Thermal Injury Trauma Debriefing Notes
1. Recognize and Respond Appropriately to a Patient with Inhalational and Thermal Injuries
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Inhalational Injury Overview
o Occurs in 20% in burn patients
o 60% in burn patients with central facial burns
o High mortality
Why Is It Bad?
o Heat and thermal injury to oropharyngeal area and lower airway
o Particulates
o Toxins (CO and CN)
o Irritants (ammonia, HCl, oxides of nitrogen, phosgene and aldehydes)
 Direct tissue injury
 Acute bronchospasm
 Activation of inflammatory cascade
 Free O2 radical and proteolytic enzymes
 Mucosal damage
 Bronchitis
 Mucus plugging
 Pulmonary edema
 SIRS/ARDS
o Asphyxiation
 Hypoxemia from low FiO2 in a fire
 Tissue hypoxia from CO causes dec myocardial contractility
 CN poisoning causes lactic acidosis
 MetHb: heat denaturation of Hb, results in decreased O2 carrying capacity
Clinical Features
o Voice changes/hoarseness
o Burns in face, especially around mouth/nose
o Singed nasal hair, deposits, carbonaceous sputum
o Airway soot, charring, mucosal erythema/edema/blisters
o Respiratory distress: hypoxia, inc A-a gradient, stridor, wheeze, tachypnea, dyspnea
o Cherry red lips if high CO
o Cherry red skin, bitter almond odor if high CN
o CO and CN toxicity: lactic acidosis, confusion, hypotension
Work-up
o CXR: atelectasis, pulmonary edema, pneumonia
o ABG
Treatment (see below)
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Major Burn Overview
o Definition of “major burn” varies
 Burns requiring fluid resuscitation, or those with an inhalational component
o Approach is the same as any other type of major trauma, the ABCDE’s
o A – Airway
 Don’t forget C-spine immobilization
 Burns are a major distracting injury and patients with burns are at risk of c-spine
injuries e.g. jumping from burning building, explosions, and lightning strikes.
 Assess for evidence of airway burns: singed facial hair, soot in the nose or
mouth, stridor, voice change
 Assess for evidence of neck burns / swelling that might impede airway
 Consider early intubation if evidence of airway compromise
o B-Breathing
 All burn patients should receive high flow oxygen 15L/min via non-rebreather
mask
 Assess for the presence of constrictive chest wall burns
 Assess for presence of toxic gas inhalation particularly CO and CN toxicity
o C-Circulation
 Place IV’s through unburnt skin where possible
 Assess for circumferential burns to limbs
 Shock due to burns is uncommon in the early phase and if present other causes
should be considered e.g. tension pneumothorax, abdominal injury, spinal injury
etc.
o D-Disability
 Remember hypoxia and toxic gas inhalation can result in altered mental status
o E-Exposure
 Caution with risk of hypothermia especially in children
 Remove jewelry and burnt / wet clothes
**The presence of circumferential burns to limbs or the chest may result in mechanical compromise
leading to limb ischemia or difficulty in ventilation. In these scenarios an escharotomy may be indicated.
Early discussion with a burn unit is advised if an escharotomy may be indicated.**
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Major Burn Assessment: two-part process consisting of:
o Estimating Total Body Surface Area (TBSA) % of Burn and estimating Depth of Burn
o Options for calculating burn area include:
 Palmar Surface: The patient‘s palmar surface, palm and fingers, is
approximately 1% of their TBSA. This can be used to estimate the size of smaller
burns or used to measure unburnt skin in large burns
 Rule of Nines: Divides the body into 11 areas each of 9% TBSA, and the
perineum ~1%. Allows quick assessment in the Adult burns patient. An
example of an Adult Rule of Nines chart can be found here
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Lund & Browder Chart: Most accurate measure tool. Difficult and time
consuming if not familiar. Works for both adults and children. Examples can be
found here
o Burn depth can be divided into five groups:
 Epidermal
 Superficial dermal
 Mid dermal
 Deep dermal
 Full thickness
 Description, pictures and poster of the various burn depths can be found here.
