How can you estimate total body surface area for an adult burn?
- patient’s hand is about 1%
- rule of 9s (leg = 18, anterior torso = 18, posterior torso = 18, head = 9, arm = 9)
How can you estimate total body surface area for a pediatric burn?
- head and neck = 18%
- arms = 9%
- anterior trunk = 18%
- posterior trunk = 18%
- legs = 14%
Describe volume resuscitation for burn victims.
- use American Burn Life Support consensus formula when TBSA > 20%
- formula is 2 x TBSA x kg
- give the first half in the first 8 hours and the second half in the next 16 hours
- target UOP of 0.5mL/kg/hr for adults and 1mL/kg/hr for children
- change fluids by 10% each hour in response to urine output and hemodynamics
What are the indications for intubating a burn victim?
- worsening hypoxemia or cyanosis
- massive volume resuscitation
- vocal cord edema, stridor, or hoarseness
- significant facial or pharyngeal edema
- soot on vocal cords
Damage to the lower airways in a burn victim is caused by what?
inhaled toxins
After intubating a burn victim, what should be the next step?
bronchoscopy
Describe the presentation, diagnosis, and treatment of carbon monoxide poisoning in burn victims.
- present with seizures, altered mental status, lactic acidosis (cellular hypoxia), arrhythmias, and myocardial ischemia
- diagnose with a carboxyhemoglobin level
- treat with high flow, 100% oxygen and serial carboxyhemoglobin measurements
- don’t wean O2 until carboxyhemoglobin is < 10%
- cannot use standard pulse ox to monitor
- if severe toxicity, can consider hyperbaric oxygen
What are the normal ranges for carboxyhemoglobin?
non-smokers should be < 2%
heavy smokers could be up to 12%
When should you treat a burn victim for cyanide poisoning and how is it treated?
- concern for inhalation injury with unexplained hypotension or lactic acidosis
- there is no good diagnostic test so treatment is empiric
- treat with 5g of hydroxocobalamin (cyanokit), which neutralizes cyanide and allows for excretion in urine
- notably, treatment can induce transient hypotension and red coloring of the urine (not rhabdo)
Describe the use and side effects of the five primary burn antibiotics. Additionally what are the two main contraindications to use?
- bacitracin: gram positive coverage, may cause rash or nephrotoxicity
- mupirocin: used for Staph infections (not prophylaxis) and may cause irritation
- silver sulfadiazine: used for 3rd degree burns and has gram negative coverage, may cause neutropenia or thrombocytopenia
- mafenide acetate: used for 3rd degree burns and has gram negative and pseudomonas coverage, may cause metabolic acidosis
- silver nitrate: used for 3rd degree burns with gram positive and negative coverage, may cause methemoglobinemia/hyponatremia/staining of the skin
- silver sulfadiazine is contraindicated with sulfa allergy
- silver nitrate is contraindicated with G6PD deficiency
What are the degrees of frostbite?
- 1: numbness, edema, firm plaque
- 2: partial thickness, milky white blister
- 3: full thickness, hemorrhagic blister, black eschar
- 4: extends to the bone, black, mummified tissue
Describe the temperatures and symptoms of mild, moderate, and severe hypothermia.
- mild (90-94): shivering and mild mental status changes
- moderate (84-90): agitated, muscle spasticity, dilated pupils, slow respirations
- severe (70-84): prolonged QRS, Osborn (aka J) waves, Vfb, flaccid, comatose
How do you treat frostbite?
- treat the hypothermia first
- perform rapid active rewarming in heated water
- debride deeper injuries
- drain milky/clear blisters but not hemorrhagic ones
Where should you use a full-thickness skin graft?
cosmetically or functionally sensitive areas (e.g. face, over joints, etc.)
What are the downsides of a full thickness graft?
- more elastin in the dermis causes primary contracture immediately after harvest
- worse cosmesis of donor site
- cannot be meshed to increase surface area
Describe a chest escharotomy.
- mid-axillary lines bilaterally
- connected by bilateral incisions along costal margin and curvilinear incision below the clavicles
- carry down to normal subcutaneous tissue and make sure the ends of incisions make it onto normal skin
Describe upper extremity escharotomies.
- ulnar incision should go down to the base of the 5th proximal phalanx be placed anterior to the medial epicondyle of the humerus to void injury to the ulnar nerve
- radial incision can go to the base of the thumb
- thumb is released on the radial side and the other fingers on the ulnar side
- an additional two dorsal incisions may be made over the second and fourth metacarpal to release deep muscles of the hand
Where are neck escharotomies performed?
posteriorly and laterally to minimize the risk of damaging carotid arteries or jugular veins
Describe lower extremity escharotomies.
- the medial incision should be placed posterior to the medial malleolus to avoid injury of the great saphenous vein or saphenous nerve
- the mid-lateral incision should be curved around the fibular neck to avoid injury of the common peroneal nerve.
When would you consider extubating a patient with inhalation injury?
generally swelling gets worse over 72hrs, after that, and if resuscitation has slowed, can consider as long as there is a cuff leak
What burn wounds require operative debridement? When should this occur?
- third degree wounds necessitate debridement and grafting
- this should be performed in the first 72hrs
Describe burn wound debridement.
- tangential excision of burned tissue
- hemostasis achieved with judicious use of cautery and epinephrine-soaked telfa
- use a dermatome to take a graft
- mesh the graft
- cover with a wound vac to prevent post-operative shearing
- consider splinting the joint if over one
