john cheng, md pem fellows’ conference emory university school of medicine december 15, 2005

John Cheng, MDJohn Cheng, MD

PEM Fellows’ ConferencePEM Fellows’ Conference

Emory University School of MedicineEmory University School of Medicine

December 15, 2005December 15, 2005

FLAME ON !!

FLAME FLAME OFFOFF!!

John Cheng, MDJohn Cheng, MD

PEM Fellows’ ConferencePEM Fellows’ Conference

Emory University School of Emory University School of MedicineMedicine

December 15, 2005December 15, 2005

HEY!

ObjectivesObjectives

Burn classification Burn classification Causes of burns Causes of burns Treatment regimens Treatment regimens Complications Complications

EpidemiologyEpidemiology((from http://www.ameriburn.org/pub/BurnIncidenceFactSheet)from http://www.ameriburn.org/pub/BurnIncidenceFactSheet)

More than 1 million burn injuries per year More than 1 million burn injuries per year 4,500 fire and burn deaths per year 4,500 fire and burn deaths per year 45,000 hospitalizations per year45,000 hospitalizations per year

half to burn centers and half to other hospitalshalf to burn centers and half to other hospitals 700,000 annual emergency department 700,000 annual emergency department

visitsvisits

EpidemiologyEpidemiology

3rd leading cause of death in childhood3rd leading cause of death in childhood Morbidity is 3x mortalityMorbidity is 3x mortality >$1 billion/year in medical costs>$1 billion/year in medical costs 80% minor scalds, 3-5% life threatening80% minor scalds, 3-5% life threatening 13% flames and smoke inhalation, 2-3% 13% flames and smoke inhalation, 2-3%

electricity and chemicalelectricity and chemical Causes of burns vary with ageCauses of burns vary with age

Skin AnatomySkin Anatomy

Preserves body fluidsPreserves body fluids Temperature Temperature

regulationregulation Infection barrierInfection barrier

From Advances in Skin & Wound Care 2005, 18 (6): 323-332

Pre-Hospital Care of BurnsPre-Hospital Care of Burns

Stop the burnStop the burn Dissipate/cool the heatDissipate/cool the heat

DON’T…DON’T… Use ice or extreme coldUse ice or extreme cold Use other emollients, eg peanut butter, butter, Use other emollients, eg peanut butter, butter,

greasegrease

Superficial BurnsSuperficial Burns

1st degree burns1st degree burns Redness, mild Redness, mild

inflammationinflammation No significant edema No significant edema

and vesicleand vesicle PainfulPainful 3-5 days to heal, 3-5 days to heal,

usually without scarusually without scarFrom American Family Physician 2000, 62 (9): 2016

Superficial BurnSuperficial Burn

From American Family Physician 2000, 62 (9): 2016

Treatment for Superficial Treatment for Superficial BurnsBurns

Moisturize burn area Moisturize burn area with bland emollientswith bland emollients

Anti-pruriticsAnti-pruritics Pain relief: Tylenol, Pain relief: Tylenol,

NSAIDsNSAIDs Protect from sun for Protect from sun for

at least a yearat least a year

Superficial Partial Thickness Superficial Partial Thickness BurnBurn

Superficial 2nd Superficial 2nd degree burndegree burn

Pink-red, moistPink-red, moist Blisters and edemaBlisters and edema Painful with exposed Painful with exposed

nerve rootsnerve roots Heals in 2 weeks, Heals in 2 weeks,

with minimal scarwith minimal scar


Superficial Partial Thickness Superficial Partial Thickness BurnBurn


Treatment for Superficial Treatment for Superficial Partial Thickness BurnsPartial Thickness Burns

Clean with mild soap and water or 1/4 Clean with mild soap and water or 1/4 strength povidone-iodine or NSstrength povidone-iodine or NS

Wipe away dead tissueWipe away dead tissue Leave bullae alone, unless they are very Leave bullae alone, unless they are very

large or in an area where will burstlarge or in an area where will burst Petrolatum gauze if <2% BSAPetrolatum gauze if <2% BSA Topical antibioticsTopical antibiotics Change dressing BID and re-evaluate in 1-Change dressing BID and re-evaluate in 1-

2 days2 days

Superficial Partial Thickness Superficial Partial Thickness Burns: Other ConsiderationsBurns: Other Considerations

Clean technique for dressing changesClean technique for dressing changes Wash handsWash hands Clean the bathroom!Clean the bathroom!

