Point of Injury Burn Care
Anil Menon, MD, MS
UTMB/NASA-JSC Aerospace Medicine Residency
Aerospace Medicine Grand Rounds
August 23rd 2011
Disclosures
• None
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
26 SEP 1983 / Soyuz T-10-1
19 APR 2008 / Soyuz TMA‐11
Space Related Burns and Fires
• Bondarenko - 1961
Space Related Burns and Fires
• Apollo 1 – 1967
Space Related Burns and Fires
• Apollo 12 – 1969
Space Related Burns and Fires
• STS-9 - 1983
Space Related Burns and Fires
• STS-41D – 1984
Space Related Burns and Fires
• MIR – 1997
Space Related Burns and Fires
• Robertson - 2001
Question?
What one factor might account for the
reduction of burn related deaths from 12,000
per year in 1979 to 6000 in 1990 in the
United States?
Prevention
• Primary
– Fire-retardant clothes, materials, fuel tank
• Secondary
– Extinguishers, fire response
• Tertiary
– Immediate and long-term burn care
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Pathophysiology
• Zone of coagulation
– Cell/proteins
destroyed
– no blood flow
• Zone of stasis
– Cell/proteins damaged
– decreased blood flow
• Zone of hyperemia
– Inflammation area
Physiology
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Emergent phase
Fluid shift phase
Hypermetabolic phase
Resolution phase
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Depth
Superficial
Partial Thickness
Classification of Burn Depth
Full Thickness
Full Thickness (3rd Degree)
– Destruction of all
epidermal and dermal
elements
– Burn into subcutaneous
fat or deeper
– Skin is charred and
leathery Pearly-white
sheen / waxy
– Generally not painful
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
PHTLS
• Scene safety
• Source control
• Patient safety
Kandahar
POLYTRAUMA
• MOST BURN PATIENTS NEED A RAPID
TRAUMA ASSESSMENT, NOT A
FOCUSED BURN ASSESSMENT
• Remember PHTLS and ATLS
POLYTRAUMA
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
– Airway – Intubation / Inhalation
– Breathing – Escharotomy / Ventilation
– Circulation – Fluid resuscitation
Airway
– Thermal
– Cyanide
– CO
– Smoke
Smoke Inhalation
CASE
• 54 yo male working
on gas stove when it
exploded
• In house
• Singed nasal hairs,
facial burns,
intubated in ED
Inhalation Injury
CASE
• 29 yo male working
a deionizing
machine at coal
plant
• Difficulty in
breathing
• Intubated in the field
Breathing
Ventilation
• Tracheobronchial and pulmonary edema
– Fluids
– ARDS
– PNA
• 1-3 days high risk period
• ARDSnet 6ml/kg
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Pressure-limited, time-cycled, 5 Hz
362 -> 31 per arm, RCT
Severe hypoxemia and hypercapnia
LTV 29% vs HFPV 6%
Circulation
• Fluids
– Rule of 9’s
– Rule of hand
– Lund-Browder
• Insensible loss
• Third spacing
Lund‐B
Circulation
Circulation
• Parkland (modified brooke use 2ml)
– 4 ml * kg * %TBSA/24 hours
– 50% over 1st 8 hours since time of burn
– 50% over next 16 hours
• 40 year old healthy female weighs 70 kg
and 50% burned at 1300 hours
• 4*70*50 =14000ml/2 =7000ml/8 =875ml/hr
Rule of 10s
• Estimate burn size to nearest 10
– %TBSA x 10 = initial rate mL/hr (for adult
weights)
– Increase 100 mL/hr for every 10kg above
80kg
• Previous patient
– 50*10 = 500ml/hr
• Insufficient data to support standard of
care (Brooke / Parkland / Pre-hospital )
• > 20 % TBSA require fluid resuscitation
• Use 2-4 ml/kg/%TBSA/24 hours
• Titrate to UOP of 0.5-1 ml/kg/hr
• Increase volume for full thickness, delayed
care, inhalation injuries
Monitoring Response
• If UOP < target for 1-2 hours increase infusion
by 20-25%
• If UOP > target for 1-2 hours decrease infusion
by 20-25%
• Diuretics are NEVER indicated to establish
UOP
– Can be used when gross pigmenturia is present
AND patient has been appropriately resuscitated –
euvolemic
• HR is a very poor indicator of volume status
– Significant systemic inflammation with burns
• Consider BP/CVP/SvO2/HCT/BE
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Question?
