burn resuscitation · 2019-05-15 · burn resuscitation burn injuries: the problem 2002 burns...

BURN RESUSCITATIONBURN RESUSCITATION


Burn Injuries: The ProblemBurn Injuries: The Problem

2002 burns responsible for 322,000 deaths world 2002 burns responsible for 322,000 deaths world widewide

44thth as cause of unintentional child injury death in as cause of unintentional child injury death in the USAthe USA

33rdrd leading cause of unintentional death in leading cause of unintentional death in aboriginal community in NAaboriginal community in NA

Most burns occur in the urban environmentMost burns occur in the urban environment

adverse consequences more common in the rural adverse consequences more common in the rural environment environment


EARLY ACUTE CARE IMPACTS THE EARLY ACUTE CARE IMPACTS THE LONG TERM OUTCOME IN BURN LONG TERM OUTCOME IN BURN PATIENTSPATIENTS

MOST INITIAL CARE IS PROVIDED MOST INITIAL CARE IS PROVIDED OUTSIDE THE BURN CENTREOUTSIDE THE BURN CENTRE


Burn resuscitation begins at the sceneBurn resuscitation begins at the scene

Stop the burning processStop the burning processKeep the patient warmKeep the patient warmO2O2Assess for other injuriesAssess for other injuriesSmall burns ( partial thickness) < 10% can Small burns ( partial thickness) < 10% can

be cooledbe cooled


On arrival at hospitalOn arrival at hospital

History of the injuryHistory of the injuryPast medical historyPast medical historyMedicationsMedicationsAllergiesAllergiesLocation, depth and Location, depth and

size of the burnsize of the burn

ABCABC’’SS

AIRWAY INJURYAIRWAY INJURY Present in 10 Present in 10 –– 20 % of 20 % of burn patientsburn patients

Identified in 60 Identified in 60 –– 70 % 70 % of patients who die in of patients who die in burn centersburn centers

RISK FACTORS:RISK FACTORS:Extremes of ageExtremes of agePhysical disabilityPhysical disabilityChemically impairedChemically impairedLoss of consciousnessLoss of consciousnessLarge BSA burnLarge BSA burn


Often present without Often present without burn injuryburn injury

Potential early Potential early problem due to problem due to edema edema

BURNBURN RESUSCITATIONRESUSCITATION


Carbon monoxide poisoningCarbon monoxide poisoning

Awake:Awake:Hi flow O2Hi flow O2Until Until COHgbCOHgb < 5%< 5%

Obtunded:Obtunded:IntubateIntubate & provide & provide

100% O2 via 100% O2 via ventilatorventilator


StridorStridor or Respiratory Distress &/OR Deep burns or Respiratory Distress &/OR Deep burns of the head & neckof the head & neck

If AbsentIf Absent::

100% O2100% O2Look for signs of airway Look for signs of airway InjuryInjury? ? LaryngocoscopyLaryngocoscopyIf edema present If edema present INTUBATE NOWINTUBATE NOW


Upper Airway ManagementUpper Airway Management

StridorStridor or Respiratory Distress &/OR Deep burns of the or Respiratory Distress &/OR Deep burns of the head & neckhead & neck

If presentIf present::

INTUBATE NOW !!INTUBATE NOW !!Ideally before excessive edema developsIdeally before excessive edema develops

Adequate tube size and lengthAdequate tube size and lengthPEEPPEEPElevate HOBElevate HOBTransfer to Burn CenterTransfer to Burn Center


Management of Lower Airway InjuryManagement of Lower Airway Injury

Asymptomatic: Asymptomatic: no treatmentno treatment

Symptomatic:Symptomatic:Cough, Wheeze, Good Gas Exchange, Cough, Wheeze, Good Gas Exchange, BronchorreheaBronchorrehea

100% O2, aggressive pulmonary toilet, 100% O2, aggressive pulmonary toilet, bronchodilators, monitor O2bronchodilators, monitor O2CONTINUED REASSESSMENTCONTINUED REASSESSMENT


Management of Lower Airway:Management of Lower Airway:

Symptomatic:Symptomatic:

Short of breath, progressive symptomsShort of breath, progressive symptomsimpaired gas exchangeimpaired gas exchange

IntubateIntubate, 100% O2 (maintain Sat > 92%), 100% O2 (maintain Sat > 92%)Baseline CXR, bronchodilatorsBaseline CXR, bronchodilatorschest wall chest wall escharotomyescharotomy if indicatedif indicated

AS INJURY / RESUSCITATION EVOLVES AS INJURY / RESUSCITATION EVOLVES MODIFICATIONS WILL BE NECESSARY!!!MODIFICATIONS WILL BE NECESSARY!!!