Signs and symptoms of infectionSigns and symptoms of infection Hypertrophic scarringHypertrophic scarring

Massage (with moisturizer)Massage (with moisturizer) Pressure garment dressingsPressure garment dressings Silicone gel sheetsSilicone gel sheets

HyperpigmentationHyperpigmentation

From American Journal of Clinical Dermatology 2002, 3 (8): 533

Bacteria in BurnsBacteria in Burns

Gram + colonization Gram + colonization Gram - Gram - fungi fungi Signs of infection: increased redness, Signs of infection: increased redness,

pain, swelling to edges, exudate, fever, pain, swelling to edges, exudate, fever, deteriorating burn statusdeteriorating burn status

Cover for MRSA, Cover for MRSA, Pseudomonas, StrepPseudomonas, Strep No role for prophylactic antibioticsNo role for prophylactic antibiotics Td immunizationTd immunization

Topical AntibioticsTopical Antibiotics

Silver sulfadiazene (Silvadene) (1%)Silver sulfadiazene (Silvadene) (1%) Covers Gram - (Covers Gram - (E. coli, Enterobacter, E. coli, Enterobacter,

PseudomonasPseudomonas), Gram + (), Gram + (S. aureusS. aureus) and yeast) and yeast May interfere with wound-healing May interfere with wound-healing Adverse ReactionsAdverse Reactions: leukopenia, kernicterus: leukopenia, kernicterus DON’TDON’T use if have Sulfa allergy use if have Sulfa allergy DON’TDON’T use with preemies, <2 mo, or on use with preemies, <2 mo, or on

pregnant womenpregnant women

Topical Antibiotics (cont’d)Topical Antibiotics (cont’d)

Bacitracin ointmentBacitracin ointment Covers Gram + cocci and bacilli Covers Gram + cocci and bacilli Inhibits cell wall synthesis, stimulates PMNsInhibits cell wall synthesis, stimulates PMNs Rare reactionsRare reactions: hypersensitivity, rash (if used : hypersensitivity, rash (if used

on healed wounds)on healed wounds) Resistance rareResistance rare


Neomycin ointmentNeomycin ointment Covers Gram - (Covers Gram - (E. coli, EnterobacterE. coli, Enterobacter) and ) and

Gram + bacteriaGram + bacteria Inhibits replication (bind ribosomal subunit)Inhibits replication (bind ribosomal subunit) Rare reactionsRare reactions: hypersensitivity, ototoxicity, : hypersensitivity, ototoxicity,

nephrotoxicity (dose related)nephrotoxicity (dose related) Resistance rareResistance rare


Mafenide acetate (0.5%) creamMafenide acetate (0.5%) cream Methylated sulfonamideMethylated sulfonamide Bacteriostatic against Gram - and +, but not Bacteriostatic against Gram - and +, but not

yeastyeast May impair wound healingMay impair wound healing Penetrates areas with limited blood supply Penetrates areas with limited blood supply

well, eg eschars, earswell, eg eschars, ears Adverse reactionsAdverse reactions: metabolic acidosis: metabolic acidosis

HONEYHONEY

((American Journal of Clinical DermatologyAmerican Journal of Clinical Dermatology 2001, 2 (1): 13-19) 2001, 2 (1): 13-19)

Create layer so dressing doesn’t stickCreate layer so dressing doesn’t stick Moist environmentMoist environment Antibacterial (main ingredient, HAntibacterial (main ingredient, H22OO22))

Activates immune system (B/T cells, PMNs)Activates immune system (B/T cells, PMNs) Anti-inflammatoryAnti-inflammatory Stimulate angiogenesis, fibroblasts and epi cellsStimulate angiogenesis, fibroblasts and epi cells Debriding effectDebriding effect

