Upload
emil-owens
View
219
Download
0
Embed Size (px)
Citation preview
Initial Burn Care
Lee D. Faucher, MD FACSDirector UW Burn CenterProfessor of Surgery &
Pediatrics
Objectives
• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition
Objectives
• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition
September 11, 2001• 8:20am
– American Airlines Flight 77 Departed Washington Dulles at 8:20am
– 58 passengers, crew of 6
• 9:38am– A 757-200 crashes
into the Pentagon
Washington Hospital Center
• Located in Northwest DC– Areas largest
trauma center and regional burn center
Code Orange: This is not a drill!
• Medical response– 8 trauma surgeons– 6 trauma residents– 7 intensivists and
their teams– All others
• Anesthesia, lab, blood bank, radiology, RT, security
Patients begin to arrive
• 3 patients in first 30 minutes– 1 smoke only, 2
burns
• Then all air traffic grounded– 4 more by ground
Patient AdmissionsPatient # Gender % TBSA Arrival
1 F 0 <1 hour
2 F 21 <1 hour
3 M 22 <1 hour
4 F 66 <1 hour
5 M 49 <1 hour
6 F 68 <1 hour
7 M 41 7 hours
8 M 42 10 hours
9 M 32 28 hours
10 M 10 31 hours
Post-Burn Weeks
0
5
10
15
20
25
30
35
1 2 3 4 5 6 7 8 9 10 11 12 13 14
OR Hours
# Operations
Products consumedIV Fluids 141 Liters
Silvadene cream 950 Jars
Burn Dressing Gauze 2006 packs
4X4 gauze 18,490
Kerlix gauze 3108 rolls
Ace Bandages 2111
Allograft 26,700 sq cm
Synthetic “skin” 30,365 sq cm
Autograft 22,087 sq cm
PRBCs 269 units
OutcomesPatient # Gender %
TBSAAge + TBSA
Mortality Risk
Outcome
1 F 0 32 N/A Survived
2 F 21 74 11 Survived
3 M 22 61 4 Survived
4 F 66 115 62 Survived
5 M 49 100 41 Survived
6 F 68 109 44 Died
7 M 41 80 15 Survived
8 M 42 71 9 Survived
9 M 32 63 1 Survived
10 M 10 82 23 Survived
Final numbers
• 189 deaths– 125 in Pentagon– 64 on Flight 77
• 106 injured– 50 admitted to 9 area
hospitals– 9 serious burns
Objectives
• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition
Medics• Airway• Assess for other injuries• Start IV with LR, in burn OK
– < 6 years = 125mL/hr– 6-13 years = 250mL/hr– >13 years = 500mL/hr
• 100% O2 if closed space fire
• Transport to closest hospital
History
• Source of burn• Enclosed space
– Signs of smoke inhalation
• Circumstances surrounding injury• Previous medical problems• First-aid done
Reduction of CO
0
20
40
60
80
0 20 40 60 80
Time in Minutes
% C
O
Room Air100% Oxygen3 ATM
Medics - Electrical
• Do not become victim– Turn off power
• Initiate CPR– If < 1000 volt,
ventricular fibrillation– If > 1000 volt, cardiac
standstill and respiratory paralysis
Medics - Chemical
• Remove involved clothing• Flush with water• Flush with more water• Then flush with more water• When you think you are done, flush
with more water• NO NEUTRALIZATION
Cold
• DOES NOT– Reverse temperature– Inhibit destruction– Prevent edema
• DOES– Delay edema– Reduce pain
Case presentation
• EMS responds with Fire to structure fire with reported trapped occupants
• On arrival, see two bystanders dragging person out the front door.
Medic evaluation
• Airway– Moving air, moaning, unresponsive,
entire head, face, neck, and chest burned
Medic evaluation
• Breathing– Equal bilateral breath sounds
• Circulation– Palpable distal pulses
Medic evaluation
• What else should be done at the scene?
• Where should this patient be taken?
Medic Report to ED
• 47 y/o male, extricated from structure fire, burns over head, chest, back, bilateral upper extremities and legs, intubated with one peripheral IV in place running LR at 500mL/hr
• Vitals: HR 130, BP 150/90, Sat 100%
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
Smoke inhalation assessment
• Flame burns• Enclosed space• Burns to face, mucosal
membranes• Singed eyelashes, nasal
hairs• Carbonaceous sputum
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
Rule of Nines
Lund and Browder ChartAArreeaa 00--11
yyrr.. 11--44 yyrr..
55--99 yyrr..
1100--1144 yyrr..
1155 yyrr..
