Urgent Care Burn Management. Neil Uspal Division of Emergency Medicine Seattle Children s Hospital October 6 th, 2017

Transcription

1 Urgent Care Burn Management Neil Uspal Division of Emergency Medicine Seattle Children s Hospital October 6 th, 2017

2 Objectives Epidemiology of Burn Injuries Classification of Burns Initial Burn Management Disposition Minor Burn Treatment Special Cases

3 Burns Epidemiology >120,000 cases to EDs / year Third leading cause of unintentional injury in children Children <6 years old majority of pediatric burns 60% thermal burns, 26% scalds, 9% chemical, 3% electrical, 3% radiation* 94% patients managed as outpatients D Sousa Pediatrics 2009

4 Burn Related Injury Rates D Sousa Pediatrics (2009)

5 D Sousa Pediatrics (2009)

6 Classification of Burns Depth Involved Total Body Surface Area (TBSA)

7 Burn Depth First, Second, Third Degree Burns Superficial, Superficial partial-thickness, deep partialthickness, full thickness Fourth Degree burn terminology sometimes used Burn heterogeneity, evolution with time Volar forearms, medial thighs, perineum, and ears deeper than initial appearance Children < 5 thin skin

8 Burn Depth Rice UpToDate (2017)

9 Lloyd Am Fam Physician (2012)

10 Superficial Burns Involve the epidermis only Do not blister Do not include in %TBSA Painful, red, blanch with pressure Skin peeling at day 4

11 Haines Pediatr Emerg Med Pract (2015)

12 Superficial Partial Thickness Burns To upper dermis Bliisters; wet and weeping Painful Blanching Heal in 2-3 weeks Typically non-scarring

13 Lloyd Am Fam Physician (2012)

14 Deep Partial-Thickness Burns To the deep dermis Yellow / white / red Tend not to blanch Heal 3 weeks 2 months Often result in scarring and contractures

15 Haines Pediatr Emerg Med Pract (2015)

16 Full Thickness Burns To subcutaneous fat White to brown, firm leather like Non-painful Healing > 2 months Will require excision and grafting

17 Burn Depth Identification Kim J Paediatr Child Health (2012)

18 Burn Depth Identification 8 days Later Kim J Paediatr Child Health (2012)

19 Classification of Burns - TBSA Rule of 9s - Over estimates %TBSA in children <15 Age appropriate charts Lund and Browder 1% - hand rule Partial thickness burns > 10% TBSA burn center Partial thickness burns > 20% TBSA fluid resuscitation

20 Rice UpToDate (2017)

21 Palm AND FINGER Method

22 Case You are notified by a nurse that a 2-yearold male is being rushed back into an exam room after presenting to the lobby with an area of burn to his chest sustained 30 minutes ago How do you approach the initial care of this patient?

23 Initial Burn Management ABCs Irrigation of chemical burns Removal of clothes, jewelry Potential continued heat source Constricting rings Pain management

24 Burn Management Cooling Porcine models cold water applied for 20 minutes 1 Faster epithelization 2-3 weeks post burn Improve cosmetic outcomes Study in Viet Nam 33% vs 49% need for operative intervention in patients who had wound cooling prior to transfer to burn center 2 Cuttle Wound Repair Regen (2008) Nguyen Burns (2002)

25 Burn Management - Cooling 20 min optimum time for cooling 1 Running water superior to cold towels, gauze 2 Preferable ASAP, my be beneficial up to 3 hrs after injury 2 Ice / ice water worsens necrosis 1 Yuan J Burn Care Res (2007) 2 Kim J Paediatr Child Health (2012)

26 Does My Patient Need to go to a Burn Center?

27 Burn Center Referral Criteria 1. Partial thickness burns greater than 10% total body surface area (TBSA). 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 3. Third degree burns in any age group. 4. Electrical burns, including lightning injury. 5. Chemical burns. 6. Inhalation injury.

