New Approaches in Burn Management
Ken Butler D.O.
Associate Professor
Associate Residency Director
Emergency Medicine Residency Program
University of Maryland
New Concepts in the Management of
Thermal Injuries

Objectives
 Smoke inhalation--who can be sent home?
 What really predicts intubation in smoke inhalation?
 RSI in smoke inhalation
 Whose palm is it anyway?
 Is the rule of nines really the rule?
 Challenging the Parkland formula
 New imaging for burn depth
 Blister management
 Hands
Prehospital Care

Pain Management by EMS


EMS personnel hesitate to give an appropriate amount of
pain medication to burn patients
Airway Management

EMS personnel are concerned about the airway NOT about
making it to the regional burn center.

so these patients show up in your ED
Know the Burn Depth
“Lingo”
For the Consultants

Emergency Physicians

1st Degree

2nd Degree

3rd Degree
Know the Burn Depth
“Lingo”
For the Consultants

Plastic Surgeons

3 Zones

Partial Thickness

Full Thickness
Epidemiology as Easy as Two-Three






2/3 male
2/3 white
2/3 drunk
2/3 have flammable liquid
2/3 reduction in death due
to smoke detectors
23 mean age
Mechanisms

Six groups based on mechanism of injury







Scalds 30%
Contact burns 30%
Fire 30%
Chemical 3%
Electrical 5%
Radiation 1%
Flash Burns
 lighting BBQ – microsecond of exposure
singed facial hairs – NO INHALATIONAL BURN
Chemistry Flash Backs

Tar Burns
 “Likes dissolve likes”
 Excellent removal with butter

Wet Cement
 CaOH Treat like an ocular alkali burn

Hydrofluoric Acid Burn
Dissolve 10% calcium gluconate
solution in 3 times the volume of a
water-soluble lubricant.
For burns to the fingers, retain gel in a
latex glove.
Chemistry Flash Backs

Microwaves cause “superheating”

Heating a liquid to a temperature above its
normal boiling point, making it unstable.

Microwave energy burns are based on the
water content of tissue

Muscle burns more than fat

Delay between time of injury and signs of skin
damage or pain
Alexander RC, Surrel JA, Cohle SD. Microwave oven burns to children: An unusual manifestation of child
abuse. Pediatrics. 1988;79(2):255-260.
Just Admit Him for Syncope?

Fireman has sudden collapse at a house fire

His firefighter partner called it a “Knock Down Fire”

This is classic presentation of CN

CO requires longer exposure for symptoms
Smoke Inhalation
Who Can We Discharge Home?

Arterial blood gases, chest radiography and carboxyhemoglobin
estimation rarely influence immediate management.

Bottom Line
 Patients presenting with normal vital signs and examination
and short smoke exposure may be safe to discharge from the
emergency department without further investigation.
Mushtag,F, et al, Discharge from the accident and emergency department after smoke inhalation: influence of
clinical factors and emergency investigations. J Emerg Med. 2004 Jun;11(3):141-4.
Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

No statistically significant correlation was found between
intubation and any of the “classic symptoms” of smoke
inhalation:
 stridor
 hoarseness
 drooling
 dysphagia (all p = 1.0)
Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke
Inhalation Injury Ear Nose Throat J. 2006 Apr ;85(4):278-80
Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

Intubation positively correlates with the physical examination
findings of

soot in the oral cavity (p < 0.001)

facial burns (p = 0.025)

body burns (p = 0.025)
Madnani DD, et al, Factors that Predict the Need for Intubation in Patients with Smoke
Inhalation Injury Ear Nose Throat J. 2006 Apr;85(4):278-80
Factors that Predict the Need for Intubation in
Patients with Smoke Inhalation Injury

Conclusion
Patients with
1. soot in the oral cavity,
2. facial burns, or
3. body burns
have a higher likelihood of laryngeal
edema and the need for intubation.
Madnani DD, et al, Ear Nose Throat J. 2006 Apr;85(4):278-80
Intubation and Smoke Inhalation


“Take it early” as it never gets better !
Prevent a “DOA”
 Developing Obstructed Airway due to progressive edema
 First attempt is best attempt - This is for the most
experienced intubator NOT a junior resident
Three Factors of Smoke Inhalation That
Produce a Difficult Airway

Thermal damage – Upper airway takes the brunt and causes
edema due to the poor conductivity of air and the high
amount of dissipation that occurs in the upper airways.
Air inhaled at 142°C - by the time it reaches the carina it will
have cooled to 38°C.

Asphyxiation – Tissue hypoxia alone - with CO or CN??

