Burns

Burns

Epidemiology:

US Ð'- 2M seek serious burns  70k require hospitalizations, 5k die

Usually caused by careless and ignorance, nearly half are smoking or alcohol -related.

Goal: well healed durable skin with normal function and near-normal appearance.

Pathology

Cutaneous burns Ð'- caused primarily by the application of heat to the skin resulting in coagulative necrosis of some or all of the epidermis and dermis.

Depth of burn Ð'- depends on heat of the burn source, thickness of the skin, duration of contact, and the blood flow.

Classifications:

Shallow burns

Ð'* First Degree Ð'- involve only the epidermis; no blisters; painful and erythematous due to dermal vasodilation; erythema and pain subsides in 2-3 days; desquamation occurs in day 4

Ð'* Superficial Dermal Burns (Second Degree) - include the upper layer of the dermis; form blisters at the interface of the epidermis and dermis; when blisters are removed, wound is pink and wet, and currents of air passing over it cause pain; wound is hypersensitive and blanches with pressure; if without infection, spontaneous healing in 5% TBSA in any age group

5. Electrical burns including lightning injury

6. Chemical injury

7. Inhalation injury

8. Burns of any size in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality

9. Burns with concomitant mechanical trauma (e.g. fractures) where the burn injury poses the greatest risk of morbidity and mortality

10. Burns in children if there are no qualified personnel or equipment for pediatric care at the initial hospital

11. Burns in patients requiring special social, emotional, and/or long-term rehabilitative support, including cases of suspected child abuse, substance abuse, etc

Emergency Care

Airway Ð'- initial attention must be directed to this; if patient is rescued from a burning building or exposed to a smoky fire, place on 100% oxygen by tight-fitting mask; if patient unconscious, place ET tube attached to a source of 100% oxygen

Once airway is secured, assess patient for other injuries and transport to the nearest hospital. Begin fluid administration of crystalloid solution at a rate of approximately 1L/h. Wrap patient in clean sheet, remove constricting clothing and jewelries.

Cold application is used in smaller burns, particularly scalds. Ice should not be used.

Assessment of Inhalational Injury - suspect for patients with a flame burn, esp in enclosed space. Hoarseness and expiratory wheezes are signs of potentially serious airway edema or smoke poisoning; inspect mouth for swelling, blisters, soot; copious mucus production and carbonaceous sputum are signs of smoke inhalation and other products of combustion; get ABGs and carboxyhemoglobin levels (if >1, smoke inhalation)

Fluid Resuscitation Ð'- patients with burns >20% typically develop shock due to hypovolemia 2 to extravasation of fluid and protein; institute fluid resuscitation ASAP with LRS 1L/h in adults and 20ml/kg in children; insert foley catheter and monitor urine output q1

Tetanus Ð'- previous immunization within 5 years requires no treatment, immunization within 10 years requires a tetanus toxoid booster, and unknown immunization status require hyperimmune serum (hyper tet)

Gastric Decompression Ð'- many begin tube feeding by admission to protect the stomach from stress ulceration and prevent paralytic ileus, as well as provide nutrition

Pain control Ð'- during shock phase, give meds by IV. Best managed by small IV doses of morphine, 2-5mg.

Esharotomy and Fasciotomy Ð'- rarely required within the first 6 hours

Eschar Ð'- necrotic and coagulated skin; rigid and unyielding; as fluid and protein