Advanced Burn Life Support Manual Review

Robyn Watts, M.D. Nadia Afridi, M.D. Division of Plastic Surgery Dalhousie University, Halifax NS

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Skin Anatomy
Epidermis Dermis

Hypodermis

Function of Normal Skin

Protection from infection & injury Prevention of loss of body fluid Regulation of body temperature Sensory contact with environment

What is a Burn?
An injury to tissue from:
Exposure to flames or hot liquids Contact with hot objects Exposure to caustic chemicals or radiation Contact with an electrical current

Pathophysiology of Burn Injury

Zone of Coagulation:
Irreversible damage

Zone of Stasis:
Impairment of blood flow Recovery variable

Zone of Hyperemia:
Prominent vasodilation Usually recovers

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Severity of a Burn
Depends on: Depth of burn Extent of burn Location of injury Patients age Presence of associated injury or diseases

Depth of a Burn

First Degree Superficial Second Deep Second Third Degree

Depth of a Burn
First Degree
Epidermis only Erythematous Hypersensitive Classic sunburn Heals without scar

Depth of a Burn
Second Degree Epidermis + part of dermis Superficial Deep Blisters Edematous and red Very painful Scaring variable

Depth of a Burn
Third Degree Full thickness burn Can involve underlying muscle, tendon, bone Waxy white, leathery brown or charred black Painless Heals with scar

Extent of a Burn
Rule of Nines
Most universal guide for initial estimate Deviates in children due to larger head surface area

Robyns Rule of 4s

ABA Burn Referral Criteria

2nd & 3rd degree burns of greater than 10% BSA in patients under 10 or over 50 yrs old 2nd & 3rd degree burns of greater than 20% BSA in other age groups 2nd & 3rd degree burns with functional or cosmetic implications 3rd degree burn of greater then 5% BSA

ABA Burn Referral Criteria

Significant electrical burn Chemical injury with functional or cosmetic impairment Inhalation injury Circumferential burn of chest or extremity Burn injury with pre-existing medical disorder Any burn with concomitant trauma

Primary Survey
A Airway B Breathing C Circulation / C-spine / Cardiac status D Disability / Neurologic Deficit E Exposure and Examination F Fluid Resuscitation

Secondary Survey
Complete heat-to-toe examination Obtain as much information as possible regarding injury:
A Allergies M Medications P Past medical history L Last meal or drink E Events preceding injury

Management Principles
Stop the Burning Process Universal Precautions Airway Management Circulatory Management Insertion of a Nasogastric Tube Insertion of a Foley Catheter

Management Principles
Relieve Pain Assess Extremity Pulses Regularly Assess for Ventilatory Limitation Provide Emotional Support Suicide Management

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Inhalation Injury
Important determinant of morbidity & mortality Manifests within the first 5 days after injury Present in 20-50% of pts admitted to burn centers Present in 60-70% of pts who die in burn centers

Indicators of Inhalation Injury

Burned in closed space Facial or intra-oral burns Singed nasal hairs Soot in mouth, nostrils, larynx Hoarseness or stridor Respiratory distress Signs of hypoxemia

History of Event
Is there a history of unconsciousness? Were there noxious chemicals involved? Did injury occur in closed space?

Types of Inhalation Injury

Carbon Monoxide Poisoning Inhalation Injury Above the Glottis Inhalation Below the Glottis

Carbon Monoxide Poisoning

Colorless, odorless gas Binds to hemoglobin 200 times more than oxygen Most immediate threat to life in survivors with severe inhalation injury Toxicity related directly to percentage of hemoglobin it saturates

Carbon Monoxide Poisoning

Signs & Symptoms of Carbon Monoxide Toxicity

Carboxyhemoglobin (%)
0-10 10-30 30-50 50-60 60+

Signs/Symptoms
None Headache Headache, nausea, dizziness, tachycardia CNS dysfunction, coma Death

Signs of CO Poisoning
Cherry red coloration Normal or pale skin with lip coloration Hypoxic with no apparent cyanosis PaO2 is unaffected Essential to determine carboxyhemoglobin levels !

