Burns Approach

– Primary Survey –

PPE: goggles, mask, gown, gloves

AIRWAY + C-SPINE:

• Talk to the patient (patent airway, conscious, in pain?)
• Ask pt to open their mouth (inspect for foreign bodies, burned oropharynx)
• Look, listen, and feel (hoarseness, cough, stridor)
• Oxygen mask
• Apply C-collar

BREATHING:

• Signs of inhalation injury (facial\oral burns, singed hair, carbonaceous sputum)
• Inspect neck + palpate trachea (edema, distended neck veins, subcutaneous emphysema)
• Expose chest: inspect, palapte, percuss, auscultate (circumferential burns, symmetrical breathing)
• Pulse oximetry
• CXR + pelvic X-ray

CIRCULATION:

• BP, pulses, capillary refill
• Insert 2 large-bore Iv cannula in ante-cubital fossa
  • Draw blood for CBC, cross match, coagulation, electrolytes, chemistry, pregnancy, tox, ABGs
  • Run warmed 2L crystalloids (NS)
• Examine pelvis, abdomen, limbs (for circumferential burns, swelling, fractures)
• External bleeding
• FAST

 DISABILITY:

• Pupils
• GCS

EXPOSURE:

• Check temperature
• Remove clothes and fully expose the patient
• Cover the pt w\ blankets to prevent hypothermia

LOG ROLL + PR EXAM

ADJUNCTS:

• ECG
• Decompression: NGT + foley cath

 

– Secondary Survey –

1. AMPLE history:
   • Allergies
   • Medications
   • Past medical hx
   • Last meal
   • Event \ Environment:
     • Time
     • Location (closed vs open space)
     • Cause (thermal, chemical, electrical, …)
     • Associated injuries
     • What first aid did the pt get?
2. Complete head-to-toe physical examination
3. Re-evaluation of the pt
4. Specific tests (CO level > 10%)
5. Definitive treatment

 

---

– Burn Management –

A. BURN ASSESSMENT:

• Cause:
  • Thermal (flame, scald, contact, cold)
  • Electrical
  • Chemical
  • Inhalation Injury:
    • Signs and symptoms:
      • headache, confusion, coma, arrhythmia
    • Management:
      • Immediate intubation (impending airway edema)
      • 100% O2 (titrate to maintain SaO2 > 92%)
      • Hyperbaric O2 if CO poisoning
      • Transfer to burn unit
      • Fiberoptic bronchoscope, pulmonary toilet, heparin nebz, aerosolized hypertonic saline, inhaled NO as rescue, Ventolin
      • If cyanide -> Na thiosulphate, chelators
• Depth:

B. FLUID RESUSCITATION:

• Day one:
  • Assess TBSA: *superficial burns are not included*
    • Rule of nine
    • Rule of palm (palm of the pt represents 0.8-1%)
    • Lund-Browder chart (peds)
  • Parkland formula = 4 ml x TBSA (%) x wt (kg) -> over 24 hours in total (of RL)
    • Divide it over the first 24 hrs:
      • First half -> over the first 8 hours
      • Other half -> over the next 16 hours
    • Who get’s Parkland? 
      • Adults >20% TBSA
      • Children >15% TBSA
  • In children: add maintenance fluids (4,2,1 rule) to the resuscitation
  • Who needs extra fluids? 
    • 3^rd degree
    • Inhalation
    • Electrical
    • Children
    • Post escharotomy
    • Delayed resuscitation
    • Cardiac dysfunx
    • Alcohol\drug intox
  • Monitor UO:
    • Adult: 0.5 ml\kg\hr
    • Child: 1 ml\kg\hr
• Day two:
  • Colloid (albumin) = 5-1 g \ kg \ TBSA \ day

 

C. TETANUS:

• No IV Abx, unless documented signs of infection:
  • discoloration, focal gangrene, inc sloughing, abscess, purplish skin w\ edema around burn, bacteria >10⁵, systemic manifestations
    

D. PAIN CONTROL:  IV morphine

 E. WOUND CARE:

• Remove clothing, jewelry
• Run cool water or saline soaked gauze
• Elevate burned area to prevent edema
• Cleanse and debride wound + dressing + topical antimicrobial (flamazine = silver sulfadiazine)
• Consult plastic surgery -> skin graft

F. CIRCUMFERENTIAL BURNS:

• Monitor distal perfusion via doppler U\S
• Escharotomy

G. ASSESS NEED FOR ADMISSION TO BURN UNIT:

• Criteria:
  1. 2^nd\3^rd degree >20% TBSA in 10-50 yo
  2. 2^nd\3^rd degree >10% if younger than 10 or older than 50
  3. 3^rd degree >5 % TBSA
  4. Face, hands\feet, major joints, genitalia, perineum
  5. Inhalation injury
  6. Electrical burn
  7. Chemical burn
  8. Concomitant injuries
  9. Preexisting comorbidities
  10. Older than 60, younger than 2 -> any thickness\TBSA
  11. Special emotional, social, rehabilitation intervention

 H. NUTRITIONAL SUPPORT

 I. REHABILITATION: PT, OT, speech

 

---

Download the PDF version: here