00:01
Thanks for joining me on this discussion of burns in the section of trauma.
00:05
Let’s start with the clinical scenario.
00:08
A 24-year-old man who was drinking and smoking at home
at the same time unfortunately he fell asleep
and the curtains in his apartment in the house set on fire.
00:18
His neighbors noticed the smoke and called the firefighters.
00:21
And this is what his house looked like.
00:24
What are you thinking?
If you were to have received a call like this and this is what it looked on the scene,
how would you think to prepare to receive this patient?
What would your initial management plans be?
What are your management priorities?
I’ll give you a second to think about this.
00:46
That’s right, just like any other patient in trauma,
it’s the ABCs or airway, breathing and circulation.
00:53
Of course, particularly for burn patients,
airway and breathing are extremely important
and very important for the initial management.
01:01
I'd like to pose another question to you.
01:04
What are some signs of inhalational injury?
Remember, anybody who’s in a house fire
or in the surrounding of smoke is at risk for inhalational injury
and as a clinician it’s very important for you to have recognized the signs.
01:18
I’ll give you a second to think about the answer.
01:20
That’s correct, soot around the mouth or stridor.
01:25
If the patient is complaining about difficulty speaking
or breathing, they may be late signs
and you should achieve adequate airway.
01:33
This may be indication that the patient’s upper airway is edematous.
01:38
Now, let’s quickly review the rules of Nine.
01:43
There’s no point to remembering it.
01:44
Just remember that the body parts are divided
both in the front and the back, as well as the extremities in the head
into percentages multiples of 9%.
01:54
This gives you a rough estimate of how much percent
body surface areas actually involved in the burn.
01:59
Which will be important when you try to calculate resuscitative fluid formulas.
02:05
Let's briefly discuss burn classifications.
02:07
First degree or superficial thickness burns
typically appear red and dry.
02:12
They are very painful
and are limited to the epidermis.
02:16
Second degree or superficial partial
thickness burns appear at splotchy,
painful blisters
along with significant swelling.
02:24
It primarily affects the papillary region
of the dermis.
02:28
Third degree
or deep partial thickness burns
appear as white or leathery skin.
02:34
These burns impact the reticular region
of the dermis and are relatively painless.
02:40
Finally, fourth degree or full thickness
burns results
in a charred skin
that is totally insensate.
02:48
It penetrates all subcutaneous
tissue layers, including bone
and can result in eschar formation.
02:55
Speaking of which, how do we resuscitate the patient?
Well, it’s governed by Parkland’s Formula.
03:01
Parkland’s formula states that we shall resuscitate our burn patient
with approximately 4cc of crystalloid fluid
multiply their body weight in kg by the percent body surface area
that you’ve estimated based on the rules of nine.
03:16
And how do we know the patient’s adequately resuscitated?
Well, we titrate in to an adequate urine output
as defined approximately 0.5 to 1cc per kg per hour of urine.
03:29
Now, let me change the scenario for you a little bit.
03:34
And give you something to think about.
03:36
Let’s say that you've evaluated a trauma patient, in this case a burn patient,
and now the patient has been admitted to the
surgical intensive care unit for monitoring.
03:45
The patient has been relatively stable the next few days
but on the third day in the hospital, the ICU nurse calls you to the bedside and says
the patient is hypotensive.
03:55
The patient is registering a blood pressure of 80/60.
03:58
What’s going on in your mind?
What’s some possible differential diagnosis?
I’ll give you a second to think about this.
04:07
That’s right.
04:09
The patient maybe septic from an infected wound
particularly gram negative sepsis.
04:15
Remember, this is an important association and very high yield.
04:19
If the patient has a burn and becomes septic shock,
make sure you start appropriate antibiotics.
04:27
Silver sulfadiazine and silver
nitrate are effective broad-spectrum,
antibacterial and antifungal agents
that can be used topically on burns
Next, patient also needs quick and adequate debridement
of the soft tissue that may be infected.
04:44
Remember, you must culture the skin and the burned sites
and treat with appropriate antibiotics.
04:49
But don’t over treat with antibiotics
if there is no evidence of wound infection.
04:54
What if the patient becomes difficult to ventilate?
For example, that same burn patient that you've evaluated in the trauma bay
in the ICU is subsequently intubated
but now the respiratory therapists tells you
he’s got a high peak airway pressure
and you are having a difficult time ventilating the patient.
05:11
What’s going on?
I’ll give you a second to think about this.
05:16
Particularly with patients with circumferential thoracic burns.
05:24
The patient may be having ARDS,
or adult respiratory distresss syndrome
or potentially compartment syndrome of the thorax due to eschars.
05:33
How do we treat eschars in induced compartment syndrome?
With an escharotomy.
05:41
I know this picture looks kind of gruesome
and it looks like a very painful procedure.
05:46
Luckily for the patient, because of the full thickness burns causing that eschar,
the escharotomy itself is actually not painful.
05:54
It’s very important to perform the escharotomy
in a timely fashion to reduce the peak airway pressures
and thoracic compartment syndrome.
06:02
Let me post another question to you.
06:05
What is a potential complication with
long term burn wounds that are not healing?
I’ll give you a second to think about this.
06:14
This is another high yield, important piece of information to remember.
06:17
That’s right!
Marjolin’s ulcer.
06:20
Marjolin’s also a name for squamous cell cancer as the result of a burn wound.
06:26
And here you see a picture of a Marjolin’s ulcer.
06:29
Remember, excision is usually necessary
and it usually takes place under an excisional biopsy,
meaning it’s potentially diagnostic and therapeutic.
06:40
Now, it’s time to review some important clinical pearls and high yield information.
06:44
Remember, burn resuscitation is titrated to an adequate urine output.
06:49
So, the Parkland’s formula is just the starting place.
06:53
And remember, patient’s who sustained circumferential burns
particularly of the thorax, maybe developing compartment syndrome from eschars
and need an urgent release, this is called an escharotomy.
07:08
Thank you very much for joining me on this discussion of burns.