CO Poisoning: Treatment
100% oxygen until carboxyhemoglobin levels less than 15
Increases rate of CO diffusion from 4 hours to 45 minutes

Hyperbaric oxygen is of unproven value

May be useful in isolated CO intoxication but complicates wound care

Inhalation Injury Above the Glottis

Most common inhalation injury Results from heat dissipation into tissues Commonly leads to obstruction Edema lasts for 2-4 days Dx by visualization of upper airways

Inhalation Injury Above the Glottis: Treatment

Intubate!!!

Inhalation Injury Below the Glottis

Chemical pneumonitis caused by toxic products of combustion
Ammonia, chlorine, hydrogen chloride, phosgene, aldehydes, sulfur & nitrogen oxides Related to amount and type of volatile substances inhaled

Onset of symptoms is unpredictable

Close monitoring for first 24 hours

Inhalation Injury Below the Glottis: Treatment

Prior to transfer to burn center Intubation
to clear secretions relieve dyspnea deliver PEEP Improve oxygenation

Steroids not indicated Prophylactic antibiotics unjustified Circumferential chest burns: escharotomies

Inhalation Injury in the Pediatric Patient

Small airways: rapid onset of obstruction
Well secured, appropriately sized, uncuffed tube

Rib cage is not ossified

More pliable Pt exhausts rapidly due to decrease in compliance with circumferential chest burns Escharotomies performed with first evidence of ventilatory impairment

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Shock & Fluid Resuscitation

Goal:
To maintain vital organ function while avoiding the complications of inadequate or excessive therapy

Systemic Effects of Burn Injury

Magnitude & duration of response proportional to extent of surface burned Hypovolemia
Decreased perfusion & oxygen delivery

Initial increase in PVR & decrease in CO

Neurogenic & humoral effects

Corrected with adequate fluid resuscitation

Prevent shock & organ failure

Cellular Response to Burn Injury

Severity dependant on temperature exposed and duration of exposure
Zone of Stasis: recovery of injured cells dependant on prompt resuscitation

Resuscitation Fluid Needs

Related to:
extent of burn (rule of nines) body size (pre-injury weight estimate)

Delivered through large bore peripheral IV

Attempt to avoid overlying burned skin Can use venous cut down or central line

Resuscitation Fluid Needs: First 24 Hours

Parkland Formula:
Adults: 2-4 ml RL x Kg body weight x % burn Children: 3-4 ml RL x Kg body weight x % burn

First half of volume over first 8 hours, second half over following 16 hours
Hypovolemia, decreased CO Increased capillary permeability Crystalloid fluid is keystone, colloid not useful

Resuscitation Fluid Needs: Second 24 Hours

Capillary permeability gradually returns to normal Colloid fluids started to minimize volume
Only necessary in patients with large burns (greater than 30% TBSA) 0.5 ml of 5% albumin x Kg body weight x % burn

Monitoring of Resuscitation
Actual volume infused with vary from calculates according to physiologic monitoring Optimal regimen:
minimizes volume & salt loading prevents acute renal failure low incidence of pulmonary & cerebral edema

Monitoring of Resuscitation
Urinary output is a reliable guide to end organ perfusion
Adults: 30-50 ml per hour Children (less than 30 Kg): 1 ml/Kg per hour

Infusion rate should be increased or decreased by 1/3 if u/o falls or exceeds limits by more than 1/3 for 2-3 hours

Management of Myoglobinuria & Hemoglobinuria

High voltage electrical injury and mechanical trauma Maintain urine output of 75-100 ml per hour Add 12.5 gm of Mannitol to each liter of fluid
Urine output not sustained Urine pigment does not clear

Sodium bicarbonate 1 amp (50 meq) per liter of fluid

Heme pigments more soluble in alkaline urine

Monitoring Resuscitation
Blood pressure:
Can be misleading due to progressive edema & vasoconstriction

Heart Rate:
Tachycardia commonly observed

Hemaglobin & hematocrit:

Not a reliable guide Transfusion not to be used for resuscitation

Baseline serum chemistries & arterial blood gases

Baseline to be obtained in burns of >30% BSA

Monitoring Resuscitation
CXR: daily for first 5-7 days
Normal study in first 24 hours does not r/o inhalation injury

ECG:
All electrical injuries Pre-existing cardiovascular disease

Fluid Resuscitation in the Pediatric Patient

Require greater amounts of fluid
Greater surface area per unit body mass

More sensitive to fluid overload

Lesser intravascular volume per unit surface area burned

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Depth of Burn
Partial Thickness
First degree Superficial second degree Deep second degree Ack 361