Burn ZonesBurn Zones

CoagulationCoagulation StasisStasis HyperemiaHyperemia

From BMJ 2004, 328 (7453): 1427

Burn ZonesBurn Zones

From BMJ 2004, 328 (7453): 1427

Zone of coagulation

Zone of stasis

Zone of hyperemia

Deep Partial Thickness BurnsDeep Partial Thickness Burns

Deep 2nd degree burnDeep 2nd degree burn Pale, dry, speckled from Pale, dry, speckled from

thrombosed vesselsthrombosed vessels Less painful Less painful Can progress to full Can progress to full

thicknessthickness Heals in weeks, with scarHeals in weeks, with scar Often needs skin graftsOften needs skin grafts


Deep Partial Thickness BurnDeep Partial Thickness Burn


Full Thickness BurnFull Thickness Burn

3rd degree burn3rd degree burn Pale, charred, Pale, charred,

leatheryleathery Non-tender in area of Non-tender in area of

burnburn Heals from periphery, Heals from periphery,

needs skin graftneeds skin graft


Leathery SkinLeathery Skin

George Hamilton

Full Thickness burnFull Thickness burn

From American Family Physician 2000, 62 (9): 2017 From BMJ 2004, 329 (7457): 103

Treatment of Deep Partial Treatment of Deep Partial and Full Thickness Burns and Full Thickness Burns

Irrigate with sterile salineIrrigate with sterile saline Wipe away loose tissueWipe away loose tissue Cover loosely with clean sheetsCover loosely with clean sheets ABC’s, fluid resuscitation, monitor temperatureABC’s, fluid resuscitation, monitor temperature Early excision and grafting (autograft, allograft, Early excision and grafting (autograft, allograft,

xenograft, artificial skin), negative pressure xenograft, artificial skin), negative pressure dressingsdressings

Escharotomy, Doppler studiesEscharotomy, Doppler studies

EscharotomyEscharotomy

From BMJ 2004, 329 (7457): 102

From Advances in Skin & Wound Care 2003, 16 (4): 178-187

Admission FactorsAdmission Factors

Admit kids <2 y/o Admit kids <2 y/o Kids that family won’t be able to care for Kids that family won’t be able to care for

wounds at homewounds at home >10% BSA partial thickness burns, >10% BSA partial thickness burns,

consider burn center if >20% BSAconsider burn center if >20% BSA >2 % BSA full thickness burns>2 % BSA full thickness burns >1% BSA on face, perineum, hand, feet, >1% BSA on face, perineum, hand, feet,

across joints, or circumferential burnsacross joints, or circumferential burns Inhalational injury or associated traumaInhalational injury or associated trauma

Burn Center Criteria ChartBurn Center Criteria Chart

Burn Algorithm ExampleBurn Algorithm Example

From BMJ 2004, 329 (7458): 160

Case 1: The Roof Is On FireCase 1: The Roof Is On Fire

6 y/o boy is brought to 6 y/o boy is brought to you by EMS. He was you by EMS. He was in a house fire and in a house fire and caught on the second caught on the second floor. During the floor. During the rescue, he and the rescue, he and the fire fighter fell to the fire fighter fell to the first floor. They both first floor. They both reek of burned plastic.reek of burned plastic.

Case 1: ExamCase 1: Exam

T 38.5C HR 120 RR 38 BP 100/60 T 38.5C HR 120 RR 38 BP 100/60 SaO2 95% Wt 30 kgSaO2 95% Wt 30 kg General: crying, lying on stretcherGeneral: crying, lying on stretcher HEENT: burnt hair, oral mucosal erythema, black HEENT: burnt hair, oral mucosal erythema, black

sputumsputum CV: tachycardic, RRCV: tachycardic, RR Pulm: tachypneic, wheezes Pulm: tachypneic, wheezes Abdomen/Ext/Neuro: unremarkableAbdomen/Ext/Neuro: unremarkable Derm: burns noted to all extremities and trunkDerm: burns noted to all extremities and trunk

What would you like to do?

