Flame Burn

Block Z (Villafuerte, Waga, Yuga, Zuniega)

General Data

W. O. 26/M Single with partner Furnace crew Pasig City

Chief Complaint

Flame Burn

History of Present IllnessDOI: 12/05/13TOI: 4amPOI: Metal factory (Cainta, Rizal)MOI: flame burn

8 hrs PTC, While at work, the furnace machine on which the patient was attending to suddenly exploded.

Patient was caught in flames – face, abdomen, and bilateral legs.

(+) fall from standing height, landed on his buttocks. (-) head trauma, loss of consciousness, headache, vomiting

He was immediately brought to Amang Rodriguez Hospital. No management was done.

He was transferred to East Ave. Medical Center. A> flash burn 67% (BLE, abdomen, BUE and face)

IV fluids (PLR) was started. Wound dressing was done

Was given Erythromycin eye ointment, Omeprazole 40mg IV, ATS and Te Ana

Patient was transferred to PGH due to unavailability of room.

Primary Survey

AIRWAYAwake, able to speak in sentences. (-) stridor(-) singed nostril hairs(-) neck burn(-) sooty phlegm

BREATHINGNot in respiratory distress with RR 20 breaths/minute.Equal chest expansion, clear breath sounds, (-) rales/ wheezes

Primary SurveyCirculationBP: 120/70 mmHgHR : 84 bpmFEP, PNBCRT <2secs

Compartment Syndrome

(-) pain(-) pallor(-) paresthesia(-) pulselessness(-) Paralysis(-) poikilothermia

Cervical injury(+) fall from standing height(-) head trauma(-) cervical tenderness

Primary SurveyDeficits Exposure

(-) motor deficits(-) sensory deficits

Face – 0.25%Anterior trunk – 2%R hand – 0.25%L Hand – 0.5%R thigh – 5% L thigh – 7%R leg – 7%R foot – 7%

Primary Survey

Weight: 60kgIVF Used: Plain Lactated RingerParkland formula: 4ml/kg/%TBSAComputation: 4mlx60kgx29%

6,960 ml 1st 8hrs: 3,480 ml (3480 cc/hr for 1hr since pt arrived 8 hrs

post-injury)▪ Double line: IVF 1 – PLR Fast drip

IVF 2 – PLR fast drip Next 16hrs: 3,480 ml (220 cc/hr x 16 hrs)

▪ Double line: IVF 1 – PLR @ 110 cc/hr IVF 2 – PLR @ 110cc/hr

Fluids

Initial Assessment

Flame burn 29% TBSA SPT: 27% ( face, B hands, B thighs, R leg,

R foot) DPT: 2% (anterior trunk)

Secondary Survey

Past Medical History Repair of facial fractures for

vehicular crash (2007, hospital cannot be recalled)

(-) Bronchial asthma, allergy, DM, HPN, PTB

Family Medical History (-) DM, HPN, PTB, BA, goiter, cancer

Secondary Survey

Personal and Social History Occasional alcoholic beverage

drinker (-) smoking, illicit drug use Has a partner with 2 children

Review of Systems

(-) headache, nausea, vomiting(-) cough and colds(-) chest pain, palpitations(-) difficulty of breathing(-) abdominal pain(-) changes in bowel movement(-) urinary changes

General Condition Awake, alert, E4V5M6

Vital Signs BP 120/70 HR 80 RR 20 O2S 99% T o 37.0

HEENTAnicteric sclerae, pink conjunctivae, (-) singed eyebrows and nostril hairs, (-) circumferential burns on neck

Chest and Lungs

Equal chest expansion, clear breath sounds (rales/wheezes)

Heart Adynamic precordium, normal rate, regular rhythm, distinct heart sounds, (-) murmurs

Abdomen Flat, NABS, soft, non-tender, (-) masses, organomegaly

Extremities Pink nail beds, full equal pulses, (-) cyanosis

Physical Examination

Course at the ER

NPO for nowIVF: (PLR 3.5L)

R: fast drip 1L PLR then PLR 1L @ 110cc/hr

L: fast drip 1L PLR then PLR 1L @ 110cc/hrDiagnostics:

CBC, BT, PT/PTT, BUN, Crea, Na, K, Cl, Albumin, ABG, chest xray

For SSD dressing Monitor VSQ1, UO Q1, I/O shift

Therapeutics

Omeprazole 40mg IV OD Tramadol 50 mg IV q 8 MV + Zinc 1 tab OD OD Vitamin C 1 tab OD OD Paracetamol 300mg IV q 4 prn for

T>38.5

Discussion

The skinLargest organ in the body

Prevents fluid and electrolyte loss

Prevents infection

Protection from radiation

Thermal regulation

Pathological changes of thermal burn Denaturation of

proteins and loss of plasma membrane integrity

Temperature + duration of contact = synergistic effect

hypoperfusion

dessicationedema

infection

Burn Depth

Burn ClassificationMinor Moderate Major

CHILDRENPTB <10%BSA 10-20%BSA >20%BSAFTB <2%BSA 2-10%BSA >10%BSA

ADULTSPTB <15%BSA 15-25%BSA >25%BSAFTB <2%BSA 2-10%BSA >10%BSAAge <2 yrs with minor

injury<10 yrs with major injury

Involvement of hands, face, feet and

perineum

(-) (-) (+)

Electrical injury (-) (-) (+)Chemical injury (-) (-) (+)

Inhalational Injury Not suspected (+)Major associated medical illnesses

(-) (-) (+)

Associated fractures, multiple trauma

(-) (-) (+)

Note: OPD if Minor; Admit if Moderate or Major

ER Management

Initial and Resuscitative Period First 48 hours post burn Includes:

Assessment of burn injury Classification of burn injury Criteria for admission Initial ER management Fluid resuscitation Monitoring

