Care of the Burn Patient

1
Care of the Burn Patient

• Jim Pointer, MD
• Alameda County EMS
• Medical Director

2
The Call
You respond to a structure fire at a private
home. Fire fighters have contained the fire, and
the scene is safe. As you enter the building you
encounter a 64 year-old female with severe burns.
3
Initial Assessment

• Elderly, African-American female with a c/o burns
  and screaming help me, I am in pain!
• A-B-Cs
• A soot in pharynx, oral swelling
• B somewhat labored
• C intact
• Glasgow Coma Scale 14

4
Focused H P

• Patient was trapped in a home fire and sustained
  multiple burns. She left a cigarette burning
  near her bed which started the fire.
• She was rescued from a confined space by fire
  fighters.

5
Pertinent Findings

• Vital signs B/P-162/98, RR-22, HR-106, Pulse
  Ox-95 - room air
• HEENT singed eyebrows and facial hair soot in
  pharynx.
• Lungs, heart, abdomen WNL
• Neuro alert, oriented, opens eyes to loud voice

6
Pertinent Findings (cont.)

• Skin
• Superficial, partial thickness burns involving
  20 SA face and 80 SA posterior head, entire
  posterior right arm, entire right anterior lower
  extremity.
• Full thickness burns involving entire left hand,
  30 anterior torso, 50 back, entire posterior
  right lower extremity.

7
Your Assessment

• What is her total percent of burn?
• Partial thickness burn? _____
• Full thickness burns? _____

8
Past Medical History

• Angina
• Hypertension
• 50 pack-year smoker

9
Medications

• NTG prn
• Altace 10 mg qd
• ASA 81 mg qd
• Albuterol inhaler prn
• Colace prn
• Valium 5 mg prn

• Hydrochlorthiazide 25 mg qd
• Celexa 20 mg qd
• Cimetidine 300 mg tid
• St. Johns Wort prn

10
Field Management

• in this REAL case . . . appropriate?
• Oxygen by simple mask
• IV NS TKO
• Removal of stuck clothing
• Morphine 1-2 mg IV
• Wet dressing on all burns preceded by copious
  topical NS
• Transport to the closest hospital
• (non burn center)

11
Factoids

• Impact per year in the US
• 2.5 million burn injuries
• 75,000 hospitalizations, of which 20,000
  sustained gt 25 BSA burns
• 10,000 deaths

12
Classification of Burns

• Type
• Thermal
• Chemical
• Electrical
• Radiological

13
Classification of Burns

• Depth
• First
• Second
• Third
• ABA Classification

14
Classification of Burns

• Severity
• Rule of 9s
• ABA Classification
• The surface area of an examiners hand roughly
  equals 1 of total BSA

15
Burn Assessment
Rule of 9s
Adult Child
16
Burn Assessment (cont.)

• Cannot use adult rule of 9s for kids
• Head represents
• 19 BSA in a one year old,
• 13 in a six year old and
• 7 in an adult
• Thighs represent
• 11 BSA in a one year old
• 17 in a 12 year old
• 19 in an adult

17
ABA Classification

• Minor outpatient management
• lt10 in adult
• lt 5 lt10 yo gt50 yo
• lt 2 full thickness
• Moderate admit
• 10 - 20 in adult
• 5 - 10 lt10 yo gt50 yo
• High voltage, suspected inhalation,
• circumferential or susceptibility to infection

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ABA Classification (cont.)

• Major admit to burn center
• gt 20 adult
• gt 10 lt10 yo gt50 yo
• gt 5 full thickness
• Any significant burn to face, eyes, ears,
• genitalia or joints
• Significant associated injuries
• (e.g. fractures)

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What was your assessment of our patient?
41.9
20
What if you use the ABA classification?

• gt 10 BSA
• Patient gt 50 years old
• gt 5 full thickness burns
• Significant facial burns
• Classification?

MAJOR
21
The Skin Burn Depth
22
The Skin Burn Depth (cont.)

• Superficial (first degree)
• Red dry
• Blanch with pressure
• Very painful
• Examples
• Flash injuries
• Sunburn

23
The Skin Burn Depth (cont.)

• Superficial partial thickness (superficial second
  degree)
• Deep partial thickness
• (deep second degree)
• Blisters, Swelling, pain
• Examples
• Grease, steam, flame

24
The Skin Burn Depth (cont.)

• Full thickness (third degree)
• Often white waxy
• Possible eschar
• No sensation
• No blanching
• Examples
• Grease, flame

25
Complicating Factors

• Trauma
• Inhalation injuries
• Circumferential burns
• Electricity
• Age lt10 yo gt50 yo
• Pre-existing disease
• Abuse

26
Risk of Death

• Mass General Criteria
• Age 60 or older
• Serious injury (deep partial thickness or full
  thickness burns to gt 40 BSA)
• Presence of inhalation injury

No Risk Factors
Risk of Death 0 0.3 1 3.0 2
33.0 3 90.0
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Risk of Death (cont.)

• INFECTION is the leading cause of death in the
  later stages of treatment for the burn patient

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Management 10-Steps

• Protect Yourself
• Stop the fire
• Use water to stop tissue damage
• Quickly dry the area in large burns to prevent
  hypothermia (see 8)
• Rule out airway damage
• Assess for inhalation injury
• High flow oxygen is critical
• Be prepared for intubation
•  

29
Management 10-Steps (Cont.)

• Assess and expose
• Assess ABCs
• Perform a mini neurological exam (level of
  consciousness)
• Expose and examine the patient for other areas of
  burn
• Remove jewelry, but do not remove stuck clothing

30
Management 10-Steps (Cont.)

• Start IVs
• Two large bore IVs (for major burns)
• Fluid resuscitation is particularly important!
• (burns cause increased vascular permeability
  with a concurrent reduction in cardiac output, a
  response that lasts at least 12 hours post
  injury.)

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Management 10-Steps (Cont.)

• Give Fluids! - The ABA consensus is
• ADULTS - 2 - 4 ccs per kg times the BSA
• CHILDREN - 3 - 4 ccs per kg times the BSA
• Half is given over the first 8 hours, and the
  reminder over the next 16 hours.
• In the field? wide open.

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Management 10-Steps (Cont.)

• Document severity and treat the pain
• Estimate the severity of the burns using the ABA
  scheme or the Rule of 9s.
• Treat pain. Morphine sulfate should be considered
  mandatory for moderate to severe burns.
• Adults 5 10 mg
• Children 0.05 mg/kg
• Use IV route

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Management 10-Steps (Cont.)

• Protect against hypothermia and infection - dress
  burns
• Dry dressing for any
• burn involving gt10 BSA
• - no exceptions!
• Do not use water or gels
• Moist dressings are OK
• for small burns

34
Management 10-Steps (Cont.)

• Elevate burned body parts
• 30elevation for head or face, arms, legs.
• Address psychological needs
• Be honest and compassionate
• Consider anxiolytics
• (base contact)
• Diazepam
• Midazolam

35
Conclusions Concepts

• Pointers FIVE essential burn principles
• Airway management
• Prevention of infection
• Appropriate dressing
• Pain management
• Burn center transport
• - as appropriate