3. Managing the ABC’s in the Burn Patient

•  Stop the Burning Process

• Treat Carbon Monoxide Toxicity immediately

• Manage airway injury from Smoke and Heat

• Manage Pulmonary Problems from Smoke

• Correct Chest wall Restriction

• Recognize The Burn Induced Plasma Shift

• Begin Fluid Resuscitation for Major Burns

• Correct Blood Flow Restriction from Burn Tissue Compression

1. Stop the Burning Process

• Flame Burns

- eliminating any ongoing burning, (i.e. from burning clothes) 

- synthetics in clothes can retain heat which needs to be neutralized

- cover with dry clean sheets

• Chemical Burn

- chemicals continue to burn if in contact with skin

- remove chemically contaminated clothing

          - continuous flushing with water

Management of Airway and Pulmonary Problems

Smoke inhalation is a major cause of morbidity and mortality in the immediate post burn period. These, often life threatening, effects of smoke inhalation must be recognized and aggressively managed. The degree of lung damage is usually not evident for several hours and Early transfer to a Burn Center is highly recommended, if smoke injury is suspected.

The three injury processes, resulting from smoke exposure, are presented in the order in which peak symptoms occur.

• Carbon Monoxide Toxicity

     – peak symptoms immediate

• Upper Airway Injury with Potential Obstruction

     – peak symptoms can be delayed for an hour or more

• Lower Airway Injury with Impaired Gas Exchange

- peak symptoms can be delayed for hours

Carbon Monoxide Toxicity

Pathophysiology Carbon  Monoxide binds to the hemoglobin molecule displacing oxygen thereby decreasing the oxygen delivered to tissue. Risk Factors Any exposure to smoke Any exposure to fumes Diagnosis A high index of suspicion in any fire victim with a history of smoke exposure A carboxyhemoglobin level exceeding 10% total (Morbidity is related to peak level at scene not the first value obtained) Unexplained metabolic acidosis

Hgb Level	Carbon Monoxide Intoxication
CO High	Symptoms
0-5	Normal Value
15-20	Headache, Confusion
20-40	Disorientation, fatigue, nausea, visual changes
40-60	Hallucination, combativeness, coma, shock, shock state
60 or above	Cardiopulmonary arrest, Death
*CO Hgb - carboxyhemoglobin

Effect of O2 on COHgb Level
	The carbon monoxide is rapidly displaced by breathing oxygen compared to breathing room air.

2. Cyanide Toxicity

Cyanide is also found in smoke, especially from burning polyurethane. Plasma cyanide levels are difficult to obtain so treatment is usually based on a high index of suspicion, usually due to an unexplained sever metabolic acidosis not corrected by oxygen and fluids. 

In general, for cyanide poisoning, cardiopulmonary support is usually sufficient treatment, since the liver, via the enzyme rhodenase, will clear the cyanide from the circulation. Sodium nitrite is used (300mg IV over 5-10 minutes) in severe cases, especially in those patients in which the diagnosis is made by blood cyanide levels. The nitrite, in turn, binds with the cyanide. Ordinarily, thiosulfate is also given, which in turn binds the cyanide to form thiocyanate. One must be reasonably sure of the diagnosis of cyanide toxicity before giving sodium nitrite as a side effect is the production of methhemyoglobin.

3. Upper Airway injury

Risk Factors

Oral Burn: rapid swelling of tongue and mucosa impeding airway patency Supraglottic Edema: progression to obstruction Cord and Infraglotti Edema: progression to obstruction

 

Laryngoscopic Assessment for Smoke Inhalation
	Diagnosis: History of smoke exposure or exposure to high temperature e.g. explosion Direct laryngoscopic evidence of injury Symptoms of stridor, dyspnea (often delayed in onset)
Edema and erythema with decreasing airway lumen is noted on initial assessment.
Treatment:
100% oxygen Airway support Early intubation may be required Transfer to burn center if smoke inhalation injury suspected

 

Initial Assessment & Management of the 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 * Transfer to Burn Center if history or findings are positive for smoke inhalation injury REMEMBER: DETERIORATION IS OFTEN DELAYED IN ONSET.

