BURNS
Initial Evaluation & Management
Christopher P. Brandt M.D.
Associate Professor of Surgery
Case Western Reserve University
Joseph B.
 Your patient is brought to the E.D. by the
EMS service.
 He is a 14 year-old male who was involved
in a house fire
History
What other points of history do you
want to know?
History, Joseph B.
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Neighbors heard an explosion
Patient found confused, outside of the house
Cannot remember what occurred
Denies shortness of breath
Transport time of twenty minutes
PMH of ADHD
Tetanus – up to date
Physical Examination
What would you look for?
Physical Examination
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VS T=96.5
P=140 R=24 BP=90/60
Awake; No hoarseness or stridor
Soot in mouth
Clear breath sounds
Burns involving face, neck, trunk, arms and
upper legs (see photos)
 Doppler pulses in all extremities
Physical Examination
 How do you determine the extent and
depth of the burn injuries?
 What findings suggest inhalation
injury?
Extent of burn
% total body
surface area
1
8
Burn Depth
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Color
Moistness
Capillary refill/Blanching
Sensation
Blistering
Superficial Second Degree
Deeper second degree
Third Degree
Inhalation injury
Indicators
 Occurred in closed space
 Cough, dyspnea, wheezing, hoarseness,
stridor
 Facial burns / Singed facial hair
 Carbonaceous sputum
 Hypoxia
Labs
What would you obtain?
Lab Results
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CBC - WBC-12.0 Hct-49%
Electrolytes -Na-147 Cl-100 K-4.5 BUN-12
ABG - 7.31/35/125 on 50%VM
Carboxyhemoglobin- 21%
Tox. Screen - Negative
U/A - Normal
Interventions at this point?
Interventions at this point?
Assess airway; Intubation ?
Oxygen
Fluid resuscitation
Foley Catheter
NG tube
Wound care
Pain medication
Interventions
Why is fluid resuscitation important?
How do you estimate fluid requirements?
How do you monitor response to initial fluid
therapy?
What complications can occur from over- or
under- resuscitation?
Fluid Management
Edema formation
 Systemic inflammatory response
 Capillary leak/ Increased vascular permeability
 Loss of skin barrier
Zones of injury
Parkland formula
 Crystalloid 4 x %TBSA x wt (kg)
 ½ of total in first eight hours
 Goal of ½ - 1 cc/kg/hr U.O.
Studies
What further studies/tests would you
want at this time?
Studies
 CXR – Basilar atelectasis
 EKG – Sinus tachycardia
 ? Bronchoscopy
Management
What would you do in the following scenarios?
 Low urine output
 Loss of Doppler signals in the hands
 Inadequate ventilation with high airway
pressures?
Management
Escharotomy
Management
 What are the principles of management of
the inhalation injury?
 What will be the basic strategies for
management of the burn wounds?
Questions?
Acknowledgment
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