Big Cedar Burn

8/11/2019 Big Cedar Burn

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Date

Jeffrey S Litt DOBurn and Wound Program Director

University of Missouri - Columbia


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Briefly recount key moments in burn history and epidemiology Clinically differentiate Superficial, Partial, and Full Thickness Burn

discuss emerging technologies to assist in that differentiation List the different ways to determine burn size Describe fluid resuscitation of burn patients and controversies/

complications of resuscitation Explain the initial goals and topical treatments of burn wounds Review characteristics and treatment of inhalation injuries Review child abuse burn clinical characteristics


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Burn treatment modalities have been documented as far back as>3500 yrs with Neanderthal cave paintings

Smith papyrus of 1500 BC documents ancient Egyptian usesalve of honey and resins for burn and wound care

Hippocrates, Paracelsus, Galen and others propagated varied butreatments/salves involving the usage of pig fat, vinegar, honey, mud, excrement, etc.

Ambroise Pare (1510-1590) described early burn excision, basethe works of Guy du Chauliac (ca 1300-1368).

Guillaume Dupuytren (1777-1835) developed first burn classifischema of 6 degrees, subsequently modified into current 3-degrclassification in place today.


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Most major advances have occurred in last 50-60 yrsincluding:

Fluid resuscitation Infection control and treatment Burn hypermetabolism and nutritional support Excision and grafting techniques and skin

replacements/substitutes Inhalation injury treatment


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Underhill Rialto Theater, 1921 Blalock - 1931 Cope and Moore Cocoanut Grove Club, 1942 Texas City Disaster - 1947 Evans Brooke Army Hospital 1952 Baxter and Shires, 1968 Parkland

Consensus

- 1979


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App 1.2 million burns/yr (decreasing incidence) App 500,000 seek medical attention; 40,000 hospitalized 3500 10000 deaths annually (est) 90% preventable; 50% associated with substance abuse 2nd most common cause of trauma-related death


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1940 1950 1960 1970 1980 1990 2000

Burn size(%TBSA)

Year

Penicillin

Broad spectrumantibiotics

Modern fluidmanagement

Early excision& grafting

Skin substitutes ?


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Prehospital Care

1. Remove patient from source of burn2. Universal precautions by caregivers

3. Remove all clothing and objects (especially rings, jewelry,watches, belts) that can retain heat or lead to tourniqueteffect

4. Early cooling (watch for hypothermia which may lead toV-fib and asystole)

5. Cover with warm dry dressing prior to transfer6. Chemical burns - IRRIGATE, IRRIGATE, IRRIGATE7. Do NOT neutralize chemical burns8. Electrical burns - make sure source of electricity turned

off prior to attempts at removal of patient9. Begin Parkland resuscitation for burns >20% TBSA


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ABA Burn Center Referral Criteria 1. Partial thickness burns greater than 10% total body surface area (TBSA).2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.3. Third degree burns in any age group.4. Electrical burns, including lightning injury.5. Chemical burns.6. Inhalation injury.7. Burn injury in patients with preexisting medical disorders that could complicate managementrecovery, or affect mortality.8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury p

greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate rpatient may be initially stabilized in a trauma center before being transferred to a burn unit. Phys judgment will be necessary in such situations and should be in concert with the regional medicaplan and triage protocols.9.Burned children in hospitals without qualified personnel or equipment for the care of children10. Burn injury in patients who will require special social, emotional, or rehabilitative interventi


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1. Save Life 2. Save Limb 3. Save Function 4. Preserve Cosmetics


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Depth: .5mm (eye lids) - 1.5mm (soles of feet) in depth Barrier that helps regulate body temperature and

protects the body from injuries such as infection anddehydration


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Depth: 1mm - 4mm Contains dermal appendages, hair follicles, sweat and

subaceous glands, lymphatic vessels, blood vessels,and nerves


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Superficial (1st degree) Superficial-Partial Thickness (2nd degree) Deep-Partial Thickness (2nd degree) Full Thickness (3rd degree) 4th Degree (typically electrical injury)


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Common etiology: sunburn, cold low-intensity flash caused by flame or an electrical spark brief contact with hot liquids or steam exposure to mildly caustic chemicals, i.e. cleaning supplies,

chlorine


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Inflammation with no excoriation Symptoms:

erythema that blanches easily to pressure, tingling, pain,warmth to palpation, and minor localized edema

blisters are not usually associate with a 1st degree burn,however; they can appear (small/dry) 24hr after injury


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Common etiology: (similar to 1st degree but withextended time of exposure)

contact with flames chemical exposure contact with hot liquids

cold exposure


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Damage to the dermis with excoriation Symptoms:

wet secondary to weeping of fluid blanch with application of pressure but very painful to touch

and sensitive to exposure

red in appearance blisters are common and appear quickly


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Healing: typically heal within 2-3 weeks with appropriate wound care no scarring no autografting required