4. Lung Damage from Smoke

• Onset of symptoms in often delayed

• Early transfer to Burn Center if suspect of smoke injury

Lung Injury from Toxins in Smoke
Compounds	Source	Effect	Timing
Ammonia Sulfur Dioxide Chlorine	Clothing, Furniture, Wool, Silk	Mucous membrane irritation, Bronchospasm, Bronchorrhea	Early Onset (first several hours)
Hydrogen Chloride Phosgene	Polyvinyl, Chloride, Furniture (wall, floor coverings)	Severe mucosal damage; ulcers, mucous plugging, Mucosal slough, pulmonary edema	Delayed often 1-2 days
Acetylaldehyde Formaldehyde Acrolein	Wallpaper, Lacquered wood, Cotton, Acrylic	Severe mucosal damage; ulcers, mucous plugging, Mucosal slough, pulmonary edema	Delayed often 1-2 days
Cyanide	Polyurethane upholstery	Tissue Hypoxia	Immediate
Carbon Monoxide	Any combustible substance	Tissue Hypoxia	Immediate

5. Chest Wall Burn & Impaired Ventilation

A full thickness burn of the anterior and lateral chest wall can lead to severe restriction of chest wall motion, especially as edema develops beneath the non-viable tissue (eschar), even in the absence of a completely circumferential burn. Chest wall escharotomy may be required to relieve the restriction; This procedure is best done in a Burn Center unless ventilation is severely impaired.

 

Impaired Breathing from deep chest wall burn
	The restriction to ventilation is further compromised by the abdominal burn diminishing the movement of the diaphragm.

 

The escharotomy incisions are placed along the anterior auxiliary lines with bilateral incisions connected by a subcostal incision. The incisions must extend completely through the eschar so that the subeschar space can expand and decrease tissue pressure. In a full thickness burn, nerve endings are destroyed along with the entire epidermis and dermis. Analgesics are usually not necessary for escharotomy.

2. Restoring & Maintaining Hemodynamic Stability

1. restoring Loss of Plasma Volume (Hypovolemia)

Loss of plasma volume is rapid after a burn injury as fluid collects in the burn tissue. The magnitude of loss can be easily underestimated as plasma is not visibly lost from the surface but rather is hidden beneath the burn. Early fluid resuscitation is required for burns exceeding 20% of body surface.

Assessment:

• Look for other traumatic injuries (falls, explosions, blunt trauma).

• Estimate percent (%) of body surface burned in order to estimate isotonic fluid requirements "Rule of Nine".

• Use burn resuscitation formula remembering to add more fluid or blood for other traumatic injuries.

Thoractic Vertebral Fracture in burn patient after a two-story fall	Fluid loss beneath the burn surface can be massive

 

Estimating the size of the Burn as a % of the Total Body Surface (TBS)

This formula divides the body into parts considered to be 9% (arms, head) to 18% (legs, front, back) of total body skin surface in adults. The small child has a different surface area breakdown. The burn size  (as % of total) can then be used in the resuscitation formula.

2. Impaired Distal Perfusion from Burn Tissue Compression

   As subeschar edema develops under the burn tissue, tissue pressure increases. This is of particular concern in extremities with a circumferential burn where the increasing pressure cannot be dissipated by expansion of neighboring tissue. The increased pressure initially impedes venous return, which markedly accentuates further edema production, raising pressure to a level that then impedes arterial blood flow.  

   Perfusion to the distal extremity must be closely monitored. Pain and color will be unreliable indicators of perfusion in the presence of a burn to the area. A warm extremity invariably indicates good flow during the period, but a cool skin does not always indicate that the problem is due to proximal burn constriction. Hypovolemia may well be the problem.

   Circumferential burn impairing circulation to hand.	Escharotomy: releasing tissue pressure and restoring perfusion (Preferably performed in a Burn Center).
   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)
   The monitoring of distal pulsatile flow by palpation and then by the use of a Doppler flow meter is the most practical method of assessment. Pulsatile flow must be present.

4. Criteria for Referral to a Specialty Burn Center

The American Burn Association (ABA) has identified those injuries that should be treated in a specialized burn center. Patients with these burns should be treated in a specialized burn facility after initial assessment and treatment at an appropriate hospital emergency department. Sometimes major burns are directly transferred to a burn center from scene if the center is within a safe transport time.

A large burn	A deep burn

 

High risk due to location