Burn Management and Assessment

Burns

• Criteria for burn center care includes partial thickness burns of 10% or more of Total Body Surface Area (TBSA), or burns involving the face, hands, feet, genitalia, perineum, or major joints.
• Renal failure is a key concern to monitor in patients with electrical burns.
• Inhalation injury symptoms include singed nasal/facial hairs, soot, edema, hoarseness, grunting voice, diminished breath sounds, and cherry red skin from carbon monoxide poisoning.
• Anticipate intubation and perform bronchoscopy for inhalation injuries.

Burn Depth

• Superficial burns affect only the epidermis.
  • They are considered minimal to epidermis.
• Superficial partial-thickness burns affect the entire epidermis and some dermis, resulting in blisters.
• Deep partial-thickness burns are cherry red, mottled, or pale in the center.
  • They involve the entire epidermis and dermis, with blisters either closed or open.
• Full-thickness burns affect all skin layers down to muscle, fat, and bone, resulting in dry, leathery skin.

Calculating TBSA (Total Body Surface Area)

• The "rule of nines" is used to calculate the TBSA affected by burns.

Burn Complications

• Circumferential burns of the extremities can lead to compartment syndrome
  • Neurovascular checks are important.
• Inflammatory response to burns can be confused with sepsis.
• Burn management phases are: emergent, intermediate, and rehab.

Emergent Phase Interventions

• Focus on ABCDE (Airway, Breathing, Circulation, Disability, Exposure).
• Administer oxygen via a humidified 100% nonrebreather mask.
• Elevate the Head Of Bed (HOB).
• Obtain IV access with a large bore catheter.
• Estimate TBSA.
• Reduce risk for hypothermia.
• Provide nutritional support.
• Lactated Ringers are used in the emergent burn stage.
• During the emergent phase, fluid shifts cause hyperkalemia, hyponatremia, and metabolic acidosis
  • This is due to cell destruction releasing intracellular contents (especially potassium).
• Allograft, or cadaver skin, is a temporary grafting option during the intermediate phase
  • Allografts will eventually be rejected by the body.
• In the emergent phase, use an NG tube for decompression if absent or hypo breath sounds are present.
• Avoid distention and always check placement of NG tube.
• Nutritional support in the intermediate phase for large burn injuries involves NGT or temporary G-tube due to high infection risk.
• Pressure garments are useful in the rehab phase to prevent hypertrophic scar formation.
• Encouragement and reassurance is a priority in the rehab phase
  • This is to address depression, body image issues, and PTSD.
• Escharotomy is used when a patient has severe burns with thick, leathery eschar in the black stage.

Snake Bites

• Interventions: antivenin, wash with soap and water, avoid tourniquets, ice, or alcohol.
• Monitor CBC, Coags (for DIC assessment), UA (renal), BUN, Cr, and CK (organ function).
• Disseminated Intravascular Coagulation (DIC) with petechiae on the skin is a complication.

Spider Bites

• Black widow bites: Wash the area, rarely result in death.
• Administer Tetanus shots as a prophylaxis.
• Monitor for worsening conditions, especially urine changes indicating organ damage.
• Apply cold compresses, elevate, and administer pain medication, antibiotics, or antivenin.

Hyperthermia

• Red, dry skin without sweating is a key indicator of hyperthermia/heat stroke.
• Other symptoms include: heat cramps, stress, edema, exhaustion, syncope, stroke, possibly moist skin, pulmonary edema, rhabdomyolysis, and dysrhythmias if untreated.
• Interventions: IV or oral fluids and cooling methods like ice packs or cooling blankets, avoid ice baths or tepid water cooling.

Hypothermia

• Symptoms include: shivering, vasoconstriction, early tachycardia, hypertension, late bradycardia, hypotension, and vasodilation.
• Treatment: passive external rewarming with a blanket, active rewarming with a bear hugger/heat source, internal rewarming with NG tube filled with warm water.
• Rewarm the patient slowly and monitor potassium levels.
• Assess core body temperature rectally or with a continuous probe, avoid axillary or oral measurements.
• Interventions include removing wet clothing, drying the patient, warm blankets, heat lamp, warmed IV fluids, ECMO, and cardiac monitoring.

Drowning

• Respiratory failure is a major complication.
• Interventions: slow, active rewarming, remove wet clothing, dry the patient, CPR, prepare for intubation, cardiac monitor, IV access, and ambu bag with oxygen.

Trauma and Disaster (General)

• Prioritize ABCDE: Airway, Breathing, Circulation, Disability, Exposure.
• C-spine stabilization is crucial.
• Trauma assessment includes primary and secondary surveys.

