Burns

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Background

  • Burns >60% BSA often associated with cardiac output depression unresponsive to fluids
  • Inhalation injury is main cause of mortality
    • Half of patients admitted to burn centers develop ARDS

Pre-Hospital

  • Assess for signs of inhalational injury
    • Start humidified O2
    • Intubate if necessary (below)
  • IVF (below)
  • Remove all burned/burning clothing, jewelry
  • Immerse wounds in cold water (1-5˚C)
    • Only effective within first 30 mins
    • No direct ice to wound

Clinical Features

1st Degree

  • Only epidermis affected
  • Red, tender, no blisters
  • Heals without scarring in 7d

2nd Degree

Two types:

  • Superficial partial thickness
    • Epidermis + superficial dermis affected
    • Blisters, painful
    • Good perfusion of dermis with intact cap refill
    • Heals without scarring in 14-21d
  • Deep partial thickness
    • Epidermis + deep dermis affected
    • Blisters, painful, exposed dermis is pale white-yellow in color
    • Burned area does not blanch (absent cap refill)
    • Sensation diminished to light touch and pinprick but normal pressure sensation
    • May be difficult to distinguish from 3rd degree
    • Heals with scarring in 3-8wk; may require skin-graft if do not heal within 21d

3rd Degree

  • Full thickness: epidermis + dermis + hypodermis
  • Skin is white, leathery, no pain
  • Always requires skin grafting

4th Degree

  • 3rd degree + muscle, fat, bone involvement

Differential Diagnosis

Burns

Vesiculobullous rashes

Febrile

Afebrile

Evaluation

Lund Browder Chart to document initial TBSA assessment.

Workup

  • Carboxyhemoglobin level
  • CO/CN levels
  • VBG, CBC, chem, total CK
  • CXR
  • ECG
  • Urinalysis (assess for myoglobinuria)
  • Serial assessments for compartment syndrome

Rule of Nines

Adults
Anatomic structure Surface area
Anterior Head 4.5%
Posterior Head 4.5%
Anterior Torso 18%
Posterior Torso 18%
Each Anterior Leg 9%
Each Posterior Leg 9%
Each Anterior Arm 4.5%
Each Posterior Arm 4.5%
Genitalia/Perineum 1%
Children
Anatomic structure Surface area
Anterior Head 9%
Posterior Head 9%
Anterior Torso 18%
Posterior Torso 18%
Each Anterior Leg 6.5%
Each Posterior Leg 6.5%
Each Anterior Arm 4.5%
Each Posterior Arm 4.5%
Genitalia/Perineum 1%

Rule of Palms

  • Patient's entire hand (palm+fingers) = about 1% TBSA
  • Use to estimate scatter burns
  • Also use for local burns up to 10% BSA

Management

Not Severe (Outpatient)

  • Cleanse burn with mild soap and water or dilute antiseptic solution
  • Debride wound as needed
  • Consider a topical antimicrobial:
    • Bacitracin, neomycin, or mupirocin
    • AVOID Silver Sulfadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes) [1][2]
  • Consider use of synthetic occlusive dressings (see burn dressings)
  • Blisters
    • Leave blisters intact unless they cross a joint or if a large blisters precludes application of a dressing

Severe (Inpatient)

  • IVF (see below)
  • Analgesia
  • Remove all rings, watches, jewelry, belts
  • Local burn care (burn dressing)
    • Contact burn center BEFORE applying any antiseptic dressings
    • Small wound: moist saline-soaked dressing
    • Large wound: sterile drape
  • Antibiotics
    • Administer in coordination with burn physician
    • Prophylactic antibiotics have been abandoned - debridement is paramount to prevent infection
    • Maintain glucose control to prevent infection[3]
    • Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection[4]
    • If septic, start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics
  • Nasogastric Tube
    • Consider if partial-thickness burn >20% BSA (ileus frequently occurs)[5]
    • Definite NG tubes in burns > 30% in adults and 25% in children
  • Early GI prophylaxis (PPI/H2 blocker)
    • evidence of stress ulceration even within hours after major burns[6]
  • Tetanus vaccine

Fluid Resuscitation

  • Give least amount of fluid necessary to sustain organ perfusion (avoid "fluid creep")
  • Patients with inhalation injury and/or multi-system trauma often require more than Parkland amount.
  • The Parkland is only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110
  • Goal directed therapy with Swan-Ganz catheters, inotropes, and fluid support have shown no superiority to standard clinical parameters, and have increased over-resuscitation and incidence of abdominal compartment syndrome (see below)[7]