Labs and XRaysLabs and XRays

CBC: anemia, thrombocytopeniaCBC: anemia, thrombocytopenia CMP: renal function, electrolytes, albuminCMP: renal function, electrolytes, albumin CPK: rhabdomyolysisCPK: rhabdomyolysis T&ST&S PT/PTT: coagulopathyPT/PTT: coagulopathy Chest XR: evidence of inhalational injuryChest XR: evidence of inhalational injury

Estimation of Burn Surface Estimation of Burn Surface AreaArea

Wallace rule of 9’sWallace rule of 9’s NOT accurate in childrenNOT accurate in children

Palmar surface areaPalmar surface area Area of an adult palm, Area of an adult palm, including fingersincluding fingers, is 0.8% for , is 0.8% for

males and 0.7% for femalesmales and 0.7% for females Area of a pediatric palm, Area of a pediatric palm, including fingersincluding fingers, is 1%, is 1% May have to alter estimate if BMI > 31May have to alter estimate if BMI > 31

Lund and Browder chartLund and Browder chart

Wallace Rule of NinesWallace Rule of Nines

From BMJ 2004, 329 (7457): 101

Lund and Browder ChartLund and Browder Chart

From AACN Clinical Issues 2003, 14 (4): 429-441

Fluid CalculationsFluid Calculations

Parkland formulaParkland formula 4 mL/ kg/ %BSA (partial and full thickness burns)4 mL/ kg/ %BSA (partial and full thickness burns)

• 1/2 over first 8 hours, half over next 16 hours1/2 over first 8 hours, half over next 16 hours Add in maintenance fluids for <5 y/o Add in maintenance fluids for <5 y/o

Carvajal formulaCarvajal formula 5000 mL/ m5000 mL/ m22/ %BSA (partial and full thickness burns)/ %BSA (partial and full thickness burns)

• 1/2 over first 8 hours, half over next 16 hours1/2 over first 8 hours, half over next 16 hours 2000 mL/ m2000 mL/ m22/ day for maintenance/ day for maintenance

Galveston formulaGalveston formula 5000 mL/m5000 mL/m22 BSA + 1500 mL/m BSA + 1500 mL/m2 2 BSA (for BSA (for

maintenance) in first 24 hoursmaintenance) in first 24 hours

Fluid + Colloid CalculationsFluid + Colloid Calculations

Theory: if add back colloids, use less Theory: if add back colloids, use less crystalloid overallcrystalloid overall

Adding back colloids, eg albuminAdding back colloids, eg albumin Brooke Army formulaBrooke Army formula Evans formulaEvans formula Guegniaud et alGuegniaud et al

Sedation & AnalgesiaSedation & Analgesia

Hyperalgesic state Hyperalgesic state Lower thresholdsLower thresholds Exposed nerve rootsExposed nerve roots

Primary (injury site) vs secondary pain (injury Primary (injury site) vs secondary pain (injury and adjacent sites) and adjacent sites)

Hypermetabolic state, ergo altered Hypermetabolic state, ergo altered pharmacokineticspharmacokinetics

Background vs procedure-related painBackground vs procedure-related pain IV/IO is best route. Intranasal is an option.IV/IO is best route. Intranasal is an option.

Sedation & Analgesia (cont’d)Sedation & Analgesia (cont’d)

OpioidsOpioids: Morphine, Fentanyl, Oxycodone, : Morphine, Fentanyl, Oxycodone, Methadone, Remifentanil, AlfentanilMethadone, Remifentanil, Alfentanil

Opioid Agonist/AntagonistOpioid Agonist/Antagonist: Nubain, : Nubain, PentazocinePentazocine

BenzodiazepinesBenzodiazepines: Versed, Valium, Ativan: Versed, Valium, Ativan Dissociative drugsDissociative drugs: Ketamine: Ketamine Non-opioid analgesicsNon-opioid analgesics: NSAIDs, : NSAIDs,

Tramadol, TylenolTramadol, Tylenol

Sedation & Analgesia (cont’d)Sedation & Analgesia (cont’d)