Burn Depth:Burn Depth:


Burn Depth:Burn Depth:Visually deceiving burnsVisually deceiving burnsDestroyed epidermis still remains on the Destroyed epidermis still remains on the

woundwoundExtent/depth of injury is underestimated Extent/depth of injury is underestimated

unless removedunless removed


Burn DepthBurn DepthAll burns All burns ““progressprogress”” over the first 24 over the first 24 –– 36 36 hourshours

As a result all burns will appear to worsen As a result all burns will appear to worsen over the 1over the 1stst day or 2day or 2


Burn Shock:Burn Shock:outcome of a multiple factors including outcome of a multiple factors including hypovolemiahypovolemia, microcirculation changes, , microcirculation changes, and release of local and systemic and release of local and systemic inflammatory mediators which result in the inflammatory mediators which result in the bodybody’’s ability to meet cellular needss ability to meet cellular needs

The mainstay of treatment is fluid The mainstay of treatment is fluid resuscitationresuscitation


FLUID RESUSCITATION:FLUID RESUSCITATION:Rule of NinesRule of Ninesquick and easy method to estimate BSA burnedquick and easy method to estimate BSA burned

*most people forget*most people forgetthe differences the differences adult and infantadult and infant

* most burn sizes are * most burn sizes are GROSSLY over estimatedGROSSLY over estimated


FLUID RESUSCITATION:FLUID RESUSCITATION:Lund Lund BowderBowder ChartChartmore complicatedmore complicatedand time consuming and time consuming method to estimate method to estimate BSA burnedBSA burned

BUT MORE BUT MORE ACCURATE!!ACCURATE!!


Parkland (Baxter) Formula:Parkland (Baxter) Formula:most commonly used formula todaymost commonly used formula today

4cc/Kg/%BSA burn4cc/Kg/%BSA burn1/2in the first 8 hrs1/2in the first 8 hrs½½ in the next 16 hrsin the next 16 hrs

Lactated RingersLactated RingersUsing urine output as a clinical guideUsing urine output as a clinical guide

GOAL: 30GOAL: 30--50 cc50 cc’’s /hrs /hr1cc/kg in patients less than 30 1cc/kg in patients less than 30 kgskgs

Accurate in about Accurate in about 70%70% burn patientsburn patients12%12% require morerequire more, 18%, 18% require lessrequire less

Plasma can be given at any time but is most effective after Plasma can be given at any time but is most effective after 24 24 –– 36 hrs36 hrs

Can be of benefit in patients who do not respond to initial Can be of benefit in patients who do not respond to initial predicted fluid needspredicted fluid needs


Not all burn patients require INTRAVENOUSNot all burn patients require INTRAVENOUSfluid resuscitationfluid resuscitation

LESS THAN 10 LESS THAN 10 –– 15 %15 %if patient cooperative, no nausea and if patient cooperative, no nausea and vomitingvomitingDO NOTDO NOT allow unrestricted access to plain allow unrestricted access to plain water, especially in childrenwater, especially in children


New Problem: New Problem: FLUID CREEPFLUID CREEPPatients frequently receive fluid in excess Patients frequently receive fluid in excess of the predicted requirements!!of the predicted requirements!!

up to 48% MORE !!up to 48% MORE !!Problems: compartment syndrome Problems: compartment syndrome

(extremity & (extremity & abdabd.).)ARDS / pulmonary edemaARDS / pulmonary edemacerebral edemacerebral edemamultiple organ failuremultiple organ failure


Most burn resuscitation fails to meet the standard Most burn resuscitation fails to meet the standard set forth by the set forth by the PARKLAND PARKLAND formulaformula

Emphasis needs to be placed onEmphasis needs to be placed on MONITORINGMONITORING the response to fluid resuscitation rather than the response to fluid resuscitation rather than following the formulafollowing the formula

Best monitor is Best monitor is URINE OUTPUTURINE OUTPUT1 ml/kg/hr 1 ml/kg/hr CBC CBC –– hemoconcentrationhemoconcentrationABGABG’’ss -- acidosisacidosis


Other monitoringOther monitoring::Pulse Pulse -- young patient young patient -- < 120 reasonable< 120 reasonable

> 130 fluid> 130 fluid-- elderly / heart disease elderly / heart disease -- pulse not apulse not a

good reflection of perfusiongood reflection of perfusionECG ECG -- > 40 > 40 yoyoBlood pressure Blood pressure –– only useful if lowonly useful if lowElectrolytesElectrolytesPTT / INRPTT / INRProtein / AlbuminProtein / AlbuminCVP / Central pressures only if patient not CVP / Central pressures only if patient not

responding to predicted requirementsresponding to predicted requirements


RISK FACTORS FOR REQUIRING INCREASED RISK FACTORS FOR REQUIRING INCREASED RESUSCITATION FLUID VOLUMESRESUSCITATION FLUID VOLUMES

80% BSA burn80% BSA burn

Extremes of ageExtremes of age

Electrical injury Electrical injury –– current flowcurrent flow

Associated inhalation injuryAssociated inhalation injury

Associated traumaAssociated trauma

Delayed resuscitationDelayed resuscitation

MyoglobinuriaMyoglobinuria


MyoglobinuriaMyoglobinuria

If present requires increased volumes to flush the If present requires increased volumes to flush the pigment form the systempigment form the system

