Burns: Difference between revisions
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==Background== | ==Background== | ||
*Burns >60% BSA often associated with | *Any burns involving the dermis, superficial partial-thickness, or deeper allow for significant transdermal fluid losses | ||
*Burns >60% BSA often associated with cardiac output depression unresponsive to fluids | |||
*Inhalation injury is main cause of mortality | *Inhalation injury is main cause of mortality | ||
**Half of patients admitted to burn centers develop [[ARDS]] | **Half of patients admitted to burn centers develop [[ARDS]] | ||
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**Only effective within first 30 mins | **Only effective within first 30 mins | ||
**No direct ice to wound | **No direct ice to wound | ||
*Remove all burned/burning clothing, jewelry | **Do not apply creams or ointments | ||
*Assess for signs of inhalational injury | *Remove all burned/burning clothing, jewelry | ||
**Start humidified O2 | **Also remove rings or jewelry distal to injury due to anticipated swelling | ||
*Assess for signs of inhalational injury | |||
**Hoarse voice, soot in nose or mouth, stridor, wheezing | |||
**Start humidified [[O2]] | |||
**[[Intubate]] if necessary (see below) | **[[Intubate]] if necessary (see below) | ||
*[[Intravenous fluid]] (see below) | *[[Intravenous fluid]] (see below) | ||
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! Appearance | ! Appearance | ||
! Expected Course | ! Expected Course | ||
! Image | |||
|- | |- | ||
| Superficial (first-degree) | | '''Superficial (first-degree)''' | ||
| | | | ||
*Epidermis | *Epidermis | ||
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*Painful | *Painful | ||
| | | | ||
*Dry, | *Dry, erythema (no blisters) | ||
*Blanching (intact cap refill) | *Blanching (intact cap refill) | ||
| | | | ||
*Heals without scarring, 5-10 days | *Heals without scarring, 5-10 days | ||
| | |||
[[Image:Sunburn.jpg|70px]] | |||
|- | |- | ||
| Superficial Partial (second-degree) | | '''Superficial Partial (second-degree)''' | ||
| | | | ||
*Superficial dermis (papillary region) | *Superficial dermis (papillary region) | ||
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| | | | ||
*Heals without scarring, <3 weeks | *Heals without scarring, <3 weeks | ||
| | |||
[[Image:Hand2ndburn.jpg|70px]] | |||
[[Image:Scaldburn.jpg|70px]] | |||
|- | |- | ||
| Deep Partial (second-degree) | | '''Deep Partial (second-degree)''' | ||
| | | | ||
*Deep dermis (reticular region) | *Deep dermis (reticular region) | ||
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*Likely to scar if healing >3 weeks | *Likely to scar if healing >3 weeks | ||
*May require skin-graft if does not heal within 3 weeks | *May require skin-graft if does not heal within 3 weeks | ||
| | |||
[[Image:major-2nd-degree-burn.jpg|70px]] | |||
|- | |- | ||
| Full (third-degree) | | '''Full (third-degree)''' | ||
| | | | ||
*Hypodermis (subcutaneous tissue) | *Hypodermis (subcutaneous tissue) | ||
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*Decreased sensation | *Decreased sensation | ||
| | | | ||
*White, leathery | *White, leathery | ||
*Does ''not'' blanch (absent cap refill) | *Does ''not'' blanch (absent cap refill) | ||
| | | | ||
*Heals by contracture, >8 weeks | *Heals by contracture, >8 weeks | ||
*Almost always requires skin grafting | *Almost always requires skin grafting | ||
| | |||
[[Image:8-day-old-3rd-degree-burn.jpg|70px]] | |||
|- | |||
| '''Fourth-degree''' | |||
| | |||
*Underlying fat, muscle and bone | |||
| | |||
*Decreased sensation | |||
| | |||
*Black; charred with eschar | |||
*Does ''not'' blanch (absent cap refill) | |||
| | |||
*Does not heal | |||
*Frequently requires amputation | |||
| | |||
[[Image:Ожог кисть.jpg|70px]] | |||
|} | |} | ||
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==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
*Carboxyhemoglobin level | *Carboxyhemoglobin level | ||
* | *[[Carbon monoxide]] and [[cyanide]] levels | ||
*VBG, CBC, chem, total CK | *[[VBG]], CBC, chem, total CK | ||
*[[CXR]] | *[[CXR]] | ||
*[[ECG]] | *[[ECG]] | ||
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*Serial assessments for compartment syndrome | *Serial assessments for compartment syndrome | ||