GasesGases: Nitrous oxide, Sevoflurane: Nitrous oxide, Sevoflurane Sedative-HypnoticsSedative-Hypnotics: barbiturates, chloral hydrate: barbiturates, chloral hydrate NeurolepticsNeuroleptics: Haldol, Risperdol, Neurontin, : Haldol, Risperdol, Neurontin,

Zyprexa, Ziprasidone, ClonidineZyprexa, Ziprasidone, Clonidine StimulantsStimulants and and AntidepressantsAntidepressants: Ritalin, : Ritalin,

tricyclics (as adjuvants for pain control)tricyclics (as adjuvants for pain control) OtherOther: Etomidate, Propofol, Lidocaine, hypnosis, : Etomidate, Propofol, Lidocaine, hypnosis,

distraction, behavioral techniques, etc.distraction, behavioral techniques, etc.

Case 1: He’s getting more Case 1: He’s getting more agitatedagitated

HR 100s RR 44 BP 100/60 SaO2 97%HR 100s RR 44 BP 100/60 SaO2 97%

Upper airway disperses heatUpper airway disperses heat Damage to lower airway usually chemical: Damage to lower airway usually chemical:

cell and surfactant damage, inflammation cell and surfactant damage, inflammation (ARDS)(ARDS)

CXR of Smoke InhalationCXR of Smoke Inhalation

Inhalational InjuryInhalational Injury

Place on 100% O2Place on 100% O2 Check ABGCheck ABG

Acidosis, hypoxemia, hypercarbiaAcidosis, hypoxemia, hypercarbia Carboxyhemoglobin Carboxyhemoglobin

Intubate with RSIIntubate with RSI DON’T use succinylcholine!DON’T use succinylcholine! May need higher than usual doses of meds May need higher than usual doses of meds

Ventilate with high frequency, CPAPVentilate with high frequency, CPAP Frequent suctioningFrequent suctioning Consider bronchodilators (nebs or IV) Consider bronchodilators (nebs or IV) Consider heparin/acetylcystine nebsConsider heparin/acetylcystine nebs

Beware Facial BurnsBeware Facial Burns

From BMJ 2004, 328 (7455): 1555

Carbon Monoxide PoisoningCarbon Monoxide Poisoning

CO binds to hemoglobin and cytochromesCO binds to hemoglobin and cytochromes In non-smoker, carboxyHgb < 1%In non-smoker, carboxyHgb < 1% Causes metabolic acidosis through Causes metabolic acidosis through

hypoxia, possible cerebral edemahypoxia, possible cerebral edema ““Cherry red” skin colorCherry red” skin color Rhabdomyolysis from pressure Rhabdomyolysis from pressure ARF ARF Delayed neuropsychologic sequelae Delayed neuropsychologic sequelae

(DNS)(DNS)

CarboxyhemaglobinemiaCarboxyhemaglobinemia

0-10%: may impair judgment and fine motor 0-10%: may impair judgment and fine motor skillsskills

10-20%: HA, nausea, dyspnea, confusion, visual 10-20%: HA, nausea, dyspnea, confusion, visual changeschanges

20-40%: AMS (lethargy, drowsiness, confusion, 20-40%: AMS (lethargy, drowsiness, confusion, agitation), nausea, vomitingagitation), nausea, vomiting

40-60%: weakness, incoordination, memory 40-60%: weakness, incoordination, memory loss, imminent CV and neurologic collapseloss, imminent CV and neurologic collapse

>60%: coma, convulsions, death>60%: coma, convulsions, death

CO Poisoning TreatmentCO Poisoning Treatment

OxygenOxygen TT1/21/2= 4 hours at RA, 1 hour at 100% O2, 30 minutes at = 4 hours at RA, 1 hour at 100% O2, 30 minutes at

hyperbaric O2 (2-3 atm)hyperbaric O2 (2-3 atm)

Sodium BicarbonateSodium Bicarbonate Consider other poisoningsConsider other poisonings

Sulfur or Nitrogen Sulfur or Nitrogen acids acids Cotton or plastics Cotton or plastics aldehydes aldehydes

• Acrolein, polyvinylchloride, polyethylene, benzeneAcrolein, polyvinylchloride, polyethylene, benzene Polyurethane Polyurethane cyanide cyanide Fire retardants Fire retardants phosgene phosgene

Case 2: ZapCase 2: Zap

18 month old girl is brought in by mom 18 month old girl is brought in by mom after she found her chewing on an after she found her chewing on an electrical cord. + LOC. electrical cord. + LOC.

