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PL20 Plastic Surgery
Burns Toronto Notes 2019 Indications for Transfer to Burn Centre
American Burn Association Criteria
• patientswithpartialorfull-thicknessburnsthatinvolvethehands,feet,genitalia,face,eyes,ears,and/or major joints or perineum
• partialthicknessburns≥20%TBSAinpatientsaged10-50yrold
• partialthicknessburns≥10%TBSAinchildrenaged≤10oradultsaged≥50yrold
• fullthicknessburns≥5%TBSAinpatientsofallages
• electricalburns,includinglightning(internalinjuryunderestimatedbyTBSA),andchemicalburns
• inhalationinjury(highriskofmortalityandmayleadtorespiratorydistress)
• burninjuriesinpatientswithmedicalcomorbiditiescouldcomplicatemanagementandrecovery
• anypatientwithsimultaneoustraumaplusburnsshouldbestabilizedfortraumafirst,thentriaged
appropriately to burn centre
• anypatientswithburninjuryandwhowillrequirespecialemotional,social,andrehabilitation
intervention
• childrenwithburnsinahospitalnotequippedwithpediatriccarespecialists
Acute Care of Burn Patients
• adheretoATLSprotocol
• resuscitationusingParklandformulatorestoreplasmavolumeandcardiacoutput.Parklandformula
is a starting estimate and patients may require more volume. Other formulas exist, but the Parkland formula is predominately used in North America
■ 4 cc/kg x %TBSA (greater than first degree) x wt(kg) (1/2 within first 8 h of sustaining burn, 1/2 in next 16 h)
• extrafluidadministrationrequiredif ■ burn>80%TBSA
■ 4° burns
■ associated traumatic injury
■ electrical burn
■ inhalationinjury
■ delayed start of resuscitation ■ pediatric burns
• monitorresuscitation
■ urine output is best measure: maintain at >0.5 cc/kg/h (adults) and 1.0 cc/kg/h in children <12 yr ■ maintain a clear sensorium, HR <120/min, MAP >70 mmHg
• burn-specificcare
■ relieve respiratory distress: intubation and/or escharotomy
■ escharotomy in circumferential extremity burn, including digits
■ prevent and/or treat burn shock: 2 large bore IVs for fluid resuscitation
■ insert Foley catheter to monitor urine output
■ identify and treat immediate life-threatening conditions (e.g. inhalation injury, CO poisoning)
■ determine TBSA affected first, since depth is difficult to determine initially (easier to determine after
24 h)
• tetanusprophylaxisifneeded
■ all patients with burns >10% TBSA, or deeper than superficial-partial thickness, need 0.5 cc tetanus toxoid
■ also give 250 U of tetanus Ig if prior immunization is absent/unclear, or the last booster >10 yr ago
• baselinelaboratorystudies(Hb,U/A,BUN,CXR,electrolytes,Cr,glucose,CK,ECG,cross-matchif
traumatic injury, ABG, carboxyhemoglobin)
• cleanse,debride,andtreattheburninjury(antimicrobialdressings)
• earlyexcisionandgraftingimportantforoutcome
Respiratory Problems
• 3majorcauses
■ burn eschar encircling chest
◆ distress may be apparent immediately
◆ perform escharotomy to relieve constriction ■ COpoisoning
◆ may present immediately or later
◆ treat with 100% O2 by facemask (decreases half-life of carboxyhemoglobin from 210 to 59 min)
until carboxyHb <10%
■ smoke inhalation leading to pulmonary injury
◆ chemical injury to alveolar basement membrane and pulmonary edema (insidious onset) ◆ risk of pulmonary insufficiency (up to 48 h) and pulmonary edema (48-72 h)
◆ watch for secondary bronchopneumonia (3-25 d) leading to progressive pulmonary
insufficiency
◆ intubate patient with any signs of inhalation injuries
Inhalation Injuries 101
• Indicators of inhalation injury
• Injury in a closed space
• Facial burn
• Singed nasal hair/eyebrows
• Soot around nares/oral cavity
• Hoarseness
• Conjunctivitis
• Tachypnea
• Carbon particles in sputum
• Elevated blood CO levels (i.e. brighter red)
• Suspected inhalation injury requires
immediate intubation due to impending airway edema; failure to diagnose inhalation injury can result in airway swelling and obstruction, which, if untreated, can lead to death
• Neither CXR or ABG can be used to rule out inhalation injury
• Direct bronchoscopy now used for diagnosis
• Signs of CO poisoning (headache, confusion, coma, arrhythmias)