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Topics in Burn Injury

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Topics in Burn Injury Topics in Burn Injury David W. Voigt, MD Medical Director Saint Elizabeth’s Regional burn and Wound Care Center Disclamer Never do anything that is not consistant with your medical director’s direction Ambroise Pare’ 1510 - 1590 Thou shalt far more easily and happily attain to the knowledge of these thing by long use and much exercise, than by much reading of books or daily hearing of teachers. For speech how perspicuous and eloquent soever it be, cannot so vividly express anything as that which is subjected to the faithful eyes and hands. Ambroise Pare’ 1510 - 1590 1st to demonstrate gunshot wounds weren’t poisoned Invented the technique of ligation of blood vessels which allowed him to perform amputations 1st to exarticulate an elbow & to use artificial limbs. Trained in the barbershop Ended the practice of pouring boiling oil on open wounds Found projectiles by placing patient in approximately the position he was when he was shot Ambroise Pare’ 1510 - 1590 2 newborn puppy dogs 1 lb. of earthworms 2 lbs. of lily oil 6 oz venic turpentine 1 oz aquavitae MAJOR DETERMINANTS OF OUTCOME FOLLOWING BURN AGE EXTENT OF BURN (TBSA) PRESENCE OF INHALATION INJURY 100 90 80 70 Thermal Injury 21 Year Old LD 50 60 50 40 30 50 53 56 59 62 65 68 71 74 77 80 83 86 89 YEAR Threshold for Injury 248 212 176 C0 140 F0 104 68 32 Exposure (Seconds) Time Temperature Curve for Full Thickness Injury in an Adult 700 600 TI M 500 E I 400 N S 300 E C O 200 N D 100 S 0 120 125 130 140 150 Degrees F. Time Vs Temp in Children 12 10 S e 8 c 6 o 4 n d 2 s 0 130 135 140 149 Degrees F. Primary Survey ABCs AIRWAY FOREIGN BODIES SWELLING STRIDOR BREATHING ACCEPTABLE GAS EXCHANGE PATIENT COMFORTABLE CIRCULATION BLOOD PRESSURE DISTAL PERFUSION SECONDARY SURVEY HEAD TO TOE C-SPINE TORSO INJURY CIRCUMFRENTIAL CHEST BURNS ? EXTREMITY TRAUMA CIRCUMFRENTIAL EXTREMITY BURNS? Hyperbaric Oxygen? NO ! TREATMENT HYPERBARIC OXYGEN ? HALF LIFE OF CO HgB ROOM AIR - 4 HOURS 100% - 40 MINUTES 3 ATMs AND 100% - 27 MINUTES QUESTIONABLE BENEFIT WITH INHERENT RISKS CYANIDE POISONING TRACE AMOUNTS DEMONSTRABLE ANTIDOTES SELDOM NECESSARY SELDOM THE CAUSE OF ACIDOSIS TREAT IF DX CONFIRMED SODIUM THIOSULFATE HYDROXYCOBALAMIN AMYL NITRITE, SODIUM NITRITE, OR DIMETHYLAMINOPHENOL Common Signs and Symptoms of Cyanide Poisoning •Symptoms •Signs Headache Altered Mental Status (e.g., confusion, •Confusion disorientation) •Dyspnea •Seizures or Coma •Chest tightness •Mydriasis •Nausea •Tachypnea / Hyperpnea (early) •Bradypnea / Apnea (late) •Hypertension (early) / Hypotension (late) •Cardiovascular collapse •Vomiting •Plasma lactate concentration ≥8 mmol/L Things that can mimic Cyanide posoning panic symptoms Tachypnea Vomiting The presence of altered mental status (e.g., confusion and disorientation) and/or mydriasis is suggestive of true cyanide poisoning although these signs can occur with other toxic exposures as well Carbon Monoxide Exposure Carboxyhemoglobin Symptoms 0 - 15 % None 15 - 20 % Headache, confusion 20 - 40 % Disorientation, nausea, visual impairment, lethargy 40 - 60 % Hallucination, combativeness, delirium, coma, cardiovascular