Pulmonary irritation – Particulate matter causes a decrease in
all lung volumes and lung compliance
CHEMICAL COMPONENTS OF SMOKE
COMPOUNDS
SOURCE
Ammonia
CLOTHING, FURNITURE,
SULFUR DIOXIDE
WOOL, SILK
CHLORINE
HYDROGEN
CHLORIDE
PLYVINYL CHLORIDE,
PHOSGENE
FURNITURE, (WALL, FLOOR
COVERINGS)
ACETALDEHYDE
WALL PAPER
FORMALDEHYDE
LACQUERED WOOD
ACROLEIN
COTTON, ACRYLIC
CYANIDE
POLYURETHANE UPHOLSTERY
CARBON
MONOXIDE
NYLON (ANY COMBUSTIBLE
SUBSTANCE)
EFFECT
TIMING
Mucous membrane
irritation,
bronchospasm,
bronchorrhea
Early onset (first
several hours)
Severe mucosal
damage; ulcers,
mucous plugging,
mucosal slough,
pulmonary edema
Delayed often 1-2
days
immediate
Tissue hypoxia
immediate
RSI in Burn Patients

Don’t take away what they already have
 Should be your thought before pushing any paralytic

Why a 7.5 ETT ?

What is your plan B ?
The Difficult Airway in Smoke Inhalation
You’re in. All you see is a “pink dead end” with charcoal.
No landmarks.
You reposition. Still a “pink dead end.”
Now what?
With your right hand, press down on the lower rib cage.
LOOK FOR “tiny bubbles.”
Now pass the tube or bougie.
Hypotension Post Intubation in a Burn
Patient
Now the patient is intubated but your bagging is becoming an
isometric exercise.
And the patient is developing hypotension.
Why?
Is this burn shock?
Is the vent setting wrong?
What else might the patient need?
Escharotomy

“SNAP, CRACKLE, POP”
The Palm and the Assessment of TBSA
#1 Problem


The area of the palm alone is
 0.5 percent TBSA in males
 0.4 percent TBSA in females
Whereas the area of the palm plus the palmar surface of the
five digits is
 0.8 percent BSA in males
 0.7 percent BSA in females
Therefore, if a hand alone is used to assess
the size of a burn, the percent BSA is overestimated.
Rossiter ND et al. How big is a hand? Burns. 1996 May;22(3):230-1.
Palmar Estimation and BMI
#2 Problem

The mean HSA diminishes significantly as BMI increases in both
sexes (P<0.001).

This difference is more pronounced in women, particularly those
with a BMI >31 kg/m2

Awareness of the potential for overestimation of burn surface
area using this method alone may improve the accuracy of burn
area estimation.
Berry MG et al. The influence of body mass index on burn surface area
estimated from the area of the hand. Burns. 2001 Sep;27(6):591-4.
The Rule of Nines Isn’t Always the Rule
The Rule of Nines Isn’t Always the Rule

The Rule of Nines provides reasonable estimates of body
surface area for patients ranging from 10 to 80 kg.

For obese patients weighing more than 80 kg, a rule of fives is
proposed:
 5% body surface area for each arm
 5 x 4 or 20% for each leg
 10 x 5 or 50% for the trunk
 and 2% for the head
Livingston EH. Percentage of burned body surface area determination in obese and nonobese
patients. J Surg Res. 2000 Jun 15;91(2):106-10
5%
50%
20%
Livingston EH. Percentage of burned body surface area determination in obese and nonobese patients J Surg Res. 2000
Jun 15;91(2):106-10.
Fluids and Formulas

Lactated Ringer’s in all burn resuscitation

Burn resuscitation requires more fluid than trauma resuscitation.

Prevent hyperchloremic acidosis and buffer lactate
Fluids and Formulas

On the Horizon

Adjuvant administration of high-dose ascorbic acid
(66 mg/kg/hr) during the first 24 hours after thermal injury
significantly reduces

resuscitation fluid volume requirements by 30%

wound edema

severity of respiratory dysfunction
Reduction of Resuscitation Fluid Volumes in Severely Burned Patients Using
Ascorbic Acid Administration Arch Surg. 2000;135:326-331.
Fluids and Formulas

Formulas

Parkland
LR 4 mL/kg per percent burn ????

Modified Brook LR 2 mL/kg per percent burn

Galveston
LR 5000 ml/m² BSA burned/day plus
2000 ml/m² BSA total/day
(also used in TEN)
Barret J.P et al. Survival of paediatric burns involving 100% total body surface area Ann Burns
Fire Disasters 1999; 12:139.
Spies et al. Treatment of extensive toxic epidermal necrolysis in children Pediatrics 2001;108:11621168.
How Well Does the Parkland Formula Estimate
Actual Fluid Resuscitation Volumes?

