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:

burns 1.png

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? burns 2
      • 3rd 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. 2nd\3rd degree >20% TBSA in 10-50 yo
    2. 2nd\3rd degree >10% if younger than 10 or older than 50
    3. 3rd 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

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this:
search previous next tag category expand menu location phone mail time cart zoom edit close