=== | ===Diagnosis=== | ||
*Normally a clinical diagnosis | |||
**See [[estimating body surface area]] | |||
* | |||
* | |||
* | |||
==Management== | ==Management== | ||
*Consider empirically treating for [[cyanide toxicity]] especially if fire was in an enclosed place | |||
===Not Severe (Outpatient)=== | ===Not Severe (Outpatient)=== | ||
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*Debride wound as needed | *Debride wound as needed | ||
*Consider a topical antimicrobial: | *Consider a topical antimicrobial: | ||
**[[Bacitracin]], neomycin, or mupirocin | **[[Bacitracin]], [[neomycin]], or [[mupirocin]] | ||
**''AVOID Silver Sulfadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes) <ref>Hussain S et al. Best evidence topic report: Silver sulphadiazine cream in burns. Emerg Med J. 2006 Dec;23(12):929-32.</ref><ref>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</ref>'' | **''AVOID Silver Sulfadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes) <ref>Hussain S et al. Best evidence topic report: Silver sulphadiazine cream in burns. Emerg Med J. 2006 Dec;23(12):929-32.</ref><ref>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</ref>'' | ||
*Consider use of synthetic occlusive dressings (see [[burn dressings]]) | *Consider use of synthetic occlusive dressings (see [[burn dressings]]) | ||
*Blisters | *Blisters | ||
**Leave blisters intact unless they cross a joint or if a large blisters precludes application of a dressing | **Leave blisters intact unless they cross a joint or if a large blisters precludes application of a dressing | ||
**Aspiration is preferred to deroofing<ref>29703044</ref> | |||
*[[Tetanus vaccine]] (if 2nd degree or higher) | *[[Tetanus vaccine]] (if 2nd degree or higher) | ||
===Severe (Inpatient)=== | ===Severe (Inpatient)=== | ||
*IVF (see below) | *IVF (see below) | ||
*Analgesia | *[[Analgesia]] | ||
*Remove all rings, watches, jewelry, belts | *Remove all rings, watches, jewelry, belts | ||
*Local burn care ([[burn dressing]]) | *Local burn care ([[burn dressing]]) | ||
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**Maintain glucose control to prevent infection<ref>Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. Crit Care. 2013; 17(4): 232.</ref> | **Maintain glucose control to prevent infection<ref>Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. Crit Care. 2013; 17(4): 232.</ref> | ||
**Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection<ref>Weber J and McManus A. Infection Control in Burn Patients. http://www.worldburn.org/documents/infectioncontrol.pdf</ref> | **Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection<ref>Weber J and McManus A. Infection Control in Burn Patients. http://www.worldburn.org/documents/infectioncontrol.pdf</ref> | ||
**If septic, start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics | **If [[sepsis|septic]], start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics | ||
*Nasogastric Tube | *[[Nasogastric Tube]] | ||
**Consider if partial-thickness burn >20% BSA (ileus frequently occurs)<ref>Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier Saunders, 2007</ref> | **Consider if partial-thickness burn >20% BSA ([[ileus]] frequently occurs)<ref>Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier Saunders, 2007</ref> | ||
**Definite NG tubes in burns > 30% in adults and 25% in children | **Definite NG tubes in burns > 30% in adults and 25% in children | ||
*Early GI prophylaxis (PPI/H2 blocker) | *Early GI prophylaxis ([[PPI]]/[[H2 blocker]]) | ||
**evidence of stress ulceration even within hours after major burns<ref>DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med. 1995;98(4):159.</ref> | **evidence of stress ulceration even within hours after major burns<ref>DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med. 1995;98(4):159.</ref> | ||
*[[Tetanus vaccine]] | *[[Tetanus vaccine]] | ||
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===Fluid Resuscitation=== | ===Fluid Resuscitation=== | ||
====General==== | ====General==== | ||
*The Parkland formula ( | *The Parkland formula (4mL*kg × % TBSA of burns, not including superficial burns) and modified Brooke formula (2ml/kg/%[[TBSA]]) are the two most widely used resuscitation formulas.<ref>American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249</ref> | ||