Despite its effectiveness, the Parkland formula underestimates
the volume requirements in most adults with isolated cutaneous
burns, especially in those with large full thickness burns.

New data suggest 5.5-6.0 ml/kg per TBSA%
Cartotto RC et. al. How well does the Parkland formula estimate actual fluid resuscitation
volumes? Burn Care Rehabil. 2002 JulAug;23(4):258-65.
Mitra B et.al. Fluid resuscitation in major burns J Surg. 2006 Jan-Feb;76(1-2):35-8.
Inhalation and Fluid Requirements

Patients with flame burns and inhalation injury have a mean fluid
requirement of

2 ml/kg/% burn above patients with flame burns without
inhalation injury for adequate resuscitation.
Dai NT et al. The comparison of early fluid therapy in extensive flame burns between inhalation
and noninhalation injuries. Burns 1998 Nov;24(7):671-5.
Early Fluid Resuscitation Improves
Outcomes in the Pediatric Patient

The incidence of sepsis, renal failure, death due to cardiac arrest,
and overall mortality is significantly higher in burned children
receiving fluid resuscitation that was delayed >2 hr.

Fluid resuscitation, given within 2 hr of a thermal injury, may be
one of the most important steps in the prevention of multiorgan failure and mortality.
Barrow RE et al. Early fluid resuscitation improves outcomes in
severely burned children. Resuscitation. 2000 Jul;45(2):91-6.
Emergency Department Fluid Resuscitation of
Burn Patients Transferred to a Burn Center

The average total body surface area (TBSA) estimated by the
referring emergency department staff was 23.9%

Compared with the burn intensive care unit staff ’s average
estimation of 17.8%

More importantly 47% were underresuscitated.
Hagstrom M et al. A review of emergency department fluid resuscitation of burn
patients transferred to a regional, verified burn center. Ann Plast Surg. 2003;51:173-6.
Emergency Department Fluid Resuscitation of
Burn Patients Transferred to a Burn Center

Bottom Line

Early communication permits review of estimated TBSA burn
evaluation and permits cooperative calculations and optimal
delivery of early fluid resuscitation.

Burn center practitioners can improve care of patients before arrival
by appropriately guiding the referring physician.
Hagstrom M et al. A review of emergency department fluid resuscitation
of burn patients transferred to a regional, verified burn center.
Ann Plast Surg. 2003 Aug;51(2):173-6.
Advances in Modalities Used for the
Assessment of Burn Wound Depth

Depth dictates prognosis

Although bedside clinical evaluation remains the most
widespread and cost-effective method, it is accurate only 2/3 of
the time and is limited by poor interrater reliability

New techonological modalities are now in use

Laser Doppler Imaging (LDI)
Burn Assessment by Laser Doppler Imaging




Noncontact scanning technique that measures the entire burn wound surface.
Color-coded perfusion map corresponds to varying burn depth.
Accuracy up to 99%
The latest, most accurate, most advanced modality of diagnosing burn depth
Lara Devgan, BA, Modalities for the Assessment of Burn Wound Depth J Burns Wounds.
February 2006; 5: e2.
Management of Blisters in the
Partial-Thickness Burn

Previously a controversial topic

Preservation: intact blister provides natural biological
protection to the wound; blister fluid supports wound healing

Blister debridement and fluid evacuation; components of
blister fluid are detrimental to wound healing
Management of Blisters in the
Partial-Thickness Burn

Blisters do not indicate burn depth

Blisters typically signify the presence of a superficial partialthickness wound.

We can get into trouble: they may occur over deeper dermal
injuries that require excision and skin grafting.

It is imperative to accurately identify the depth, as it
correlates with the risk of wound infection.
Visually Deceiving Burns

Many burn injuries involve various depths of burn.

Debridement of blisters aids in accurate wound depth
identification by allowing direct visualization of the wound bed.
Flame burn (direct contact) looks superficial with blisters.
When gently cleansed, the wound is found to be a
combination of deep second- and third-degree burn.
Management of Blisters in the
Partial-Thickness Burn

Infection

3 Zones of Injury

Coagulation


Stasis


central devitalized tissue
marginally perfused
Hyperemia

outlying tissue
Management of Blisters in the
Partial-Thickness Burn

Knowledge of these zones and the associated risk of conversion
of partial-thickness to full-thickness injury requires ongoing
assessment, especially during the first 48 hours.

Prevention of wound conversion is key.
Debridement of Burn Blisters

Protective to the fragile zone of stasis in the early stages of
injury

Inflammatory mediators within blister fluid contribute to
increasing size of the blister as the result of effect on
microcirculation and increased capillary permeability

Mechanical pressure from the blister on ischemic tissue
contributes to deepening the wound
Debridement of Burn Blisters

Prevention of wound conversion reduces the risk of infection.

