ABLS (Burn Medicine)

Torso and Neck
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Torso and Neck
What area may require escharotomy if circumferential burns are present that may impact ventilation?
>120 bpm
Definition of tachycardia in a burn patient?
Pain, Anxiety, hypovolemia, inadequate oxygenation
Common causes of tachycardia in a burn patient?
>20% TBSA 2nd/3rd
What TBSA should necessitate 2 large bore IV access and foley?
<6 years old = 125mL/hr LR
6-13 years old = 250mL/hr LR
>13 years old = 500mL/hr LR
Initial prehospital fluid administration rates for burns
1. Current weight
2. TBSA of burn
3. Using 1 & 2 determine adjusted fluids rate
4. Manage burn wounds (i.e. dressings, escharotomy)
Key specific components of secondary survey for burn patients
Hands, feet, face, genitalia
What are specialized areas of concern for burns?
9% Head (4.5% front and back)
9% Upper Extremity (4.5% front and back)
18% Lower extremity (9% front and back)
36% Torso (18% front and back)
1% Perineum
Rule of 9s Adult
18% Head (9% front and back)
9% Upper Extremity (4.5% front and back)
14% Lower extremity (7% front and back)
36% Torso (18% front and back)
Rule of 9s Infant
Patients palmar surface (palm and fingers) approximate 1% of BSA
Describe palmar surface method
Flame Burn (Use LR) >13 = 2mL x kg x %TBSA Children >30kg = 3mL x kg x %TBSA Infants/young kids (<30kg) = 3mL x kg x %TBSA AND D5/LR at maintenance rate Electrical Burn (Use LR) All Ages = 4mL x kg x %TBSADescribe the adjusted fluid rate for burn patients once TBW and TBSA are determined? Flame/Scald burn vs electrical burn?Primary = direct effect of blast wave Secondary = Due to projectiles from the blast Tertiary = Due to person being thrown from blast wind Quaternary = All other explosion-related injuries, including BURNS, crush, inhalation and toxic exposuresWhat are the four primary blast injury classifications and what do they mean?Size: - 10% or greater TBSA partial thickness - Any 3rd degree burn Mechanism: - Electrical - Chemical - Inhalation Special Locations: - Hands and Feet - Face - Perineum/genitalia - Across major jointsABA Referral Criteria to a Burn CenterThermal = supraglottic Chemical = lower airwayWhere does thermal and chemical burns injure the airway?- Deep facial burns - Soot in throat - Carbonaceous sputum - Agitation (hypoxia) - HoarsenessWhat physical exam risk factors indicate airway injury?Inhalation injury concerns: --Stridor, retractions, Respiratory distress, and/or deep facial burn Other: -- Suspected lower airway inhalation injury -- Impaired O2 and/or ventilation -- Anticipated large volume resuscitationWhen do you need to intubate immediately?100% O2 via NRBIf patient does not need immediate intubation, what respiratory support should they be given?100% O2 via NRB Goal: Decrease CO to <10% NOTE: 100% O2 decreases half life of CO from 4 hrs to 1 hrTreatment for CO poisoning?HydroxycobalaminCyanide poisoning treatment0.5mL/kg/hrUrine output goal for burn victims age 14 and older1ml/kg/hrUrine output goal for burn victims younger than 14>140 bpmWhat heart rate is likely to be related to hypovolemia compared to other causes?Adjust fluids down or up by 1/3 of current rateHow do you titrate fluids if patient is exceeding or not meeting urine output goals?Greater surface area per unit body mass Note: Kids are more susceptible to fluid overload NOTE: <1 year old have insufficient glycogen stores and require D5 supplementationWhy do peds require more fluids than adults?Usually >24 hours post injuryWhen does maximal edema occur?soap and waterWhat should you use for initial bedside cleaning of burn wounds?DebridementHow should you manage loose epidermis or blisters >2cm?Topical antimicrobial nonadherent dressings; NOTE: secondary dressings protect wound from contamination and absorb any exudate from woundHow do you manage wounds after initial cleaning?Full thickness burns only with circumferential (or near circumferential) componentWhat kind of burns require escharotomy?1. Cut only along full thickness burn 2. Cut through the full thickness burn and not deeper (avoid deeper layers such as fat or fascia) 3. Usually the skin separates at least 1-2 cmsHow do you perform escharotomy?1. Reassess escharotomy for adequate release 2. Consider compartment syndrome as etiology that may require fasciotomyWhat is the approach to lack of reperfusion after escharotomy?Small external injuries can mask significant internal injuriesWhy are eletrical injuries referred to as "The great masquerader" of burn injuries?AC current