Treatment of Burns:
o Airway
 If acutely compromised, then RSI, smaller ETT +/- surgical airway
 If not compromised, then nasal endoscopy; low threshold for elective intubation
 Leave tube uncute, tie tube firmly (wire to teeth)
 Elevate head (decreases edema)
o Breathing
 High flow O2 for 6 hours and until CO levels return to normal
 Bronchospasm: B2 agonists, humidification
 Aggressive pulmonary toilet
o Circulation
 Use of resuscitation fluids is recommended if:
 Adult:
> 15 – 20% Total BSA
 Children:
> 10% Total BSA
 Fluid resuscitation may be required include:
 Electrical burns
 Coexistent traumatic injuries
 Delayed presentation
 Inhalation injury
 Estimation of fluid requirement can be made using the Parkland or Modified
Parkland Formula. These formulas estimates the amount of fluid required for
the first 24 hours post burn.
 Parkland Formula:
 Initial 24 hours: Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults
and 3 ml/kg/% burn for children. RL solution is added for maintenance
for children:
 4 ml/kg/hour for children weighing 0–10 kg
 40 ml/hour +2 ml/hour for children weighing 10–20 kg
 60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higher
 This formula recommends no colloid in the initial 24 hours.
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Next 24 hours: Colloids given as 20–60% of calculated plasma volume.
No crystalloids. Glucose in water is added in amounts required to
maintain a urinary output of 0.5–1 ml/hour in adults and 1 ml/hour in
children.
Modified Parkland Formula
 Total Fluid Estimation for first 24 hours post burn = 3 – 4mls x TBSA %
Burn x Weight (kg)
 1/2 Total Fluid Volume to be given in first 8 hours
 1/2 Total Fluid Volume to be given over next 16 hours
 LR is the first line fluid for burns
 Timeframe for resuscitation of the initial 8 hour period, and subsequent
16 hour period is taken from the time of the burn, NOT the time of
presentation.
All burn patients requiring resuscitation fluids should have a urinary catheter
placed to allow titration of fluids as the formula provides only an estimate. Aim
for 0.5 ml/kg/hr in adults and 1 ml/kg/hr in children.
Any patient who requires burns resuscitation fluids early discussion with burn
center is advised for clarification on local policy and preferences.
Additional treatment includes the removal of jewelry, wet clothes (scalds), or hot clothing. If
clothing is stuck to the patient leave it.
Cooling can be considered using cool running water for 20 minutes; this can be effective up to 3
hours following a burn. In larger burns (>10 TBSA %) and pediatric burns there is a risk of
hypothermia from cooling measures and early advice from a burn centre on first aid measures is
advised.
Choice of dressings for a large burn will depend on local policy, and resources. Early discussion
with regional burns unit is advised for advice on local policy and preferences.
Clean wounds with mild soap and water. Topical antibiotics are applied to all nonsuperficial
burns. If the patient is immediately transferred to a burn center, burns are covered with clean,
dry dressings and antibiotics are applied at the burn center. There is no role for prophylactic IV
antibiotics.
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Pain control is achieved with opioids. Benzos may be used for treatment of anxiety.
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All patients should receive tetanus prophylaxis.
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Coordination with burn team should begin immediately. See table below for indications for
transfer to a burn center.
2. Appropriately Treat Carbon Monoxide and Cyanide Toxicities.
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CO Toxicity
o History: duration/mechanism of exposure, LOC, confusion, chest pain, HA, N/V
o PE: MSE, PE usually wnl.
