MANAGEMENT OF BURNS

1. MANAGEMENT OF BURNS CPT Allen Proulx, MPAS, PA-C

2. OBJECTIVES • Describe the differences between partial and full-thickness burns. • Describe how to estimate the size of a burn. • Describe initial care of burns. • Describe follow-up care of partial thickness burns.

3. References for photos • Advanced Burn Life Support Course, American Burn Association, 1994 • Textbook of Military Medicine, Part I, Vol 5 Conventional Warfare, OTSG, 1991 • Textbook of Surgery, Sabiston, editor W. B. Saunders, 1986 • SESAP VI, American College of Surgeons, 1988 • Burn care product info

4. Depth of burn Partial thickness burn = involves epidermis Deep partial thickness = involves dermis Full thickness = involves all of skin

5. Partial thickness burns • Sunburn is a very superficial burn. • Expect blistering and peeling in a few days. • Maintain hydration orally. • Heals in 3-6 days- generally no scaring • Topical creams provide relief. • No need for antibiotics

6. Deeper partial thickness • Blisters are typical of partial thickness burns. • Don’t be in a hurry to break the blisters. • Heals in 14-21 days • Blisters provide biologic dressing and comfort. • Once blisters break, red raw surface will be very painful.

7. Full thickness burn • Yellow, “leathery” appearance; or charred • Often have no sensation (nerve endings destroyed) • Outer edges might be partial thickness. • Initial management same as partial thickness. • Later will need skin grafts.

8. Mixed partial and full thickness • Central yellow area might be full thickness. • Outer edges are probably partial thickness. • Initial management is the same. • Later will need skin grafts for the full thickness areas.

9. Zones of Burn Wounds • Zone of Coagulation • devitalized, necrotic, white, no circulation • Zone of Stasis ‘circulation sluggish’ • may covert to full thickness, mottled red • Zone of Hyperemia • outer rim, good blood flow, red

10. Wound excision until fine punctate bleeding occurs

11. Estimate the size of the burn • The patient’s own palm is about 1% of his body surface area. • “Rule of Nines”

12. Rule of 9s ABA

13. American Burn Assoc says send these to a burn center • Partial thickness burns >10% BSA • Burns involving the face, hands, feet, genitalia, perineum, or major joints • full thickness/3 degree burn • Electrical, Chemical, and Inhalation burns • In combat, all but the most superficial burn should be evacuated

14. Burn care products • < 20% TBSA 2nd degree – Silvadene (SVC) Cream BID • Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID • 3rd degree burn – SVC and SMC alt BID • *SMC only to the ears * Bacitracin Opth to face

15. Care of small burnsWhat can YOU do?

16. Care of small burns • Clean entire limb with soap and water (also under nails). • Apply antibiotic cream (no PO or IV antibiotic). • Dress limb in position of function, and elevate it. • No hurry to remove blisters unless infection occurs. • Give pain meds as needed (PO, IM, or IV) • Rinse daily in clean water; in shower is very practical. • Gently wipe off with clean gauze.

17. Blisters • In the pre-hospital setting, there is no hurry to remove blisters. • Leaving the blister intact initially is less painful and requires fewer dressing changes. • The blister will either break on its own, or the fluid will be resorbed.

18. Blisters break on their own Upper arm burn day 1 day 2 Burn “looks worse” the next day because of blisters breaking and oozing

19. Upper arm burn • Blisters show probable partial thickness burn. • Area without blister might be deeper partial thickness. 121

20. Debride blister using simple instruments

21. Medic debriding blister

22. After debridement

23. Before and after debridement • Removing the blister leaves a weeping, very tender wound, that requires much care.

24. Silver sulfadiazene

25. Arm burn 4 days

26. Arm burn 7 days – note the exudate

27. Foot burn debridement Before debriding and applying cream, clean entire foot (including toes and nails).

28. Silver- impregnated dressings (Silverlon) • Apply wet silver dressing directly on the burn. • Creams or dressings under the silver dressing impede the antimicrobial action. • Keep it moist! • Remove it, rinse it out, replace it on the burn.

