United States Naval
Flight Surgeon Handbook
2nd Edition 1998
Burn Management
References:
-
Pruitt, BA, Jr.: The burn patient: I. Initial care, II. Late
care and complications of thermal injury. Current Problems in
Surgery. April-May 1979;16:4 and 5.
-
Martyn, JAJ: Acute management of the burned patient.
Philadelphia: Saunders, 1990.
-
Munster, AM: Burn Care for the House Officer. Baltimore:
Williams and Wilkins, 1980.
-
Committee on Trauma, American College of Surgeons: Advanced
Trauma Life Support. Chicago: 1993.
Point of Contact:
U.S. Army Institute for Surgical Research (ISR)
Brooke Army Medical Center
DSN: 429-2876/2604/0501
Com: (210) 916-2876/2604/0501 or 1-800-222-BURN
Message Address: CDR USAISR FT SAM HOUSTON TX
First Aid at Scene:
-
Stop the burning process and remove the patient to a safe
area.
-
Place patient in a supine position and initiate CPR if
indicated. The same general principles of cardiopulmonary
resuscitation apply, and are a priority.
-
Cover patient (clean sheet &/or "space blanket").
-
If 30 min. to ER, start large bore (16 ga.) IV with Lactated
Ringer's solution (LR).
-
Oxygen; intubate if necessary. Carbon monoxide poisoning is
the most frequent cause of death in the first hours after a
fire.
Notes:
-
Rapidly remove burning clothing.
-
Electrical burns: Ensure patient is clear of electrical source
prior to rescue.
-
Chemical burns: Remove soaked clothing, and irrigate with
copious amounts of water ASAP.
-
Ensure that the patient and the medical team are completely
clear of the fire area for their protection and to avoid
interference in fire fighting efforts.
ER/Medical Department Treatment:
-
Re-assess ABC's of BLS. FLUID RESUSCITATION is of great
concern.
-
Oxygen, NG tube & foley for all serious burns. Intubation
if indicated.
-
Assess extent and severity of burns. (Rule of 9's or mapping;
patients hand = 1% body surface).
-
IV analgesics titrated to reduce pain to tolerable levels
during initial cleaning and debridement.
-
Gently clean and debride
wounds; cover wounds with Silvadene
or Sulfamylon. Keep patient warm; clean and re-cover wounds
daily.
-
Evaluate the eyes using fluorescein.
Special Situations
1. Electrical Burns:
-
Cutaneous lesions may be misleadingly small (tip of the
iceberg) in the face of serious deep tissue damage.
-
Watch for myoglobinuria and treat promptly. Give 25 grams of
mannitol IV and add 12.5 grams (1 amp) to subsequent liters of
fluid. Alkalinization of the urine with sodium bicarb will
increase excretion (1 amp in a liter of LR). Use of any diuretic
makes urine output an invalid estimator of circulatory status.
-
May cause tetanic contractions leading to fractures of the
vertebrae and falls may lead to other injuries.
-
May impair circulation; monitor pulses closely. Escharotomy,
as with any circumferential burn may be needed. However, a
fasciotomy maybe required due to deep muscle injury.
2.Chemical Burns:
-
Alkali powder (lime): brush the powder from the skin before
lavage is begun.
-
Phenol: instead of lavage and in any case after lavage as
well, the skin should be washed with a solvent such as
polyethylene glycol, propylene glycol (anti-freeze), or glycerol
to remove residual phenol.
-
White phosphorous: must be kept moist to prevent ignition of
the retained phosphorous particles. Wash the involved area with an
0.5% or 1.0% solution of copper sulfate. This will cause the
formation of a blue-black film of cupric phosphide on the surface
of the retained particles. Debride the particles and keep them
moist or you will have another fire.
3.Closed Space Fires:
-
May have inhalation injuries. Look for facial burns, singed
nasal hair or eyebrows, oropharyngeal burns, carbonaceous sputum,
hoarseness and stridor, etc.
-
Intubate early for inhalation injuries.
-
Evaluate for carbon monoxide and toxic gas inhalation. Don't
forget re-evaluation for delayed effects.
Fluid Resuscitation:
First 24 hours post-burn:
-
2-4 ml of LR / kg body weight / % body surface
burned.
-
infuse 1/2 calculated dose within first 8 hours post-burn;
second half over next 16 hours.
-
adjust IV rate to maintain urine output at 30-50 ml/hr in
adults.
-
make decreasing adjustments of IV rate gradually (10%
increments q 1hr).
-
use of diuretics make urine
output an invalid measure of
circulatory status.
Second 24 hours:
PLUS:
-
D5W (or 1/4 Normal saline (1/4
NS) primarily for children) to
yield same hourly infusion rate as the first 24 hours.
-
Adjust D5W or the 1/4
NS rate, not the 5%
albumin
soln., in order to maintain urine output 30-50 ml/hr.
General Considerations:
-
ALL medications must be given IV during the
resuscitation because of the dramatic changes in capillary
permeability. Otherwise, the patient can receive an overdose when
fluid mobilization occurs.
-
Sodium shifts can cause serious hyponatremia. The rate
of fall of serum sodium levels is very important, especially in
young patients. Serum sodium must be carefully monitored when
giving large volumes of IV fluids.
-
Transfusion is indicated for hematocrit under 30. Packed RBC's
are preferred.
-
Insulin infusion may be instituted for
serum glucose over
200mg%.
-
Histamine (H2) blockers and
antacids should be used to keep
the gastric pH at7.0.
Aeromedical Evacuation:
-
Patient must be accompanied by a physician or nurse.
-
2 IV lines, sewn in place;
NG tube; foley. (Balloons filled
with water, not air).
-
Intubate if airway is a concern.
-
Chest X-ray to evaluate placement of lines and tubes, and rule
out pneumothorax. Insert a chest tube if indicated.
-
Apply Silvadene to burns, and cover patient with "space
blanket".
-
Cardiac monitor & ACLS meds.
-
Notify the Burn Center if a ventilator is required.
Criteria for Burn Center Referral:
-
Burns over 25% body surface area (BSA).
-
Partial thickness (second degree) burns over 20% BSA.
-
Full thickness (third degree) burns over 10% BSA.
-
Burns involving face, hands, eyes, feet, or perineum.
-
Burns associated with significant fractures or other major
trauma.
-
High voltage electrical burns.
-
Inhalation injury.
-
Pre-existing disease.
-
Very young and very old.
United States Naval Flight Surgeon Handbook: 2nd Edition
1998
The Society of U.S. Naval Flight Surgeons
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Operational Medicine
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