Burns

Management of Moderate and Severe Burns

Melanie Madsen, MD

University of Minnesota, Department of Pediatrics

Outline

• Epidemiology
• Physiology and Classification
• Management
• Ongoing Management
• References

Epidemiology

• 400,000 children are treated annually for burns
• fires and burns are a leading cause of household accidental deaths in children less than 14 yo
• 80% of burns are secondary to house fires, the remainder due to scalds and electrical burns
• children up to 4 yo account for 47% of house fire deaths
• 3,000 pediatric deaths annually due to burns, 3-4X this suffer disability
• 50% of children with burns require up to 1 month hospitalization, and 25% require up to 2 months of hospitalization, 25% require more than 3 months hospitalization
• 1%-16% of burns are intentionally inflicted
• children less than 15 yo with burn injury > 95% of BSA can survive

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Physiology and Classification

Based on depth of injury, percent of body surface areas involved, location of the burn, and association with other injuries.

Injury:

• First Degree: superficial, involving only epidermal damage
  • erythematous and painful due to intact nerve endings
  • heal in 5-10 days; pain resolves within 3 days
  • no residual scarring
• Second Degree: partial thickness, involving the epidermis and dermis
  • more superficial burns are moist and blister; deeper burns are white and dry, blanch with pressure, and have reduced pain
  • heal in 10-14 days
  • can develop into third degree burns with infection, edema, inflammation and ischemia
  • treatment varies with degree of involvement - grafting is indicated for deep burns
• Third Degree: full-thickness, most severe of burns
  • results in necrosis and avascular areas
  • tough, waxy, brownish leathery surface with eschar, numb to touch
  • grafting required
  • usually have permanent impairment
• Fourth Degree:
  • full-thickness as well as adjacent structures such as fat, fascia, muscle or bone
  • reconstructive surgery is indicated
  • severe disfigurement is common

Body Surface Area (BSA):

• Adult
  • · "rule of nines": each arm is 9% of BSA, leg is 18%, anterior trunk is 18%, posterior trunk is 18%, head is 9%, and perineum is 1%
• Children
  • BSA varies with age (children have a larger percentage of body surface area which exaggerates fluid losses)
  • children under 10 yo should be evaluated by the Lund-Browder burn chart (see chart)
  • quick method : the patient's palm is 1% of the total body surface area

Location:

• Important for assessing potential disability
• greatest risk with face, eyes, ears, feet, perineum and hands
• Upper extremities involved in 71% of burns, head and neck 52%

Associated Injuries:

• Smoke inhalation
• hoarseness, cough, singed nasal hairs, oral burns, wheezing
• Carbon monoxide poisoning
• Fractures
• Trauma

Severity:

• Minor:
  • partial thickness: < 15% BSA in adults, < 10% BSA in children
  • full thickness: < 2% BSA
• Moderate:
  • partial thickness: 15%-25% BSA in adults, 10%-20% BSA in children
  • full thickness: 2%-10% BSA
• Major:
  • partial thickness: > 25% BSA in adults, > 20% BSA in children
  • full thickness: > 10% BSA
  • burns of hands, face, eyes, ears, feet or perineum
  • associated injuries, such as inhalation injury, fractures, other trauma
  • poor risk patients with underlying disease or suspicion of child abuse

Complications

• Dehydration and shock
• Renal failure secondary to myoglobinuria or isovolemia
• Sepsis
• Physical impairment/limitations
• Cosmetic disfigurement
• Death

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Management of Moderate and Severe Burns

Initial Management:

ABC: Airway, Breathing and Circulation

• oxygen to all patients, intubate if there is airway, respiratory or neurological compromise
• pulmonary disease is progressive and may have a delayed onset of 24 hours
• laryngeal edema increases during the first 24 hours
• common to have burns of the upper airway - usually the subglottic area is protected from burns
• intubation is indicated with deep facial burns, inhalation injury documented by bronchoscopy or
• laryngoscopy, and with massive thoracic burns which interfere with adequate respiratory movement (due to decreased compliance of the chest wall)
• avoid early tracheostomy
• IV fluid resuscitation with large bore catheters (*LR or NS)
• avoid placing PIV through burned tissue because of increased risk of infection
• until fluid/electrolyte needs are calculated, can start at 20 ml/kg/hr
• shock is common when the burn exceeds 12% BSA
• cardiac output decreases almost immediately due to hypovolemia
• remember-hypotension is a late event and needs to be treated aggressively

