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Burns

Over 50,000 people are hospitalized every year for burn injuries, and more than one million people are burned each year in the US. Burn injuries cause over 5000 deaths each year in the US.

An evaluation of the Airway, Breathing, and Circulation (the ABCs) should receive first priority. The history should include the time, location and circumstances of the injury, where the patient was found, and their condition. Past medical and social history, current medication usage, drug allergies, and tetanus status should be rapidly determined.

Smoke inhalation causes more than 50% of fire-related deaths. Patients sustaining an inhalation injury may require aggressive airway intervention. Most injuries result from the inhalation of toxic smoke; however, super-heated air may rarely cause direct thermal injury to the upper respiratory tract.

Patients who are breathing spontaneously and at risk for inhalation injury should be placed on high-flow humidified oxygen. Patients trapped in buildings or those caught in an explosion are at higher risk for inhalation injury. These patients may have facial burns, singeing of the eyebrows and nasal hair, pharyngeal bums, carbonaceous sputum, or impaired mentation. A change in voice quality, stridorous respirations, or wheezing may be noted. The upper airway may be visualized by laryngoscopy, and the tracheobronchial tree should be evaluated by bronchoscopy. Chest radiography is not sensitive for detecting inhalation injury. Burns

Patients who have suffered an inhalation injury are also at risk for carbon monoxide (CO) poisoning. The pulse oximeter is not accurate in patients with CO poisoning because only oxyhemoglobin and deoxyhemoglobin are detected. Co-oximetry measurements are necessary to confirm the diagnosis of CO poisoning. Patients exposed to CO should receive 100% oxygen using a nonrebreather face mask. Hyperbaric oxygen (HBO) therapy reduces the half-life of CO to 23 minutes. HBO is recommended for patients with COHb levels greater than 25%, myocardial ischemia, cardiac dysrhythmias, or neuropsychiatric abnormalities. HBO is also recommended for pregnant women and young children with COHb levels of 15% or greater. Burns

Burn Management - Medical Treatment Burn Management - Medical Treatment

Burn Assessment.

After completion of the primary survey, a secondary survey should assess the depth and total body surface area (TBSA) burned.

First-degree burns involve the epidermis layer of the skin, but not the dermal layer. These injuries are characterized by pain, erythema, and lack of blisters. These burns heal without scar formation. First-degree burns are not considered in calculation of the TBSA burned.

Second-degree burns are subdivided into superficial and deep partial-thickness burns.

Superficial partial-thickness burn injury involves the papillary dermis, containing pain-sensitive nerve endings. burn management, burns, burn Blisters or bullae may be present, and the burns usually appear pink and moist. These burn management, burns, burn injuries heal with little or no scarring. Burns

Deep partial-thickness burn injury damages both the papillary and reticular dermis. These injuries may not be burn management, burns, burn painful and often appear white or mottled pink. Deep partial-thickness burns can produce burn management, burns, burn significant scarring.

Full-thickness or third-degree burns involve all layers of the epidermis and dermis and may destroy subcutaneous structures. They appear white or charred. These burns are usually insensate because of destruction of nerve endings, but the surrounding areas are extremely painful. Third-degree burns are best treated with skin grafting to limit scarring.

Fourth-degree burns involve structures beneath the subcutaneous fat, including muscle and bone. Burns

Estimation of TBSA burn is based upon the "rule of nines."

Management of Moderate to Severe Burns

Initial Fluid ResuscitationBThe Parkland Formula

Initiation of fluid resuscitation should precede initial wound care. In adults, IV fluid resuscitation is usually necessary in second- or third-degree burns involving greater than 20% TBSA. In pediatric patients, fluid resuscitation should be initiated in all infants with burns of 10% or greater TBSA and in older children with burns greater than 15% or greater TBSA.

Two large-bore IV lines should be placed. Lactated Ringer's solution is the most commonly used fluid for burn resuscitation.

The Parkland formula is used to guide initial fluid resuscitation during the first 24 hours. The formula calls for 4 cc/kg/TBSA burn (second and third degree) of lactated Ringer's solution over the fast 24 hours. Half of the fluid should be administered over the first eight hours post burn, and the remaining half should be administered over the next 16 hours. The volume of fluid given is based on the time elapsed since the burn.

Urine output should be used as a measure of renal perfusion and to assess fluid balance. In adults, a urine output of 0.5-1.0 mL/kg/h should be maintained. Patients with significant burns should have a Foley catheter inserted in order to monitor urine output.

A nasogastric (NG) tube should be placed in patients with burns involving 20% or more TBSA in order to prevent gastric distention and emesis associated with a