Primary Survey

• The primary survey includes:
  • Airway assessment with C-spine consideration.
  • Breathing: high flow oxygen.
  • Circulation: hemorrhage control.
  • Disability: GCS assessment.
  • Exposure/environment management.
• Use a jaw thrust maneuver to establish an airway when a spinal cord injury is suspected
• Control bleeding in the circulation phase.
  • Monitor vital signs, cap refill, and Cullen's sign.
• Hemorrhage is the most common cause of death in trauma within the first 48 hours.
• Monitor neuro checks using GCS in the disability phase.
• In the exposure phase, look for injuries and controlling the environment

Secondary Survey

• Includes FAST (focused assessment with sonography for trauma) ultrasound to assess the abdominal cavity, Foley catheter insertion, G-tube insertion, and damage control survey.
• A positive FAST sign means there is blood in the abdominal cavity, pericardium, or pelvis, indicating the need for surgery.
• Cut off the patient's clothes to visualize and assess injuries.
• When performing ER trauma care, understand that "very low or very high" is a priority.
  • Focus on ABCs and vital signs.
• If a trauma patient begins to desaturate, give humidified oxygen 100% via nonrebreather.
• Patients with kidney issues or bleeding issues should not receive NSAIDs.
• Tension pneumothorax symptoms: tracheal deviation if a chest tube is clamped.
• Monitor for hemorrhage in any blunt trauma.

Blunt Trauma

• Bladder injury related to seatbelt use is a common abdominal injury in MVCs.
• Blunt chest trauma can cause lung or cardiac injuries.
• Flail chest (paradoxical chest movement) indicates a rib fracture.
• Opioids, narcotics, and sedatives can prevent accurate neuro assessments.
• Absent breath sounds indicate a pneumothorax.
• CT scan is an important diagnostic tool for head injuries.

Trauma Assessment

• The 6 Ps important to assess when extremities are injured are: Pain, Pressure, Paralysis, Pallor, Paresthesia, Pulselessness.
• Perform neuro checks for patients with brain/head injuries.
• A GCS under 8 indicates a need to intubate.
• Bullets do not travel in a linear fashion and can cause unpredictable injuries
• Yaw, tumble, and fragmentation result in complex injuries.

Compartment Syndrome

• Neurovascular checks and cap refill distal to the cast are important.
• Cap refill is priority over vitals for assessment
• Fasciotomy is the intervention.
• Numbness and inability to move is caused by compression of nerves
• Charcoal, gastric lavage, and whole bowel irrigation are decontamination methods

Poisoning

• Acetylcysteine, antiemetic, and charcoal is the reversal agent for acetaminophen overdose.
• For acetaminophen overdose, monitor liver function test, PT, INR, BMP, and glucose.

Disaster/Mass Casualty Triage

• The goal is to save the greatest number of people.
• A green tag is for individuals who can walk around.
• A red tag is for individuals with an increased RR after airway management (RR > 30).
• A black tag is for individuals with no respirations after airway management.
• Expectant individuals have life-threatening injuries.

Radiation Disaster

• Radiation can come from everyday items: microwaves, TV, sun.
• Irradiation is exposure to radiation.
• Contamination means radioactive material is present on the body.

Biologic Disaster

• Category A biological agents: Anthrax, Botulism, Plague, Smallpox, Tularemia, Viral hemorrhagic fevers (arenaviruses & filoviruses).
• Place patients with respiratory symptoms in a negative pressure room.
• Medical responders should wear correct PPE when dealing with chemicals

Natural Disasters

• Natural disasters include: Earthquakes, Blizzards, Hurricanes and Tornadoes
• Injuries caused by earthquakes: Skull fractures, spinal cord injuries, crush injuries, hypothermia, wound infections, and pulmonary exacerbations like asthma
• Injuries caused by blizzards: Orthopedic injuries, MI, carbon monoxide poisoning, cold exposure, hypothermia, frostbite, and MVCs/injuries from debris
• It is important to evacuate and prepare when hurricanes are incoming.

Disaster Planning

• Identify the hazard in disaster planning.
• Mitigation reduces damage.
• Preparedness includes planning a response.
• Response is the period before and after a disaste
• Recovery restores normal operations.
• Levels of PPE:
  • Level A: highest level, full protection, used with bioterrorism
  • Level B
  • Level C
  • Level D: surgical gown, mask, and gloves.
• Decontaminate patients at the hospital following a disaster before they enter.