**There is general agreement that there is an increasing tendency to over-resuscitate during burn shock.<ref>American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249</ref> | **There is general agreement that there is an increasing tendency to over-resuscitate during burn shock.<ref>American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249</ref> | ||
**Resuscitation recommendations are only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110 | **Resuscitation recommendations are only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110 | ||
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*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)<ref>Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95.</ref> | *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)<ref>Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95.</ref> | ||
====Indications based on Total Body Surface Area (TBSA) of Burn==== | ====Indications based on Total Body Surface Area ([[TBSA]]) of Burn==== | ||
*Definite IV: Adults > 20%, Peds > 15% | *Definite IV: Adults > 20%, Peds > 15% | ||
*Perhaps IV: Adults 15-20%, Peds 10-15% | *Perhaps IV: Adults 15-20%, Peds 10-15% | ||
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=====Types of fluids===== | =====Types of fluids===== | ||
*Many burn centers prefer lactated ringers unless shock liver or hepatic failure suspected | *Many burn centers prefer lactated ringers unless shock liver or hepatic failure suspected | ||
*Colloids generally not used unless burns > 40% TBSA | *Colloids generally not used unless burns > 40% [[TBSA]] | ||
*Do not use dextrose in adults (false | *Do not use dextrose in adults (false UOP), but children should receive small amounts due to small glycogen stores | ||
=====Fluid Quantity===== | =====Fluid Quantity===== | ||
*2-4mL x weight (kg) x %TBSA ('''2nd and 3rd degree only''') = mL NS (or LR) over 24hr | *2-4mL x weight (kg) x %[[TBSA]] ('''2nd and 3rd degree only''') = mL NS (or LR) over 24hr | ||
*Give 1/2 in first 8hr, remainder in next 16hr | *Give 1/2 in first 8hr, remainder in next 16hr | ||
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====Goal UOP==== | ====Goal UOP==== | ||
*If UOP is greater than expected, consider glycosuria and reactive hyperglycemia as cause. | *If UOP is greater than expected, consider glycosuria and reactive [[hyperglycemia]] as cause. | ||
*Maintain urine output of | *Maintain urine output of ''0.5-1 mL/kg/hr''' urine in adults and''' 1-2 mL/kg/hr in children''' weighing < 30 kg<ref>Singer AJ, Lee CC. Thermal burns. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:715–724.</ref> | ||
*If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol diuresis) | *If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol diuresis) | ||
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*Full-thickness burns of the face or perioral region | *Full-thickness burns of the face or perioral region | ||
*Circumferential neck burns | *Circumferential neck burns | ||
*Acute respiratory distress | *Acute [[respiratory distress]] | ||
*Progressive hoarseness or air hunger | *Progressive hoarseness or air hunger | ||
*Respiratory depression | *Respiratory depression | ||
*Altered mental status | *[[Altered mental status]] | ||
*Supraglottic edema and inflammation on bronchoscopy | *Supraglottic edema and inflammation on bronchoscopy | ||
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==Special Cases== | ==Special Cases== | ||
*In burns > 40% in adults and > 30% in children < 5 yo, consider colloids which reduce abdominal compartment syndrome<ref>MetroHealth Burn ICU Handbook (Not a policy manual), Cleveland, OH </ref><ref>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.</ref> | *In burns > 40% in adults and > 30% in children < 5 yo, consider colloids which reduce abdominal compartment syndrome<ref>MetroHealth Burn ICU Handbook (Not a policy manual), Cleveland, OH </ref><ref>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.</ref> | ||
