Trauma Survey: Burns are trauma, treat these pts as such. Don’t let yourself get distracted by the obvious superficial injuries/wounds and be sure to go down your algorithm so you don’t miss anything.
PRIMARY:
- Airway: Look for signs of active or potential airway compromise/inhalation injury (e.g. soot, edema, or burns on the face, in oropharynx/nares, stridor, AMS). Although “soot in the oropharynx” is a board exam trigger phrase for intubation, in reality, the decision is a lot more nuanced. When in doubt, intubate earlier rather than later, as inhalation-related airway edema can progress rapidly and make for a rather unchill tube. That being said, intubation and mechanical ventilation are not without their own risks, so if you do choose not to intubate, these are pts that you want to keep in your direct line of sight and have a definitive airway plan for, including adjuncts like fiberoptics and potentially a cricothyrotomy kit. As far as intubation meds, although we’ve generally strayed away from using succinylcholine, studies have shown that your risk of hyperkalemia iso isolated burn injuries is relatively low within the first 24-48hrs, so if you wanted to reach for it in a DSI situation it’s a remains a reasonable option.
- Breathing: Check for wheezing/rhonchi, which could indicate inhalation-related bronchospasm/edema. An explosion/blast mechanism, in particular, should raise suspicion for possible PTX or pulmonary contusion. Circumferential eschars may also limit ventilation and require rapid intervention.
- Circulation: Evaluate distal pulses/temperature discrepancies, look for circumferential eschars or profound edema that could potentially compromise a limb. Be sure to give fluids early but be judicious as these pts are third-spacing (more on this later), and don’t let yourself anchor on the burns in your shocky burn pts, particularly iso of a blast/explosion mechanism (e.g. cardiac contusion/tamponade, aortic injury, internal hemorrhage)
- Disability: AMS or focal deficits could be 2/2 a number of things, including but not limited to hypoxia, CO/cyanide poisoning, hypovolemic/hemorrhagic shock, blast-related head injury/ICH.
- Exposure: Always important, remove clothing and hot jewelry/debris, but be sure to cover them back up, as burn pts are at increased risk for hypothermia, as they’ve lost a lot of their thermoregulatory protection (aka. their skin).
SECONDARY:
Be systematic and thorough. Can perform a Rule-of-Nines assessment to quantify burned surface area to roughly approximate fluid resuscitation. Also look out for signs and symptoms that could help determine the mechanism or severity of injury if ambiguous upon arrival (e.g. explosion, structural collapse, penetrating projectiles, MVC-related injuries) that should then guide your workup, imaging choices, and ultimate disposition.
Fluid Resuscitation:
I would be remiss if I did not at least mention the Parkland Formula. For those who need a refresher (which I commonly do at least once a year) it is as follows:
Total 24hr Recommended IVF Volume = 4mL/kg x (Body Weight in kg) x (% TBSA of 2nd/3rd Degree Burns)
* Half given over first 8hrs, remainder over last 16hrs
Keep in mind that this applies to pts with burns >20% TBSA in adults and >10% in children and the elderly, and is only a guide that is subject to nuances in individual clinical presentation. Be judicious with your fluids, as burn pts are often over-resuscitated, which can lead to complications like extremity/abdominal compartment syndrome, ARDS, and pulmonary or cerebral edema. These pts should get a foley and resuscitation should really be guided via monitoring strict I:Os, with an UOP ~0.5-1cc/kg per hour.
Inhalation Toxicity:
You should be concurrently evaluating these pts for signs of carbon monoxide and cyanide poisoning.
CO Poisoning: CO has 240x higher affinity to Hgb than oxygen does
- Obtain carboxyhemoglobin levels in all pts (is included in our VBGs)
- Put on 100% FiO2 via NRB upon arrival
- Hyperbarics in levels >25% in most pts, >15% in pregnant pts, or in pts with AMS, endorsed LOC, severe metabolic acidosis (pH <7.1), or end-organ damage
- Remember chronic smokers may live at a level of 10-15%
Cyanide Poisoning: mitochondrial toxin, forces cells to utilize anaerobic metabolism (resulting in the rise in lactate)
- Some studies show prevalence is as high as 35% of fire victims
- Maintain high clinical suspicion in pts with inexplicably high lactates
- Antidote: hydroxycobalamin aka. Cyanokit (available in our antidote box) is preferred, 70mg/kg dose (5g max)
Antibiotics + Wound Care:
Systemic abx generally not indicated unless obvious infectious source or other indications (i.e. open fx). Topicals are also not advised and actually discouraged if you are transferring to a Burn Center, as it impedes their evaluation of the wound itself. Cover wounds with clean dry gauze or sheet for transfer. Avoid ice application as it can induce hyperthermia and vasoconstriction, resulting in inhibited healing and possible gangrene/ischemia.
Escharotomy:
Indications generally revolve around circumferential eschars that compromise the ABCs. As much as we would love to do them, should really be done in the OR or at a Burn Center. Perform only if transfer to Burn Center or appropriate surgical services is delayed or >6hrs. The diagram below shows where you should cut on dotted lines (down to fat, you are not performing a fasciotomy) + places you should avoid in bold.
Disposition:
Call the Burn Center early (Burn Center Referral Criteria). Keep in mind partial or full thickness burns with >10% TBSA is at minimum a Yellow Trauma activation with any compromise of ABCDs warranting a red.
Other Things:
- Tdap (+/- IG if necessary)
- Pain control: burns don’t feel great
Hope this helps!