Full Thickness
Third degree

Initial Management: Chest Escharotomy

Circumferential chest wall burns Performed in the anterior axillary line Extend to abdominal wall if involved Divide eschar completely
Electric cautery Sharp division

Initial Management: Extremity Escharotomy

Circumferential burn of the extremity Remove rings, watches Elevation of limb Hourly monitoring:
Skin color, Temperature Sensation, Pain Capillary refill Peripheral pulses Ultrasonic flowmeter

Finger Escharotomy
Seldom required Performed after consultation with burn center physician Extend through full thickness of skin only Avoid tactile areas

Performing an Escharotomy
Bedside procedure Sterile technique (sharp division or electrocautery) Local anesthesia not required
Control anxiety

Avoid major nerves & vessels Extend incision into subcutaneous fat Incision to be carried across involved joints 2nd incision on contralateral aspect of limb may be required

Escharotomy Sites

Specific Anatomical Burns

Facial Burns
Require hospital care Possibility of respiratory damage Elevate HOB 30 degrees Use water or NS to clean to avoid chemical conjunctivitis

Specific Anatomical Burns

Burns of the Eyes
Examine ASAP Use fluorescein to identify corneal injury Chemical burns to be rinsed with copious NS Opthalmic antibiotic drops if corneal injury present Solutions with steroids dangerous Tarsorrhaphy is never indicated in acute phase

Specific Anatomical Burns

Burns of the Ears
Examine external canal & drum early Determine if OM/OE present Avoid pressure dressings & additional trauma

Specific Anatomical Burns

Burns of the Hands
Determine vascular status & need for escharatomy Presence of radial pulse does not exclude compartment syndrome Monitor with Doppler U/S Elevate hand above heart Dressings impair ability to monitor

Specific Anatomical Burns

Burns of the Feet
Assess circulation on scheduled basis Elevate limb Dressings to be avoided to not interfere with monitoring

Specific Anatomical Burns

Burns of the Genitalia & Perineum
Burn to the penis requires immediate insertion of Foley catheter With circumferential burns, a dorsal escharotomy may be indicated Scrotal swelling does not require treatment Diverting colostomy not indicated in perineal burns

Tar Burns
Contact burns Bitumen is non-toxic Immediate cooling of molten with cold H20 Removal of tar not an emergency Cover with petroleum based product & dressed to emulsify tar

Please Pass the Mayo!

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Electrical Injury
Occurs when electricity is converted to heat as it travels through tissue Divided into:
High voltage greater than 1000 V Low voltage less than 1000

Hands & wrists are common entrance wounds Feet are common exit wounds

Electrical Injury
Extremely difficult to evaluate clinically Greatest tissue damage occurs under and adjacent to contact points Superficial tissues cool more rapidly than the deeper tissue
Accounts for non-viable tissue beneath viable, more superficial muscle

Types of Tissue Injury

Cutaneous Burn with no underlying tissue damage
No passage of current through patient

Cutaneous Burn plus deep tissue damage

Involving fat, fascia, muscle and/or bone

Muscle damage associated with myoglobin release

Urine may be light red to port wine color Risk of kidney damage

Lightning Injury
Direct current of >100 000 000 volts and up to 200 000 amps Injury results from:
Direct strike Side flash
Flow of current between person & nearby object

Often travels on surface of body

Burns typically superficial splashed on spidery pattern

Management of Electrical Injury

ABCs Assess Injury
History LOC, cardiac arrythmia, other trauma Physical Exam neuro exam, long bone #, dislocations, cervical spine

Maintain Patency of Airway Cardiac Monitoring:

Standard 12 lead EKG on admission Continuous cardiac monitoring for first 24 hours

Management of Electrical Injury: Fluid Resuscitation

Administer Ringers Lactate in amounts estimated with Parkland Formula
Will underestimate required volume due to underlying tissue damage Increase fluids as per urine output

Examine urine for pigment

Maintain urine output 75-100 ml/hr until clear Add 1 amp (50 meq) per liter of RL to alkalize urine Mannitol 12.5 mg/liter to maintain urine output

Management of Electrical Injury: Peripheral Circulation

Hourly monitoring of skin color, sensation, capillary refill and peripheral pulses Remove all rings, watches, jewelry Surgical correction of vascular compromise
Decompression by escharotomy or fasciotomy Upper limb-volar & dorsal incisions with protection of ulnar nerve Lower limb-medial & lateral incisions