**Consider replacing 25% of IVF with FFP, so that total IV rate is unaltered through the 24 hrs post-burn | **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 | **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 | **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 | *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 | ||
*Vitamin C to reduce fluid volume requirements and prevent capillary leak<ref>Dubick MA, Williams C, et al. High-dose Vitamin C infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139-144.</ref> | *Vitamin C to reduce fluid volume requirements and prevent capillary leak<ref>Dubick MA, Williams C, et al. High-dose Vitamin C infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139-144.</ref> | ||
**Consider infusion of 66 mg/kg/hr for 24 hours of Vitamin C infusion for > 30% TBSA | **Consider infusion of 66 mg/kg/hr for 24 hours of Vitamin C infusion for > 30% [[TBSA]] | ||
**To be started within 6 hours of burn injury | **To be started within 6 hours of burn injury | ||
===Beyond 24 hrs=== | ===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 | *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 | *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== | ==Disposition== | ||
===Outpatient Treatment=== | ===Outpatient Treatment=== | ||
''24-48hr'' | ''24-48hr follow-up'' | ||
*Partial thickness <10% BSA, age 10–50y | *Partial thickness <10% BSA, age 10–50y | ||
*Partial thickness <5% BSA, age <10y or >50y | *Partial thickness <5% BSA, age <10y or >50y | ||
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*[[Lightning Injuries]] | *[[Lightning Injuries]] | ||
*[[Burn dressings]] | *[[Burn dressings]] | ||
*[[Estimating body surface area]] | |||
*[[Carbon monoxide toxicity]] | |||
*[[Cyanide toxicity]] | |||
*[[Hydrogen fluoride toxicity]] | |||
==External Links== | ==External Links== | ||
*https://www.racgp.org.au/afp/2017/march/burns-dressings/ | *https://www.racgp.org.au/afp/2017/march/burns-dressings/ | ||
==References== | ==References== | ||
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[[Category:Trauma]] | [[Category:Trauma]] | ||
[[Category:Dermatology]] | [[Category:Dermatology]] | ||
[[Category:Symptoms]] |
Revision as of 16:01, 17 April 2020
Background
- Any burns involving the dermis, superficial partial-thickness, or deeper allow for significant transdermal fluid losses
- 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
Jackson’s Burn Wound Model
Zone Name | Location | Tissue Damage | Change with Treatment |
---|---|---|---|
Coagulation | Inner | Dead | Not changed |
Stasis | Middle | Dynamic penumbra | Target of burn care: good first aid and wound management can significantly reduce the need for skin grafting (otherwise it can turn into zone of coagulation, if not properly treated) |
Hyperemia | Outer | Reactive inflammation | Will return to normal within hours of the injury regardless of care |
Explains the dynamic nature of burn injuries and how assessment of size and depth at the time of injury can be different compared to 48 hours later
Pre-Hospital Care
- Immerse wounds in cold water (1-5˚C)
- Only effective within first 30 mins
- No direct ice to wound
- Do not apply creams or ointments
- Remove all burned/burning clothing, jewelry
- Also remove rings or jewelry distal to injury due to anticipated swelling
- Assess for signs of inhalational injury
- Intravenous fluid (see below)
Clinical Features
Burn Thickness Chart[1]
Thickness | Deepest Skin Structure Involved | Pain & Sensation | Appearance | Expected Course | Image |
---|---|---|---|---|---|
Superficial (first-degree) |
|
|
|
|
|
Superficial Partial (second-degree) |
|
|
|
|
|
Deep Partial (second-degree) |
|
|
|
|
|
Full (third-degree) |
|
|
|
|
|
Fourth-degree |
|
|
|
|
Differential Diagnosis
Burns
- Smoke inhalation injury (airway compromise)
- Chemical injury
- Acrolein
- Hydrochloric acid
- Tuolene diisocyanate
- Nitrogen dioxide
- Systemic chemical injury
- Specific types of burns
- Associated toxicities
Vesiculobullous rashes
Febrile
- Diffuse distribution
- Varicella (chickenpox)
- Smallpox
- Monkeypox
- Disseminated gonococcal disease
- DIC
- Purpural fulminans
- Localized distribution
Afebrile
- Diffuse distribution
- Bullous pemphigoid
- Drug-Induced bullous disorders
- Pemphigus vulgaris
- Phytophotodermatitis
- Erythema multiforme major
- Bullous impetigo
- Localized distribution
- Contact dermatitis
- Herpes zoster (shingles)
- Dyshidrotic eczema
- Burn
- Dermatitis herpetiformis
- Erythema multiforme minor
- Poison Oak, Ivy, Sumac dermatitis
- Bullosis diabeticorum
