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Section 1

Section 2

Section 3 

Section 4 

Section 5

Section 6

Section 7

Section 8

Section 9 

 

 

  1. Initial Management Protocols 

A.  Initial Management: Airway & Pulmonary Problems

 Management of Carbon Monoxide Exposure

Awake Obtunded
High flow by mask oxygen (Fi02 100%) until COHgb<5%) Intubate and provide 100% oxygen via a ventilator

Hyperbaric oxygen therapy (HBO) is used if patient not responding to 100% oxygen (specific indications for HBO remain undefined.

 Management of the Upper Airway

Stridor Retraction or Respiratory Distress present or Deep Burns: Face, Neck

↓――――――――――――――――――――――――――――――――↓

If Present

If Absent

  • Intubate now!

  • Use adequate size tube

  • Humidified oxygen

  • Elevate Head

  • Transport to Burn Center
  • Provide 100% Oxygen
  • Look for Signs of Airway Injury

      - Oropharyngeal erythema

      - Hoarseness

      - Pulmonary status

  • Can perform laryngoscopy

  • If edema present, intubate now

 

Management of Lower Airway Injury

Asymptomatic

Symptomatic

Symptomatic
 

Cough, wheezing, bronchorrhea, good gas exchange

Shortness of breath, progressive symptoms, impaired gas exchange
  • Continued
  • Reassessment
  • Oximetry
  • Provide 100% oxygen by mask
  • Aggressive pulmonary toilet
  • Bronchodilators
  • Monitor oximetry and blood gases
  • Continued reassessment
  • Intubate (use tube size 7 or greater)
  • Begin 100% O2 to maintain O2   sat  >95% and displace CO-HGB
  • Clinically assess lower airways function
  • Obtain base-line chest x-ray
  • Aggressive suctioning for bronchorrhea
  • Use bronchodilators for bronchospasm
  • Consider chest wall escharotomy for 3° circumferential burn
  • Reassessment 
                   *As the injury process evolves, modifications will be necessary

 

B.  Initial Maintenance of Hemodynamic Stability (0-24 hrs)

Patient Not Stable

Patient Reasonably Stable
  • Remove clothing, assess for other injuries
  • Keep warm
  • Determine if patient meets burn criteria  for transfer to burn center
  • If so, continue to stabilize and make Arrangements
    •

 
  • Remove clothing, assess for other injuries, keep warm
  • Remove dirt (and dead epidermis if burn is small)
  • Use intravenous route for pain and anxiety meds
  • If major burn, transfer arrangements to burn center and cover wound with clean dry dressings

Fluid Resuscitation

All patients with burns more than 15% Total Body Surface

(Burns less than 15% TBS may not need IV resuscitation)
  • Large Bore Peripheral Intravenous Lines
  • Begin lactated Ringers Solution: Estimate Initial rate - 4cc/kg/%TBS burn (half in first 8 hrs)
  • Can add colloid 5% albumin if fluid requirements exceeding the predicted formula
  • Adjust fluid rate according to patient response

·   Expect increase in fluid requirements in

- Elderly, small children

- Smoke inhalation

- Electrical burns

  • Consider low dose dopamine if urine output low in the presence of hemodynamic stability

 

Monitoring Guidelines
  • Pulse: young patient – pulse less than 120, reasonable perfusion; pulse >130, increase fluid
  • Elderly or with heart disease – pulse not accurate reflection of perfusion
  • Electrocardiogram – particularly important for patient more than 45 years old
  • Urine output – 0.5 to 1 cc/kg/hr is adequate in absence of diuretic such as alcohol
  • Exception: Myoglobin or Hemoglobinuria where over 1 cc/kg/hr is indicated
  • Peripheral perfusion: for circumferential arm, leg burns

- Use of Doppler to monitor

- If circumferential burn with decreasing pulse pressure consider escharotomy

  • Temperature – Avoid hypothermia

 
  • Blood gases – high risk of hypoxemia, hypercapnia due to direct  pulmonary complications of burn and treatment
  • Acid-base – Base deficit very useful indicator of tissue oxygenation (if increasing give more fluid)
  • Hemoglobin (increasing value indicator of decreasing blood volume or greater than 5 meq/l
  • Blood pressure – only reliable as volume indicator if low
  • Electrolytes – initial abnormality may be hyper- or hypokalemia, HCO3 value dependent on acid-base balance
  • Prothrombin time, partial thromboplastin time, platelets – moderate burn: usually near normal
  • More than 50% total body surface: abnormal due to consumption coagulopathy

(Transfer to Burn Center if a major burn is present)

 

Steps for the Prevention and Treatment of Impaired Distal Perfusion

  • Remove constricting objects, such as jewelry

  • Immediate elevation of burned extremities Escharotomies in circumferential third or forth degree burns, if perfusion is impaired (preferably done in Burn Center

  • Monitor using pulse palpation and Doppler

  • Escharotomies in circumferential third or fourth degree burns, if perfusion is impaired (preferably done in Burn Center)

C.  Initial Wound Management

·       Assure adequate ventilation and perfusion

·       Remove heat source and any constricting items

·       Maintain body temperature

·       Cool water for small second degree burns only

·       Assess size and depth “Rule of Nine”

·       Tetanus Prophylaxis

Minor to Moderate Burn (To be managed & not transferred)

Superficial Partial Thickness

Wound Relatively Clean

Wound Dirty
  • Can use Xeroform gauze with dressing
  • Consider temporary skin substitute
  • First treat open with Bacitracin
  • Perineum, feet use silver sulfadiazine
  • Elevate burned extremity
  • Gentle cleaning
  • Use antibiotic ointment
  • Elevate burn extremity

 

Wound Relatively Clean

Deep Wound
  • Can use topical antibiotic ointment
  • Closed dressing technique, exception: face, perineum
  • Consider temporary skin substitutes (TransCyte) if wound bed clean
  • Elevate burn extremity
  • Use topical silver cream or dressing
  • No prophylactic antibiotics
  • Closed dressing technique, exception: face, perineum
  • Elevate burn extremity
  • Consider escharotomy

 

 

 


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