If persists > 12 hours risk of renal failureIf persists > 12 hours risk of renal failureu/ou/o of 100 of 100 –– 200 cc200 cc’’s /hours /hourAlkalinize the urineAlkalinize the urineUse Use manitolmanitol to force to force diuresisdiuresisMay need to use central pressure monitoring to May need to use central pressure monitoring to

assess response to fluids as urine output no assess response to fluids as urine output no longer usefullonger useful


Management of the burn wound:Management of the burn wound:

Tetanus Tetanus ProphlaxisProphlaxisAnalgesiaAnalgesiaDebrideDebride the woundthe wound

chlorhexidinechlorhexidine, hydrotherapy, hydrotherapyTopical antibiotics Topical antibiotics -- ointmentsointments

-- flamazineflamazine creamcreamConsider closed dressings except for the face & perineumConsider closed dressings except for the face & perineum

Dressings protect the injured skin, reduce heat loss & provDressings protect the injured skin, reduce heat loss & provide ide comfortcomfort

NEW OPTIONS:NEW OPTIONS:silver containing dressingssilver containing dressingsacticoatacticoataquacelaquacel AgAg

IF IN DOUBT STERILE NONIF IN DOUBT STERILE NON--ADHERENT DRESSING LIKE JELONET ADHERENT DRESSING LIKE JELONET OR ADAPTIC UNTIL DEFINITIVE DEPTH CAN BE DETERMINED!OR ADAPTIC UNTIL DEFINITIVE DEPTH CAN BE DETERMINED!

THINGS WE CAN DO BETTER!THINGS WE CAN DO BETTER!

ASSESSMENT OF AIRWAYASSESSMENT OF AIRWAYACCURATE ASSESSMENT OF BSA ACCURATE ASSESSMENT OF BSA

BURNSBURNSACCURATE ASSESSMENT OF BURN ACCURATE ASSESSMENT OF BURN

DEPTHDEPTHMORE CAREFUL MONITORING OF THE MORE CAREFUL MONITORING OF THE

RESPONSE TO FLUIDS ADMINISTEREDRESPONSE TO FLUIDS ADMINISTERED

THANK YOUTHANK YOU

QUESTIONS ????QUESTIONS ????


Burn Depth:Burn Depth:


Burn Shock:Burn Shock:Circulatory collapse when blood pressure Circulatory collapse when blood pressure is too low to maintain tissue perfusionis too low to maintain tissue perfusion

The magnitude of intravascular fluidThe magnitude of intravascular fluidloss can be easily underestimated loss can be easily underestimated much of the fluid accumulates beneath much of the fluid accumulates beneath the burnthe burn


Burn Resuscitation & Cholera??Burn Resuscitation & Cholera??

Dr. ODr. O’’Shaughnessy 1831 analyzed cholera Shaughnessy 1831 analyzed cholera patients noting diarrhea leads to dehydration, patients noting diarrhea leads to dehydration, electrolyte depletion, acidosis and Nitrogen electrolyte depletion, acidosis and Nitrogen retention retention

Treatment depended on IV Treatment depended on IV fluiidfluiid replacement of replacement of deficient salt and waterdeficient salt and water

1854 Ludwig von Buhl correlated the 1854 Ludwig von Buhl correlated the hemoconcentrationhemoconcentration seen in both burns and seen in both burns and cholera patients due to fluid losscholera patients due to fluid loss

ReccomendedReccomended saline either orally, saline either orally, subcutaneoulysubcutaneouly or intravenouslyor intravenously


Burns and the Theatre??Burns and the Theatre??

Dr. Frank Dr. Frank UnderhilUnderhil: The Rialto Theatre fire 1921 New : The Rialto Theatre fire 1921 New Haven Conn. Rudolph Valentino in the Haven Conn. Rudolph Valentino in the ShiekShiek

Showed blister fluid was similar to plasmaShowed blister fluid was similar to plasmaConcluded burn shock was due to fluid shiftsConcluded burn shock was due to fluid shiftsRecommended replacement of fluid with salt and protein Recommended replacement of fluid with salt and protein

using using HgbHgb as a guideas a guide

Coconut Grove Fire Boston Mass. 1942 Drs. Cope & Coconut Grove Fire Boston Mass. 1942 Drs. Cope & Moore Moore

patients treated with IV fluid resuscitation based on body patients treated with IV fluid resuscitation based on body surface area surface area

Monitored Monitored HctHct, U/O, BUN, U/O, BUNPatients with inhalation injury required more fluidPatients with inhalation injury required more fluidBUDGET FORMULA resuscitation was not based on BUDGET FORMULA resuscitation was not based on

patient sizepatient size

burn resuscitation · 2019-05-15 · burn resuscitation burn injuries: the problem 2002 burns...

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