4. Etiologies
⢠Based on the mechanism of injury:
⢠scalds,
⢠contact burns,
⢠fire,
⢠chemical,
⢠electrical, and
⢠radiation.
5. Classification
⢠1st Degree (superficial)
⢠2nd Degree (partial thickness)
⢠3rd Degree (full thickness)
⢠4th Degree (subdermal)
⢠Routinely underestimated during the initial examination.
⢠Devitalized tissue may appear viable for some time after injury
⢠Some degree of progressive microvascular thrombosis is observed on the
wound periphery.
6. 1st Degree / Superficial
⢠Usually red, dry, and painful.
⢠Burns initially termed first-degree are often actually superficial
second-degree burns, with sloughing occurring the next day.
7. 2nd Degree / Partial Thickness
⢠Second-degree burns are often red, wet, and very painful.
10. Estimating Burn Size
⢠Accurate estimate is important.
⢠(Size does matter.)
⢠Lund-Browder diagram (age-specific)
⢠Rule of 9
⢠Palm of patientâs hand
11. Initial Burn Size and Depth
⢠Outside reports are notoriously unreliable.
⢠Correctly estimated only 1/3 of times.
⢠Leads to over-resuscitation.
12. Systemic inflammatory response (1/4)
⢠When TBSA > 30%, cytokines and other mediators are released into
the systemic circulation, causing a systemic inflammatory response.
⢠Because vessels in burned tissue exhibit increased vascular
permeability, an extravasation of fluids into the burned tissues occurs.
⢠Hypovolemia is the immediate consequence of this fluid loss, which
accounts for decreased perfusion and oxygen delivery.
⢠In patients with serious burns, release of catecholamines,
vasopressin, and angiotensin causes peripheral and splanchnic bed
vasoconstriction that can compromise in-organ perfusion.
⢠Myocardial contractility also may be reduced by the release of
inflammatory cytokine tumor necrosis factor-alpha.
13. Edema Formation (2/4)
⢠At the peak of edema formation, essentially all whole blood elements up to the
size of RBCs are able to transmigrate through the vessel wall in burned tissue.
⢠As a result of this capillary leak, replacing the intravascular
deficits drives the continued accumulation of edema.
⢠Nearly 50% of infused crystalloid volume lost to the interstitium.
⢠As the burn size approaches 15-20% total body surface area (TBSA), shock sets in
if the patient does not undergo appropriate fluid resuscitation.
14. Edema Formation (3/4)
⢠The peak of this third-spacing occurs at some point 6-12 hours postburn as
the capillary barrier begins to regain its integrity.
⢠Hence the reduction in fluid requirements observed in resuscitation formulas around
this point.
⢠At this point, the theoretic benefits of adjuvant colloid therapy during the
resuscitation allow the careful downward titration of fluid administration to
reduce the obligatory edema.
15. Systemic inflammatory response (4/4)
⢠Hemolysis may occur in deep 3rd deg burns.
⢠PRBC to HCT of 30-35
⢠Decrease in pulmonary function can occur in severely burned patients
without evidence of inhalation injury from the bronchoconstriction
caused by humoral actors, such as histamine, serotonin, and
thromboxane A2.
⢠Burned skin ď increased evaporative water loss ď heat loss ď
hypothermia.
16. Patient Evaluation
⢠Primary Survey: ABCDE
⢠Secondary Survey: Hx and Physical Exam (burn-
specific)
⢠Determination of mechanism of injury,
⢠Presence or absence of inhalation injury and carbon
monoxide intoxication,
⢠Examination for corneal burns,
⢠Consideration of the possibility of abuse, and
⢠Detailed assessment of the burn wound
⢠Imaging studies
⢠Laboratory studies
17. Vital Signs
⢠Very difficult to interpret in patients with large burns.
⢠BP ok due to catecholamine release despite extensive intravascular
depletion.
⢠Edema limits usefulness of NIBP.
⢠Arterial line measurements limited by peripheral vasospasm from
high-cathecolamine state.
⢠Tachycardic due to pain and high adrenergic state, not just
hypovolemia.
⢠Following a trend is much more useful than any single reading.
19. Caution
⢠Not all burns require use of the Parkland formula for resuscitation.
⢠Adult with < 15-20% TBSA without inhalation injury does not require
Parkland Formula.
⢠Not enough to initiate the systemic inflammatory response.
⢠These patients can be rehydrated successfully primarily via the oral route with
modest IV fluid supplementation.
20. Parkland Formula
4 mL x BSA x kg
⢠50% in first 8 hrs
⢠50% in remaining 16 hrs
⢠Example: 4 x 45 BSA x 100 kg = 18,000 mL (24 hrs)
⢠9,000 mL in 1st 8 hrs
⢠1,125 mL per hour (1st 8 hrs)
21. Adequate Fluid Resuscitation
⢠Urine output
⢠Adults 0.5 â 1 mL / kg / hr
⢠Peds 1 mL / kg / hr
⢠If myoglobinuria and/or rhabdomyolysis
suspected?
⢠1 â 1.5 mL / kg / hr
23. Hypoperfused?
⢠Failure to meet these goals should be addressed with gentle upward
corrections in the rate of fluid administration by approximately 25%.