In general, moderate to severe burns should
be cared for with:
A.
B.
C.
D.
E.
moist occlusive dressings
dry sterile dressings
cool water immersion
plastic wrap covered by a soft dressing
warm water immersion
Topical
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Bacitracin (bad gram neg and yeast)
Polymyxin (bad gram pos)
Muprocin (MRSA)
Neomycin (strong gram neg only)
Silver sulfadiazene (Broad coverage)
Mafenide (Broad coverage)
Nanocrystals
Use only if transfer time is > 12 hours
Silver Sulfadiazine
(Silvadene)
• Effective Against GPC,
GNR, and Fungus
• Soothing
• Poor Eschar
Penetration
• May cause a transient
leukopenia (5-15%),
anemia
Mafenide Acetate
(Sulfamylon)
• Effective against GPC and
GNR but NOT effective
against fungus
• Good Eschar Penetration
Painful
• Metabolic Acidosis can
result from use (Carbonic
Anhydrase Inhibition)
• Cream or 5% solution
ISS
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Fluid Creep
• Retrospective studies 40% overresuscitation
• Average volumes administered 5-7
ml/kg/TBSA
• Excess fluid administration causes
– Overestimation of size, EGDT, opioids, not
UOP
• Life-threatening results
Abdominal Compartment
Syndrome
Resuscitation
Under-resuscitation
Over-resuscitation
• Worsening acidosis
• Renal Failure
• Hemodynamic
Instability
• Multisystem organ
failure
• Cardiac Dysrhythmia
• Death
• Airway Obstruction
• Extremity
compartment
syndromes
• Abdominal
compartment
syndrome
• Multisystem organ
failure
• Death
Difficult Burn Resuscitation
Decreased Urine Output
• Invasive central pressure
monitoring
– Goal CVP 8-10 mm Hg
– Goal ScVO2 60-65%
• Bladder pressures every
4 hours
• 5% Albumin Protocol
If CVP not at goal
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Increase
crystalloid/5% albumin
rate
If ScVO2 not at goal and
HgB <10
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Transfuse PRBC
If CVP and ScVO2 at
goal then
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Vasopressin 0.04
Units/min
Dobutamine 5-20
µg/kg/min (Norepi 520 µg/min)
Difficult Burn Resuscitation
Decreased Urine Output
• Hypotension must be individualized
– MAP > 55 mm Hg likely adequate to maintain
UOP/end organ perfusion
– Burn with head injury vs No head injury
Outline
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Introduction and background
Pathophysiology
Classification
Point of injury treatment considerations
Initial stabilization and ABCs
Topical care
Advanced and difficult management
Cases
Case
Race driver suffers superficial partial
thickness burns to the hands one-week prior
to the race, how can you treat?
Blister
• Evidence supports leaving blisters intact
– Barrier to infection
– Moist environment promotes
reepithelialization
– Enhanced angiogenesis
– Healing enhanced by blister fluid cell
mediators (calmodulin, IL-1, FGF)
• Tension can cause pain
Burn Classification
CCATT
Transport considerations
• Decision to fly (pre-treat or test)
• Decompress Foley / NGT / ETT
• Contact destination burn center
• Avoid infection risk (transport time?)
• Protect lungs
• Monitor resuscitation goals
Conclusion
• Polytrauma
– Scene safety, A…B…C…
• Calculate fluid requirements
– then watch clinical response
• Over-resuscitation – BAD
• Under-resuscitation – BAD
• Prophylactic IV/PO antibiotics – Bad
• Topical antibiotics – Good > 12 hrs
• Remember:
– Early intubation
– Escharotomy – Chest wall and extremities
– Fasciotomy – If escharotomy fails to restore
circulation
• Resuscitation Guidelines
Acknowledgments
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Walter Ingram, MD (Chief Grady Burn Unit)
Richard Jennings, MD
Shannan Moynihan, MD
Jim Cushman, MD
Melinda Hailey, RN
Julie Wells, RN
Bob Patlach
Chris Robinson (Global Rescue)
Warren Dorlac, MD (USAF/CSTARS)