collapse 60+ % Laboratory Interference Observed with In-Vitro Samples of Hydroxocobalamin Laboratory No Interference Observed Parameter Artificially Increased Artificially Decreased Unpredictable Duration Clinical Calcium Creatinine ALT Phosphate 24 hours with the Chemistry Sodium Bilirubin Amylase Uric Acid exception of bilirubin Potassium Triglycerides AST (up to 4 days) Chloride Cholesterol CK Urea Total protein CKMB GGT Glucose LDH Albumin Alkaline phosphatase Hematology Erythrocytes, Hematocrit Hemoglobin 12 - 16 hours MCV, Leukocytes MCH Lymphocytes, Monocytes MCHC Eosinophils, Neutrophils Basophils Platelets Coagulation aPTT 24 - 48 hours PT (Quick or INR) Urinalysis pH (with all doses) pH (with equivalent 48 hours up to 8 Glucose doses of <5 g) days; color change Protein May persist for 28 erythrocytes days Leukocytes Ketones Bilirubin Urobilinogen Nitrite Treatment interference Because of its deep red color, hydroxocobalamin may cause hemodialysis machines to shut down due to an erroneous detection of a “blood leak”. This should be considered before hemodialysis is initiated in patients treated with hydroxocobalamin. Resuscitation Guidelines IV DEFINITELY INDICATED PEDIATRIC BURNS > 15% ADULT BURNS > 20% IV MAY BE INDICATED INFANT OR TODDLER BURNS - 10% - 15% ADULT BURNS - 15% - 20% PITFALLS OVERRESUSCITATION BOLUS OVERESTIMATION OF BURN SIZE “WRONG” FORMULA MISSED NON-THERMAL INJURIES FAILURE TO PERFORM ESCHAROTOMIES EARLY AND ONGOING CONTACT WITH BURN CENTER Basil A. Pruitt, Jr., M.D. MODIFIED BROOKE FORMULA: DEVELOPMENT 1971: VARYING AMOUNTS OF COLLOID SHOWED NO BENEFIT OVER CRYSTALLOID IN AUGMENTING PLASMA VOLUME DURING 1ST 24 H COLLOID ASSOCIATED WITH LATER INCREASE IN LUNG WATER Dr. Cleon Goodwin, MD FACS MODIFIED BROOKE FORMULA: ADULTS FIRST 24 H LR AT 2 ML/KG/%BURN 1/2 OVER 1ST 8 H, 1/2 OVER NEXT 16 H ADJUST RATE ACCORDING TO RESPONSE URINE OUTPUT ADULTS 30-50 ML/H CHILDREN 1 ML/KG/H INFANTS 1.5ML/KG/H MODIFIED BROOKE FORMULA: Adults 2cc/kg/%TBSA Burn 1/2 OVER 1ST 8 H, 1/2 OVER NEXT 16 H ADJUST RATE ACCORDING TO RESPONSE URINE 30-50 ML/H Children (< 30 KG) LR AT 3 ML/KG/% BURN PLUS D5 1/2NS - MAINTENANCE RATE 1/2 OVER 1ST 8 H, 1/2 OVER NEXT 16 H ADJUST RATE ACCORDING TO RESPONSE URINE OUTPUT CHILDREN 1 ML/KG/H) (> 30 KG) - TREAT AS AN ADULT MODIFIED BROOKE FORMULA: SECOND 24 H COLLOID: 5% ALBUMIN OVER 24 H 30-50% BURN: 0.3 ML/KG/% BURN 50-70% BURN: 0.4 ML/KG/% BURN 70-100% BURN: 0.5 ML/KG/% BURN MAINTENANCE ADULTS: D5W/CHILDREN: D5W 1/2NS BEGIN AT 1/2 RATE OF LR, TITRATE TO U.O. & NA+ MODIFIED BROOKE FORMULA: AFTER 48 H STOP ALBUMIN CONTINUE MAINTANCE ADULTS: D5W/CHILDREN: D5W 1/2NS TITRATE AS BEFORE INSENSIBLE WATER LOSSES (ML/H) = (25 + % BURN)(BSA, M2) (ML/D) = (1 ML/KG/% BURN/24H Charles R. Baxter, MD PARKLAND FORMULA WAS MOST COMMONLY USED FORMULA 4 ML/KG/% BURN ½ over the first 8 hours with the rest over the next 16 hours OVERESTIMATES REQUIREMENTS IN MOST PATIENTS HYPERTONIC SALINE 250-290 MEQ NA/L DECREASED FLUID REQUIREMENT INTRACELLULAR DEHYDRATION HYPERNATREMIA FOURFOLD INCREASE IN ACUTE RENAL FAILURE AND TWOFOLD INCREASE IN MORTALITY IN RECENT STUDY Rue, Loring, M.D. TITRATION VS PUSHES PUSHES GIVE A MORE RAPID CLINICAL RESPONSE EFFECT