Faculty Responding to Victims Dr. James Cross with Burn Injuries in Associate Professor University of Alabama at Birmingham Disaster Events Department of Surgery Director UAB Burn Center Satellite Conference and Live Webcast Tuesday, July 21, 2009 Dr. Ziad Kazzi 12:00 - 1:30 p.m. Central Time Assistant Professor Emory University Medical Toxicologist Produced by the Alabama Department of Public Health Georgia Poison Center Video Communications and Distance Learning Division

Burn Definition Causes of Burns

• A burn is • Fires damage to the • Hot water or object skin and mucus • Electrical membranes • Chemical • Radiological

Burn Injuries in Burn Injuries in the United States? the United States? • Each year, 1.1 million burn injuries • Each year, 1.1 million burn injuries require medical attention (American require medical attention (American Burn Association, 2002) Burn Association, 2002) – Approximately 50,000 burn injuries – Approximately 4,500 of these require hospitalization people die – Approximately 20,000 are major burns involving at least 25 percent of the total body surface

1 Residential Fires Account Burn Data in Alabama For 79% of All Fire • 1992-1997 Deaths in the US – Residential fires accounted for the largest proportion of deaths • Fatality rates were higher for mobile home residents – Overall, smoke detectors were present in only 32.5% of the residential fires

Burn Data in Alabama At Risk • Children • 1992-1997 • Elderly – The most frequently reported • Poor cause of fatal fires was misuse of cigarettes • Manufactured or substandard housing – More than half of the victims aged 18 years and older tested positive • Rural for alcohol • African Americans, native Americans • Firefighters

Causes of Fatal Firefighter Injury

Overexertion

Vehicle Collision Struck by

Trapped

Other

2 Nature of Fatal Injury The Station Nightclub Fire

• 439 patrons were in the building at the time of the fire, of whom 96 died at the scene Trauma Heart Attack • 100 people ultimately died Asphyxiation Burns • 215 patients were evaluated at area CVA Electrocution hospitals – 64 at one trauma center – 151 at 15 other area facilities

The Station Nightclub Fire The Station Nightclub Fire - Resources • 79 patients were admitted – 47 to one center • Eight patients were transferred from Rhode Island Hospital (RIH) to other – 32 to other hospitals Level I trauma centers

• 28 (60%) of the patients admitted to RIH were intubated for inhalation injury

The Station Nightclub Types of Burns Fire - Resources • For patients admitted to RIH, the • Flame extent of the total body surface burn • Scald/steam was • Electrical – Less than 20% in 33 patients (70%) • Chemical – 21% to 40% in 12 patients (26%) – Greater than 40% in 2 patients (4%) • Radiological

3 Cellular and Tissue Effects Cellular and Tissue Effects

• Damage to the cells and tissue is a function of temperature and time • Sustained temperatures between 40°C and 44°C cause various enzymes to malfunction • Higher temperatures cause protein breakdown

Pathophysiology of the Zones of Injury Burn Wound • The burn wound is the source of virtually all ill effects seen in the burn patient

• Removal of the burn wound results in much improved patient outcome

Depth of Burn First Degree Burn

• First degree

• Second degree or partial thickness

– Superficial and deep

• Third degree or full thickness

• Fourth degree

4 Second Degree Burn

Third Degree Burn Third Degree Burn

Electrical Primary Survey

• Injury dependent on voltage and • Airway length of time of contact – Can deteriorate abruptly and • Three mechanisms of injury rapidly – Tetany, arrhythmia, and specific • Breathing tissue damage • Circulation – Thermal injury – BP, Pulse, circumferential burns – Mechanical injury from falls and violent muscle contraction

5 Primary Survey Secondary Survey • History • Disability • Circumstances – Neurologic status – Accidental • Exposure – Suicidal – Pay attention to hypothermia – Abuse or assault • Cause – Fire – Hot water scalding

Secondary Survey Secondary Survey

• Duration of contact with flame or hot • Associated trauma water – Motor vehicle accident • Method used to extinguish the fire – Blunt trauma while escaping the • Setting fire – Home – Explosion – Workplace • Associated inhalation – Indoors versus outdoors

Past Medical History Burn Surface Area (BSA) Estimation • Comorbid conditions • The patient’s – Diabetes hand including – Immunocpmpromised fingers is approximately – Disability and special needs 1% of total BSA • AMPLE

6 Rule of 9

Assessment for Perfusion Assessment for Perfusion

• Extremity perfusion may be compromised by a circumferential third degree extremity burn • Respiratory status may be compromised by a circumferential third degree thoracic burn

Special Consideration Special Consideration-Abuse Pediatrics • History not • Larger surface area of head compatible with injuries • More susceptible to hypothermia • Delay in seeking • Moral support to patient and parents care • Several burns at different stages • Suspicious family dynamics and reactions Photo Credit DAVID M. PRESSEL, M.D., PH.D.

