thermal injury. objectives comprehend the pathophysiology of the burn wound review the initial care...

THERMAL INJURY

OBJECTIVES

• Comprehend the pathophysiology of the burn wound

• Review the initial care and resuscitation of the burn patient

• Understand burn wound therapy

• Be familiar with specific problems related to the burn patient

EPIDEMIOLOGY

• 4th Leading Cause of Unintentional Death• United States

– 1 million burns yearly– 6,000 deaths yearly (73% from house fires)– Scalds: Most frequent in < 5 and > 65 age groups

• Inhalation Injury– Leading cause of death– Cigarettes are most common cause– Alcohol use is a factor

PATHOPHYSIOLOGYBURN CATEGORIES

• Flame

• Scald

• Contact (cold or hot)

• Chemical

• Electrical

PATHOPHYSIOLOGYMECHANISMS OF INJURY

• Categorical– Transfer of energy:

Flame, Scald, Contact

– Direct Injury: Chemical, Electrical

• Capillary Injury– Increased

Permeability– Hyperemia– Hemoconcentration

PATHOPHSIOLOGYMECHANISMS OF INJURY

• Inflammatory Mediator Release– From mast cells, WBCs, and platelets– Result is:

• Vasoconstriction• Vasodilation• Increased vascular permeability• Decreased cardiac output• Edema formation

PATHOPHYSIOLOGYZONES OF INJURY

• Coagulation: Necrotic area• Stasis

– Area immediately around necrotic zone– Initially causes decreased tissue perfusion– Can progress to coagulation necrosis

• Hyperemia– Vasodilation from inflammation around wound– Clearly viable tissue from which healing begins

PATHOPHYSIOLOGYDEPTH OF BURN

• First Degree– Confined to epidermis– Painful, erythematous,

blanches– Sunburn or minor

scald– Does not result in

scarring– Treatment aimed at

comfort


• Second Degree (Superficial)– Erythematous, painful,

may blanch– Scald injuries, flash flame

burns– Spontaneous

reepithelializes from retained epidermal structures in rete ridges, hair follicles, and sweat glands (7 to 14 days)

– Long term shows slight skin discoloration


• Second Degree (Deep)– Into reticular dermis– Pale, mottled, does not

blanch– Painful to pinprick– Healing by

reepithelialization from hair follicles and keratinocytes in sweat glands (14 to 28 days)

– Timely healing requires excision and grafting

– Severe scarring due to loss of most of dermis


• Third Degree– Full thickness through

dermis– Hard, leathery eschar,

painless– Heals by

reepithelialization from wound edges

– Timely healing requires excision and grafting


• Fourth Degree– Involves other organs beneath skin– Muscle, bone, brain– Requires excision, grafting, flap coverage.– May require amputation

INITIAL CARE & RESUSCITATIONPRIMARY SURVEY

• ABCs• Stop the Fire• Remove burned clothing• Large-Bore IV Access• Keep warm and covered

INITIAL CARE & RESUSCITATIONSECONDARY SURVEY

• Burn Size Evaluation– Rule of Nines

INITIAL CARE & RESUSCITATIONSECONDARY SURVEY

• Other Injuries & Therapies– Traumatic injuries– CO poisoning– Inhalation injury– Tetanus– Pain management

INITIAL CARE & RESUSCITATIONFLUID MANAGEMENT – First 24 Hours

• Timing– From burn injury– Not from arrival

• Who Gets Resuscitated– Adults > 15% TBSA– Children < 10 with > 10% TBSA


• Type of Fluid– Adults & Children > 2:

Lactated Ringers

– Children < 2: D5LR

• How Much


• Goal/Endpoint

INITIAL CARE & RESUSCITATIONFLUID MANAGEMENT – Second 24 Hours

• Vascular Permeability– Nonburn Tissue: Normal soon after burn– Burn Tissue: Slowly over 12 – 18 hours

• Re-evaluate fluid requirement based on:– Patient hemodynamic response– UOP

• Addition of Colloid– Not given for < 20% TBSA– 0.1 mL/kg %TBSA 25% Albumin over 1-2 hours

• Maintenance Fluids– D5 ½ NS– D5 ¼ NS

INITIAL CARE & RESUSCITATIONEMERGENT SURGICAL INTERVENTION

• Extremity– Deep 2nd & 3rd degree burns

encompass extremity– Tissue Pressures > 40 mm Hg– Tissue perfusion is

compromised– Escharotomy and/or

Fasciotomy

INITIAL CARE & RESUSCITATIONEMERGENT SURGICAL INTERVENTION

• Trunchal Eschar– Limits chest wall excursion

= decreased ventilation– Increased peak airway

pressures– Desaturation– Therapy: Escharotomy

INITIAL CARE & RESUSCITATIONTRANSFER TO BURN UNIT

• 2nd & 3rd Degree Burns > 10% TBSA• Face, hand, feet, genitalia, perineum, or major joint involvement• 3rd Degree Burns any age group• Electrical burns, including lightening injury• Chemical burns• Inhalation injury• Patients with significant comorbid conditions• Concomitant trauma in which the burn poses the greatest

mortality and morbidity• Children in a hospital without qualified personnel or equipment

to care for children• Patients who will require special social, emotional, or long-term

rehabilitation

INITIAL CARE & RESUSCITATIONPRIOR TO BURN UNIT TRANSFER

• Keep patient warm

• Cover with clean or sterile sheets

• Early application of topical antimicrobial in deep partial and full thickness burns

