Objectives. Initial Burn Care and Fluid Resuscitation 6/5/2015 INITIAL MANAGEMENT

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1 Initial Burn Care and Fluid Resuscitation Sarah Taylor MSN, RN, ACNS-BC Clinical Nurse Specialist Trauma Burn Center University of Michigan Health System Ann Arbor, MI Objectives Discuss the initial assessment of the burn patient Discuss methods of burn estimation Describe fluid resuscitation strategies Describe initial wound care INITIAL MANAGEMENT 1

2 Primary Survey Airway with C-spine immobilization Breathing and ventilation Circulation, cardiac status with hemorrhage control Disability, neurological deficit and gross deformity Exposure, Examine, Environment American Burn Association 20 Airway Maintenance with Cervical Spine Protection Immediate assessment Airway control protect the c-spine with C collar if indicated Chin lift Jaw thrust Oral airway Assess need for ET intubation early is better Breathing and Ventilation Examine the patient Assess rate and depth of respiration Administer high flow oxygen using a non-rebreather system Monitor ventilation closely in patients with circumferential burns of the torso and neck 2

3 Circulation Monitor blood pressure, pulse, skin color of unburned skin Establish IV access Assess circulatory status of burned extremities Circulation Circumferential Extremity Burns 5 P s (Pain, Pallor, Pulselessness, Paresthesia and Paralysis) may be unreliable Monitor with physical exam Monitor with pulse oximeter Monitor with Doppler exam *Pre-hospital elevation of extremities if possible Circulation and Cardiac Status Normal heart rates for burn patients should be in range of bpm Tachycardia Pain, anxiety, hypovolemia, inadequate oxygenation < 100 bpm (relative bradycardia) Medication Cardiac abnormality American Burn Association 3

4 Circulation and Cardiac Status Patients with >30% TBSA burns require 2 large bore, indwelling venous catheters IO if IV not possible Pre-hospital fluid management 5 yrs. 125ml LR/hour 6-13 yrs. 250ml LR/hour 14 yrs. 500ml LR/hour Assess using AVPU method Alert Disability, Neurologic Deficit and Gross Deformity Verbal response Painful stimuli response Unresponsive Disability, Neurologic Deficit and Gross Deformity If patient is not alert, consider: Associated injuries CO poisoning Substance abuse Hypoxia Pre-existing medical disease/ medications 4

5 Exposure and Environmental Control Remove all clothing and jewelry Remove contact lenses Maintain core temperature Warm room, warm fluids and dry sheets ***The burning process is stopped when the patient is removed from the heat source*** Secondary Survey may not occur until the ED Upon completion of primary survey After resuscitation efforts well underway Accurate history Complete head to toe exam Secondary Survey Obtain current weight Determine TBSA of burn Insertion of lines and tubes Follow fluid resuscitation based on ABLS 2010 formula Monitor fluid resuscitation 5

6 Secondary Survey Obtain necessary labs and x-rays Manage pain and anxiety Provide psychological support Manage wound care History: Circumstances of Injury Flame Burns Occur in a closed space or outside? Concerns with this type of fire? Clothing ignition? Explosion involved? Decontamination needed? Is the history consistent with the burn? Circumstances of Injury Flame Burns Structure fire Was patient in a smoke filled space? How did the patient escape? Others injured? Loss of consciousness? 6

7 Circumstances of Injury Flame Burns Motor vehicle crash? Others injured? How badly was car damaged? Mechanism of injury? Evidence of fuel or chemical spill Circumstances of Injury Scald Injuries How did the scald occur? What liquid was involved? What was the temperature? How much liquid was involved? Was the patient wearing clothes? Was the burned area cooled? Circumstances of Injury Scald Injuries Is abuse or neglect possible? Who was with the patient? Where did the burn occur? How quickly was medical care sought? Is the history consistent with the burn? 7

8 Circumstances of Injury Chemical Burns What agent was involved? How did the exposure occur? What was duration of contact? What decontamination occurred at the scene? Circumstances of Injury Electrical AC/DC current? What was the voltage? Duration of contact? Was the patient thrown or fall? Was there loss of consciousness? Was CPR administered at the scene? * Scene safety is key Medical History AMPLET A Allergies M Medication PPast medical history, pregnancy L Last meal or drink EEvents T Tetanus and childhood immunizations 8

