burns & escharotomy by don hudson, d.o. facep/acoep lifeflight medical director
TRANSCRIPT
Burns & EscharotomyBurns & Escharotomy
ByBy
Don Hudson, D.O. Don Hudson, D.O. FACEP/ACOEPFACEP/ACOEP
LifeFlight Medical DirectorLifeFlight Medical Director
BurnsBurns
In the USA over 2.2 million/year In the USA over 2.2 million/year
Major burns have a significant risk of Major burns have a significant risk of morbidity & death.morbidity & death.
The pre-hospital care is a major The pre-hospital care is a major contributor to patients final out come.contributor to patients final out come.
BurnsBurns
The skin is the largest organ in the bodyThe skin is the largest organ in the body
It provides Thermal regulation & It provides Thermal regulation & prevention of fluid loss by evaporation.prevention of fluid loss by evaporation.
Hermetic barrier to infection.Hermetic barrier to infection.
Contains sensory receptors that provide Contains sensory receptors that provide information about the environment.information about the environment.
Skin AnatomySkin Anatomy
The skin is divided into 3 layersThe skin is divided into 3 layers
Epidermis- outer layer of cornified Epidermis- outer layer of cornified epithelial cells.epithelial cells.
Dermis- the middle layer, mostly Dermis- the middle layer, mostly connective tissue. Contains capillaries, connective tissue. Contains capillaries, nerve endings, & hair follicles.nerve endings, & hair follicles.
Hypodermis- a layer of fat & connective Hypodermis- a layer of fat & connective tissue between skin & underlying tissuetissue between skin & underlying tissue
Approach to Burn PatientApproach to Burn Patient
AgeAge
HistoryHistory
Duration of exposureDuration of exposure
Type of fireType of fire
Tetanus statusTetanus status
Consider Abuse in pediatricsConsider Abuse in pediatrics
Determine depth, type & extent of injuryDetermine depth, type & extent of injury
Important PointsImportant Points
AA- Allergies- Allergies
MM- Medications even OTC- Medications even OTC
PP- Past medical Hx/previous illness- Past medical Hx/previous illness
LL- Last meal or fluids consumed- Last meal or fluids consumed
EE- Events leading up to injury/Hx present- Events leading up to injury/Hx present
illness illness
Burn PatientsBurn Patients
Burn patients need lots of medical skillBurn patients need lots of medical skill
You must identify the amount of burnYou must identify the amount of burn
You must define degree of burnYou must define degree of burn
You must identify associated injuriesYou must identify associated injuries
You must establish events preceding the You must establish events preceding the injuryinjury
Establish basic care firstEstablish basic care first
TreatmentTreatment
Airway- establish earlyAirway- establish early
Fluids- Two (2) big bore IV’sFluids- Two (2) big bore IV’s
Consider Foley for fluid managementConsider Foley for fluid management
Protect from further injuryProtect from further injury
ConsultConsult
Notify dispatch of findingsNotify dispatch of findings
Arrange appropriate referral &/or treatmentArrange appropriate referral &/or treatment
Studies NeededStudies Needed
CBS & Chemistry profileCBS & Chemistry profileABGABGCO levelCO levelCoagulation profileCoagulation profileUAUAType & screenType & screenCPK & urine myoglobin (especially in electrical CPK & urine myoglobin (especially in electrical injuries)injuries)CXRCXR
FluidsFluids
(4 ml crystalloid) X (% BSA burn) X (body wt in Kg)(4 ml crystalloid) X (% BSA burn) X (body wt in Kg)
Ex a man weighting 70 Kg with 30% BSA would Ex a man weighting 70 Kg with 30% BSA would require (30) X (4ml) X 70 = 8400 ml in 1require (30) X (4ml) X 70 = 8400 ml in 1stst 24 hr. 24 hr.
Half of the fluid is given in the first 8 hr. with the Half of the fluid is given in the first 8 hr. with the balance given in the next 16 hr.balance given in the next 16 hr.
Maintain urine output at 1 ml/kg/hourMaintain urine output at 1 ml/kg/hour
EscharotomyEscharotomyNeeded when there is a full thickness burn Needed when there is a full thickness burn involving the extremities or chest.involving the extremities or chest.
The eschar acts like a tourniquet.The eschar acts like a tourniquet.
Edema forming in the middle layer pushes Edema forming in the middle layer pushes out ward & the eschar restricts further out ward & the eschar restricts further motion.motion.
This compromises the vascular flowThis compromises the vascular flow
ProcedureProcedurePerform along lateral aspect of extremityPerform along lateral aspect of extremity
Incision should go completely through the Incision should go completely through the eschar.eschar.
Be prepared for the subq fat to bubble up Be prepared for the subq fat to bubble up through the incisionthrough the incision
Once the incision is made some bleeding Once the incision is made some bleeding will occur.will occur.
ProcedureProcedureDo not forget chest, it may also need a Do not forget chest, it may also need a procedureprocedure
Don’t forget Don’t forget PAIN MEDSPAIN MEDSDon’t forget, clean, bandage, Universal Don’t forget, clean, bandage, Universal Precautions about blood products & Precautions about blood products & potential for hypothermiapotential for hypothermia
REMEMBERREMEMBERBe earlyBe earlyBe aggressive in TxBe aggressive in TxAirway ControlAirway ControlIV’s, adequate fluidsIV’s, adequate fluidsFoleyFoleyConsider other injuriesConsider other injuriesSplintsSplintsEscharotomyEscharotomyTemperature controlTemperature control