Multi-CasualtyIncident:Burn

PatriciaPadlilpsky,MDSeptember26,2019EDAPConference

Disclaimer

• Thesecaseswerecoveredbythemedia

• PleasedonotdiscussthesecasesoutsideofthisconferencesoastonotviolateHIPAArules

EMSTreatmentProtocol:Burnshttp://file.lacounty.gov/SDSInter/dhs/1040471_1220-PBurns2018-04-24.pdf

• BaseHospitalContact:RequiredforburnsmeetingTraumaCentercriteria,2ndor3rddegreeburns≥10%TBSA.• 1.Assessairwayandinitiatebasicand/oradvancedairwaymaneuversprn(MCG1302)• Ifevidenceofinhalationinjury,treatinconjunctionwithTP1236-P,InhalationInjury

• 2.AdministerOxygenprn(MCG1302)• Ifcarbonmonoxideexposuresuspected,providehigh-flowOxygen15L/minandtreatinconjunctionwithTP1238-P,CarbonMonoxidePoisoning❶

• 3.Assessforsignsoftrauma• Iftraumaticinjurysuspected,treatinconjunctionwithTP1244-P,TraumaticInjury

• 4.Removejewelryandclothingfrominvolvedarea• 5.Applyblankettokeeppatientwarm❷• 6.ForELECTRICALburns• Coverwithdrydressingorsheet,treatinconjunctionwithTP1221-P,Electrocution

• 7.ForTHERMALburns❸• CoverwithdrydressingorsheetDonotflushwithwater,evenifaccelerantpresent

• 8.ForCHEMICALburns• Ifdry,brushandflushwithcopiousamountsofwaterIfliquid,flushwithlargeamountsofwater❹ Ifeyeinvolvement,irrigateeyewithNormalSaline1Lduringtransport;allowpatienttoremovecontactlensesifpossible,treatinconjunctionwithTP1240-P,HAZMAT

• 9.Establishvascularaccessprn(MCG1375)• 10.Forpartial/fullthicknessburninvolves>10%bodysurfaceareaorpoorperfusion:• NormalSaline20mL/kgIV/IOrapidinfusionperMCG1309CONTACTBASEforpersistentpoorperfusiontoobtainorderforadditionalNormalSaline20mL/kgIV/IO

• 11.Elevateburnedextremitiesasableforcomfort• 12.Forpainmanagement:(MCG1345)• Fentanyl(50mcg/mL)1mcg/kgslowIVpushorIM,doseperMCG1309orFentanyl(50mcg/mL)1.5mcg/kgIN,doseperMCG1309Repeatin5minprnx1,maximum2totaldosespriortoBasecontact• Morphine(4mg/mL)0.1mg/kgslowIVpush,doseperMCG1309Repeatin5minprnx1,maximum2totaldosespriortoBasecontact• CONTACTBASEforadditionalpainmanagementaftermaximumdoseadministered:MayrepeatFentanylorMorphineasabovemaximum4totaldoses

SpecialConsiderations

• ❶Considerpotentialforcarbonmonoxideand/orcyanidetoxicityinclosedspacefires.Pulseoximetryisnotaccurateincarbonmonoxidepoisoning.(TP1238-P,CarbonMonoxidePoisoning)

• ❷Infantsandsmallchildrenareathighriskforhypothermiaduetotheirlargesurfaceareatobodymassratio,reducedabilitytoshiver,andlimitedbodyfat.

• ❸EMSPersonnelaremandatedreportersofchildabuseandneglect,andareportshouldbemadewhensuspectedasperRef.822.• Communicatesuspicionforchildabuseand/orneglecttoacceptingEDstaffwhenhomesuggestschildrencouldbeatriskforharm(e.g.,unkept home,evidenceofdrugoralcoholabuse,unsafelivingconditions,knownorsuspecteddomesticviolence),…).

