Burns 848th Forward Surgical Team

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Burns848th Forward Surgical Team
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Initial Assessment Management of Burn Patients
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Objectives

• Upon completion of this lecture
• 1. Understand pathophysiology of the skin
• 2. Understand thermodynamics of burns (Types of
  Burns)
• 3. Identify components of primary and secondary
  survey (Assessment)
• 4. Distinguish between partial and full thickness
  burns
• 5. Apply the rule of nines formula

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Burns

• A burn is an injury to the tissue resulting from
  exposure to flames or hot liquids, contact with
  hot objects, exposure to caustic chemicals or
  radiation, or contact with an electrical current.
  Understanding the following will help in
  formulating an initial management plan for all
  types of burn patients.
• Structure and physiological functions of the skin
• Definitions related to extent and depth of burn
  injuries
• Classifications of burn injuries
• Initial assessment and stabilization procedures

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Pathophysiology

• Skin is the largest organ of the body, 15 of the
  bodies wt.
• Protects from infection
• Regulates heat
• Acts as vapor barrier
• Skin is broken down into three layers
• 1. Epidermis- Outer layer
• Protects against infection and toxins
• Helps the body conserve moisture
• Has the ability to regenerate new tissue

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Pathophysiology Continued

• 2. Dermis-Middle layer
• Thickness or dermal layer is 1 to 4 mm ,depending
  on body location
• Thickest- Back of thighs
• Thinnest-Genitals and eye lids
• Contains nerves, sweat glands,hair follicles,
  blood vessels,sebaceous glands
• Has some regenerative capabilities
• 3. Subcutaneous layers
• Does not possess any regenerative capability if
  the above layers are destroyed

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Thermodynamics of Burn Injuries

• 1) Scald Burns
• Account for 30 of all burn injuries
• This proportion is larger in pediatric patients
• Can result from water, grease, or oil
• Temperatures gt123F(51C)cause burns within
  seconds
• Temperatures gt160F(70C) instantaneous full
  thickness burns
• Superheated steam is likely to cause airway
  problems if head and neck are involved

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Thermodynamics Continued

• 2) Thermal Burns
• Caused by flame, flash, or contact
• Flames account for 50 of burn injuries
• 3) Chemical Burns
• Progressively damage the skin until inactivated
  or removed. In the military we can expect
  phosphorus, napalm, or oil
• Accounts for 10 of burn injuries
• 4) Electrical Burns
• Extent of burns is under-appreciated due to small
  entry or exit wound, internal damage may be
  profound
• Accounts for 10 of burn injuries

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Pathophysiology of Burns

• Classification by depth
• 1st Degree Burns
• Superficial burns involving epidermis
• Local pain and erythema (sun burn or red skin)
• No blister formation
• Spontaneous healing without treatment
• Skin pealing may occur

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Pathophysiology of Burns

• 2nd Degree Burns
• 1. Superficial/Partial thickness
• Involves entire epidermis superficial dermis
• Wounds are warm moist
• Blisters may/may not be present (can appear
  later)
• Extremely painful
• Heal in 14-21 days with proper treatment
• 2. Deep Partial Thickness
• Involves entire epidermis dermis
• Wounds appear waxy with blisters
• These wounds occasionally less painful(because of
  damage to nerve endings
• Wounds become more painful as wounds heal, which
  is approximately 4to6 weeks
• Scarring and contractures can complicate
  healing(may require skin grafts)

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Pathophysiology Contd

• 3rd Degree Burns
• Involves epidermis,dermis, and subcutaneous
  tissue
• Are caused by flash,chemical,electrical, and
  prolonged contact with hot surfaces
• Wounds are painless,however surrounding tissue
  may be extremely painful
• Burns appear white,cherry,red,or black
• Deep blisters may be present
• Skin feels leathery
• Healing slow
• Wound contractures and scarring are common
• Skin grafting often needed

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Pathophysiology Contd

• 4th Degree Burns
• Destroys epidermis,dermis,subcutaneous tissue,
  and muscle, fascia, and bone
• Skin is charred
• Great potential for renal failure, cardiac
  complications, and numerous other problems
• Extensive reconstructive surgery is generally
  required

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Extent of Burns

• Rule of Nines
• Quick estimate of BSA(Body Surface Area)
• Adult Child
• Head 9 9
• Torso 18 18
• Arms 9ea 9ea
• Groin 1 1
• Legs 18ea 18ea

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Burn Severity Classification