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Common etiology: (same as superficial-partialthickness)

contact with flames chemical exposure contact with hot liquids cold exposure


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Similar to superficial-partial thickness, may only be afew tenths of a millimeter deeper. Can be difficult todifferentiate, therefore; sometimes referred to asbeing of indeterminate depth

Symptoms:

may appear wet or dry, red or mottled blanch very slowly (if at all) with pressure, very painful to touch

and sensitive to exposure potential to convert to full thickness


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Healing: should re-evaluate wound weekly for 2-3 weeks for

determination of final depth and likelihood of surgicalintervention

Will frequently benefit from application of xenograft, allograft,and possible autograft


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Common etiology: prolonged exposure to chemicals, flames, or contact with

surfaces (road rash, mufflers) prolonged cold exposure (frostbite) contact with high voltage electricity (may be 4th degree if

involves muscle, bone, etc)


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Damage to epidermis, dermis, and subcutaneoustissues

Symptoms: painless to wound bed (NOT surrounding tissue!) appears mottled, grey, white, or black due to lack of blood flow

with no blanching to palpation appears firm, dry, and leathery secondary to damage to

collagenous structures


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Healing: early excision of dead tissue is key will require surgical debridement and application of autograft

to optimize function, minimize scar formation if no graft or amputation - infection, prolonged wound, scarring


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Visual tool approximates burn size Adults: Head 9, Trunk 36, Arm 9, Leg 18, Genitals 1 Children: Head 14, Trunk 36, Arm 9, Leg 16 Infants: Head 18, Trunk 36, Arm 9, Leg 14 Only count 2nd and 3rd degree burns


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Least effective method of measuring burn size Used to approximate size of smaller burn wounds; is

not uniform to all patients The size of the patients palm and outstretched digits i

approximately 1% TBSA (total body surface area)

Only count 2nd and 3rd degree burns


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Lund-Browder most specific measurement tool for determining size of burn Guides fluid resuscitation Takes into account the age of the patient Takes proportions of the body into account Only Count 2nd and 3rd degree burns


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Grading system of 4-5 degrees well-known to most physicians apersons.

The depth of a burn wound and/or its healing potential are the mimportant determinants of the therapeutic management and of thresidual morbidity or scarring.

Traditionally, burn surgeons divide burns into superficial which by rapid re-epithelialization (sup/sup pt) with minimal scarring adeep burns requiring surgical therapy (deep pt/full).

Clinical assessment remains the most frequent technique to meathe depth of a burn wound although this has been shown to beaccurate in only 60 75% of the cases, even when carried out bexperienced burn surgeon.


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Thermography using infra-red photography inversely

correlates skin temperature with degree of damage. Interference by pseudoeschar/ointments, etc


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Vital Dyes: IV Fluoroscein Indocyanine Green

Angiography


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Laser DopplerImaging

Upwards of 90%sensitivity forassessing wound

depth (dependingon study) Expensive


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Videomicroscopy: Uses a microscope to assess capillary pleuxus

Seemingly more sensitive and specific than LDI Limited system availability


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Advances in wound coverage have included many skinsubstitutes/dermal templates to assist with coverage.

None have proven consistently better than any other Large TBSA burns still remain a challenge in coverage

Integra


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Bi-layer dermal analogue with a lattice of fibers from bovine collagen covalently linked tochondroitin 6 sulfate

Epidermal component is medical grade silicone (100 um thick) Dermal component becomes adherent to wound, and silicone layer protects from bacterial

contamination and desiccation Dermis becomes populated with native cells and vascular components Fibroblasts replace the bovine collagen to produce the final dermis (theoretically resembling

regimentednormal pattern, rather than the appearance of scar dermis)

I mesh the Integra 1:1 for better egress of fluid and penetration of topical silver (prefer to cover withWoundVAC)

Silicone layer removed after 2 to 3 weeks and thin skin graft applied No rejection or toxicity has been observed as artificial dermis is biodegraded, metabolized, and

absorbed by the host Disadvantages are cost ($1200 to $3700) and the need for at least 2 surgical procedures

Integra


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A technique for harvesting cells fir delivery to the wound as asuspension.

Facilitates rapid epithelialization. Used in conjunction with STSG; assists in rapid closure and im

quality of outcomes.


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Process takes app 30 minutes. Thin STSG taken from donor site and mixed with enzymatic

preparation to allow cellular dissociation at dermal/epidermal junction.

Sample moved to separate fluid filled dish and cells are scrapedsample.

Fluid is then collected, filtered to remove keratin debris, and thesprayed onto wound using supplied syringe.