⢠Frequent boluses result in transient elevations in hydrostatic pressure
gradients that further increase the shift of fluids to the interstitium and
worsen the edema.
⢠However, do not hesitate to administer a bolus to patients as appropriate early
in the resuscitation for hypotensive shock.
24. Hyperperfused?
⢠Avoid urine output at rates > 0.5 - 1 mL / kg / h.
⢠Fluid overload in the critical hours of early burn management leads to unnecessary
edema and pulmonary dysfunction.
⢠It can necessitate morbid escharotomies and extend the time required for ventilator
support.
25. Even More Fluids
⢠Inhalation injuries sometimes as much as 30-40% higher (close to 5.7 mL/kg
x BSA)
⢠Delays in initiating resuscitation promptly have also been shown to increase
fluid requirements by as much as 30%, presumably by permitting the
occurrence of an increased inflammatory cascade.
⢠Home diuretic therapy frequently have preexisting free-water deficits in
addition to burn shock.
⢠Escharotomy or fasciotomy can substantially increase free water loss from
the wound.
⢠Electrical burns, associated with large and underappreciated tissue insult
26. Formula Fluid in First 24 Hours Crystalloid in Second 24-Hours Colloid in Second 24-Hours
Parkland RL at 4 mL/kg per percentage burn 20-60% estimated plasma volume Titrated to urinary output of 30 mL/h
Evans[2]
NS at 1 mL/kg per percentage burn, 2000 mL
D5W*, and colloid at 1 mL/kg per percentage
burn
50% of first 24-hour volume plus 2000 mL D5W 50% of first 24-hour volume
Slater[2] RL at 2 L/24 h plus fresh frozen plasma at 75
mL/kg/24 h
Brooke[2]
RL at 1.5 mL/kg per percentage burn, colloid at
0.5 mL/kg per percentage burn, and 2000 mL
D5W
50% of first 24-hour volume plus 2000 mL D5W 50% of first 24-hour volume
Modified Brooke RL at 2 mL/kg per percentage burn
MetroHealth
(Cleveland)
RL solution with 50 mEq sodium bicarbonate per
liter at 4 mL/kg per percentage burn
Half NS titrated to urine output
1 U fresh frozen plasma for each liter of half NS
used plus D5W as needed for hypoglycemia
Monafo hypertonic
Demling[22, 23]
250 mEq/L saline titrated to urine output at 30
mL/h, dextran 40 in NS at 2 mL/kg/h for 8 hours,
RL titrated to urine output at 30 mL/h, and fresh
frozen plasma 0.5 mL/h for 18 hours beginning 8
hours postburn
One-third NS titrated to urine output
*D5W is dextrose 5% in water solution
Table 2. Resuscitation Formulas
27. Pediatrics
⢠Burns < 15% BSA are not associated with an
extensive capillary leak.
⢠Fluid resuscitation = 150% maintenance rate
⢠And continuous monitoring of fluid status.
⢠In smaller children, low hepatic glycogen reserves
can be exhausted quickly:
⢠Hypoglycemia is a threat. Monitor every 4-6 hrs.
⢠Ringer lactate solution with 5% dextrose should be
added at a maintenance rate.
28. Pain Control
1. Morphine @ 2mg increments up to 20 mg max;
2. Ativan @ 1-2 mg increments up to 4 mg max.;
3. Fentanyl @ 1-3mcg/kg or 50-200 mcg IV q 30-40 minutes;
4. Propofol (Diprivan) @ 5 mcg/kg/min
⢠Increase 5-10 mcg/kg/min to max of 80 mcg/kg/min.
⢠Maintenance rate @ minimum 25-50 mcg/kg/min;
5. If patient is wheezing administer: Albuterol 2.5/3 cc with repeat
prn and if pt. is intubated administer in-line;
29. Circunferential Burns
⢠Neck = INTUBATE NOW.
⢠Chest
⢠Interferes with ventilation.
⢠Extremity
⢠Progressive edema leads to poor chest wall compliance.
⢠Extremity escharotomies
⢠As soon as peripheral perfusion is threatened.
⢠Do not wait until the extremity is overtly ischemic.
⢠Torso escharotomies
⢠As soon as ventilation appears compromised.
30. Monitor Electrolytes
⢠Hyponatremia can lead to cerebral edema and seizures.
⢠Rapid correction of hyponatremia may result in central pontine
demyelinating lesions.
31. Take-home
â˘Airway deteriorates over time. Consider early intubation.
â˘Breathing may become difficult if patient is awake and has low
chest wall compliance. Manage pain aggressively.
â˘Circulation is very labile. 4 mL x BSA x kg. Keep an eye on BP and
urine output if using multiple analgesics and sedation.
â˘Disability is due to low perfusion unless TBI is also suspected.
â˘Exposure is critical to re-evaluate extent. Prevent hypothermia.
32. References
⢠Initial Evaluation and Management of the Burn Patient
⢠http://emedicine.medscape.com/article/435402-overview#showall
⢠Burn Resuscitation and Early Management
⢠http://emedicine.medscape.com/article/1277360-overview#showall