– 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 –
- 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?
- Complete head-to-toe physical examination
- Re-evaluation of the pt
- Specific tests (CO level > 10%)
- 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
- Signs and symptoms:
- 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
- Divide it over the first 24 hrs:
- In children: add maintenance fluids (4,2,1 rule) to the resuscitation
- Who needs extra fluids?
- 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
- Assess TBSA: *superficial burns are not included*
- 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
- 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:
- 2nd\3rd degree >20% TBSA in 10-50 yo
- 2nd\3rd degree >10% if younger than 10 or older than 50
- 3rd degree >5 % TBSA
- Face, hands\feet, major joints, genitalia, perineum
- Inhalation injury
- Electrical burn
- Chemical burn
- Concomitant injuries
- Preexisting comorbidities
- Older than 60, younger than 2 -> any thickness\TBSA
- Special emotional, social, rehabilitation intervention
H. NUTRITIONAL SUPPORT
I. REHABILITATION: PT, OT, speech