29. Steps in using silver-impregnated dressings • Clean the burn and surrounding area. • Soak silver-impregnated dressing and gauze in STERILE WATER or BOTTLED DRINKING WATER • Apply silver-impregnated dressing (over-lapping edges are best). • Wrap with the moist gauze. • Secure with mesh, gauze, or tape. • Keep it moist with WATER, every 12h or so More frequent in hot arid environments

30. pics Soak silver dressings and gauze in WATER (not saline). Apply the silver dressing. Wrap with moist gauze. Secure with mesh, gauze, or tape.

31. First few days • Moisten dressing with WATER every 12h or so. • Remove outer gauze and silver dressing every day. • Inspect the burn. • Rinse exudate off burn. • Rinse exudate off silver dressing with WATER. • Return same silver dressing to the burn. • Apply new outer gauze moistened with WATER.

32. pics Moisten with WATER q12h or so. Moisten well to remove it each day. Rinse it out, and put it back on the burn.

33. After several days • Replace silver dressing • every 2 - 5 days • depending on amount of exudate, cellular debris • First wet the silver dressing before removing it. • Don’t pull on it if it’s stuck – moisten it more. • Apply new moist silver dressing and gauze.

34. QUESTIONS ABOUT SMALL BURNS? SUMMARY • Describe the differences between partial and full-thickness burns. • Describe how to estimate the size of a burn. • Describe initial care of small burns. • Describe follow-up and post-burn care. NEXT TOPIC - BURNS OF SPECIAL AREAS

35. Burns of special areasof the body Face Mouth Neck Hands and feet Genitalia

36. Face • Be VERY concerned for the airway!! • Eyelids, lips and ears often swell alarmingly. • In fact, they look even worse the next day. • But they will start to improve daily after that. • Cleanse eyes with warm water or saline. • Apply antibiotic ointment or liquid tears until lids are no longer swollen shut. • Bacitracin cream/ointment will serve

37. Hands and feet This is rather deep and might require grafting. But initial management is basic. Dressings should not impede circulation. Leave tips of fingers exposed. Keep limb elevated.

38. Hands and feet • Allow use of the hands in dressings by day. • Splint in functional position by night. • Keep elevated to reduce swelling.

39. Hands and feet • Fingers might develop contractures if active measures are not taken to prevent them.

40. Genitalia • Shower daily, rinse off old cream, apply new cream. • Insert Foley catheter if unable to urinate due to swelling.

41. Large Burns

42. Causes of death in burn patients • Airway • Facial edema, and/or airway edema • Breathing • Toxic inhalation (CO, +/- CN) • Respiratory failure due to smoke injury or ARDS

43. Edema Formation • Amount of edema can be immense (even without facial burns) • Depression of mental status can worsen problem • Edema peaks at 12 to 24 hours • Pediatric patients even more concerning

44. Causes of death in burn patients • Circulation: “failure of resuscitation” • Cardiovascular collapse, or acute MI • Acute renal failure • Other end organ failure • Missed non-thermal injury

45. Patients with larger burns First assess • CBA’s • “Disability” (brief neuro exam) • Expose Later • Examine rest of patient • Calculate IV fluids • Treat burn

46. Airway? • “Flash” burns may refer to those that suddenly flare up, then die down quickly. • Patients may have burnt facial hair and carbon on lips. • Patients with this kind of facial burn will probably NOT need an artificial airway. • Give humidified oxygen while under close observation.

47. Circulation • Record vital signs. • Check distal pulses and nail beds. • Keep him warm! • Loss of skin impairs ability to retain heat and fluids. • Being cold will cause vasoconstriction. • Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr • Monitor at least HCT and urine specific gravity. • When available, monitor electrolytes.

48. Neuro status • The burn itself does not alter the level of consciousness. • If patient is not alert, think of other causes: • hypovolemia • carbon monoxide • head injury • Don’t allow swollen eyelids to prevent you from examining the pupils. • Test sensation and motion in burned extremities.

49. Expose • Undress the patient to examine the whole body. • But burned patients lose body heat quickly, so keep them warm. • To keep warm, use whatever means available: blankets heating lamps bed frame large box covered with blankets

50. Head to toe exam • Obtain history and examine rest of body. • Ask about allergies, meds, medical conditions. • Look for other injuries.