9 ACCURATE BURN ESTIMATION Rule of Nines Rule of Nines Infants 9

10 Extent of the Burn Rule of nines in 2 nd and 3 rd degree burns Calculate percent of each area burned and not the entire area Example: ½ of upper extremity burned = 4 ½ percent TBSA and not 9% Adult and Pediatric version Pre-hospital estimate Lund Browder Chart Better Estimation Hospital/Burn Unit EMS Patient s palmar surface (hand + fingers) 10

11 FLUID RESUSCITATION The fluid Adult (80kg) 60% body water 48L 1/3 Extracellular Fluid ¾ Interstitial 12L 16L ¼ intravascular 4L 2/3 Intracellular Fluid 32L 80 kg adult = 48 L fluid Pathophysiology of Thermal Injury Intravascular volume leaks into surrounding tissues both in burned and unburned areas Like a garden soaker hose that oozes fluid continuously Capillary leak usually resolves within hours post burn 11

12 Fluid in Burn Patients Intravascular = DRY! Increased Extracellular Fluid = edema Decreased cellular membrane potential from electrolyte shifts = cellular swelling. Na+ in the cell, K+ out of the cell Systemic Effects of Burn Injury PVR and CO from vasoconstriction Unrelated to hypovolemia Due to neurogenic and humoral effects Blood pressure due to edema Blood volume reduction Compensatory vascular response Peripheral Vascular Resistance Cardiac Output Systemic Effects of Burn Injury Response proportional to extent of body surface injury Fluid loss slow and progressive Fluid Replacement sustained not rapid Adequate resuscitation ameliorates burn shock 12

13 Isotonic Fluids 0.9 NS, LR Stay EXTRACELLULAR, will increase your intravascular volume by 1 c. Use in patients who need circulating volume replacement 1000 ml 750 ml 250 ml Extracellular Fluid Intracellular Fluid Goal of Fluid Resuscitation Support tissue perfusion and organ function while avoiding complications of inadequate or excessive fluid therapy Inadequate Fluid Resuscitation Shock and acute renal failure due to hypovolemia Multiple organ dysfunction syndrome Delay in resuscitation increases capillary leak Prompt fluid resuscitation is critical 13

14 Excessive Resuscitation Exaggerates edema formation Compromises local blood flow May cause compartment syndrome May contribute to acute respiratory distress syndrome May contribute to multiple organ dysfunction syndrome Edema is at maximum in 2 nd 24 hours post burn injury Excessive Resuscitation Patients sensitive to excess fluids Children The elderly Patients with pre-existing cardiac disease 14

15 Circumstances that affect fluid needs Age: Monitor pediatric and elderly patients closely Associated trauma: May require more fluid Inhalation injury: Higher fluid requirements Electrical burns: Damage is underestimated Pre-hospital Fluids 5 yrs. 125ml LR/hour 6-13 yrs. 250ml LR/hour 14 yrs. 500ml LR/hour *Based on 2012 ABLS Resuscitation Formula Fluid Needs: Immediate Post Burn Related to extent of burn and body size Influenced by patient s age Accurate weight important Fluid requirements are estimated using: Weight in kg Rule of nines to determine TBSA burn 15

16 Resuscitation Fluid Adults and older children ( > 14 years old, > 40 kg ) 2 ml LR x kg x % TBSA Infants and children ( < 14 years old, < 40 kg ) 3 ml LR x kg x % TBSA Electrical Injuries 4 ml LR x kg x % TBSA Resuscitation Fluid Administration Infuse ½ estimated volume over first 8 hours Infuse remainder over the next 16 hours Adjust actual volume based upon patient s response Resuscitation Fluid Promptly initiated adequate resuscitation permits Modest decrease in blood and plasma volume Restores plasma volume in 2 nd 24 hours post burn Base volume infused from time of injury not initiation of fluid resuscitation 16