28 Burn Center Referral Criteria 7. Burn injury in patients with preexisting medical disorders that could complicate management, 8. Any patient with burns and concomitant trauma in which the burn poses the greatest risk of morbidity or mortality. 9. Burned children in hospitals without qualified personnel or equipment for the care of children. 10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

29 Burns Decision to Transfer In adults patients burn centers underutilized 1 Local guidelines (Harborview Medical Center) Other burns appropriate for outpatient f/u at burn center Burns < 3 cm, superficial burns PCP f/u Use judgement may transfer even if burns don t meet criteria Debride before determining burn size! Carter J Burn Care Res (2010)

30 Patient Transfer Consider 911 based on ABC assessment Minimize delays in transport Obtain IV access if possible Fluid resuscitate Boluses if hemodynamically unstable Multiple formulas (i.e. Parkland) for fluid management Cover burns with dry sheet, clear plastic wrap, or cloth Address potential for hypothermia

31 Minor Burns Few areas in medicine are fraught with as much mysticism, personal bias, and unscientific dogma as the care of the minor burn wound. Roberts and Hedges, 2009

32 Burn Care - Goals Prevent infection Create best environment for re-epithelization Adequately prepare parents for care at home

33 Principals of Wound Care Haines Pediatr Emerg Med Pract (2015)

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37 Minor Burn Care Clean with mild soap and water or water Debridement - sterile saline and gauze Rice UpToDate (2017)

38 Burn Blisters Bullae that form from local capillary leak between dermis and epidermis Reasons to preserve: Natural barrier to infection Wound healing factors in blister fluid Reasons to remove: Immunosuppressive factors in blisters Mechanical issues, potential for rupture Early research blisters > dry dressings

39 Blisters Larger blisters mechanical pressure may result in wound deepening Blister fluid numerous factors which promote and inhibit healing Debridement may promote more rapid return to function Less pain once blisters debrided, but can be a painful procedure

40 Blisters debridement General Guidelines Blisters < 6-10 mm can be preserved Larger blisters consider debridement Thin walled blisters, haired surfaces more likely to rupture, should be debrided Debride blisters that impede patient function Debride blisters that impair removal of non-viable tissue, burn asssessment Sargent J Burn Care Res (2006)

41 Blister

42 Blister Warner Surg Clin North Am (2014)

43 Debridement - Tips Partial superficial burns most painful! Oxycodone, Tylenol If need more inpatient Suture removal kit Blisters small cut, drain fluid, debride Wash, don t scrub Water, soap, one direction

44 Blister Opening

45 Blister Debridement

46 Wound Dressing General Principles Superficial burns moisturizers alone Superficial partial-thickness burns Longer healing time greater scarring Re-epithelialization is most rapid if wound is moist Dry scab barrier to re-epithelization Allow for full ROM, some swelling Keep it simple, replicable Supplies for families, plan for pain management

47 Wound Dressings - Antibiosis Goal avoid critical level of bacterial growth Initial gram positive colonization, later gram negative Possible Treatments Topical antibiotic ointments Silver Sulfadiazine Wound Membranes

48 Topical Antibiotic Ointments Bacitracin good gram positive coverage Polysporin, Neosporin gram + and negative coverage Mupirocin superior MRSA coverage, resistance can develop > 10 days Place on Vaseline impregnated or non-adherent gauze

49 Topical Antibiotic Creams Silver sulfadiazine Soothing, broad antimicrobial coverage OK in sulfa allergy trial of a test patch Impairs re-epithelialization in superficial partial thickness burns? Self resolving leukopenia Avoid on face can cause bleaching Good for deep burns, burns with eschar Mafenide acetate Penetrates deep tissues, painful Eschar, wounds overlying cartilage

50 Dressing changes Topical ointments / creams change daily 1 No difference in morbidity Decreased pain, increased satisfaction Families should remove dressings, gently wash area with soap and water Remove all old cream / ointment Advise to examine for signs of infection Reapply dressing as previous Sheridan J Burn Care Rehabil (1997)

51 Cleaning burns

52 Wound Membranes Advantages Decreased frequency of dressing changes often ~ every 5 days Generally superior healing vs SSD Disadvantages Cost Availability Inability to reassess wound Hydrocolloids, silver-containing, biosynthetics

53 Wound Membranes Hydrocolloids Comfeel, DuoDerm, Combiderm Form a gel that adheres to skin Low quality evidence of superiority vs other tx Biosynthetics Biobrane, TransCyte Designed to mimic dermis/epidermis Consistent but poor quality evidence superior to SSD Cost limitation in UC settings Wasiak Cochrane Database Sys Reviews (2013)

