BURNS Initial Evaluation & Management Christopher P. Brandt M. D. Associate Professor of Surgery Case Western Reserve University
Joseph B. § Your patient is brought to the E. D. by the EMS service. § He is a 14 year-old male who was involved in a house fire
History What other points of history do you want to know?
History, Joseph B. § § § § Neighbors heard an explosion Patient found confused, outside of the house Cannot remember what occurred Denies shortness of breath Transport time of twenty minutes PMH of ADHD Tetanus – up to date
Physical Examination What would you look for?
Physical Examination § § § VS T=96. 5 P=140 R=24 BP=90/60 Awake; No hoarseness or stridor Soot in mouth Clear breath sounds Burns involving face, neck, trunk, arms and upper legs (see photos) § Doppler pulses in all extremities
Physical Examination § How do you determine the extent and depth of the burn injuries? § What findings suggest inhalation injury?
1 8 Extent of burn % total body surface area
Burn Depth § § § Color Moistness Capillary refill/Blanching Sensation Blistering
Superficial Second Degree Deeper second degree Third Degree
Inhalation injury Indicators § Occurred in closed space § Cough, dyspnea, wheezing, hoarseness, stridor § Facial burns / Singed facial hair § Carbonaceous sputum § Hypoxia
Labs What would you obtain?
Lab Results § § § CBC - WBC-12. 0 Hct-49% Electrolytes -Na-147 Cl-100 K-4. 5 BUN-12 ABG - 7. 31/35/125 on 50%VM Carboxyhemoglobin- 21% Tox. Screen - Negative U/A - Normal
Interventions at this point?
Interventions at this point? Assess airway; Intubation ? Oxygen Fluid resuscitation Foley Catheter NG tube Wound care Pain medication
Interventions Why is fluid resuscitation important? How do you estimate fluid requirements? How do you monitor response to initial fluid therapy? What complications can occur from over- or under- resuscitation?
Fluid Management Edema formation § Systemic inflammatory response § Capillary leak/ Increased vascular permeability § Loss of skin barrier Zones of injury Parkland formula § Crystalloid 4 x %TBSA x wt (kg) § ½ of total in first eight hours § Goal of ½ - 1 cc/kg/hr U. O.
Studies What further studies/tests would you want at this time?
Studies § CXR – Basilar atelectasis § EKG – Sinus tachycardia § ? Bronchoscopy
Management What would you do in the following scenarios? § Low urine output § Loss of Doppler signals in the hands § Inadequate ventilation with high airway pressures?
Management Escharotomy
Management § What are the principles of management of the inhalation injury? § What will be the basic strategies for management of the burn wounds?
Questions?
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