- Bullous impetigo
- Folliculitis
Evaluation
Workup
- Carboxyhemoglobin level
- Carbon monoxide and cyanide levels
- VBG, CBC, chem, total CK
- CXR
- ECG
- Urinalysis (assess for myoglobinuria)
- Serial assessments for compartment syndrome
Diagnosis
- Normally a clinical diagnosis
Management
- Consider empirically treating for cyanide toxicity especially if fire was in an enclosed place
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) [2][3]
- 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
- Aspiration is preferred to deroofing[4]
- Tetanus vaccine (if 2nd degree or higher)
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[5]
- Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection[6]
- If septic, start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics
- Nasogastric Tube
- Early GI prophylaxis (PPI/H2 blocker)
- evidence of stress ulceration even within hours after major burns[8]
- Tetanus vaccine
Fluid Resuscitation
General
- The Parkland formula (4mL*kg × % TBSA of burns, not including superficial burns) and modified Brooke formula (2ml/kg/%TBSA) are the two most widely used resuscitation formulas.[9]
- There is general agreement that there is an increasing tendency to over-resuscitate during burn shock.[10]
- Resuscitation recommendations are only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110
- Give least amount of fluid necessary to sustain organ perfusion (avoid "fluid creep")
- Patients with inhalation injury and/or multi-system trauma may require more fluid.
- 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)[11]
Indications based on Total Body Surface Area (TBSA) of Burn
- 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
Fluid Quantity
- 2-4mL x weight (kg) x %TBSA (2nd and 3rd degree only) = mL 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 0.5-1 mL/kg/hr' urine in adults and 1-2 mL/kg/hr in children weighing < 30 kg[12]
- 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[13][14]
- 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
- Vitamin C to reduce fluid volume requirements and prevent capillary leak[15]
- Consider infusion of 66 mg/kg/hr for 24 hours of Vitamin C infusion for > 30% TBSA
- To be started within 6 hours of burn injury
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 follow-up
- Partial thickness <10% BSA, age 10–50y
- Partial thickness <5% 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[16]
- Partial thickness >20% BSA (10-50 years old)
- Partial thickness >10% BSA (<10 or > 50 yrs old)
- Full thickness >5% BSA (any age)
- Burns involving face, eyes, ears, genitalia, joints, hands, feet
- Burns with inhalation injury
- High voltage electrical burn
- Chemical burns
- Burns complicated by fracture or other trauma (in which burn is main cause of morbidity)
- Burns in high-risk patients
See Also
- Caustic burns
- Electrical Injuries
- Lightning Injuries
- Burn dressings
- Estimating body surface area
- Carbon monoxide toxicity
- Cyanide toxicity
- Hydrogen fluoride toxicity
External Links
References
- ↑ Haines E, et al. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients. Pediatric Emergency Medicine Practice. 12(5):1-23. EB Medicine.
- ↑ Hussain S et al. Best evidence topic report: Silver sulphadiazine cream in burns. Emerg Med J. 2006 Dec;23(12):929-32.
- ↑ 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
- ↑ 29703044
- ↑ Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. Crit Care. 2013; 17(4): 232.
- ↑ Weber J and McManus A. Infection Control in Burn Patients. http://www.worldburn.org/documents/infectioncontrol.pdf
- ↑ Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier Saunders, 2007
- ↑ DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med. 1995;98(4):159.
- ↑ American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249
- ↑ American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249
- ↑ Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95.
- ↑ Singer AJ, Lee CC. Thermal burns. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:715–724.
- ↑ MetroHealth Burn ICU Handbook (Not a policy manual), Cleveland, OH
- ↑ 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.
- ↑ Dubick MA, Williams C, et al. High-dose Vitamin C infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139-144.
- ↑ American Burn Association