Indications based on TBSA

  • Definite IV: Adults > 20%, Peds > 15%
  • Perhaps IV: Adults 15-20%, Peds 10-15%
  • Oral adequate: Adults < 15%, Peds < 10%
Types of fluids
  • Many burn centers prefer lactated ringers unless shock liver or hepatic failure suspected
  • Colloids generally not used unless burns > 40% TBSA
  • Do not use dextrose in adults (false uop), but children should receive small amounts due to small glycogen stores
Parkland
  • 4cc x wt (kg) x %BSA (2nd and 3rd degree only)= cc NS (or LR) over 24hr
  • Give 1/2 in first 8hr, remainder in next 16hr
Peds
  • Give Parkland + maintenance fluid (2-4cc/kg x %BSA) if age < 5 yrs old
  • Give 1/2 in first 8 hr, remainder in next 16 hr
  • Can consider giving D5 1/2 NS if patient < 20 kg to prevent hypoglycemia

Goal UOP

  • If UOP is greater than expected, consider glycosuria and reactive hyperglycemia as cause.
  • Maintain urine output of 0.5 mL/kg/hr urine in adults and 0.5–1.0 mL/kg/hr in children weighing < 30 kg[8]
  • If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol diuresis)

Intubation Guidelines

  • Full-thickness burns of the face or perioral region
  • Circumferential neck burns
  • Acute respiratory distress
  • Progressive hoarseness or air hunger
  • Respiratory depression
  • Altered mental status
  • Supraglottic edema and inflammation on bronchoscopy

Escharotomy Burn Indications

  • Circumferential eschar with one of the following:
    • Circumferential torso - restricted ventilation
    • Circumferential extremities - vascular compromise
  • Immediate escharotomy if compartment pressure > 30 mmHg
  • Elevate limb and optimize fluid status

Special Cases

  • In burns > 40% in adults and > 30% in children < 5 yo, consider colloids which reduce abdominal compartment syndrome[9][10]
    • Consider replacing 25% of IVF with FFP, so that total IV rate is unaltered through the 24 hrs post-burn
    • In children, give 1/2 of total volume as FFP and 1/2 as LR throughout 24 hrs
    • For infants < 2 yrs with > 30%, use 5% dextrose in LRs with the FFP
  • Burns > 50% or SEVERE metabolic acidosis may require 44 mEq of bicarb to each 1 L of LR in first 24 hrs, maintain bicarb > 18
  • Beyond 24 hrs:
    • 24-48 hrs - patients require ~1/2 total volume given in first 24 hrs; change LRs to D5,1/2NS; give FFP 2 units for every liter of crystalloid
    • 48-72 hrs - no formula; take into account TBSA/depth of burns (open partial thickness loss > full thickness with thick eschar), re-mobilization of 3rd space fluid beginning at this time

Disposition

Outpatient Treatment

24-48hr

  • Partial thickness <10% BSA, age 10–50y
  • Partial thickness <15% BSA, age <10y or >50y
  • Full thickness <2% in anyone
  • No major burn characteristics present

Hospital admission

  • Partial thickness 10-20% BSA 10-50 yrs old
  • Partial thickness 5-10% BSA in <10 or > 50 yrs old
  • Full thickness burns 2-5% BSA in anyone
  • High voltage injury
  • Circumferential burns of an extremity
  • Burns complicated by suspected inhalation injury
  • significant comorbidities
  • No major burn characteristics present

Burn Center Transfer Criteria[11]

  • Partial thickness >20% BSA in 10-50
  • Partial thickness >10% BSA in <10 or > 50 yrs old
  • Full thickness >5% BSA in anyone
  • Burns involving face, eyes, ears, genitalia, joints, hands, feet
  • Burns complicated by confirmed inhalation injury
  • High voltage burn
  • Burns complicated by fracture or other trauma (in which burn is main cause of morbidity)
  • Burns in high-risk patients

See Also

References

  1. Hussain S et al. Best evidence topic report: Silver sulphadiazine cream in burns. Emerg Med J. 2006 Dec;23(12):929-32.
  2. Atiyeh B et al. Effect of silver on burn wound infection control and healing: Review of the literature. Burns. 2007 Mar;33(2):139-48
  3. Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. Crit Care. 2013; 17(4): 232.
  4. Weber J and McManus A. Infection Control in Burn Patients. http://www.worldburn.org/documents/infectioncontrol.pdf
  5. Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier Saunders, 2007
  6. DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med. 1995;98(4):159.
  7. Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95.
  8. Greenhalgh DG. Burn resuscitation. J Burn Care Res 2007; 28:555–565
  9. MetroHealth Burn ICU Handbook (Not a policy manual), Cleveland, OH
  10. Lawrence, A et Al. Colloid Administration Normalizes Resuscitatin Ratio and Ameliorates "Fluid Creep." Journal of Burn Care & Research: January/February 2010 - Volume 31 - Issue 1 - pp 40-47.
  11. American Burn Association