54 Wound Membranes Silver Impregnated Aquacel Ag, Acticoat, Contreet, etc Nanocrystalline structures sustained silver release Can be changed as infrequently as once per week Cochrane Review improved healing times, evidence of poor quality

55 Aquacel Ag Application

56 Mepilex AG Application

57 Heyneman Burns (2016)

58 Triple Antibiotic vs Silver Containing Foam Dressing Toussaint Acad Emerg Med (2015) Comparison of partial thickness burn treatments in a porcine model At 21 days 100% of abx ointment wounds epithelialized, vs 55% silver dressing (p<0.0001) Less scaring at 28 days in abx ointment group

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60 Special Circumstances Boos UpToDate (2017)

61 Burns Child Abuse Scalds clear line of demarcation, symmetric, lower extremities or perineum, absence of splatter Burns in a distinct shape History not consistent with findings Other evidence of abuse

62 Burns Child Abuse Haines Pediatr Emerg Med Pract (2015)

63 Special Circumstances Electrical burns Indication for burn center transfer Small area of skin burn may mask extent of injury EKG, cardiac monitoring, labs Chemical burns decontamination Protect staff decontamination protocol Remove clothes, wash area with water

64 Summary Accurate characterization of burn severity key to appropriate treatment Appropriate first aid can improve outcomes in patients transferred to burn centers Wound cleaning and debridement Consider debriding large, function reducing blisters Wide variety of topical treatment, unclear which are superior Be vigilant for abuse

65 Thank You!

66 References American Burn Association. Burn center referral criteria. Accessed September 13 th, Boos SC. Physical child abuse: recognition. In: UpToDate, Lindberg DM (Ed), UpToDate, Waltham, MA. (Accessed on September 20, 2017.) Burn Foundation. Early care and transfer of burn patients: a source manual for hospital emergency departments. 3rd Ed. 2010; Accessed September 13 th, Burns part I: injury grading. Accessed Sept 13 th, Carter JE, Neff LP, Holmes JH 4 th. Adherence to burn center referral criteria: are patients being appropriately referred? J Burn Care Res. 2010; 31: Cuttle L, Kempf M, Kravchuk O, et al. The optimal temperature of first aid treatment for partial thickness burn injuries. Wound Repair Regen. 2008; 16:

67 References D Sousa AL, Nelson NG, McKenzie LB. Pediatric burn injuries treated in US emergency departments between 1990 and Pediatrics. 2009; 124: Greenhalgh DG. Topical antimicrobial agents for burn wounds. Clin Plastic Surg. 2009; 26: Haines E, Fairbrother H. Optimizing emergency management to reduce morbidity and mortality in pediatric burn patients. Pediatr Emerg Med Pract. 2015; 12: Heyneman A, Hoeksema H, Vandekerckhove D, Pirayesh A, Monstrey S. The role of silver sulphadiazine in the conservative treatment of partial thickness burn wounds: a systematic review. Burns. 2016; 42: Kim LK, Martin HC, Holland AJ. Medical management of paediatric burn injuries: best practice. J Paediatr Child Health. 2012; 48: Lloyd EC, Rodgers BC, Michener M, Williams MS. Outpatient burns: prevention and care. Am Fam Physician. 2012; 85: Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of initial management: a case series of childhood burns in Vietnam. Burns. 2002; 28:

68 References Rice Jr PL, Orgill DP. Classification of burn injury. In: UpToDate, Jeschke MG, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on September 9, 2017.) Sargent RL. Management of blisters in the partial-thickness burn: an integrative research review. J Burn Care Res. 2006; 27: Sheridan RL, Petras L, Lydon M, Salvo PM. Once-daily wound cleaning and dressing change: efficiency and cost. J Burn Care Rehabil. 1997; 18: Tenenhaus M, Rennekamoff H. Local treatment of burns: topical antimicrobial agents and dressings. In: UpToDate, Jeschke MG, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on September 20, 2017.) Thomas L, Kman NE. Burns and Smoke Inhalation. Updated 2016, Accessed Sept 13 th, Yuan J, Wu C, Holland AJ, et al. Assessment of cooling on an acute scald burn injury in a porcine model. J Burn Care Res. 2007; 28: