this slide is selection important part of thermal burn topic in Tintinalli's Emergency Medicine with this presentation you can have a great present in your collage.

1. THERMAL BURNS
M . M A H D I . H E Y D A R I

2. • An estimated 450,000 individuals in the United States receive medical treatment each
year for burn injuries. Although 40,000 patients require hospitalization and more than
60% of those are treated at one of 127 specialized burn centers, the vast majority of
burn patients are treated in the acute setting by emergency physicians and discharged
with outpatient follow-up.
• Nearly 70% of burn victims are male, and risk is highest between the ages of 18 and
35. Seventy-seven percent of all injuries are accounted for by fire or scalding; 43% of
scald injuries occur in children less than 5 years of age.
• Although overall survival exceeds 96%, fire, burn, and smoke inhalation still account
for approximately 3400 deaths each year in the United States.
• The risk of death from a major burn increases with larger burn size, older age, the
presence of inhalation injury, and female sex

3. • Skin consists of two layers: the epidermis and
the dermis (Figure 216-1). Skin thickness
varies both by age and anatomic location: it is
relatively thinner at extremes of age, whereas
it is thicker on the palms, soles, and upper
back. Thus, the depth and severity of thermal
injury varies by both the age of the victim and
the anatomic location exposed. Skin functions
as a semipermeable barrier to evaporative
water loss, protects against environmental
assault, and aids in the control of body
temperature, sensation, and excretion. Partial-
thickness thermal injury disrupts these barrier
functions and contributes to free water
deficits. This effect may be significant with
moderate to large burns.

5. CLINICAL FEATURES
• The Rule of Nines is a simple and
commonly used method to calculate
burn size (Figure 216-2), It divides the
body into segments that are
approximately 9% or multiples of 9%,
with the perineum forming the
remaining 1%. Because of the
proportionately larger heads and
smaller legs of infants and children,
this method must be modified in
pediatric burn injury.
BURN SIZE
A second method assumes that the area of the back of the
patient’s hand is approximately 1% of their total body
surface area. The number of “hands ”that equal the area of
the burn can approximate the percentage of body surface
area burned

6. CLINICAL FEATURES
•A third and more precise method uses the Lund-
Browder burn diagram (Figure 216-3). This allows an
accurate age-adjusted determination of burn size
for a given depth, allowing for the anatomical
differences of children.15 Experienced burn care
nurses and physicians can reliably estimate burn
size regardless of the method used. Although it is
common for inexperienced individuals to estimate
burn size incorrectly when patients are first assessed
in the ED, it remains a vital determinant of both
fluid resuscitation and the need for ultimate
transfer.
BURN SIZE

7. CLINICAL FEATURES
BURN DEPTH

10. BURN CENTER TRANSFER
• The American Burn Association provides guidelines for referral to a burn center, in
addition to indications based on burn depth (Table 216-4).
• Children <10 years of age and adults >50 years are considered high-risk patients.
Patients with significant comorbidities, such as heart disease, diabetes, or chronic
pulmonary disease, are also likely to require prolonged care and should be considered
for transfer to a burn unit.
• Burn severity, underlying medical and social conditions, and the capabilities of the
institution initially receiving the patient must all be considered in the decision to
transfer the patient to a burn unit.
• As always, use clinical judgment. While some institutions may transfer all burn patients
to a burn center, others may choose to care for patients with minor and some
moderate burns locally

11. INHALATION INJURY
• As treatment of burn shock and sepsis has improved, inhalation injury has become the
main cause of mortality in burn patients. Most firerelated deaths are due to smoke
inhalation.5,6,10 Inhalation injury is associated with closed-space fires and conditions
that decrease mentation, such as overdose, alcohol intoxication, drug abuse, and head
injury. Exposure to smoke includes exposure to heat, particulate matter, and toxic
gases.18 Direct thermal injury is usually limited to the upper airway; thermal injuries
below the level of the vocal cords can occur in cases of steam inhalation
• Therefore, when inhalation injury is present, careful fluid resuscitation guided by
hemodynamic monitoring can help avoid pulmonary edema and acute respiratory
distress syndrome

12. • The management of patients with moderate to major burns can be divided into three
phases:
• (1) prehospital care,
• (2) ED resuscitation and stabilization, and
• (3) admission or transfer to a specialized burn center.

13. PREHOSPITAL CARE
• The basis of prehospital care of the burn-injured patient consists of the following:
• (1) stop the burning process;
• (2) assess and, if necessary, secure the airway;
• (3) initiate fluid resuscitation;
• (4) relieve pain;
• (5) protect the burn wound;
• (6) transport the patient to an appropriate facility.
Pay close attention to the airway: rapid deterioration
may occur even when the initial assessment judges the
airway to be acceptable

14. PREHOSPITAL CARE
• Consider prophylactic intubation in patients with perioral burns sustained in a closed-
space fire. Give IV isotonic crystalloid. Cover the patient with clean sheets to protect
the wound. While early cooling can reduce the depth of burn and reduce pain,
uncontrolled cooling may result in hypothermia. Provide analgesia according to
protocol or with direction of the online medical control physician. Transport the
patient to the nearest ED capable of caring for a burn-injured patient or, if none is
available, to the nearest ED for stabilization and subsequent transfer

15. ED MANAGEMENT
If there is any evidence of airway compromise with
swelling of the neck, burns inside the mouth, or
wheezing, perform early endotracheal intubation .

