VII. Extremity Burns in an Austere Environment

CPT Daniel J. Stinner, M.D.
CPT Chad A. Krueger, M.D.
 
A. Describe the initial evaluation and management of a burn patient
 
I. Background
            A. Types of burn injuries
                        1. thermal
                        2. electrical
                        3. chemical
                        4. cold
                        5. radiation
            B. Recent civilian disasters resulting in multiple burn casualties1
                        1. forest fires
                        2. fires in enclosed spaces (shopping centers, night clubs)
                        3. terrorist attacks
            C. Burn injuries in conflicts in Iraq and Afghanistan2
                        1. approximately 4% of extremity injuries
                        2. approximately 5% of wounded evacuated from combat environment
            D. Burn care same in austere environment as in tertiary care facility with abundant resources
            E. Burn patients with greater than 80% total body surface area (TBSA) burns                             
                        1. historically, received expectant care
                        2. now, with rapid response teams and modern medical management, many are surviving
                        3. still, some patients are appropriate for expectant care (see figure 1)
            F. Burn patients with less than 20% TBSA burns
                        1. treatment can typically be delayed
                        2. certain situations, such as circumferential burns are an exception
 
II. Point-of-Injury Care (First Aid)
            A. Stop burning process
                        1. if chemical burn is suspected, burn must be irrigated
            B. Ensure airway is patent, control hemorrhage, splint fractures
                        1. Note any carbonaceous material around the nares or oropharynx (see figure 2)
                                    a. could indicate inhalational injury and need for intubation
            C. Remove all constricting or potentially constricting articles/clothing
            D. Cover patient to prevent hypothermia
            E. Establish IV access
                        1. ideally through unburned skin
                        2. intraosseous acceptable if options limited while in field
            F. Begin resuscitation with Lactated Ringer’s solution
III. Primary Survey
            A. Remember the basics
                        1. standard advanced trauma life support (ATLS)
                        2. don’t be distracted by the burn
            B. Airway with C-spine control (airway is of utmost importance, especially in severe burn)
                        1. airway edema of particular concern for patients with facial burns or suspected inhalation injuries
                        2. if particularly concerned, perform endotracheal intubation early, before obliteration of airway
            C. Breathing – ensure adequate ventilation
                        1. circumferential chest burns
                                    a. can inhibit ventilation by decreasing chest wall excursion
                                    b. patients with chest wall burns in respiratory compromise often require immediate thoracic escharotomy as life-saving procedure to permit adequate chest excursion
                                    c. see chest escharotomy section below
                        2. inhalation injury – be aware at any point prior to post injury day 2 (see figures 3a and 3b)
                                    a. found in 10% of all burn victims5
                                    b. symptoms – stridor, hoarseness, cough, carbonaceous sputum, dyspnea
                                    c. clues – carbonaceous material at oropharynx or nares, extensive cutaneous burns, history of injury in closed space, facial burns
                                    d. treatment – early intubation, supplemental oxygen
                                                i. patients should be closely monitored (ICU if available) for potential respiratory compromise (pulse oximetry, chest X-ray, arterial blood gas) and intubated if necessary
                                                ii. if transporting patients to another facility, prior to transport, intubate those with symptoms; definitively secure tubes with cloth ties, such as umbilical tape, because standard tape may not stick to burned skin
                                    e. definitive diagnosis of lower airway injury – fiberoptic bronchoscopy
                        3. carbon monoxide poisoning – can cause cardiac and neurological symptoms – 100% oxygen for 3 hours or until symptoms resolve
            D. Circulation – ensure patient is adequately perfused by checking peripheral pulses and begin appropriate resuscitation
                        1. fluid resuscitation
                                    a. stop hemorrhage – use tourniquets or compressive dressings as necessary
                                    b. establish IV access
                                                i. preferred ≥ 16 G peripheral through non-burned skin, otherwise uninjured extremity
                                                ii. alternative – central venous access and/or peripheral IV through burned skin
                                                iii. intraosseous acceptable if no other access can quickly be reliably obtained
                                    c. begin resuscitation with Lactated Ringer’s solution (see resuscitation section below)
            E. Disability
                        1. perform brief neurological assessment using Glasgow Coma Scale
                        2. perform brief inspection for other injuries, i.e., fractures require reduction and/or stabilization
                        3. ensure spine has been appropriately immobilized
                        4. more detailed assessment can be performed during secondary survey  
            F. Exposure/environment
                        1. remove clothes
                        2. stop burning process
                        3. provide access for assessment and intervention
                        4. remove jewelry and potentially constricting devices, i.e., watches and rings, because patients will swell as they are resuscitated
            G. Examination of burn injury
 
Depth
Nomenclature
Involved layers
Clinical findings
Superficial (nonoperative treatment (i.e. moist dressings) appropriate)
First Degree
Epidermis
Erythema, no blisters
Second Degree
Superficial dermis
Blisters with clear fluid, painful, moist
Deep (operative treatment (i.e. debridement, grafting) needed)
Third Degree
Deep dermis
White, dry, leathery, decreased pain
Fourth Degree
Through dermis into underlying fat, fascia, muscle
Hard, insensate,
 
