EM@3AM: Burns

Author: Katharine White, MD (PGY-2 UTSW/Parkland Memorial Hospital) // Edited by: Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX), Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

You are a few hours into a busy overnight shift when you receive a page that EMS is bringing in an 18-year-old male who was found unresponsive in a house fire with severe burns. VS include T 37.5C, BP 144/77, HR 110, RR 15, Pulse Ox 98% on RA. You have minutes to prepare your team to care for this patient.

What’s the diagnosis, and what’s your next step in evaluation and treatment?

Answer: Burn; possible inhalation injury

Initial Steps:

• Assemble your team – consider involving your Respiratory Therapists, Anesthesiologists, and Surgery colleagues as clinically indicated.
• Prepare your room and assign roles: early IVF access and airway assessment are critical in this patient population.
• Evaluate goals of care. Consider early conversations with patient and family if possible in the clinical context. Patients with a Baux Score (Age + TBSA) >160 have nearly a 100% mortality rate.¹

Airway: Always consider inhalation injury^2,3

• Most fire-related deaths are due to inhalation injury.
• Inhalation injuries are most commonly associated with enclosed space injuries, facial burns, hoarse voice, carbonaceous sputum, fires, stridulous voice, feeling of a lump in the throat, altered mental status. The more features they have, the more likely inhalation injury is.³
• Don’t hesitate to intubate early in the clinical course – mild pharyngeal edema with visible soot can rapidly progress to airway obstruction.
• Always prepare back-up airway tools. Consider Direct Laryngoscopy, Video Laryngoscopy, bougie, fiberoptic intubation, and surgical airway as clinically indicated.

Breathing: Consider Carbon Monoxide and Cyanide toxicities^2,3

• Obtain VBG and carboxyhemoglobin levels to evaluate for CO toxicity.
• CXR to evaluate for concomitant traumatic injuries as well as evidence of ARDS.
• Consider a lactate – burn injuries with hypoxia and an elevated lactate suggest CN toxicity.
• In the intubated patient, don’t forget to think about compartment syndrome and circumferential burns that could arise in the patient without complaint.
• The combination of body burn and smoke inhalation causes a marked increase in mortality – these patients generally require more aggressive fluid resuscitation.

Circulation: Early IVF resuscitation is paramount^2,3

• Obtain two large bore peripheral IVs (through intact skin or not) and place a Foley catheter to monitor your resuscitation.
• Burn shock is a combination of hypovolemic and distributive shock – early resuscitation is paramount.³

• Research is on-going regarding the exact amount of fluid resuscitation these patients require. Several options are available, including the Parkland Burn Formula, Brooke formula, and ISR rule of 10’s.^4,5

• • Parkland: Weight (Kg) x 4mL/kg x %TBSA.
  • Brooke: Weight (Kg) x 2mL/kg x %TBSA.
  • ISR Rule of 10’s: %TBSA x 10cc/hr for adults weighing 40-80 kg. For every 10 kg ABOVE 80 kg, increase initial rate by 100 ml/hr.

• Give ½ in the first 8 hours (time zero = time of burn) and the remaining ½ over the next 16 hours.
  • Goal UOP is 0.5mL/kg/hr.
• Note: %TBSA only includes partial and third degree burns (up to 50% TBSA).

Ancillary Testing²

• Consider obtaining a CBC, BMP, Lactate, ABG, UA, Carboxyhemoglobin levels as clinically indicated.
• CXR can be obtained, particularly when concerned about flame and blast injuries.

Burn Treatment:

• Treat pain with analgesics and update tetanus.
• Consider escharotomy for extremity circumferential burns with decreased pulses, compartment syndromes, or difficulty with ventilation.
• Avoid hypothermia by warming the resuscitation room, administer warm inspired air, apply warm blankets, infuse warmed fluids, and cover wounds with clean dry sheets.

Special Populations:

• Blast Injuries: In particular for blast injuries, consider secondary trauma (corneal abrasions, rupture of tympanic membranes, pneumothorax/hemothorax, hollow viscus injuries, fractures, crush injuries, toxic inhalations).
• Pediatrics: Because of their larger body surface area to body mass ratio, children are more likely to become hypothermic and are more sensitive to fluid loss.⁷

Who Requires Admission to a Burn Center:^3,6,7

• Partial Thickness burns >10% of TBSA (age <10 or >50) or >20% of TBSA (age 10-50)
• Third Degree Burns
• Electrical Burns (including lightning injury)
• Chemical Burns
• Inhalation Injury
• Circumferential burns
• Burns to hands, face, genitalia, perineum, major joints
• Burns in patients with other medical comorbidities that may prolong recovery

Pearls and Pitfalls:

• Follow your ABCs. Remember, these patients can present with rapidly evolving, critical airways.
• Obtain a directed history from patient or EMS regarding burning agent (don’t forget about chemical burns!), whether injury was sustained in an open or enclosed space, risk of blast injury.
• Treat CO and cyanide if history, exam, or labs are suggestive.
• Begin resuscitation with IV fluids (LR) based on specific burn formula (ISR, Brooke, Parkland).
• Don’t forget that burn patients can be MORE than just a burn: think about trauma, toxicologic etiologies, and blast injuries.
• Pain management is paramount in this critically ill population. Reassess early and often.

For more on burns, see this awesome emDocs post.

References:

1. Steinvall I, Elmasry M, Fredrikson M, Sjoberg F. Standardised mortality ratio based on the sum of age and percentage total body surface area burned is an adequate quality indicator in burn care: An exploratory review. Burns. 2016;42(1):28-40.
2. Cline D, Meckler G, Ma OJ et al. Tintinalli’s Emergency Medicine Manual, Eighth Edition. McGraw-Hill Education / Medical; 2017.
3. Latenser BA. Critical Care of the Burn Patient. In: Hall JB, Schmidt GA, Kress JP. eds. Principles of Critical Care, 4e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1340&sectionid=80027724. Accessed November 22, 2017.
4. Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely burned military casualties: fluid begets more fluid. J Trauma. 2009;67(2):231-7.
5. Chung KK, Salinas J, Renz EM, et al. Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10. J Trauma. 2010;69 Suppl 1:S49-54.
6. American Burn Association. Advanced Burn Life Support Provider Manual. Chicago. 2011. 25-27. Print.
7. Shah AR, Liao LF. Pediatric Burn Care: Unique Considerations in Management. Clin Plast Surg. 2017;44(3):603-610.