Module 3 Advanced: Burn Treatment and Stabilization

The basics of initial burn assessment and management, estimate TBSA percentage of burn, fluid resuscitation and urine output, analgesia and sedation, and discuss follow-up care and/or transfer criteria.

17:01 minutes

Next: Module 4 Advanced: Special Treatment Considerations

Burn Surge Videos

Transcript

Dr. Gayken: The third module, we're going to talk about burn treatment and stabilization. We're going to describe the basics of initial burn assessment and management. We'll estimate the total body surface area of a burn. We'll talk about fluid resuscitation and what it means to urinary output. We'll talk about analgesine sedation, and we'll discuss some of the follow-up care and transfer criteria.

The initial care is to stop the burning process. You also want to look at the initial resuscitation flow like any other trauma patient where you want to assess the airway, the breathing, circulation, disability, exposures of other extremities and areas of the body and then begin your fluid resuscitation.

Again, don't be overwhelmed with the burn. Lose sight of your natural algorithm of caring for patients. When assessing the airway and breathing on a burn patient and or trauma patient, don't take any one of these changes or physical diagnoses as an indication to intubated patient, but rather take the story as a whole. If you have a patient with singed nasal hairs and that alone, that's not an indication to intubate a patient. However, if you have singed nasal hairs with a hoarse voice, a large percentage total body surface area that was in a closed space resulting in respiratory fatigue or a patient utilizing his accessory muscles, then these are reasons to control a patient's airway and intubate.

Circulation, we want you to assess for pulses in extremities and their hemodynamic stability. Again, look for areas that are bleeding or areas that are not being profuse due to trauma. If there's active hemorrhage, control to direct pressure, and if this fails, you may require a tourniquet or surgical control. The burn will remain stable throughout the hemorrhage, and so think of it after you've moved through the first few bullet points. You resuscitate with crystalloid at a predetermined rate that we'll talk about later. However, if the patient is hypotensive and has low blood pressure, treat that first with bolus fluid therapy. This is the only time you'll treat a patient with bolus therapy. Circulation, you may need to place arterial lines for accurate monitoring as this tissue on the extremities may be extremely burned and become very swollen and have the inability to use blood pressure cuff measurements. You want to monitor and trend central venous pressures. You want to monitor bladder pressures and compartment pressures of the affected extremities. You want to monitor for ongoing traumatic injury such as intracranial hemorrhages, bowel injuries, etc... Remember, just because what you see on the outside can be distracting, they may have injuries on the inside.

Burn wound management in the local cares is important. We begin by cleaning the wounds very thoroughly with a surgical scrub and then assessing the wound depth and whether or not an escharotomy is going to be required. Skin grafting may be required, however, and we do recommend surgical intervention in the first 72 hours. This is the period of time that patients are going through resuscitation and going to the operating room would actually be or could be detrimental to them.

Local wound care, basically you want to debride and remove all loose tissue from the burn. This is just dead tissue. If it wipes off or looks like a big blister, it needs to come off. It's only a source of infection. We wash all the wounds with soap and water, Hibiclens, Betadine, etc. You place the full thickness, third-degree burns, in Silvadene or into a bacitracin dressing, loose fitting. Partial thickness burns you can place in Silvadene, but however, it builds up a pseudoeschar that can be difficult to remove and it's very painful to scrub off, so bacitracin or triple antibiotic ointment is preferred. First-degree burns are placed in aloe vera cream or a lotion or bacitracin. You want to repeat this step of washing and replacing the topical ointments daily. These are some of the dressings and creams that we use at our facility. There are other options for caring for burns other than the daily topical ointments, and these are that of the extended wear such as Acticoat and Mepilex. These are silver-based dressings that can usually remain in place for at least three to five days.

When estimating total body surface area, there are a number of methods that we use. One of the most common is that of utilizing the palmar surface size of the patient. Now remember, my palm is a lot larger than 1% of the body surface area of a ten-month-old. So, remember to use the patient's palm and not your own when estimating the burn size.