                        1. depth of injury is determined by the intensity and duration of the thermal energy that the patient is exposed to5
                        2. deep burns may require escharotomies, fasciotomies, or other surgical interventions.
                        3. burn size estimation – “Rule of Nines” (see figure 4)
                                    a. palm of hand (not including digits) typically about 1% of TBSA and can be used to estimate smaller portions
                                    b. children have different proportions than adults, therefore, rule of nines modified for pediatric population
            H. Resuscitation
                        1. burn patients have large fluid losses
                                    a. decreased blood volume leads to decreased cardiac output and increase systemic vascular resistance
                                                i. these worsen shock
                        2. much debate continues regarding resuscitation formulas (modified Brooke and Parkland are the most commonly used)
                                                       (A). modified Brooke formula – % TBSA × weight (kg) × 2 c = 24-hour total needed
                                                                  (I). give half over the first 8 hours
                                                                  (II). remaining half over the next 16 hours
                                                       (B). Parkland formula – % TBSA × weight (kg) × 4 cc = 24-hour total need
                                                                   (I). give half over the first 8 hours
                                                                   (II). remaining half over the next 16 hours
                                                       (C). “the Rule of Ten” – simplified resuscitation formula used at United States Army Institute of Surgical Research, which falls within American Burn Association guidelines, making it ideal for emergency care providers
                                                                   (I). estimated burn size in % TBSA × 10 for initial fluid rate in ml/hour
                                                                   (II). for every 10 kg over 80 kg, 100 ml is added to rate
                                                                   (III). further hourly adjustments made based on urine output and clinical observations
                        3. goal – urine output of 30-50 ml/hour in adults or 1 ml/hour in children
                                    a. if target urine output is less than target for 1-2 consecutive hours, increase the Lactated Ringer’s infusion by 25%
                                    b. if target urine output is more than target for 1-2 consecutive hours, decrease the Lactated Ringer’s infusion by 25%    
                                    c. must access for rhabdomyolysis and hyperkalemia
                                    d. severe burn patients may require renal replacement therapy5
                       4. avoid over-resuscitation due to edema-related complications, such as pulmonary edema and compartment syndrome
                                   a. abdominal compartment syndrome in critically burned patient has a mortality rate of over 80%        
                       5. can use Burn Resuscitation Worksheet to assist (see figure 5)
            I. Prevent hypothermia (very important for large TBSA burns) which can lead to ventricular fibrillation or asystole
                       1. cool the burn but warm the patient
                       2. warm blankets
                       3. warm fluids when available
                       4. warm room
                       5. hypothermia can worsen coagulopathy and acidosis that is common in these patients
 
IV. Secondary Survey
            A. Important notes
                        1. identify extent of burn through more thorough head-to-toe exam
                        2. recognize that burns evolve
                        3. get help early and anticipate transfer to higher level of care, if available
            B. Adequate pain control – IV, not intramuscular or subcutaneous, due to varied patterns of uptake because of resuscitation and injured soft tissues
            C. Antibiotic prophylaxis
                        1. should not be given5
                                    a. may promote the emergence of resistant organisms
            D. Tetanus prophylaxis – based on immune history
                        1. all should receive 0.5 mL of tetanus toxoid
                        2. if prior immunization unknown or last booster over 10 years ago, also give 250 units tetanus immunoglobin
            E. Chemical prophylaxis for DVTs
                        1. should be initiated and monitored for large burns
                        2. especially consider use during transport of patient
            F. Monitoring the burn patient
                        1. ensure adequate intravenous access (preferably two peripheral IVs or central access)
                        2. insert Foley catheter – urine output must be meticulously recorded and will guide resuscitation
                                    a. can monitor bladder pressure to avoid abdominal compartment syndrome
                        3. continuous electrocardiogram monitoring
                        4. continuous pulse oximetry
                        5. core thermometer – some modern Foley catheters have thermometers built in
                        6. nasogastric tube
                                    a. for patients with planned admission to ICU or TBSA burns more than 20%
                                    b. essential for these patients due to potential gastric ileus
                        7. all vitals and strict fluid input/output must be recorded on hourly basis
            G. Extremity neurovascular evaluation
                        1. elevate, evaluate pulses/neuro hourly, perform escharotomies as indicated
                        2. watch for full-thickness, circumferential burns
                                    a. inelastic eschar can have “tourniquet effect”
                        3. as edema forms beneath inelastic eschar, leads to increased compartment pressure, which can constrict venous outflow and ultimately arterial outflow, causing neurovascular compromise
                        4. may result in ischemia and necrosis of underlying tissues, a compartment syndrome  
                        5. edema can increase for up to 36 hours following initiation of resuscitation                                                                        
                                    a. indication for escharotomy: ischemia
                                    b. progressive flow reduction by Doppler ultrasound – primary indication for escharotomy (when evaluating upper extremities, Doppler ultrasound the palmar arch, not the wrist, i.e., evaluate distally)
                                    c. decreased capillary refill (less than 2 seconds)
                                    d. cyanosis
                        6. relentless deep pain progressing to numbness
                                    a. escharotomy
                                                i. escharotomy ≠ fasciotomy – escharotomies are not the same as fasciotomies
                                                ii. sometimes fasciotomy must also be performed
                                    b. escharotomy for circumferential burns
                                    c. Subeschar and Subfascial compartment syndromes can co-exist
                                    d. reassess perfusion after escharotomy

                                                                         (CONTINUED)

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.

Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD and Col. Benjamin Kam, MD.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 15, 2014 10:45 am