IS OFTEN SHORT-LIVED PUSHES ULTIMATELY REQUIRE MORE FLUID NO BOLUS HYPOVOLEMIA IS GRADUAL ONSET PLASMA DEFICIT IS OBLIGATORY BOLUSES ARE RAPIDLY LOST INTO INTERSTITIUM EXCEPTIONS: PROFOUND HYPOTENSION DELAYED RESUSCITATION PRE-EXISTING DEHYDRATION CONCOMITANT MECHANICAL TRAUMA ADJUSTMENT OF IV RATE ALL FORMULAS - AN ESTIMATE RATE IS ADJUSTED TO RESPONSE URINE OUTPUT 30-50CC/H IN ADULT 1cc/Kg/Hr IN CHILD 1.5 cc/Kg/Hr in INFANT OTHER INDICATORS: MENTAL STATUS, RESOLUTION OF BASE DEFICIT, APPROPRIATE TACHCARDIA AND BLOOD PRESSURE INCREASED FLUID NEEDS DELAY IN RESUSCITATION (ISCHEMIA- REPERFUSION?) INHALATION INJURY MECHANICAL OR ELECTRICAL INJURY DIURESIS DUE TO HYPERGLYCEMIA OR ETHANOL PRE-EXISTING DEHYDRATION TREATMENT PAIN CONTROL MORPHINE INTRAVENOUS ROUTE TITRATED DOSES AVOID SQ AND IM ROUTES TREATMENT BURNS ARE TETANUS PRONE IF MORE THAN TWO PRIOR VACCINATIONS IF GREATER THAN 5 YEARS SINCE LAST GIVE 0.5 ML TOXOID IF LESS THAN 5 YEARS SINCE LAST NOTHING REQUIRED IF LESS THAN 2 PRIOR VACCINATIONS GIVE 0.5 ML TOXOID CHILDREN < 7 YEARS DPT - UNLESS PERTUSSIS CONTRAINDICATED GIVE 250 UNITS TIG ( AT DIFFERENT SITE SPECIAL BURNS ELECTRICAL CARDIAC MONITORING BURN SIZE IS MISLEADING CHECK URINE FOR PIGMENT CHECK EXTREMITIES FOR COMPARTMENT SYNDROME SPECIAL BURNS CHEMICAL REMOVE SATURATED CLOTHING AVOID CHEMICAL NEUTRALIZATION BRUSH OF POWDERED CHEMICALS BEFORE SHOWERING DILUTION, DILUTION, DILUTION UNTIL PAIN RESOLVES AND SURFACE pH NORMAL HYDROFLUORIC ACID/PHENOL SPECIAL BURNS TAR STOP THE BURNING PROCESS COOL MOLTEN MATERIAL W / COOL WATER CAN REMOVE TAR LATER WITH PETROLEUM OINTMENTS OR MINERAL OIL INHALATION INJURY: DIAGNOSIS CLOSED SPACE OR EXPLOSION NOXIOUS FUMES AT THE SCENE FACIAL BURNS LARGE BURNS CARBONACEOUS SPUTUM HOARSENESS, ABNORMAL LUNG EXAM Forrest Morton Bird, M.D., Ph.D., Sc.D., D.S. VDR VENTILATOR WOUND CARE LEAVE BLISTERS INTACT DO NOT APPLY TOPICAL AGENTS TETANUS STATUS (“DIRTY WOUND”) ADEQUATE: BOOSTER IF > 5Y INADEQUATE: BOOSTER PLUS TIG IV ANTIBIOTICS NOT INDICATED DELAYED TRANSFER: DEBRIDE AGENTS Eschrotomies DONE IN BURN UNIT USE SCALPEL AND CAUTERY COPLETELY RELEASE THE SKIN CONTROL BLEEDING TOPICAL ANTIMICROBIALS IDEAL AGENT PENETRATES ESCHAR BROAD ANTIMICROBIAL ACTIVITY NO INTERFERENCE WITH WOUND HEALING MINIMAL SYSTEMIC ABSORPTION AND TOXICITY TOPICAL ANTIMICROBIALS SILVER SULFADIAZINE ADVANTAGES BROAD SPECTRUM OF ACTIVITY PAINLESS TO APPLY DISADVANTAGES TRANSIENT LEUKOPENIA RASH - 5% OF PATIENTS MINIMAL PENETRATION OF ESCHAR DEVELOPMENT OF RESISTANT STRAINS Dr. Janice Mendelson TOPICAL ANTIMICROBIALS MAFENIDE ACETATE ADVANTAGES PENETRATES BURN ESCHAR WELL EXCELLENT SPECTRUM OF ACTIVITY DISADVANTAGES TEMPORARILY PAINFUL TO THE PATIENT RASH - 5% OF PATIENTS A CARBONIC ANHYDRASE INHIBITOR - CAUSES MILD METABOLIC ACIDOSIS TOPICAL ANTIMICROBIALS SILVER NITRATE ADVANTAGES GOOD SPECTRUM OF ACTIVITY LEAST TISSUE TOXIC OF ALL ANTIMICROBIALS DISADVANTAGES HYPOTONIC SOLUTION; WILL LEACH NA+, K+ AND CL- INTO DRESSINGS PENETRATES ESCHAR POORLY REQUIRES FREQUENT WET DOWNS Robert Burrell, Phd Acticoat Silver Impregnated Telfa Last 72 Hours Wide Spectrum of Antimicrobial Activity Modulates Meteloproteases Costly, but cost effective
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