The rule of nines is different for that of children and adults in that the children's heads are larger compared to the rest of their body and they're granted 18% of their total body surface area for the head and their legs are smaller, whereas adults, you have 9% of the total body surface area for your head, 18 for front and back, 9 for each arm and then 18 for each lower extremity. We use at our burn center the method of Lund and Browder, and this is where you break down each subcategory of the body given a total percentage of that area and that is how you calculate the total body surface area or TBSA. It's just a more accurate method of calculating burn surface area than the rule of nines.

Dr. Mohr: Next, we'll talk about fluid resuscitation. To help understand the interplay between fluid resuscitation and tissue edema, we use the soaker hose analogy. As more and more fluid pressure comes through the hose, more and more leaks out into the surrounding grass. This is very similar to what happens in the vasculature when more fluid volume given results in more tissue edema and third space. The goal is to continue blood flow to the kidneys without causing hypotension or significant excess volume. Urine output is our marker of intravascular volume and is what we still use to titrate our IV fluid rates. Although there is literature describing different ways to restore intravascular volume after a burn utilizing colloid or hypertonic saline, the use of crystalloids is what the Parkland formula and the modified Brooke formula, the two most commonly used formulas in burn care throughout the world.

We will concentrate on crystalloid resuscitation. One of the important aspects of crystalloid resuscitation is that we gradually titrate the IV fluid rate so that we maintain urine output, but minimize the amount of third space fluid, the fluid that leaks out into the tissues a let the soaker method, and we do not use bolus therapy unless you have a patient who is hypotensive. What we're trying to do is match the capillary leak rate with the IV fluid rate to maintain perfusion to the kidneys, and that way, the kidneys are like the canary in the coal mine. They are our sensitive barometer to adequate perfusion and maintaining an adult urine output of 30-50 milliliters per hour as adequate perfusion. For other individuals, using one-half CC per kilo of their ideal body weight is also acceptable. The ABA recommended fluid resuscitation rate in the pre-hospital setting, meaning coming to your facility, would be for adults 500 milliliters an hour, for pre-teens and older children it's half of that, or 250 milliliters an hour, and for pre-school children, it's half of that, or 125 milliliters an hour. Ongoing resuscitation for second and third-degree burns only that you would use at your burn surge facility would be, for adults, starting off at two milliliters per kilogram per percent burn totaled over the first 24 hours. For children, three milliliters and for any high-voltage electrical injury or evidence of rhabdomyolysis, you would use four milliliters per kilogram per percent burn.

The fluid of choice for burn resuscitation is Ringer's Lactate. Although normal saline can be used in the pre-hospital setting, once large volumes of normal saline is used, the patient develops a hyperchloremic metabolic acidosis, so only LR for burn resuscitation while at the burn surge facility. When the patient is not making their target urine output, the fluid amount should be increased by 10% each hour. Albumin is often used to re-establish appropriate urine output at different times during the resuscitation, but should be done in consultation with the burn center collaboration. It's important to remember that titration of the fluid amount should go both up and down based on the urine output targets, meaning that if the patient is making more than their target urine output volume, the IV fluid should be turned down. This is as important as increasing IV fluid based on low urine output. One of the important complications from burn resuscitation can be compartment syndrome. This occurs when the capillary leak results in so much tissue edema that it puts pressure on inflexible tissue spaces, putting pressure on both nerves and arterial in-flow and venous out-flow. This can cause vascular compromise to distal structures and a limb-threatening ischemia. Things to look for are progressive pain, pain with passive stretch of the extremities, sensory changes including paresthesias. By the time that circulatory changes are noted, this tends to be a later finding and when in doubt, you may be asked to check compartment pressures.

