thru more layers = longer healing) - often heals with hypertrophic scar (Atrophy in certain areas)
Fluid Creep (gave too much fluid ^ third spacing)
- Over-resuscitation - Larger burns frequently exceed calculated volumes - Colloid rescue- persistent lactic acidosis increasing Hct. And instability - ? Plasma exchange - Hypertonic solutions TX this with- diuretics, Lasix <- (what she said only)
More mediators of Burn Injury* she skipped this **
- Oxygen free radicals - Platelet Aggregation Factor - Angiotensin II and Vasopressin - Corticotrophin Releasing Factor
NG Tube
- Place NGT to suction if there is nausea, vomiting, or distension, or if burn involves > 25% TBSA (place NGT if N/V ... you need to hydrate and give nutrition) - Start enteral feeds early (use NGT to do so) (if your busy resuscitating you prob won't be doing TPN)
Histamine
- Reaction with xanthine oxidase - Arterial dilatation, venular epithelial cell contraction - No benefit antihistamines (won't do anything)
Remove Burn Source
- Remove clothing (remove source of burn) - Irrigation (clean it!) - Cooling- 10% second degree (compresses, but no ice)
Improvements In Burn Outcomes (1)
- Rx of Burn Shock (*Rehydrate the pt*- they are dehydrated - treat this!) - Topical antimicrobials (if skin breakdown or tissue destruction etc. to protect that area) - Improved ICU Care/Burn Units
Full Thickness/Third Degree *Treatment* *******TQ*******
- Treat initially with *topical antimicrobial* - + *Debridement needed* (chemical or physical like I&D) - *Requires excision* (skin isn't intact and you know something is going on bad underneath - unlike a decubitus ulcer) (eschar needs to come off- that exudate all needs to come off in order to heal) - ^ Excision and 1 degree closure or skin grafting (or skin substitute to close these) - *Admit* for resuscitation
Deep Partial Thickness/Deep Second Degree *treatment* *******TQ*******
- Treat initially with topical antimicrobial - *may require skin graft* (depends on how deep and how much surface area is affected) - *Admitted* for hydration and pain management (NSAIDs + something extra: narcotic pain med as well)
1st degree burn - treatment: *******TQ*******
- Treat with cool compress (no ice) - analgesics - NSAIDS (pain medications) - Ointment for comfort (silvadine)
Partial Thickness/Superficial Second Degree *Treatment* *******TQ*******
- Treat with topical anti-microbial (neosporin, bactrian, mupirocin = (Bactroban)) + analgesics
Goals of Resuscitation *******TQ*******
- Urine output should be *30-60 cc/hr in adults* (25 cc may be okay in a really tiny person as long as they are not tachy/hypoten) - Urine output should be *0.5-1.0 cc/kg/hr in children* - Maintain blood pressure >90 systolic - MAP of 60-65 (mean arterial pressure) - Maintain peripheral perfusion (assess their cap refill <2-3 seconds, distal pulses-radial etc.) (in general for those in the ICU, post surgery)
Zones of Burn Injury
- Zone of Coagulation - Zone of Stasis (Injury) - Zone of Hyperemia (blood flow/redness)
Mortality with Inhalation Injury *******TQ*******
- adding an inhalation injury --> increases mortality greatly, almost doubles the mortality.
Partial Thickness/Superficial second degree *(wound care products)*: *******TQ*******
- can use wound care products (Biobrane®, Dermagraft TC®, ionic silver release etc.) (aloe vera, medihoney) Ionic Silver- has anti-microbial properties Honey also has anti-microbial properties (medihoney) Water leeches- suck and create new capillaries and a physical debridement. Maggots can be used as well in the treatment of wounds
Shock
- depends on how large of a burn it is... hemodynamic changes occurs b/c we are loosing fluid *(Hypovolemic shock)* (you have the injury itself and then you have the response to that injury)
when giving diuretics (what she said)
- do alternating diuretic-- and then fluid. give diuretics- check electrolytes & urine output.. assess them. - can also assess volume overload by: Weight (can increase by 3rd spacing) *weigh person everyday to see how much they increased from baseline**
Mortality from burns *******TQ*******
- higher survival rates w/ less of a burn (across all age groups) - *older pt tend to do worse* (*worse outcome* due to more co-morbiities besides just the burn - EX: smoker with COPD)
why might someone be a difficult resuscitation?? (what she said)
- poor kidney function *** - pregnancy - poor coronary function ** - low EF (don't want to resuscitate too quickly) - may want to delay their resuscitation (instead of that initial 8 hour.. but depending on their degree of burn tho- 3rd degree = benefits vs risks)
might you debride the area for a Partial Thickness/Superficial Second Degree burn? *******TQ*******
- yes you might. - you can have eschar even with a dermal injury - (usually won't but you can with someone with a compromised blood supply : DM and PAD)
what if you give too much fluid (what she said)
3rd spacing... goes everywhere (will the body reabsorb that and go back into circulation? yes but its diff timing for everyone) - over resuscitated --> SX: swelling, labored breathing, fluid in lungs (crackles heard) **
Rule of Nines *******TQ*******
Child = C Adult = A Head/neck= C 18 A 9 Arm= C 9 A 9 Anterior Trunk= C 18 A 18 Posterior Trunk= C 18 A 18 Leg each= C 14 A 18 Perineum= C 1 A 1
Serotonin
Increase capillary permeability (loosing fluid this way)
Kinins
Increase vascular permeability
Full Thickness/Third Degree *******TQ*******
Involves *epidermis, dermis and subcutaneous fat* (under that is muscles, bone, nerves)
Full Thickness/Fourth Degree *******TQ*******
Involves deep structures e.g.. - *Muscle, bone are destroyed* (tendons, everything is contracted and fibrosed)
Second 24 hour "not testing you on this"
Maintenance D5 ½ NS 1st 10kg-100ml/kg 2nd 10kg-50ml/kg Above 20kg-20ml/kg SP- albumin 0.1 x kg x %TBSA over 4-6h Add evaporative H2O loss-% TBSA +(25 x BSA m²) = ml/hr loss
Antibiotics *******TQ*******
No prophylactic antibiotics are needed (it depends) - on 1st degree - just topical abx thats it - (2nd/3rd degree - it depends) - if its deep 3rd degree then you may.. - if down to bone/muscle then yes - if large areas of eschar- then you would want to wait for a secondary infection to occur before adding anything on to them
Children "won't test on this" *SKIPPED*
Shriners Hospital Cincinnati = 4ml/kg/%TBSA burn + 1500 ml x m2 BSA = maintenance fluid Using: -- LR with 50 mg NaHCO3 / L in the first 8 hours, -- LR over the second 8 hours and, -- LR with 12.5gm Albumin/L over the last 8 hours >> Generally young children require 5-6 ml/kg/%TBSA >> Give infants glucose if FS<80
NG tube is given to prevent
Stress ulcers Bacterial translocation Protein and calorie malnutrition *(only said this)
Immunization status
Tetanus (q10y) prophylaxis is dictated by patient's immunization status (vv what she said) - tetanus component in the tdap etc is good for 10 yr - the other components (diphtheria/acellular pertussis are less protective and are given more freq than 10yr - d/t change in vac)
Analgesic *******TQ*******
given as needed given intravenously in small doses (start with the least amount and work your way up) *
The mediators of Burn Injury include:
histamine thromboxane A2 and B2 Kinins Serotonin Catecholamines
when you give diuretics - be careful b/c you can cause ...
maybe giving high dose of Lasix but then worried about : - dehydration/electrolyte abnormality ---> their K+ decreases... - cardiac arrhythmia can occur --> Afib (maybe strokes)