• ❹Observeforhypothermia;• coolinglargesurfaceareaburns(>15%bodysurfacearea)mayresultinhypothermia

LosAngelesCounty-Definitionofmajorburns

•Major/CriticalBurn(exluding thoseinwhichtheMARisarecognizedBurnCenter,e.g,Lac+USCMedicalCenter,TorranceMemorialMedicalCenter,WestHillsHospital)

• Patients15yearsofageorolderwith2nd (partialthickness)and/or3rd (fullthickness)degreeburnsinvolving> 20%TBSA

• Patients<or=14yearsofagewith2nd(partialthickness)or3rd (fullthickness)degreeburnsinvolving>10%TBSA

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WhoShouldbereferredtoaBurnCenter

• Partialthicknessburns>10%TBSA• Burnsinvolvingface,hands,feet,genitalia,perineum,ormajorjoints• Thirddegreeburnsinanyagegroup• Electricalburns,includinglighting• Chemicalburns• Inhalationinjury• Burninjuryinpatientwithpreexistingmedicaldisorders• Anypt withburnsandconcomitanttraumainwhichtheburninjuryposesthegreatestriskofmorbidityormortality

BurnCenterreferralCont.

• Burnedchildreninhospitalswithoutqualifiedpersonnelorequipmentfortheircare• Burninjuryinpatientswhowillrequiresocial,emotional,orrehabilitativeintervention

Don’tPanic:BePrepared– GetHelp

PreparingforanMCI– Equipment/Rooms

Preparation- Staff

• PEDNursesandAEDnurses;callchargenurseasap• RT(s)• Pharmacists• PEDstaff:attending(EM-trainededucationfellow),2EMR4s,intern• Thebench:2AEDteams,eachconsistingofattending,seniorresident(EMR4onone,EMR3onother)• Traumasurgery,anesthesia• CallPICUforhelp

FirstPriorities

• Airway• Breathing• Circulation(Fluidresuscitation)• Disability• Environment/exposure• Fluids(Oftenincludedundercirculation)

• Needtothinkaboutpreventinghypothermia,otherinjuries,removingclothingandjewelryandpaincontrol.

AirwayandBreathing

• Burnscancausemassiveedemaleadingtoupperairwayobstruction• Canbeinitiallysubtle• Earlyevaluationneededforpossibleintubation

HowtoIdentifyInhalationInjury:ClinicalIndications

• face/neckburns• Singeingofeyebrowsandnasalhairs• Carbondepositsinmouthand/ornose• Carbonaceoussputum• Acuteinflammatorychangesinoropharynx• Hoarseness• AMS• Confinedinburningenvironment• Explosionwithburnstoheadandtorso• Carboxyhemoglobinlevelgreaterthan10%

Circulation

• Assessforadequatecirculation• VSmaynotbehelpful• Circumferentialburnsmayneedescharotomies

• EstablishIVaccesspreferredthroughunburnedskin– 2largeboreIvspreferred• IOorcentrallineifnecessary• Givepainmedication• Determineinitialfluidrequirements

F:FluidResuscitation

• InitialResuscitationbyFormulaBasedOnPatientWeightandBurnSize• Basedonextentofburnandpre-burnweight(kg)• Onlyconsidersecondandthirddegreeburn• “RuleofNines”• OnePATIENThand=onepercentTBSA• Lund-Browderchart• Overestimationofburnsizeiscommon

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DepthofBurns

Depth=degree

DeepSecondandThirddegree

TotalSurfaceAreaBurned

• Burns%areoftenoverestimated.Thiscanresultinhypervolemia• Abdominalcompartmentsyndrome• Extremitycompartmentsyndrome• Intraocularcompartmentsyndrome• Pleuraleffusions

TotalBodySurfaceAreaburned

Ruleof9s

LundandBrowder

FluidResuscitation

WhyIsFluidResuscitationSoImportant?• Appropriateresuscitationiscriticaltothesurvivalofpatientswithextensiveburns.• Itisneededtomaintainadequatetissueperfusion&organfunction• Inadequateorexcessivefluidresuscitationcanresultinmulti-systemcomplications