Partial thickness wounds
 retain intact vascular supply and tissue viability
 are therefore less susceptible to microbial invasion
CLINICAL PRACTICE
GUIDELINES

Bottom line of blister management

Blisters should be debrided to
 stop burn wound conversion
 remove non-viable tissue
 allow proper visualization of the wound bed
 evacuate fluid that will increase the size of the blister
 evacuate fluid that suppresses local and systemic immune
function
Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review.
J Burn Care Res. 2006;27(1):66-81
Hand Burns





Disability
Edema hinders motion contraction compartment syndrome
Elevation is crucial
Evaluation of radial, ulnar, and palmar arch pulses by
palpation/Doppler hourly
“If they can’t make a fist, make it to a Burn Center.”
Two Bedside Tests for the Detection of
Developing Compartment Syndrome of a Digit

Use a pulse oximeter to detect extremity hypoxia.
 <95% O2 saturation may require escharotomy

Place an 18-gauge needle on the pressure tubing
used to monitor arterial pressure and insert the
needle into the compartment.
 Pressures >30 mmHg require escharotomy
Hand Burn Contractures

The typical contracture is an "intrinsic minus" position:
the MP joints are fixed in hyperextension and the PIP joints are
fixed in flexion.

For this reason, positioning of the burned hand should place the MP
joints at maximum flexion (90 degrees) to maximally stretch the
collateral ligaments.
Hand Burn Devices

A vacuum-assisted closure device for treatment of hand burns is in
prospective clinical trials.

This device reduces edema and provides an excellent method of
splinting.
Synthetic Skin Substitutes

Biobrane® is a bilayer synthetic skin substitute

An outer epidermal analog is constructed of a thin silicone film
that functions comparable to skin.
 Small pores in the silicone allow exudate removal and
permeability to topical antibiotics.

An inner dermal analog is composed of a three-dimensional
irregular nylon filament weave to which type I collagen peptides
are bonded.
Synthetic Skin Substitutes
Synthetic Skin Substitutes
Outpatient Management of PartialThickness Burns: Biobrane versus 1% Silver
Sulfadiazine

Across multiple trials comparing rates of healing in partialthickness wounds, Biobrane® significantly reduced healing time
without increased infection rates compared with topical SSD.

When used on properly selected wounds, Biobrane therapy
significantly decreases pain and total healing time without
increasing the cost of outpatient burn care.
Gerding RI et al. Outpatient management of partial thickness burns. Biobrane versus
1% silver sulfadiazine. Ann Emerg Med 1990:19:121-124.
Sulfamylon

Mafenide acetate diffuses through devascularized tissue.

80% is delivered to burned tissue over the first 4 hours following
topical application.

Sulfamylon® exerts bacteriostatic action against many gramnegative and gram-positive organisms, including Pseudomonas
aeruginosa and certain strains of anaerobes.
Silver Sulfadiazine
SSD




The use of SSD in partial-thickness wounds delays healing.
Use of SSD requires dressing changes BID, which may cause
trauma to the epidermal cellular bed.
Despite its availability, its soothing effects and ease of
application make its use widespread.
Contraindicated
 Pregnancy
 Nursing mothers
 Allergy to sulfa
 Facial burns
Aug. 8, 2005 Issue
The Fallout:
'I Felt My Face Just Melting'
Burn units struggle to cope with the
flow of meth users straining their
resources.
Methamphetamine Burn Patients:
What Makes Them Different?

Key points

A 2-year retrospective revealed that the methamphetamine
burn patient requires two to three times the standard
Parkland formula resuscitation.

Methamphetamine burns larger than 40% TBSA have a
100% mortality.
Warner P et al. The methamphetamine burn patient J Burn Care Rehabil. 2003;24:275-8.
Burns in Pregnancy

Clinical Challenges






Intravascular volume is increased by 50%
Fall in colloid pressure – increases extravasation
Increase in TBSA
Parkland formula is inaccurate
INCREASE IN FLUID LOSS VS NONPREGNANT
Third-trimester patients may require TWICE the Parkland
formula for adequate resuscitation
Pacheoco LD. et al. Burns in Pregnancy Obstet Gynecol. 2005 106:1210-2.
Outcome and Changes in Survival Following
Severe Burns (1985 to 2004)

Outcome was evaluated in relation to the presence of three
major risk factors for death:




age 60 years or over
total burned surface area 40% or more
inhalation injury
When zero, one, two, or three risk factors were present,
mortality was respectively 0.5%, 9.9%, 48.0%, and 90.5%.
Brusselaers N. et al. Outcome and changes over time in survival following severe burns from
1985 to 2004 Intensive Care Med. 2005;31(12):1648-53