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US – 2M seek serious burns  70k require hospitalizations, 5k die
Usually caused by careless and ignorance, nearly half are smoking or alcohol -related.
Goal: well healed durable skin with normal function and near-normal appearance.
Cutaneous burns – caused primarily by the application of heat to the skin resulting in coagulative necrosis of some or all of the epidermis and dermis.
Depth of burn – depends on heat of the burn source, thickness of the skin, duration of contact, and the blood flow.
• First Degree – involve only the epidermis; no blisters; painful and erythematous due to dermal vasodilation; erythema and pain subsides in 2-3 days; desquamation occurs in day 4
• Superficial Dermal Burns (Second Degree) - include the upper layer of the dermis; form blisters at the interface of the epidermis and dermis; when blisters are removed, wound is pink and wet, and currents of air passing over it cause pain; wound is hypersensitive and blanches with pressure; if without infection, spontaneous healing in 5% TBSA in any age group
5. Electrical burns including lightning injury
6. Chemical injury
7. Inhalation injury
8. Burns of any size in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality
9. Burns with concomitant mechanical trauma (e.g. fractures) where the burn injury poses the greatest risk of morbidity and mortality
10. Burns in children if there are no qualified personnel or equipment for pediatric care at the initial hospital
11. Burns in patients requiring special social, emotional, and/or long-term rehabilitative support, including cases of suspected child abuse, substance abuse, etc
Airway – initial attention must be directed to this; if patient is rescued from a burning building or exposed to a smoky fire, place on 100% oxygen by tight-fitting mask; if patient unconscious, place ET tube attached to a source of 100% oxygen
Once airway is secured, assess patient for other injuries and transport to the nearest hospital. Begin fluid administration of crystalloid solution at a rate of approximately 1L/h. Wrap patient in clean sheet, remove constricting clothing and jewelries.
Cold application is used in smaller burns, particularly scalds. Ice should not be used.
Assessment of Inhalational Injury - suspect for patients with a flame burn, esp in enclosed space. Hoarseness and expiratory wheezes are signs of potentially serious airway edema or smoke poisoning; inspect mouth for swelling, blisters, soot; copious mucus production and carbonaceous sputum are signs of smoke inhalation and other products of combustion; get ABGs and carboxyhemoglobin levels (if >1, smoke inhalation)
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Fluid Resuscitation – patients with burns >20% typically develop shock due to hypovolemia 2 to extravasation of fluid and protein; institute fluid resuscitation ASAP with LRS 1L/h in adults and 20ml/kg in children; insert foley catheter and monitor urine output q1
Tetanus – previous immunization within 5 years requires no treatment, immunization within 10 years requires a tetanus toxoid booster, and unknown immunization status require hyperimmune serum (hyper tet)
Gastric Decompression – many begin tube feeding by admission to protect the stomach from stress ulceration and prevent paralytic ileus, as well as provide nutrition
Pain control – during shock phase, give meds by IV. Best managed by small IV doses of morphine, 2-5mg.
Esharotomy and Fasciotomy – rarely required within the first 6 hours
Eschar – necrotic and coagulated skin; rigid and unyielding; as fluid and protein extravasate into the underlying tissues the eschar does not expand, and may result in increased tissue pressure sufficient to interfere with breathing or limb perfusion
Chest escharotomy – performed in the anterior axillary line bilaterally; if with significant extension of the burn onto the adjacent abdominal wall, extend incisions to this area and should be connected by a transverse incision along the costal margin
Escharotomy of extremities – edema formation of the tissues may produce significant vascular compromise that may lead to permanent neurologic and vascular deficits. Skin color, sensation, capillary refill, and peripheral pulses must be assessed q1. Poor perfusion: cyanosis, deep tissue pain, progressive paresthesia, progressive decrease in or absence of pulse, or sensation of cold extremities
- may be done as bedside procedure; place incision along the midmedial or midlateral aspect of the extremity and should extend through the echar down to the subcutaneous fat
Rule of Nines
Each upper extremity – 9
Each lower extremity – 18
Anterior trunk – 18
Posterior trunk – 18
Head and neck – 9
Perineum – 1
Primary goal : replace fluid sequestered as a result of thermal injury because massive fluid shifts can occur even though total body water remains unchanged. What changes is the volume of each fluid compartment, with intracellular and interstitial volumes increasing at the expense of plasma and blood volume.
Crystalloid resuscitation – in particular, LRS, is the most popular fluid
Parkland formula – 4ml/kg/%burn in the first 24 hours, ½ of the amount administered in the first 8 hours.
Modified Brooke formula – 2ml/kg/%burn in the first 24 hours
Cincinnati Unit – 4ml/kg/%burn + 1500 ml/m2 BSA
1st 8 hours: LRS + 5-mg NaHCO3
2nd 8 hours: LRS
3rd 8 hours: LRS + 12.5g albumin
Burn wound is usually treated with once or twice daily washing, removal of loose, dead tissue, and topical application of antimicrobial agent (mafenide acetate, silver sulfadiazine, silver nitrate)
Excision and Grafting – for deep dermal and full thickness burns
- small (