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Resuscitate burns greater than 18-20%TBSA

Consensus Formula (formerly known as ParklandFormula) 4ml (Lactated Ringer) x kg x TBSA

1st 1/2 of fluid given in 1st 8hr from injury2nd 1/2 of fluid given in remaining 16hr from injury

Modified Brooke Resuscitation: 2ml - 6ml of LR x kgx TBSA

Titrate to .5ml - 1ml urine/hr(too much UOP is just as bad as not enough)


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Fluid resuscitation is aimed at physiologic support throughout the initial 2hr period of hypovolemia.

Hypovolemia caused by inflammation: Histamine Serotonin Thromboxanes Prostaglandins Microvascular changes and loss of capillary integrity Extra-vascular fluid sequestration Massive whole-body fluid shifts in large burns Immune/Inflammatory derangement


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Burn Resuscitation formulas/substances Fluid creep development Markers of resuscitation ACS


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Adequate resuscitation has been succeeded by fluidcreep,producing excessive resuscitation in theapparent belief that if some fluid is good, lots of fluidwill be even better. The consequences of too muchfluid can be life-threatening. Especially when they takethe form of the abdominal compartment syndrome .

B. Pruitt


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Complications may include: Pulmonary edema, Gastrointestinal dysfunction, Abdominal and Extremity compartment syndromes, Delayed wound healing, Increased incidents of infection, Elevated orbital pressures and multiorgan failure.


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Few centers use colloid as initial resuscitative fluid; many use it arescue therapy.

Other rescue therapies explored include plasma exchange, with gresults


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Adequate endpoints of resuscitation are not entirely clear. Historically, UOP is the classic measure of adequate resuscitation. Interestin

however, Dr. Baxter never described UOP as a specific parameter in the orstudies.

Utilized correction of the depressed cardiac output (CO) as well as the defithe extracellular fluid (ECF) volume space and plasma volume as the reporendpoints.

The 11 human subjects

usually achieved UO > 50 mL/h within 2-6 hoinjury

but this was not a formally reported variable.

In the description that followed of the clinical series of 277 human burn pawith 20% > 70 % TBSA burns in this same article, the UO response was agspecifically reported.

In fact, to quote Dr. Baxter, in 1979 :

urine volume, about which we call day, is an inaccurate sign, and yet it is the best clinical sign we havecourse, with 1979 technology


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Unroof blisters vs. not

Unroof -- pain but allows visualization of wounds,application of topical treatment, release ofinflammatory cytokines in blister fluid

Unhealthy tissue needs to be removed ASAP,


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Medical Debridement

typically performed in hydrotherapy room upon admission decontamination of chemical/gasoline for no less than 20-30

minutes unroofing blisters, removal of eschars, initial cleansing of

wounds, application of topical medications


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Surgical Debridement

typically performed in operating room once wounds declaredready for surgery excision of all damaged tissue (eschar, fat, muscle, limbs) until

healthy tissue is reached


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1. Antimicrobial layer

2. Non-adherent layer3. Anti-sheer layer4. Compression layer


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Silver Sulfadiazine

Mafenide Acetate Bacitracin/Bactroban Silver impregnated dressings (i.e. acticoat)

Inhalation Injury (~7% of patients in NBR)


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Hx: closed space fire, meth lab explosion, orpetroleum product combustion

Upper airway injury: acute mortality facial/intraoral burns, naso/oropharyngeal soot, sore throat,abnormal phonation, stridor

Lower airway injury: delayed mortality (honeymoonperiod) dyspnea, wheezing, carbonaceous sputum, COHb,

PaO2/FiO2 Will increase resuscitation volumes

Clinical dx - bronchoscopy confirmation Intubate EARLY!!! Orotracheal Surgical airway uncommon

P b bl th i f t ibl f t lit i th ll


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Probably the main factor responsible for mortality in thermallyinjured patients

Inhalation injury increases burn mortality by 20% Pneumonia independently increases the mortality by 40% Children and elderly are especially prone to injury/pneumonia

due to limited physiologic reserve Improvements in mortality from inhalation injury mostly due to

improvements in critical care Treatment of inhalation injury has not kept pace with

improvements in care of cutaneous burns Multiple mechanisms in addition to thermal injury that

contribute Lack of uniform criteria for diagnosis No standardized quantifying system

Little evidence based medicine-mostly based on case reports,animal data, and anecdoctal experience

Few multi-center trials in burn care No class I evidence for any treatment modalities


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Cli i l I di ti f I t b ti


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Clinical Indications for Intubation: Stridor Hoarseness Dysphonia Massive burns requiring aggressive crystalloid resuscitation (not absolute PaO250 (acutely)

Consider possibility of CO or HCN poisoning in structural fires


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Consider possibility of CO or HCN poisoning in structural fires Hgb has >200x affinity for CO over O2 CO t1/2 at normal pressure/O2 is app 2.5 hrs O2 therapy can decrease t1/2 life HBO can decrease to app 40 min, but not standard of care