AAdduulltt 22 33 TToottaall
HHeeaadd 1199 1177 1133 1111 99 77 NNeecckk 22 22 22 22 22 22 AAnntt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 PPoosstt.. TThhoorraaxx 1133 1133 1133 1133 1133 1133 RR.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. BBuuttttoocckk 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ GGeenniittaalliiaa 11 11 11 11 11 11 RR.. UU.. AArrmm 44 44 44 44 44 44 LL.. UU.. AArrmm 44 44 44 44 44 44 RR.. LL.. AArrmm 33 33 33 33 33 33 LL.. LL.. AArrmm 33 33 33 33 33 33 RR.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ LL.. HHaanndd 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ 22 ½½ RR.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ LL.. TThhiigghh 55 ½½ 66 ½½ 88 88 ½½ 99 99 ½½ RR.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 LL.. LLeegg 55 55 55 ½½ 66 66 ½½ 77 RR.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ LL.. FFoooott 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½ 33 ½½
TToottaall
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
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
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
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
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• Keep patient warm
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
Emergency room treatment
• Assess airway/breathing• Ensure source of heat removed• Estimate % TBSA• Obtain/ensure adequate IV access• Initiate/continue resuscitation• Closely monitor urine output• KEEP PATIENT WARM!!!!!
Next priorities
• Insert NG tube• Escharotomies• Medications• Wound care
Next priorities
• Insert NG tube• Escharotomies• Medications• Wound care
Escharotomies
• Only for leathery, circumferential, full-thickness burns
• Rarely needed in transport < 12 hours• Almost always done at the Burn Center• Emergent indications:
– Unable to ventilate– Pulseless, painful extremity
Escharotomy pic
Next priorities
• Insert NG tube• Escharotomies• Medications• Wound care
Medications
• Pain control• Pain control• More pain control• Tetanus immunization• NEVER need antibiotics
Next priorities
• Insert NG tube• Escharotomies• Medications• Wound care
Wound care
• Debridement and topical application is usually done after transfer
• Can cover with plastic wrap• Transport patient in DRY sheet and
blanket• If transport delayed > 12 hours,
– Debride loose tissue and clean with mild soap and water
– Apply Silver Sulfadiazine and wrap loosely
Resuscitation 24 - 48 hours
• Continue maintenance fluids, watch serum Na+
• May use albumin or plasma for volume– Infuse 5 – 10mL/kg as needed
• Maintain adequate urine output
Objectives
• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric consideration• Burn Center Definition
Burn Etiology
ABA National Burn Repository, 2012 ReportABA National Burn Repository, 2012 Report
UWHC Admissions <18 years
Admissions to Burn Centers
ABA National Burn Repository, 2012 Report
Overall Burns and Mortality
05
10152025303540
0 to 2 2 to 5 5 to 16 16-20
Age
Pe
rce
nt
Lived Died
ABA National Burn Repository, 2012 Report
Overall Mortality and TBSA
0
20
40
60
80
100
0 to 10 10 to 20 20 to 30 30 to 40 40 to 50 50 to 60 60 to 70 70 to 80 80 to 90 > 90
TBSA
Perc
en
t
0 to 2 2 to 5 5 to 16 16 - 20
ABA National Burn Repository, 2012 Report
Where Childhood Burns Occur
80
8
10 2
Home
Auto
Recreation
Other
ABA National Burn Repository, 2012 Report
A kid with a small burn
Why we do this
• An acute burn may not be completely blistered
• Can’t do wound care in clinic• Sedation easier when adequate pain
control
Appropriate wound care
What is Mepilex Ag• Silicone• Foam• Silver
Then what do we do
• Dressing changed every 3 to 5 days• Our length of stay drastically
reduced• Still same number of surgical
procedures
Objectives
• Burn Care: From where we came• Initial Burn Patient Evaluation• Pediatric Considerations• Burn Center Definition
Burn Center Referral• All children• Any burn > 10% TBSA• Any full-thickness burn• Burns to hands, face, feet or perineum• Any Electrical or Chemical burns• Other associated injuries, medical
problems, or inhalation injury• Systemic diseaseExcerpted from Guidelines for the Operations of Burn Units (pp. 55-62), Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons
Outpatients Do Not include
• Special locations• Extremes of age• Associated injuries• Previous medical problems• Unusual etiologies
– Some chemical, some electrical
• Unstable social situations
NursesResidents
PhysiatristsPediatricians
Burn SurgeonsNurse PractitionerPhysical therapistsPhysician AssistantChild Life therapistsHealth psychologists
Respiratory therapistsRecreational therapistsOccupational therapists
Social Worker PharmacistsNutritionists
Administrators