16. ED MANAGEMENT
• The burn shock resuscitation formulas in use today are derived from laboratory studies
of burn shock and resuscitation, and the utility of such formulas has been called into
question. Although the importance of early fluid resuscitation is supported by clinical
experience, no consensus exists on the appropriate assessment of resuscitation and its
effect on outcome.
• Additionally, over-resuscitation is not without consequence. In general, resuscitation
should be guided by monitoring cardiorespiratory status and urine output rather than
strict adherence to a formula. The following formulas are a guide for fluid resuscitation
of the burn-injured patient. Monitor and adjust according to individual patient
response
FLUID RESUSCITATION

17. • The Baxter or Parkland formula is
likely the most widely used
thermal injury resuscitation
regimen in North America.8,9
This formula calls for 4 mL of
lactated Ringer’s solution
multiplied by the percentage of
body surface area burned
(partial- and full-thickness burns
only) multiplied by patient body
weight in kilograms. Half of the
total is administered in the first 8
hours after injury and the
remainder during the following
16 hours
ED MANAGEMENT
FLUID RESUSCITATION

18. • Patients with thermal injury and concomitant multisystem trauma and those with inhalation
injuries generally require fluid resuscitation in excess of calculated needs. Burn patients with
preexisting cardiac or pulmonary disease require much greater attention to fluid
management. Monitor fluid resuscitation closely by frequent assessment of vital signs,
cerebral and skin perfusion, pulmonary status, and urinary output, as well as hemodynamic
monitoring. Urine output should be 0.5 to 1.0 mL/kg/h.
• Because the ED is primarily responsible for initial fluid resuscitation, discussion with burn
specialists may be helpful in avoiding early under- or over-resuscitation. Patients with major
burns can quickly receive excessive IV fluid during the prehospital and ED phases,
particularly if two large-bore peripheral catheters are in place with fluid infusing at a wide-
open rate. Document total fluid infused and titrate infusion to the patient’s response.
• Clear documentation of fluid resuscitation should accompany all patients transferred to
burn centers
ED MANAGEMENT
FLUID RESUSCITATION

19. • There are several methods of calculating fluid resuscitation for infants and children.
The Parkland formula can be modified to maintain a urinary output of 1 mL/kg/h.
Alternatively, a pediatric maintenance rate for 24 hours can be calculated, and an
additional 2 to 4 mL/kg multiplied bypercentage of body surface area burned is then
added to the total. The entire amount is infused over the first 24 hours. In children
weighing <25 kg, a goal urine output of 1.0 mL/kg/h is necessary. Add 5% dextrose to
maintenance fluids for children weighing <20 kg due to smaller glycogen stores
ED MANAGEMENT
FLUID RESUSCITATION

20. WOUND CARE
• After evaluation and resuscitation of the patient, attend to burn wounds. Initially,
wounds are best covered with a clean, dry sheet.
• Later, small burns can be covered with a moist saline-soaked dressing while the patient
is awaiting admission or transfer.
• The soothing effect of cooling on burns is most likely due to local vasoconstriction.
Cooling stabilizes mast cells and reduces histamine release, kinin formation, and
thromboxane B2 production.
• For large burns, sterile drapes are preferred, because application of saline-soaked
dressings to a large area can cause hypothermia. Consult the admitting service or burn
center early.
• Avoid the use of antiseptic dressings in the ED, because the admitting service will need
to assess the wound. Wound care for transferred patients should be discussed with the
accepting burn center. Do not delay transfer for wound debridement.
• For transferred patients, the referring facility should follow the accepting regional
burn center’s treatment protocol if available.

21. PAIN CONTROL
• Burn injuries are exceedingly painful, and superficial partial-thickness burns are the most
painful. Burn injury not only makes an otherwise already injured area and surrounding
tissue more painful, but also causes hyperalgesia, chiefly mediated by A fibe soothing but
does not provide pain control and can cause hypothermia;28 additional pain management
should be provided.
• During the acute phase, the preferred route for most medication is IV. Opioids (e.g.,
morphine, fentanyl, hydromorphone) are the mainstay of treatment, and relatively large
dosages may be required. Anxiolytic agents may also be given.
• Ensure adequate analgesia for patients being discharged, including a regimen for both
background and breakthrough pain associated with dressing changes. Achieving adequate
pain control is required for patients being considered for discharge rs. Local cooling may be
soothing but does not provide pain control and can cause hypothermia;28 additional pain
management should be provided. During the acute phase, the preferred route for most
medication is IV. Opioids (e.g., morphine, fentanyl, hydromorphone) are the mainstay of
treatment, and relatively large dosages may be required. Anxiolytic agents may also be
given. Ensure adequate analgesia for patients being discharged, including a regimen for
both background and breakthrough pain associated with dressing changes. Achieving
adequate pain control is required for patients being considered for discharge

22. ESCHAROTOMY