Wound care

• sterile technique should be observed
• remove clothing and cover or irrigate the wound with cool saline
• careful to avoid hypothermia
• debride dead material and ruptured vesicles; blisters should be left intact unless at flexor areas
• after cleansing, apply antimicrobial cream with a fine mesh absorbent dressing (no dressing to face and perineal burns)
• initially burn surfaces have no or reduced bacterial colonization, so treatment with antimicrobrial creams should wait until the patient is stabilized (should be undertaken within a few hours of the injury)
• antibiotic creams:
  • 1% silver sulfadiazine is the preferred first-line preventative agent for eschar, not as ongoing treatment for deep burns (can cause thrombocytopenia, leukopenia, and rash)
  • neosporin or bacitracin are excellent for facial burns (nontoxic to the eyes) but should not be used on large areas
  • mafenide acetate penetrates eschar well but is painful during application and causes bicarbonate wasting
• surgical consultation for removal of eschar (eschar may interfere with neurovascular function of extremities and of ventilation when present at the thorax)
• attention should be placed on distal pulses - circumferential burns can cause eschar that when combined with edema can impede distal perfusion

Curlings ulcer prophylaxis (Peptic Ulcer)

• An H2 blocker (cimetidine, ranitidine or the like) should be started within the first 6 hours
• antacids are no longer recommended - the patient should be kept NPO

Pain management

• once vital signs have stabilized, pain medication should be used (ie morphine or meperidine)

Miscellaneous

• with burns > 15% of BSA, an NG (OG) tube and bladder catheter should be placed
• tetanus immunization if out of date

Hospitalize

• injuries > 10-15% of BSA involving the hands, face, feet, perineum or joints
• electrical injuries with deep tissue involvement
• patients with other associated injuries

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Ongoing Management:

Neuroendocrine responses

• in the first 24 hours, the brain releases ACTH and ADH (as a response to pain, hypoxia and hypovolemia) and catecholamine secretion is accelerated
• hypoglycemia is common in children (hyperglycemia in adults)
• ADH causes antidiuresis, and increased aldosterone activity results in sodium retention, edema and oliguria
• after 24 hours the patient begins a hypermetabolic phase with increased cardiac output, increased oxygen consumption, and increased tissue catabolism
• will see a 1-2 degree (C) increase in body temperature due to increased metabolism
• cardiac output increased due to increased oxygen demand
• insulin levels normalize but hyperglycemia may persist due to increased cortisol secretion

Fluid and Electrolyte management

• includes normal maintenance plus replacement of burn losses
• denuded skin produces a 6-7 fold increase in evaporative losses, and exudative losses (blisters) have a protein content half of the serum protein
• burn requirements (per day): 3-4 ml x kg x % BSA involved (as a number: 70% is 70)
• Day 1:
  • use 5% dextrose Lactated Ringers solution
  • administer half of the burn replacement fluid amount over the first 8 hours, giving the remainder over the subsequent 16 hours (calculate time for replacement from time of injury, not from the initial medical presentation; ie if patient arrives 2 hours after the incident replace the initial fluid requirements over 6 hours)
  • in addition to the burn replacement, give maintenance requirements over 24 hours
  • can also use the surface area formula (Galveston formula): 5,000 ml/m2 of body surface burned per 24 hours plus 2,000 ml/m2 of total body surface per 24 hours (maintenance)
  • part of the burn replacement can be given as colloid
  • albumin extravasates into the tissues until about 8 hours post injury, but colloid helps maintain the intravascular osmotic gradient (thus reducing edema) and promotes faster resuscitation than crystalloids
  • solution of 5% dextrose LR (950 cc) and 25% albumin (50 cc) is often used for children over 1 yo; less sodium is needed for infants to prevent hypernatremia
  • do not add potassium in the fluids for the first day because injured cells release potassium into the extracellular fluid; after 24 hours potassium phosphate may be added to fluids
  • consider placement of CVP line if fluid status is tenuous
  • foley should be placed to monitor urine output - minimum urine output is 1 ml/kg/hr with ideal output at 2-
  • 3 ml/kg/hr (1-1.5 ml/kg/hr is adequate if there is concern for pulmonary edema) or 30 ml/m2/hour
  • exact urine output is controversial because increased fluid administration will increase urine output, but an imbalance occurs because of ADH anti-diuresis effect (poor indication of hydration status)
  • 4-hour trends rather than 1-hour analysis should be observed
  • *fluid requirements need to be continuously assessed given the patient's status, and will often vary from the initial plan
  • total fluid replacement can be as high as 6.3 +/- 2.2 ml/kg/%BSA
• Day 2:
  • use 5% dextrose crystalloid at one-half to 3/4 of previous day's requirements; or 1500 ml/m2 BSA/24 hr plus 3750 ml/m2 BSAB/24 hr
  • 5% albumin should be used at 0.5 g / kg / % BSA (as a number, not a %)
  • fluid and protein losses into the interstitium are decreased after the second day, but evaporative losses from the disrupted skin continue
  • evaporative losses are primarily free water and should be replaced as such (sodium requirements are decreased)
  • mobilization of edema fluid into the vascular space occurs around the third or fourth day
  • the patient is susceptible at this time to hypervolemia and congestive cardiac problems - diuretics are usually indicated as well as avoidance of sodium loading

