Burns: Difference between revisions
Line 27: Line 27:
*Each area is 9% BSA:
*Each area is 9% BSA:
**Entire head and neck
**Entire head and neck
**Each arm including hand
**Right arm (including hand)
**Left arm (including hand)
**Chest
**Chest
**Abdomen
**Abdomen
**Upper back
**Upper back
**Lower back
**Lower back
**Each front of leg
**Right front of leg
**Each back of leg
**Left front of leg
**Right back of leg
**Left back of leg
*1%: Genital region
*1%: Genital region


Line 40: Line 43:
**Anterior head and neck
**Anterior head and neck
**Posterior head an neck
**Posterior head an neck
**Each arm including hand
**Right arm (including hand)
**Left arm (including hand)
**Chest
**Chest
**Abdomen
**Upper back
**Upper back
**Lower back
**Lower back
**Right leg (front & back)
**Left leg (front & back)
*1%: Genital Region
*1%: Genital Region


*Each area is 13.5%:
 
**Each leg (not broken up to front or back)
{|
|-
||
{| class="wikitable"
|+ '''Adults'''
! Anatomic structure
! Surface area
|-
| [[Anterior]] [[head]]
| 4.5%
|-
| [[Posterior (anatomy)|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%
|-
|<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>
|}
||
{| class="wikitable"
|+ '''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%
|-
|<ref name="O'Sullivan Fig 27.9">O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.</ref>
|}
|}
 
{|
|-
||
{| class="wikitable"
|+ '''Adults Obese >&nbsp;80&nbsp;kg'''
! Anatomic structure
! Surface area
|-
| [[Head]] and [[neck]]
| 2%
|-
| [[Anterior]] [[torso]]
| 25%
|-
| [[Posterior]] [[torso]]
| 25%
|-
| Each [[leg]]
| 20%
|-
| Each [[arm]]
| 5%
|-
| [[Genitalia]]/[[perineum]]
| 0%
|}
||
{| class="wikitable"
|+ '''Infants < 10&nbsp;kg'''
! Anatomic structure
! Surface area
|-
| [[Head]] and [[neck]]
| 20%
|-
| [[Anterior]] [[torso]]
| 16%
|-
| [[Posterior]] [[torso]]
| 16%
|-
| Each [[leg]]
| 16%
|-
| Each [[arm]]
| 8%
|-
| [[Genitalia]]/[[perineum]]
| 1% [but it does not add up to 100%]
|}
|}


===Rule of Palms===
===Rule of Palms===

Revision as of 20:08, 16 July 2011

Background

Burn Degrees

  • 1st
    • red, tender, no blisters
    • two point discrimination intact
    • heals without scarring
  • 2nd
    • Partial thickness
    • Superficial
      • Thin blisters
      • Heals without scarring in 2-3 wks
    • Deep
      • Thick blisters
      • 2 point discrimination decreased
      • Can feel pressure
      • Potential for scar/contractions
  • 3rd
    • Full thickness
    • skin is white, leathery and anesthetic
    • always needs grafting
  • 4th
    • 3rd degree + involves muscle, bone, or other deep structures

Rule of Nines

Adults

  • Each area is 9% BSA:
    • Entire head and neck
    • Right arm (including hand)
    • Left arm (including hand)
    • Chest
    • Abdomen
    • Upper back
    • Lower back
    • Right front of leg
    • Left front of leg
    • Right back of leg
    • Left back of leg
  • 1%: Genital region

Children

  • Each area is 9% BSA:
    • Anterior head and neck
    • Posterior head an neck
    • Right arm (including hand)
    • Left arm (including hand)
    • Chest
    • Abdomen
    • Upper back
    • Lower back
    • Right leg (front & back)
    • Left leg (front & back)
  • 1%: Genital Region


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%
[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%
[1]
Adults Obese > 80 kg
Anatomic structure Surface area
Head and neck 2%
Anterior torso 25%
Posterior torso 25%
Each leg 20%
Each arm 5%
Genitalia/perineum 0%
Infants < 10 kg
Anatomic structure Surface area
Head and neck 20%
Anterior torso 16%
Posterior torso 16%
Each leg 16%
Each arm 8%
Genitalia/perineum 1% [but it does not add up to 100%]

Rule of Palms

  • Pt's palm = 1%
  • Use to estimate scatter burns
  • Also use for local burns up to 10% BSA

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

Workup

  1. Labs
  2. CO level
  3. CN level if suspicious and/or empiric Tx (see below)
  4. Work-up for associated trauma, if indicated

Treatment

  1. Airway (Intubation below)
  2. IVF (below)
  3. Foley cath
  4. Dressing (saline/tap/petroleum gauze)
  5. No PPxIV Abx; topical bacitracin ok
  6. Escharotomy (below)
  7. H2 blocker (stress ulcer)
  8. NG tube (gastroparesis)
  9. Td
  10. Analgesia
  11. Consider Transfer

Intubation Guidelines

  • Any hard signs:
    • Stridor
    • Hoarseness
    • Pharyngeal burns
  • 3 or more soft signs:
    • h/o unconciousness
    • Noxious fumes at scene
    • Burn occurring in closed space
    • Facial burns
    • Carbonaceous sputum
    • CO level >15%

Fluid Resuscitation

Indicated if:

  1. >20% BSA (2nd & 3rd)
  2. Evidence of shock
  • Total Fluids = Parkland + maint + blood loss
  • Parkland:
    • 4 x kg x %BSA (2nd&3rd)= cc NS (or LR)
      • Give 1/2 in first 8hrs, remainder in next 16hrs
  • Place Foley cath:
    • Goal:
      • Adult: UOP>30mL/hr
      • Peds: UOP >1mL/kg/hr
  • Consider CVP line if h/o cardiopulmonary dz

Cyanide

  • Consider empiric tx for smoke inhalation victims with (any):
  1. Hypotension
  2. Metabolic acidosis
  3. CV collapse
  • Give sodium thiosulfate (12.5 mg) alone (given possiblility of CO also)
  • See also Cyanide

Escharotomy

  • Restriced ventilation
    • Anterior axillary line
    • 2cm below clavicle to 10th rib
    • May connect (square)
  • Restricted perfusion (focal)
    • Along long axis of hands, forearms, feet, fingers, toes if no pulse by doppler
    • Lateral on extremity
    • No perfusion, add medial
    • Bovie or scalpel

Disposition

Transfer Criteria (ABA 1994)

  1. 2-3 deg >10% in pt <10 or >50yo
  2. 2-3 deg >20% anyone
  3. 3 deg >5% anyone
  4. Complicating factors
    1. Sig face/hand/feet/perineum/major joint
    2. Circumferential burns
    3. Inhalation injury
    4. Concomitant trauma
    5. Sig pre-existing dz
    6. Sig electrical/chemical burn


  • For moderate burns not meeting transfer criteria may admit

Source

8/07 DONALDSON (adapted from Bessen, Mistry); 3/10 DeBonis

  1. ↑ 1.0 1.1 O'Sullivan, Susan B., Schmitz, Thomas J. Physical Rehabilitation. 5th ed. F.A. Davis Company, Philadelphia, 2007. p. 1098, Fig 27.9.
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