changes direction DC (Direct current) current injuries are unidirectional and may have an entry and exit siteWhat's the difference between AC and DC current injuries?Lightning = high voltage, high amperage Batteries = low voltage, contact heat injury more likelyExamples of DC injuriesPower lines and household electrical outletsExamples of AC CurrentCurrent NOT Voltage causes damage; heat generated also generates heat BUT, we can not easily determine actual voltage across the body, so voltage is a surrogateWhat determines extent of electrical burn damage?Low voltage energy (<1000V) High Voltage energy (>1000V) Contact points (do not use entrance and exit points) in AC injuriesHow do you classify Electrical burns?Low voltage = follows path of least resistance, usually mild symptoms, migratory pains hours later is common; Fatal cardiac arrhythmias can occur High Voltage = heats tissues immediately; often causes deep tissue necrosis (may not be visible initially from external)How do low voltage and high voltage injuries affect the body?- Conduction = current delivered injury at the contact points - Arc flash/blast = Current traveling through the air between two conductors generating explosive force from superheated air and may cause blast injuries or secondary ingnition - Thermal contact = current flowing through metal (i.e. piercings, belt buckles) touching the skin burning the skin - Secondary ignition = ignition of clothing even in the absence of electrical conduction injury - Associated Trauma = falls, tetanic muscle contractures and dislocations/fractures (why electrical injury patients are evaluated as Trauma patients)What are the injury mechanisms for electrical burns?Superheated metal touching the body during the time of electrical contactHow do electrical burn patients develop thermal contact burns?Primarily summer months 30,000-50,000A (100,000V) Duration is usually very shortKey facts to know about lightning strikes- Cardiac arrest (its like a defibrillation) - Cardiac Arrhythmia - Respiratory arrest - Major skin injuries are uncommonInjuries seen with lightning strikeLichtenburg figures are ferning patterns of skin seen for up to 36 hrs is pathognomonic for lightning strike injuriesWhat is the pathognomonic skin finding seen with electrical injuries?Deep Contact Burn Contracted/paralyzed/mummified extremity Loss of peripheral pulses (eval compartments) Myoglobinuria Loss of consciousnessWhat findings are consistent with Electrical injuries on exam??75-100ml/hr until pigment clearsWhat urine output goal should you target for burn patients with pigmented urine?ALL ELECTRICAL INJURIES NEED TO HAVE AN EKG - Loss of consciousness - Cardiac Arrest - EKG evidence of myocardial ischemia/infarction - Abnormal heart rate or rhythm High voltage injuries with normal EKG and no wound care needs, shared decision making; Obs vs DCWhen do you need to perform 24 hour monitoring for electrical injury patients?Decontamination - duration of contactWhat is one thing you can do to impact severity of chemical burn?Acidic burns cause coagulative necrosis and protein precipitation generating a "leathery" eschar boundary that prevents further penetration Alkali burns cause liquefactive necrosis and continues to penetrate to deeper tissuesWhy are acidic burns usually less deep than alkali burns?Vesicants -- Mustard Agents -- Lewisite -- Chlorine GasWhat chemical warfare agents cause skin changes similar to burns?- Brush off powder - Irrigate with COPIOUS water - Do NOT attempt to neutralize acid with base or vice versaHow do you decon a chemical exposed patient?GOAL: Normalize skin pH Copious amounts of water (>30 minutes of irrigation) Check skin pH before and after irrigationHow do you perform water irrigation?hypocalcemia, can precipitate arrhythmiaWhat additional consideration must be considered for hydrofluoric acid exposure?Monitor ECG and Ca++ level Topical calcium gels (combine 1Amp CaGluconate with 100gm of water soluble lubricating jelly) IV or Intraarterial Ca may be necessaryHow do you treat hydrofluoric acid burns?Yes - chemical burns are an indication for burn center referralShould chemical burns receive consultation with a burn center?-- Larger BSA to weight -- Difficulty maintaining temperature (low muscle mass) - more susceptible to hypothermia -- Thinner Skin - more susceptible to deeper burnsDifferences between children and adults for burns<30kg weight add D5/LR as maintenanceWhat children should get maintenance fluids?120'FWhat is the safe temperature setting for residential water heaters?