• Do NOT apply antimicrobial before communication with receiving burn unit

BURN WOUND THERAPYINTRODUCTION

• Three Stages– Assessment– Management– Rehabilitation

• Assessment– Extent & Depth of wound– Clean & Debride wound

• Management– Wound coverage– Antimicrobial coverage (if indicated)– Daily wound care

BURN WOUND THERAPYGENERAL GUIDELINES

• Functions of wound coverage– Protect & splint damaged epithelium– Reduce evaporative heat loss & minimize cold

stress– Pain control

• Coverage by type– 1st Degree: Topical salves– 2nd Degree (Superficial): Daily dressing changes

& antimicrobial coverage (if indicated)– 2nd Degree (Deep) & 3rd Degree: Excision and

timely autografting

BURN WOUND THERAPYGENERAL GUIDELINES

• Adjunctive Therapy– NGT Decompression: In TBSA >25% for gastric

ileus (24 – 48 hours)– Foley Catheter– Stress Gastritis Prophylaxis: TBSA > 25% are at

increased risk– Pain Control

• Significant pain for 2nd degree burns• Use IV route• Oral and IM routes have unpredictable absorption

BURN WOUND THERAPYEXCISION & GRAFTING

• Post-resuscitation day 1 – 7• Associated with improved survival• Benefits over serial debridement

– Survival– Blood loss– Length of hospitalization

• Indicated for 2rd Degree (deep), 3rd Degrees, and 4th Degree burns

BURN WOUND THERAPYCONTROL OF INFECTION

• Removal of eschar and necrotic tissue• Improved outcome associated with:

– Early excision & wound closure/coverage– Timely & effective antimicrobial use

• Topical Antimicrobials– In spontaneously healing wounds:

• Limits contamination• Environment for healing

– Prevent burn wound sepsis• Tetanus Prophylaxis: DON’T Forget!!

BURN WOUND THERAPYTOPICAL ANTIMICROBIALS

Topical Agent Advantages Disadvantages

Silver Sulfadiazine

Broad Spectrum

(GPC, GNR, Fungus)

Painless application

Large burns

Some Pseudomonas resistance

Transient Leukopenia and/or Thrombocytopenia

Poor eschar penetration

Silver Nitrate

Excellent Spectrum

(GPC, GNR, Fungus)

Painless application

Large burns

Staining

Electrolyte abnormalities (hyponatremia)

Poor eschar penetration

Methemoglobinemia

Sulfamylon

Broad Spectrum

(GPC, GNR)

Good eschar penetration

Small burns

Painful Application

Metabolic Acidosis

Not effective against fungus

BURN WOUND THERAPYWOUND COVERAGE

• Considerations– Accomplish ASAP after excision (1-7 days)– Autograft is best– Cadaver allograft: Temporary for large burns

• Types of Coverage– Autograft– Cadaver Allograft– Xenograft (Porcine)– Synthetic: Integra, Biobrane, Transcyte

SPECIFIC BURN PROBLEMSINHALATION INJURY

• Characteristics– Another inflammatory focus to the burn injury– Impedes normal gas exchange– Increases burn size and resuscitation volume

• Hallmarks– Caused by inhaled toxins– Chemical injury– Edema and increased lung lymph flow– Separation of ciliated epithelium


• Diagnosis– History: Smoke exposure

in closed space– Exam

• Hoarseness, Wheezing• Carbonaceous sputum• Large burns or facial burns

– Bronchoscopy: Establishes the diagnosis


• Therapy– Supplemental O2 in ALL burn patients– Chest physiotherapy and suctioning– Prophylactic intubation is prudent

• Pharmacologic Triad– Bronchodilators– Nebulized Heparin– N-Acetylcysteine

SPECIFIC BURN PROBLEMSMYOGLOBINURIA

• Characteristics– Associated with high voltage injuries– Myoglobin precipitates in and damages renal tubules

• Diagnosis– Dark red urine– U/A positive for hemoglobin (no cells)– Elevated serum myoglobin

• Treatment– UOP 75 – 125 cc/hr– Alkalinization: Use of sodium bicarbonate– Mannitol to induce diuresis– Monitor serum potassium

OTHER BURNSCHEMICAL

• Pathophysiology– Acid: Coagulative necrosis; confined– Base: Liquefaction necrosis; extends into tissues

• Treatment– Initial Therapy: Copius irrigation with saline– Neutralization Attempts

• Result in heat production• Extend injury

– Once controlled, treat as regular burn injury

OTHER BURNSELECTRICAL

• Characteristics– Injury is MOSTLY internal– Current follows path of LEAST resistance: nerves, blood

vessels, muscle– High index of suspicion for:

• Compartment syndrome• Myoglobinuria

• Treatment– Vigorous resuscitation (watch for myoglobinuria)– UOP greater than 1 mL/kg/hr– Monitor for arrhythmias for 24 to 48 hours– Regular burn wound care

SUMMARY

• STOP the Burning Process• ABCs• Evaluate Burn & Begin Resuscitation• Evaluate and Care for Associated

Injuries• Transfer to Burn Center• Definitive Burn Wound Therapy• Specific Burn Problems

QUESTIONS

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thermal injury. objectives comprehend the pathophysiology of the burn wound review the initial care...

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