7 Assessment for Assessment for Smoke Inhalation Smoke Inhalation • Exposure to smoke in a closed • Physical findings space, cough and shortness of – Carbonaceous sputum breath – Facial burns, and singed nasal • Physical findings vibrissae – Hoarseness – Diagnosis is often established by – Wheezing the use of bronchoscopy – Carbonaceous sputum • Coma or altered mental status

Carbon Monoxide - Clinical Hydrogen Cyanide Mechanism • Most common presentation

– Flu-like illness

• CNS

• CV

Hydrogen Cyanide - Clinical Diagnostic Studies

• Clinical • Carboxyhemoglobin level

– CNS • Elevated Lactic acid

– CV • Arterial Blood Gas with a – Bitter almond: only 60% simultaneous Venous Blood Gas

of population can detect it – O2 extraction – Cherry red skin, fundoscopic • Chest radiograph exam

8 Special Considerations Resuscitation Ophthalmic Injuries • Fluid determined by severity of injury • Reflex lid closure often protects the – Amount of 2nd and 3rd degree burn eyes during facial burns • Lactated ringers • Ophthalmic burns are usually • Initial fluid determined by parkland associated with marked facial formula damage and possible inhalation – 2-4cc/kg/%TBSA injury – Half is administered over the first 8 • Corneal injury is the most common hours from the burn

Resuscitation Fluid Resuscitation

• DO NOT BOLUS FORMULA CRYSTALLOID COLLOID FREE VOLUME WATER • Titrate fluid to urine output Parkland 4 None NONE ml/kg/%TBSA – 30-50cc/hour burn Brooke 1.5 0.5 2 L ml/kg/%TBSA mL/kg/% burn TBSA burn Galveston 5000 mL/m2 None None (Pediatric) burned + 1500 mL/m2 total

Wound Care Inhalational Injury

• If the patient is to be transferred, • Early intubation cover the burns with sterile, dry, • Mechanical ventilation towels or sheets • Chest physiotherapy and suctioning • Do not soak the burns or wrap with • Carbon monoxide poisoning wet towels management – This may induce hypothermia and – 100% Oxygen worsen outcome – Hyperbaric oxygen therapy

9 Inhalational Injury Escharotomy – Indications

• Cyanide poisoning management • Used to treat full thickness (third- – The Lilly Kit degree) circumferential burns – Hydroxocobalamin • Underlying tissues become constricted due to the eschar's loss of elasticity – Leads to impaired circulation distal to the wound

Escharotomy – Indications Escharotomy - Description

• The ability to ventilate a patient may • H shaped incision be impaired by a circumferential chest burn

Electrical Burns Pathophysiology

• Devastating injury • Severity • Young, working males – Voltage, current, type of current, • Most frequent cause of amputations path of current flow, resistance at on the burn service point of contact, individual susceptibility • Morbidity, length of stay, and number of operations higher than • High voltage vs. low voltage other burns – 1000 volts

10 Pathophysiology Mechanism of Injury

• 99% of all electrical burns are caused • True electrical injury by 60 cycle per second commercial alternating current – Current flow through tissue • Arc injury

– “Flash” type injury

• Flame injury

Clinical Findings Scene Care

• Shut down the current

• Primary survey

• Spine protection if trauma is suspected

Diagnostic Studies Acute Care

• CBC and kidney function tests • Electrocardiographic monitoring

• Serum creatine kinase and • Resuscitation myoglobin • Urine output • Urine myoglobin – Myglobinuria • EKG • Radiographs to evaluate for • Local wound care secondary trauma • Compartment syndrome

11 Resuscitation Myoglobinuria • Myoglobin released from damaged • Parkland formula not accurate muscle • Can precipitate out in renal tubules • 30-50 cc/hour urine output causing renal failure – >100cc/hour if muscle damage • Prevention and treatment requires noted high index of suspicion • Treatment: Volume resuscitation, UOP>100cc/hr, mannitol

• NaHCO3 not proven to be beneficial

Traumatic Injuries Compartment Syndrome

• Patients with high voltage electrical • 15% of electrical burn victims injury are prone to developing sustain traumatic injuries compartment syndrome within the • Falls, thrown against objects, first 48 hours following injury compression fractures from tetanic • Fasciotomy may be required to contractions prevent further limb damage

12 Complications Lightning Injury

• Renal failure • 80 fatalities per year

• Fractures • Direct current blast of 2000 to 2,000,000,000 volts • Cataracts • Florida and Texas having the most • Limb Loss deaths • Neurologic • Full spectrum of injury

– Paralysis, paresthesias, etc. – Minimal cutaneous burn to full thickness

Chemical Burns • Due to contact with a chemical caustic agent • Acid, base or others • Bad prognostic factors (pH, physical form, duration of contact, amount and others) • Hydrofluoric acid and its complications

Radiological Burns Yanango, Peru. Feb 20,1999

• Due to contact or exposure to • Iridium source radiological material or source • Picked up by worker and put • In the absence of a history of a in his back contact with a flame, hot object or pocket liquid, chemical or electrical current • The patient developed • Delay in onset of clinical findings severe radiation burn in his pelvic area

13 Yanango - Peru Transfer to Burn Center May and December,1999 • Partial thickness burns >10% TBSA • He survived with significant disability • Burns involving the face, hands, feet, genitalia, perineum, or major joints • Third degree burns in any age group • Electrical burns, including lightning • Chemical burns • Inhalation injury

Transfer to Burn Center

• Burns in patients with pre-existing medical problems

• Combination of burns and trauma

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