Intubation and 100%FIO2 typically adequate COHgb checked; if elevated checked frequently


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COHgb Level Symptoms

0 - 5 Normal Value

15 - 20 Headache, Confusion

20 - 40 Disorientation, fatigue, nausea, visualchanges

40 - 60Hallucinations, combativeness, coma,

shock

> 60 Cardiopulmonary arrest, death

Controversial


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Controversial Very rare event with little human data available Cyanide can be produced by the combustion of natural or synthetic house

materials, including synthetic polymers, paper, wool, silk, polyurethane, more

Hypoxia, elevated lactic acid, and metabolic acidosis are considered hallof cyanide toxicity, but are more likely the result of an oxygen poor envirin a typical house fire, CO poisoning, underresuscitation, and associated

Hyperbaric oxygen therapy is not advocated

Cyanide antidote kit


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Cyanide antidote kit Sodium Thiosulfate acts as sulfur donor to enhance endogenous elimi

of CN Sodium Nitrate and Amyl Nitrate both act to induce methemoglobin

Methbg does not bind CN with a high-affinity, so less CN is transported ttissue

Side effect is hypotension and reduced O2 carrying capacity Hydroxocobalamin (Cyanokit)

Natural form of vitamin B12

detoxifies CN through the irreversible formation of cyanocobalamin whiexcreted in the urine (chelates cyanide)


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How new definition will lead to improvement sin care reduction


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How new definition will lead to improvement sin care, reduction VAEs, or otherwise impact critical care of the burn unit are still

unclear. Data still needs to be collected and analyzed.

Early Intubation


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Early Intubation Aggressive Pulm Toilet/Bronchial Hygiene Consider non-traditional ventilatory strategies (i.e. APRV, HFPV Consider Tx Bronchoscopy Inhaled pharmacological txs Long-term sequelae

Burns make up 10% of all child abuse cases


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Most victims under the age of 10 with the majority under the age of 2 Inflicted burns often leave characteristic patterns

Burn pattern inconsistent with account of injury Look for clean lines of demarcation Are the burns located on the buttocks, area between the legs, wrists, ankl

soles, or palms? Are other injuries present? (healed burn, bruises, fractures) Often delay in seeking medical attention

Immersion burns are most common (look for sparing on buttocks & popliteand look for splash marks)

Contact burns (burn often mirrors branding object like curling iron, steam ircigarette lighter, etc.)

Accounts for app 15% of


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Accounts for app 15% ofburn injuries in children

Suspect based on H&P Delayed presentation Conflicting histories Previous injuries Sharply demarcated

margins of burns Uniform depth

Absence of splash marksin scald burns(stocking/glovepresentation)


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Any suspicion needs

appropriate work-upby trained personnel. If unable to

appropriatelyevaluate, needs timely

transfer per ABAcriteria

Child Abuse


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xxxxx

xxxxxxx xxxxxxxxx

Child Abusee


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xxxxx

xxxxxx

ABLS delineates well will be


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offering course at MU over next

several months

Evaluate as a trauma


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ABCs (Stop the burning)

Universal Precautions Decontaminate if chemical Stabilize hemodynamically *************** resuscitate

with IV crystalloid (LR > NS) ************** Provide analgesia (IV) Intubate if clinically (by story AND PE) suspect inhalation

injury, particularly with large burns requiring significantresuscitation

Dress with warm, clean linen (sheets will do)

Adjuncts (do not delay transfer):


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Place foley for resuscitative-size burns

Place NGT (OGT if intubated) for burns >20% Assess extrmities that are burned (circumferential especially) Frequent VSs

ABA Burn Center Referral Criteria

Burn injuries that should be referred to a burn center include:


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1. Partial thickness burns greater than 10% total body surface area (TBSA).2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints.

3. Third degree burns in any age group.4. Electrical burns, including lightning injury.5. Chemical burns.6. Inhalation injury.7. Burn injury in patients with preexisting medical disorders that could complicate management,prolong recovery, or affect mortality.8. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury posesthe greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediaterisk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit.Physician judgment will be necessary in such situations and should be in concert with the regionalmedical control plan and triage protocols.9.Burned children in hospitals without qualified personnel or equipment for the care of children.10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention.

Burn Injuries are complex and multi-factorial, requiring standard


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and specialized care in Burn Centers for optimization of outcome

Any question or concern regarding a patient with a burn injury owhatever type should have a discussion with a burn center, andpossible transfer.

University of MO George David Peak Memorial Burn Care Cenavailable for consultations 24/7 and are always willing to be ofassistance in whatever fashion we can.

(573)882-6985


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(573)882 6985


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Total Burn Care, ed4 , 20012, Elsevier publishing, Herndon editor Color Atlas of Burn Reconstructive Surgery, first ed, 2010, Springer publishing, Hyakusok


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