• 1) Minor Burns
• Second-degree burns of less then 15 BSA in
  adults or 10 BSA in children elderly
• Less then 2 full-thickness burns
• 2) Moderate Burns
• Second-degree burns of 15-25 BSA in adults or
  10-20 BSA in children or elderly
• Less then 10 BSA full-thickness burns
• 3) Major Severe Burns
• Second degree burns of greater then 25 BSA in
  adults or greater then 20 in children or elderly

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Initial Assessment of Moderate and Major Burns

• Primary Survey
• A-Airway
• B-Breathing
• C-Circulation
• D-Disability(Neurologic Deficits)
• E-Expose and Examine
• F-Fluid Resuscitation

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Assessment Contd

• Triage What is a serious burn?
• TBSAgt20
• Inhalation Injury
• Very Young or Old
• Concomitant Trauma
• These patients need airway assessment,IV
  resuscitation,foley,NG-tube,ICU care

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Assessment Contd

• Secondary Survey
• Head-to-toe assessment to rule out any
  associated injuries
• Circumstances of Injury
• Cause of burn
• Did injury occur in a closed space
• Is there a possibility of smoke inhalation
• Where chemicals involved
• Was there related trauma

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Assessment Contd

• Medical History
• Pre-existing disease or associated illness
• Medications/alcohol/drugs
• Allergies
• Status of tetanus immunization

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Assessment Contd

• An easy aid in obtaining the above information
  AMPLE
• A allergies
• M medications
• P previous illness, past medical history
• L last meal or drink
• E events preceding injury

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Initial Treatment

• Airway
• The airway must be assessed immediately. The
  compromised airway may be controlled by simple
  measures
• Chin trust or jaw lift
• Possible C-spine injuries, may have need for
  spine precautions
• Oralpharyngeal airway in the unconscious patient
• Oraltracheal intubation for all symptomatic
  patients
• Tracheostomy

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Initial Treatment Contd

• Breathing
• Listen to chest and verify lung sounds
• Assess adequacy of rate and depth
• High flow oxygen via non-rebreather mask at 15
  lpm for 100
• Circumferential, full thickness burns of the
  trunk may impair ventilation

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Initial Treatment Contd

• Circulation
• Assess
• Skin color
• Sensation
• Peripheral pulses
• Capillary refill

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Initial Treatment Contd

• Disability, Neurologic Deficits
• AVPU
• A alert
• V verbal
• P pain
• U unresponsive

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Initial Treatment Contd

• Expose and Examine
• Remove all clothing and jewelry

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Short Term Management

• Fluid Resuscitation
• Fluid of choice is LR
• Estimate pre-burn weight
• Rule of nines (9s)
• Formula
• Adult
• 2-4ml/kg/ BSA burned (excluding 1st degree
  burns)
• One half of fluid to be infused in first eight
  hours post injury
• Other half of fluid to be infused over next
  sixteen hours

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Short Term Management

• Formula
• Children
• 4ml/kg/ BSA burned (excluding 1st degree burns)
• One half of fluid to be infused in first eight
  hours post injury
• Other half of fluid to be infused over next
  sixteen hours
• Add normal maintenance fluids to burn
  resuscitation fluid
• The above calculations are only a guide
• Adjust fluids to maintain urine output of
  0.5ml/kg/hr in adults and 1ml/kg/hr in children
• The above calculations are only a guide
• Adjust fluids to maintain urine output of
  0.5ml/kg/hr in adults and 1ml/kg/hr in children

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Short Term Management

• Cardiovascular
• Renal
• Gastrointestinal
• Immune System
• Analgesia
• Escharotomy

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Short Term Management

• Special Circumstances
• Hot tar burns
• Must be rapidly cooled to stop heat transfer
• Remove with an emulsifying agent
• Petroleum based
• Electrical burns
• Are deceiving and exhibit the tip of the
  iceberg
• Often associated with blunt trauma and other
  cutaneous burns
• Fingers and arms will sustain greater damage than
  chest or abdomen

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Short Term Management

• Chemical burns
• Acids continue to burn until neutralized
• Any powder must be dusted off and no water
  applied until free of agent
• When treating alkali metals such as sodium,
  potassium, and lithium no water should be
  applied. Should be covered with oil and remove
• Phosphorus burns
• Ignites when it comes into contact with air
• Yellowish burn that smells like garlic
• Treatment
• Remove any remaining non-burning phosphorus
• Irrigate with copious amounts of water
• 1 copper sulfate solution, applied to the wound
  will turn phosphorus black
• Remove and irrigate

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Questions

• MAJ Rick Jackson

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