When should you intervene for compartment syndrome? Certainly when the pressure achieves 30 millimeters of mercury. When you are having significant end organ perfusion problems, either in the hand or the kidneys or lungs. If you're talking about the abdominal compartment, once the pressures are 20 millimeters of mercury plus end organ perfusion problems should prompt an intervention. Escharotomy through third-degree burns are indicated to alleviate the pressure and restore perfusion. Fasciotomy is necessary when pressures in the muscular compartments still exist despite escharotomy. When treating these patients both in the initial phase and the ongoing subsequent 72 hours, you want to make certain that you're using your normal algorithms for pain treatment and the also assessing periodically or frequently for ongoing needs of both sedation and pain control.

Pain and analgesic treatment should be assessed hourly and also needs to be added on for procedural pain such as if you're going to perform escharotomies or dressing changes. There are a couple of different types of pain that burn patients are going through. Both the pharmalogical that we consider most notably, surgical or procedural pain, and then also the behavioral. The pharmalogical management of pain should be scheduled and not administered on a PRN basis, all the while maintaining or making sure to assess airway compromise if the patient has not been intubated. You want to also augment pain medications with antianxiety medications. You want to treat the background pain and procedural pain as discussed earlier. You want to manage the side effects for any of these pain medications and to assess their respiratory depression frequently. You want to treat the pain and anxiety in a 2:1 ratio, and again, I want you to use your best judgment when caring for these patients, and remember the elderly and the very young may have a build up to these medications.

And finally, we're going to discuss the follow-up care and transfer criteria. Typically, at our center we use bacitracin and adaptic dressings to cover our wounds as Silvadene alters the appearance and creates what's called a pseudoeschar. Silvadene is okay for very deep and infected wounds. However, for wounds that are partial thickness, I typically steer away from Silvadene, and I use bacitracin or a triple antibiotic ointment. You want to make sure that the patients have the ability to get enough of their dressings and supplies that are needed to care for their burn wounds. You want to make sure they have pain medications that can get them through until their next visit to the burn center. You want to make certain that you've updated their tetanus, follow up with any possible face burns and corneal abrasions, and you want to make certain that the patient knows how to and can get in contact with the consulting burn centers.

Typically, we see our burn patients after discharge within one to two weeks. Our referral criteria for burn patients is nicely laid out by the American Burn Association, and typically, if you have a total body surface area burn greater than 10%, a third-degree burn, burns that encompass the face, hands, feet or genitalia or injuries that are resulting from electrical injuries should be referred to our burn center. Also, patients that have associated inhalation injuries and or chemical injuries or bad or extensive preexisting conditions should be referred to a burn center and as noted earlier, our centers is also a Level 1 trauma center, and so treating patients for associated trauma as well as their burns is an indication for transfer. And then, of course, patients that are very young or very old or have special social needs or emotional or rehab requirements.

When you're prepping a patient for transfer, I want to make sure that we consider other life-threatening injuries first. You want to secure all lines and tubes. You want to place the burns in dry, sterile dressing, and you want to not wait for imaging labs, but make certain that we have the ability to get those or have the ability to send them along with us. Again, update the tetanus. As noted earlier, you want to place the patient on continuous IV fluids. You can either use the Parkland formula or going back to the age-based resuscitation for transfer is less than five-year-olds, 125 cc per hour. Adolescents and young adults, 250 cc per hour. Fifteen years and older adults you can place on 500 cc an hour for transfer. Decipher whether the patient requires air or ground transport and then whether or not the patient should be directly admitted to a burn center or able. Guidelines for safe transfer is to keep the patient warm and dry. Do not place in wet dressings as this contributes to hypothermia. We want you to secure the airway if necessary before transport. Initiate the fluid resuscitation. Place a Foley catheter so we can monitor resuscitation. Date the tetanus prophylaxis and continue pain and anxiety sedation. Remember, no bolus therapy unless the patient is overtly hypotensive. This is a laundry list of some of the facilities that we use for transfer and some of their associated dispatch numbers.