Primary Survey

Airway Breathing Circulation Cervical Deficit Exposure Fluids

Airway and Breathing

Careful airway assessment especially in with face and neck

involvement Intubation is generally only

necessary in the case of: with burns >50% BSA with suspected inhalational injury unconscious patients

Airway and Breathing All patients with major burns must receive

high-flow oxygen for 24 hours. Consider carbon monoxide poisoning Suspect inhalational injury if with:

burn to face sooty phlegm singed nostril hairs hoarseness or stridor history of burn in enclosed space or unconscious

at scene circumferential chest burn

Circulation

Check the patient’s BP Stop any external bleeding Identify potential sources of internal

bleeding Secure a large-bore intravenous (IV)

lines Provide resuscitation bolus fluid

Cervical

Check for: limitation of movement of the cervical

spine Tenderness over the neck area

May apply cervical collar when necessary

Compartment Syndrome

6 Ps pain pallor paresthesia pulselessness paralysis poikilothermia

Deficit

Check for sensory and motor deficit

Exposure

Estimate burn size Expressed as %BSA Accurately done using the Lund and

Browder charts

Fluids

Get the patient’s weight Initiate fluids for ongoing resuscitation

and fluid losses using the Parkland formula   

Plain LR must be given at 4mL/kg BW per % BSA burned

To be given: ½ during the first 8 hours after injury ½ during the next 16 hours

Criteria for Admission to the Burn UnitAcute burn patients

with moderate and major injuries <2y/o regardless of % TBSA with injuries to the hands, face, feet and

perineum, major joints with smoke inhalation injury, other

associated medical illness, or multiple trauma

Acute electrical burn patientsAcute chemical burn patients

Criteria for Admission to the Burn UnitPatients with massive exfoliative disease,

such as: Toxic Epidermal Necrosis (TENS) Steven Johnson Syndrome (SJS) Staphylococcal Scalded Skin Syndrome (SSSS)

Secondary Survey

Other Pertinent History allergies, medications, prior illness, last

meal, events surrounding the injury Family History Personal and social history Review of systems The rest of the PE

evaluation of other injuries

Diagnostics

CBC with PC Blood Typing RBS, BUN, Brea, Na, K, Cl, Albumin ABG Chest Xray

Insert foley catheter to monitor UO Insert NGT to decompress the

stomach

Medications

Start PPI to prevent stress ulcers Give ATS and TeANA Systemic antibiotics is not indicated. Topical antimicrobials is applied over

the affected areas.

Wound Care and DressingDebridement/Initial Dressing:

Sterile technique Cut hair or items that may reach any burned or

dressing area Full body bath with soap and water Debride burned areas; visualize all affected

areas. Reassess depth and %BSA of burn wounds

Wash with betadine soap, rinse with sterile water

Dress

Wound Care and Dressing SSD (Silver sulfadiazine) Silver sulfadiazine + Cerium nitrate Dakin’s Solution

Monitoring Check the following hourly:

vital signs urine output level of consciousness pulmonary status

Adequate urine output is defined as:Adults: 0.5 ml/kg BW/hr

Definitive management period

Excision and grafting Control of infection Nutrition Rehabilitation Complication

Surgical Management

Early surgical excision of the burn wound with immediate or delayed wound closure

For full-thickness or deep dermal burns unlikely to heal within 14-21 days

Common in flame and contact burns

Advantages of early excision Improve survival Decrease length of hospital stay Faster return to work Decrease expenditure Limit duration of pain that burn

patients must endure Improve cosmetic and functional

results

Nutrition

Burn patients - hypermetabolic response

Curreri’s Formula Adult (25 x kg) + (40 x %BSA

Burn) Children (60 x kg) + (35 x %BSA

Burn)

Rehabilitation

Early mobilization Prevent contracture

Complications

Sepsis ARDS contractures

Journal Article

Objectives

Examine the impact of chronic glucose control on outcomes in the acute period after burn

Methodology

Retrospective analysis comparing outcomes in patients with chronic hyperglycemia (HbA1c ≥6.5%) and euglycemia (HbA1c <6.5%)

Patients aged 18 to 89 years, admitted for initial burn care between January 1,2009, and June 30, 2010, with an HbA1c measurement at admission were included

Methodology

The primary endpoint was unplanned readmissions, with secondary endpoints of length of stay and mortality

258 burn injury patients were included 32 with chronic hyperglycemia 226 with euglycemia

Results and Discussion

Burn characteristics were similar between the two groups

Primary cause of burn injury was thermal, followed by scald, for both groups.

Patients with chronic hyperglycemia were significantly older

Results and Discussion Patients with chronic

hyperglycemia were more likely to have glucose greater than 150 mg/dl at admission

Patients with chronic hyperglycemia experienced significantly more glucose variability, as well as an increased incidence of both moderate and severe hypoglycemia during admission

Results and Discussion There was a significant

difference in the primary endpoint of unplanned readmissions, with an increased rate of unplanned readmissions in patients with chronic hyperglycemia compared with patients with chronic euglycemia

Of the 14 unplanned readmissions, eight were for uncontrolled pain and wound care, four for infection/sepsis, and two for other reasons.

Conclusions This study confirmed that patients admitted for initial

management of burn injury with elevated HbA1c levels at admission have higher glucose measurements at admission and throughout their hospital stay, as well as increased glucose variability.

Regardless of preexisting diabetic status, patients with chronic hyperglycemia are more likely to have an unplanned readmission after their initial admission for burn management

There is a significant need to further evaluate interventions to improve burn-related outcomes in patients with chronic hyperglycemia

References

Burn Center Service Manual

Stander, M. and Wallis, L. (2011). The Emergency Management and Treatment of Severe Burns. Emergency Medicine International.