17 Pediatric Patients Greater surface area per unit body mass Require relatively greater amounts of resuscitation fluids More susceptible to fluid overload When less than 1 year old, have limited glycogen stores monitor blood glucose Resuscitate with D5LR Patients Requiring Increased Fluids Associated injuries Electrical injury Inhalation injury Delayed resuscitation Prior dehydration History of drug or alcohol dependency Very deep burns Monitoring Resuscitation Assess mental status frequently Anxiety and restlessness may reflect hypoxia Urinary output most reliable guide Indwelling bladder catheter Dependent upon normal renal function 17

18 Hourly Urine Output Adults and older children 0.5 ml / kg / hour ( ml / hour ) Children 1 ml / kg / hour Indwelling bladder catheter Incrementally increase or decrease Oliguria Usually due to inadequate resuscitation Associated with elevation of SVR and reduction of cardiac output Diuretics are contraindicated Requires increased hourly fluid administration Hourly Urine Output If expected UOP increased/decreased 2 consecutive hours Decrease / increase fluid infusion by 1/3 18

19 Hemochromogenuria ( Red Urine ) Increase fluid administration to maintain urinary output at ml / kg/ hour Usually clears the pigment WOUND CARE BASICS Functions of Skin Protection from infection and injury Prevention of loss of body fluids Regulation of body temperature Sensory contact with environment American Burn Association American All Burn rights Association reserved. ABLS 2011 Wound Management 57 19

20 Skin Anatomy Epidermis Dermis Appendages Subcutaneous. American All rights reserved. Burn Association ABLS Wound 2011 Management 58 Burn Depth Often difficult to assess initially Determines required wound care Determines need for grafting Determines functional and cosmetic outcomes. All rights reserved. ABLS Wound Management Zone of Injury. All rights reserved. ABLS Wound Management 60 20

21 Increased Zone of Coagulation ( Conversion ) Improper wound care Improper resuscitation Not enough or too much fluids! Hypothermia Ice on the burn Cooling the burn American Burn Association American All Burn rights Association reserved. ABLS 2011 Wound Management 61 Wound Care Basics Pre-hospital setting WARM and DRY If extensive wound care will delay transfer to definitive care, place patient in warm, dry sheet and send. Special Considerations Pseudo eschar photos Blisters 21

22 Superficial Thickness Burns It only involves the epidermis Seldom requires medical intervention Heals spontaneously The injured site is characterized by: Redness Mild swelling No blisters Hypersensitivity Pain t Burn Classification Superficial Partial Thickness Burns The entire epidermis and a layer of the dermis are involved The injured site is characterized by: Redness Swelling Thin walled blister formation Hair in the injured site remains intact Moist appearance Extreme pain Blanches when pressure is applied, fast capillary refill Pinprick can be felt Burn Classification Superficial Partial Thickness Burns Heals spontaneously in 2-3 weeks Skin grafting may improve functional and cosmetic outcome. American All rights reserved. Burn Association ABLS Wound 2011 Management 66 22

23 Deep Partial Thickness Burns The entire epidermis and a large portion of the dermis are involved The injured site t is characterized by: Redness with whiter appearance Swelling Blister formation Hair in the injured site remains intact Moist appearance Pain Blanches when pressure is applied, slow capillary refill Decreased pinprick sensation *Usually requires skin grafting to heal. Burn Classification Full Thickness Burns Destruction of the entire epidermis and dermis layer The injured site is characterized by: Leathery white, dark red, brown or charred appearance Swelling No Blister formation No hair in the injured site Dry and hard appearance Painless Does not blanch when pressure is applied, no capillary refill No pinprick sensation t Burn Classification Full thickness Healing by: Contracture Epithelial in-growth from edges Skin grafts. American All rights reserved. Burn Association ABLS Wound 2011 Management 69 23

24 Full thickness: Fourth degree Involve fat, fascia, muscle or bone. American All rights reserved. Burn Association ABLS Wound 2011 Management 70 CASE STUDIES Questions? 24

25 References Advanced Burn Life Support, American Burn Association, Chicago, IL. Giretzlehner M, et al. The determination of total burn surface area: How much difference?. Burns (2013), Neaman K et. al. A new method for estimation of involved BSA for obese and normal-weight patients with burn injury. Journal of Burn Care and Research, 32 25