Her vital signs are normal. You note that Her vital signs are normal. You note that she has swelling and redness of her lips she has swelling and redness of her lips and that she is drooling. and that she is drooling.

What would you like to do?

From Baum, Carl. Textbook of Pediatric Emergency Medicine, 4th ed. Lippincott Williams & Wlikins, Philadelphia, 2000: Chap 89, p 961

Electrical InjuryElectrical Injury

Factors for injury severity:Factors for injury severity: Resistance (injury Resistance (injury αα 1/R) 1/R) Type of current (AC or DC)Type of current (AC or DC) Frequency of current Frequency of current Intensity (voltage)Intensity (voltage) Duration of contactDuration of contact Pathway of currentPathway of current

Electrical Injury (cont’d)Electrical Injury (cont’d)

Arcing Arcing thermal injury thermal injury Pathway of currentPathway of current

Head or thorax: risk of arrestHead or thorax: risk of arrest Hand to hand: cardiac and spinal cord injury, Hand to hand: cardiac and spinal cord injury,

suffocation, 60% mortalitysuffocation, 60% mortality Hand to foot: cardiac arrhythmias, 20% Hand to foot: cardiac arrhythmias, 20%

mortalitymortality Foot to foot: rarely fatalFoot to foot: rarely fatal

Deceptively small entry and exit woundsDeceptively small entry and exit wounds

Electrical Injury Work UpElectrical Injury Work Up

Labs: CBC, CMP, PT/PTT, T&S, CPK, Labs: CBC, CMP, PT/PTT, T&S, CPK, cardiac enzymes, U/A, urine myoglobin cardiac enzymes, U/A, urine myoglobin and electrolytesand electrolytes

EKGEKG XR: plain films, head CTXR: plain films, head CT Specialized exams: ophthalmologySpecialized exams: ophthalmology

Electrical Injury ManagementElectrical Injury Management Separate from current source! Separate from current source! Protect yourself!Protect yourself! Prolonged CPRProlonged CPR Be mindful of:Be mindful of:

Arrhythmias and airway edemaArrhythmias and airway edema CNS pathology: cerebral edema, ICHCNS pathology: cerebral edema, ICH SIADH, ARF from rhabdomyolysisSIADH, ARF from rhabdomyolysis Compartment syndromes Compartment syndromes fasciotomy, amputation fasciotomy, amputation

Td immunization and antibiotic prophylaxis for Td immunization and antibiotic prophylaxis for oral injuriesoral injuries

Excessive bleeding when eschar separates!Excessive bleeding when eschar separates!

Chemical BurnsChemical Burns

Acid vs alkaliAcid vs alkali Treat with copious irrigation with waterTreat with copious irrigation with water

Monitor pHMonitor pH Consult Poison CenterConsult Poison Center Specific chemicals:Specific chemicals:

Hydrofluoric acid Hydrofluoric acid calcium gluconate in dimethyl calcium gluconate in dimethyl sulfoxidesulfoxide

Methamphetamine Methamphetamine benzodiazepines benzodiazepines White phosphorus White phosphorus irrigate, monitor Ca and Phos, irrigate, monitor Ca and Phos,

Woods lamp examWoods lamp exam Cyanide Cyanide Lilly (two steps: nitrite and thiosulfate) Lilly (two steps: nitrite and thiosulfate)

Take Home PointsTake Home Points

Stop the burn!Stop the burn! Assess burn surface area.Assess burn surface area. Manage the fluids, pain, infection. Manage the fluids, pain, infection. Reassess burn frequently. Reassess burn frequently. Think about comorbities given history. Think about comorbities given history. Close follow up or transfer/admit.Close follow up or transfer/admit.

john cheng, md pem fellows’ conference emory university school of medicine december 15, 2005

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