Electrical Burns in the Pediatric Patient

Low voltage accidents most common
Generally household (faulty insulation, frayed cords, insertion of metal object into wall socket) Cutaneous injury, no muscle damage

Oral commisure injury

Look worse than they are No initial debridement

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Chemical Burns: Classification

Alkalis
Hydroxides, carbonates and caustic sodas of sodium, ammonium, lithium, barium & calcium Oven & drain cleaners, fertilizers, industrial cleaners

Acids
HCl, oxalic, muriatic & sulfuric acids Common in household & swimming pool cleaners

Organic Compounds
Phenols, creosote, petroleum products Contact chemical burns & systemic effects

Chemical Burns
Factors That Determine Severity:
Agent Concentration Volume Duration of contact (delay in treatment)

Treatment of Chemical Burns

Wear gloves and protective clothing Remove saturated clothing Brush skin if agent is a powder Irrigate, irrigate, irrigate!
Copious amounts of water Continued until pain or burning has decreased

Neutralization of agent contraindicated

Generation of heat may lead to further injury

Specific Chemical Burns: Treatment

Alkali Injury to the Eye
Bond to tissue proteins leading to liquefaction necrosis Require prolonged irrigation
Water or saline

Likely to present with swelling & lid spasm Place catheter in lateral sulcus to irrigate

Specific Chemical Burns: Treatment

Petroleum Injuries
Contact with gasoline or diesel fuel Delipidation: causes an initial partial thickness burn become a full-thickness burn Systemic toxicity evident within 6 to 24 hours
Pulmonary insufficiency Hepatic failure Renal failure CNS narcosis

No specific antidote

Specific Chemical Burns: Treatment

Hydrofluric Acid
Most tissue reactive inorganic acid Fluoride ion penetrates & binds tissue
Ceases when it combines with Ca or Mg Burns greater than 5%TBSA can be life threatening

Acute Tx: copious irrigation with H2O or Zephiran (benzalkonium chloride) Topical calcium gluconate gel or Epsom salts If pain persists, inject 10% Ca gluconate into site Intraarterial and IV infusions with Bier block

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Pediatric Burns
Scald burns most common burn in < 3 years Flame burns most common in children > 3 years Always consider child abuse

Pediatric Burns: Pathophysiology

Greater surface area per pound of body weight
Greater fluid needs Greater evaporative water loss Greater heat loss

Disproportionately thin skin

Burns may be deeper than initially assessed Requires less exposure time to result in burn

Pediatric Burns: Airway

Intubation performed by someone experienced Larynx more cephalad
More acute angulation of the glottis

Incuffed tube always used Cricothyroidotomy is never indicated Large bore needle placed through cricothyroid membrane may be used in emergency cases

Pediatric Burns: Circulatory Status

Burn > 10% BSA should be hospitalized IV Ringers Lactate is administered as per formula
Must also add maintenance fluid (4-2-1 rule)

NG tube Urinary catheter to monitor urine output:

<30 Kg: 1ml/Kg per hour >30 Kg: 30-50 ml per hour

If hypoglycemic, add 5% glucose to RL solution

Pediatric Patient: Wound Care

Stop burning process Remove all clothing Topical antibiotics not indicated before transfer Conserve heat with thermal blankets Escharotomy
Chest: ventilatory impairment Limb: vascular compromise

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Radiation Injury
Effects reproductive mechanism of certain tissue cells Mature cells suffer less damage Stem cells are more vulnerable to injury Large doses of radiation (> 2000 RAD) may lead to acute mortality

Outcomes Associated with Ranges of Whole Body Radiation

Whole Body Dose(RAD)
20-100 200-400

Response

Change in # of leukocytes Severe reduction in leuks, N/V, hair loss, death due to infection

600- 1 000 Destruction of mone marrow, diarrhea, 50% mortality within 1 month

1 000-2 000
2 000+

GI ulceration, death within 2 weeks

Death within hours due to severe damage to CNS

Types of Ionizing Radiation

Alpha particles
Large, highly charged particles Associated with decay of natural radioactive elements Penetrate only a few microns of tissue

Beta particles
Positive electrons or negatively charged particles Penetrate approximately 1 cm of tissue