Pulmonary management

• repeated laryngoscopy and bronchoscopy may be indicated
• with pulmonary involvement, aggressive pulmonary toilet is indicated to maintain the small airways:
  • humidified oxygen, chest physiotherapy, aerosolized bronchodilators and frequent repositioning
• prolonged intubation may be indicated secondary to repeated surgeries and use of narcotics mechanical ventilation also reduces the metabolic demand on the body by decreasing the work of breathing
• tissue edema begins to resolve in 2-3 days,however pulmonary function decreases with each and every debridement of excision (this should be anticipated when considering extubation)

Cardiovascular

• cardiac output and oxygen consumption increase by 2-3X after the injury
• decreased intravascular volume due to interstitial edema secondary to leakage
• correct hypoproteinemia with FFP
• anemia occurs secondary to erythrocyte damage from the initial injury and due to increased losses secondary to increased fragility from inflammatory mediators, as well as bone marrow suppression

Renal

• muscle breakdown occurs with > 30% total BSA burns causing myoglobinuria--this necessitates alkanization and close monitoring

Pain management

• morphine, fentanyl, and benzodiazepines as indicated

Infection

• do not give antibiotics prophylactically, but only as indicated
• the risk of pulmonary infections is greatest 1-2 weeks after the injury
• serial surveillance skin cultures are usually undertaken to monitor possible infection
• currently fungi and gram- negative bacteria are major causes of infection given current topical antibiotic regimen
• avoid cold or ice dressings to maintain appropriate body temperature

Nutrition

• burns produce an extreme catabolic state (more so than other diseases)
• maintenance requirements of 1800 kcal/m2/day plus burn requirements of 2200 kcal/m2/day
• enteral nutrition should be started ASAP given increased metabolic demands (usually the second day)

Rehabilitation

• Involve rehabilitation as soon as the patient is stabilized

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References

• Barkin, RM and Rosen, P: Emergency Pediatrics: A guide to Ambulatory Care, fourth edition, St. Louis, 1994, Mosby Year Book, pp 293-297.
• Blumer, JL : A Practical Guide to Pediatric Intensive Care, third edition, St. Louis, 1990, Mosby Year Book, pp 158-161.
• Carvajal, HF "Fluid resuscitation of pediatric burn victims: a critical appraisal" Pediatric Nephrology (1994) 8: 357-366.
• Carvajal, HF and Griffith, JA "Burn and Inhalation Injuries" in Fuhrman, BP and Zimmerman JJ: Pediatric Critical Care, St. Louis, 1992, Mosby-Year Book, pp 1209-1220.
• Finkelstein, JL et al "Pediatric Burns" in Pediatric Clinics of North America (October 1992) vol 39, number 5, pp 1145-1163.
• Foster, JE II and Ford, EG "Burn Injury" in Ford, EG and Andrassy RJ: Pediatric Trauma: Initial Assessment and Management, Philadelphia, 1994, W.B. Saunders Company, pp 291-309.
• Herndon, DN et al, "Management of Burn Injuries" in Eichelberger, MR: Pediatric Trauma: Prevention, Acute Care, Rehabilitation, St. Louis, 1993, Mosby-Year Book, pp 568-590.
• Parish, RA "Thermal Burns" in Barkin, RM: Pediatric Emergency Medicine: Concepts and ClinicalPractice, St.Louis, 1992, Mosby-Year Book, pp 424-429.
• Peate, WF "Outpatient Management of Burns" American Family Physician (1992) vol 5, number 3, pp1321-1330.

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This page is meant for educational purposes only

Questions or comments regarding this handout should be directed to the author Melanie Madsen at: mmadsen@inet-serv.com

This page last updated 6/2/97