© Grossman Burn Centers, LLC

FluidFormulasforinitialResuscitation

ParklandFormula

• 4mLxwt inkgx%TBSA• LactatedRingers• ½oftotalvolumefirst8hours• Secondhalfoverthenext16hours• ChildrenshouldalsohavemaintenancefluidswithD5added…

AdvancedBurnLifeSupport

• Adult2-4mLxkgbodyweightx%TBSAburn• Peds:3-4mLinstead• ½ofthetotalvolumefirst8hours• Secondhalfoverthenext16hours

FluidResuscitation

• Howisitgiven?• Thefirsthalfisgivenoverthefirst8hourspostinjury*• Thesecondisgivenoverthenext16hours*

• *ThefluidresuscitationcalculationisanESTIMATEofthefluidvolumethatwillbeneededinthefirst24hourspostburn.

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FluidResuscitationABLS2010FluidResuscitationFormula

Adults:• ThermalorChemicalburns:

• LR2mlxKgbodywt x%burn=24hourfluidrequirementestimate

•HighVoltageElectricalinjury(withevidenceofdeeptissueinjuryorhemochromogens inurine):• LR4mlxKgbodywt x%burn=24hourfluidrequirementestimate

ABLS2010FluidResuscitationFormula

© Grossman Burn Centers, LLC

Majorchange

FluidResuscitationABLS2010FluidResuscitationFormula

• Children(14yearsand<40kg):

• LR3mlxKgbodywt x%burn=24hourfluidrequirementestimate• Infantsandyoungchildrenunder30kgreceiveLRforresuscitationAND D5LRatamaintenancerate

• Maintenancefluidrequirements• 1st10kgofbodywt: 4ml/kg/hr• 2nd10kgofbodywt: 2ml/kg/hr• Foreachkgover20kg: 1ml/kg/hr

• Infants&youngchildrenhavelimitedglycogenstores&aresusceptibletohypoglycemia!

© Grossman Burn Centers, LLC

Majorchange

AssessmentofAdequacyofResuscitation

• Formulasprovideonlyanestimateofactualfluidrequirements• Rateadjustedtopatient’sresponse• Urineoutputismostconvenientguide• 30- 50ml/hr inadult(or0.5-1.0ml/kg/hr)• 1– 1.5ml/kg/hr inchildrenOtherindicators:clearmentalstatus,gradualresolutionofbasedeficit,appropriateHRandBP

• Incomplexcases,advancedmonitoringmaybehelpful• LookatHR,pulsepressure,caprefill,mentalstatus

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D:Disability(NeurologicExam)

• Alterationinmentalstatusisnot normalintheearlypostburnperiod

Ifpresentconsider:• Systemiccauses• braininjury• toxicingestion• carbonmonoxide

• Focaldeficit• braininjury• spinalinjury• orthopedicinjury

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E:ExposureandEnvironmentalControl

• Universalprecautionsbyproviders• Removeclothing,jewelry• Keepwarm;preventhypothermia• Insulatedblankets,sheets– mylar• WarmI.V.Fluids• Increaseambienttemperature• Covertheburn

• Avoidcooling,donot“cooltheburn”• Donotplacepatientinwetlinens

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LATimes

•432squarefoot93-yearoldbungalow•Noelectricity(usingcandles)•Securitybarsonwindows

Summary

• KnowwhoisonyourbenchandcanrespondtohelpwithanMCI;askforhelp• MCIscenesarechaotic,particularlywithsickchildren• Communicationfromthefieldcanbeincomplete• Anticipateadditionalvictims• Sometimesthesickeronesarrivelater

• Haveresuscitationroomssetuptogoatalltimes(Broselow carts,airwayequipment,vascularaccess)• RememberATLS;A,B,C,D,EandF• Makesureyouarefamiliarwiththelocationofyourequipmentandhowtouseit.