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Evaluation: check CO level with co-oximetry of arterial or venous blood gas; assess acidbase status, EKG, cardiac enzymes if risk factors, consider head CT if MS changes,
consider CN toxicity
o Treatment: secure airway (RSI as indicated); high flow O2 regardless of pulse ox or
arterial pO2, consider hyperbaric O2 tx if CO level > 25% , LOC, severe metabolic acidosis
(pH<7.1), end organ ischemia (CP, EKG changes, MS changes)
CN Toxicity
o CN is rapidly lethal unless pt given antidote
o History: ALL burn victims at risk; HA, MS changes, abdominal pain
o Physical: hypertension/tachycardia/tachypnea early then CV collapse; cherry red skin;
seizures
o Evaluation: standard tox labs, check for anion gap with elevated lactate and ABG,
carboxyhemoglobin and methemoglobin levels, assess for renal, hepatic failure, and
rhabdomyolysis.
o Treatment: secure airway (RSI usually required); administer high flow O2; do NOT give
mouth to mouth if suspect CN toxicity; call poison control.
o Give antidote:
 If cyanide toxicity is known or strongly suspected:
 Sodium nitrite 10mg/kg up to 300mg slow IV infusion, may repeat once
 Sodium thiosulfate (25%) 1.65 ml/kg up to 50 ml IV, may repeat once
 If cyanide toxicity is possible but not certain or pt has contraindication to
nitrites:
 Sodium thiosulfate (25%) 1.65 ml/kg up to 50 ml IV, may repeat once
3. Calculate and Initiate Appropriate Fluid Resuscitation for a Patient with Thermal Injuries.
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See above.
4. Additional Resources:
American Burn Association Burn Injury Severity Grading System
Minor burn
15 percent TBSA or less in adults
10 percent TBSA or less in children and the elderly
2 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes, ear, face, hands, feet, or
perineum
Moderate burn
15-25 percent TBSA in adults with less than 10 percent full-thickness burn
10-20 percent TBSA partial-thickness burn in children under 10 and adults over 40 years of age with less than 10 percent full-thickness
burn
10 percent TBSA or less full-thickness burn in children or adults without cosmetic or functional risk to eyes, ears, face, hands, feet, or
perineum
Major burn
25 percent TBSA or greater
20 percent TBSA or greater in children under 10 and adults over 40 years of age
10 percent TBSA or greater full-thickness burn
All burns involving eyes, ears, face, hands, feet, or perineum that are likely to result in cosmetic or functional impairment
All high-voltage electrical burns
All burn injury complicated by major trauma or inhalation injury
All poor-risk patients with burn injury
TBSA: total body surface area; burn: partial or full-thickness; young or old: <10 or >50 years old; adults: >10 or <50 years old.
http://www.mdcalc.com/parkland-formula-for-burns/
American Burn Association Burn Center Referral Criteria
Any patient with burns and concomitant trauma (e.g., fractures) in whom the burn injury poses the greatest risk of
morbidity or death
Burns in children at hospitals without qualified personnel or equipment for the care of children
Burns in patients who will require special social, emotional, or rehabilitative intervention
Burns in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect
mortality
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Chemical burns
Electrical burns, including lightning injury
Inhalation injury
Partial-thickness burns on more than 10 percent of the total body surface area
Third-degree (full-thickness) burns in any age group
References and Links
1. Rice PL, Orgill DP. Emergency care of moderate and severe thermal burns in adults. In:
UpToDate, Hockberger RS, Moreira ME (Ed), UpToDate, Waltham, MA, 2012.
2. Mandell J, Hales CA. Smoke inhalation. In: UpToDate, Hockberger RS, Moreira ME (Ed),
UpToDate, Waltham, MA, 2012.
3. Nickson C. “Trauma! Major burns.” Weblog entry. Life in the Fastlane Blog.
http://lifeinthefastlane.com/2012/09/trauma-tribulation-032/
4. Nickson C. “Smoking is deadly.” Weblog entry. Life in the Fastlane Blog.
http://lifeinthefastlane.com/2010/09/toxicology-conundrum-038/
5. American College of Surgeons. ATLS Textbook, 9th Edition. 1 September 2012.