Types of Ionizing Radiation

Gamma and X-rays
Radioactive decay or x-ray machines Penetrate deeply Once removed from source, no further radiation injury occurs Poses no threat to attendants

Protons, Deuterons, Neutrons, Mesons and Heavy Nuclei

Produced by equipment for medical and industrial use

Radiation Burns
Identical in appearance to thermal burns
Treat as you would a non-contaminated burn

Differ from thermal burns from time between exposure and clinical manifestation
SKIN RESPONSE TO RADIATION 200-300 (RADS) 300 1000-2000 2000 Epilation Erythema Transdermal Injury Radionecrosis

Toxic Epidermal Necrolysis (TEN)

Exfoliative deramatitis
Begins with target lesions, develop into papules & bullae Injury identical to partial thickness burn Mucosal involvement of conjunctiva & GI tract

Multiple eitiologies
Drugs (penicillins, sulfas, anti-inflammatories) Infection: (staph toxin, HSV, menigococcus, septicemia) Often unknown

Toxic Epidermal Necrolysis

TEN Type I
(Staph scalded skin syndrome) Only stratum corneum denuded Frequently in children Excellent prognosis 5% mortality

TEN Type II
( Stevens-Johnson syndrome) Separation is at the dermal/epidermal junction Adult population High mortality (2550%)

Initial Management of TEN

Steroids not indicated Systemic antibiotics limited to specific infection Fluid replacement Biologic dressing Maintain nutrition Prevent complications

Cold Injuries: Frostbite

Formation of ice crystals in the tissue fluids Occurs in areas that lose heat rapidly Three degrees of frostbite:
First degree: painful white or yellow firm plaque Second degree: painful superficial clear or milky blisters Third degree: deep red or purple blisters or skin color that is markedly changed

Severity influenced by both patient & environment factors

Cold Injuries: Treatment of Frostbite

Rapid re-warming in 4O degree water bath Avoid mechanical trauma - No massaging! Tetanus prophylaxis Escharotomy if vascularity compromised Tissue injury is often underestimated

Cold Injuries: Hypothermia

Defined as a core temperature < 34 degrees C Signs are vague & non-specific
May mimic other disease states

Treatment:
Limit stimulation of patient V.Fib easily induced Rapid re-warming i9n warm water bath Intubation to administer warm air Central administration of warm Ringers solution

Cold Injuries: Hypothermia

Monitor for systemic acidosis with serial ABGs
Treat with sodium bicarbonate

Cardiopulmonary bypass Cardiac monitoring

Ventricular dysrhythmia

Patients not to be declared dead until rewarmed

Continue CPR until core temperature> 36 degrees C.

Secondary assessment for contributing diseases

Hyperthermia: Clinical Syndromes

Heat Cramps
Result from excessive loss of salt by evaporation Experiences severe pain & cramping in muscles Tx: oral replacement of salt & water

Hyperthermia: Clinical Syndromes

Heat Exhaustion
Consequence of inappropriate cardiovascular response to stress of heat Diversion of blood to skin is not accompanied by vasoconstriction to other areas or by volume expansion Present with postural hypotension, profuse sweating, pallor, nausea, light-headedness Tx: oral replacement or IV normal saline if severe

Hyperthermia: Clinical Syndromes

Heat Stroke
Failure of body cooling mechanism
severe hyperpyrexia

Setting of physical exercise w/o acclimatization Present with temperature>103, no sweating, decreased LOC Tx: rapid cooling until temperature <102 deg If shivering develops, slowly give IV Thorazine DIC frequently reported

Tetanus Immunization
CLINICAL FEATURES Age of wound Configuration
Mechanism

TETANUS-PRONE WOUNDS > 6 Hours Stellate, avulsion

Missile, crush, heat, cold Signs of Infection Present Devitalized Tissue Present Contaminants Present

CLEAN WOUNDS <6 Hours Linear, abrasion Sharp surface

Absent Absent Absent

Tetanus Immunization
History Of Tetanus Clean Wounds TD1 TIG yes yes yes no no no no no Tetanus-Prone Wounds TD1 TIG yes yes yes no yes yes no no

Uncertain 0-1 2 3 or more

Consider patient partially immunized if:

**For a clean wound, if last Td given > 1O years ago **For a dirty wound, if last Td given > 5 years ago

The End!