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Emergency Department Management of Patients With Thermal Burns (Trauma CME)

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Emergency Department Management of Patients With Thermal Burn - Trauma CME

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  About This Issue

Classifying and measuring thermal burns in the ED will dictate all of the treatment decisions that follow:

•  First degree, second degree, third degree burns: How can you tell?
•  How should you calculate the total body surface area of burns?
•  IV fluids: what kind and how much? How can you tell when you've given the right amount?
•  Wound care: when should you debride blisters, and should you use silver dressings?
•  Escharotomy: when must it be done?
•  Was it really an accident or was it abuse?
•  Referral: How do you know when to refer a patient to a burn center?

 Issue Info

Author: Juliana Tolles, MD, MHS

Peer Reviewers: Boyd Burns, DO; Christopher Palmer, MD

Publication Date: February 1, 2018

CME Expiration Date: February 1, 2021

CME Credits: 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2A or 2B Credits. Included as part of the 4 credits, this CME activitiy is eligible for 4 Trauma Credits.

PubMed ID: 29369586

  Issue Features
  Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
    1. Prehospital Administration of Hydroxocobalamin
    2. Prehospital Cooling
    3. Prehospital Pain Management
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Testing
      1. Chemistry Panel
      2. Complete Blood Cell Count
      3. Arterial Blood Gas With CO-Oximetry Testing
      4. Lactate Level
      5. Cyanide Level
      6. Type and Screen
      7. Urine Pregnancy Testing
    2. Imaging
      1. Chest X-Ray
      2. Computed Tomography
      3. Bronchoscopy
  10. Treatment
    1. Airway Management
      1. Managing Inhalation Injury
      2. Carbon Monoxide and Cyanide Toxicity
    2. Cooling
    3. Intravenous Fluid Resuscitation
      1. Choosing Resuscitation Fluids
      2. Fluid Volume Resuscitation Formulas
      3. Monitoring Fluid Resuscitation
      4. Blood Transfusion
    4. Wound Care
      1. Unroofing, Debridement, and Surgical Excision
      2. Escharotomy
      3. Ocular Burns
    5. Antibiotics
    6. Pain Control
    7. Tetanus Prophylaxis
  11. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
  12. Controversies and Cutting Edge
    1. Analgesia
    2. Wound Care Controversies
    3. Assessment of Burn Depth With Laser Doppler Imaging
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls for Management of Burn Patients in the Emergency Department
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Key Points
  19. Clinical Pathway for Management of Burns in the Emergency Department
  20. Tables and Figures
    1. Table 1. Classification of Burns by Depth
    2. Table 2. Physical Examination of Burn Patients
    3. Table 3. Common Intravenous Resuscitation Formulas for Adult Burn Patients
    4. Table 4. Occlusive Dressings for Partial-Thickness Burns
    5. Table 5. Topical Therapies for Partial-Thickness Burns
    6. Table 6. Centers for Disease Control and Prevention Guidelines for Tetanus Wound Management
    7. Table 7. American Burn Association Burn Center Referral Criteria
    8. Figure 1. Zones of Burn
    9. Figure 2. Illustration of Burn Depth Classifications
    10. Figure 3. Lund and Browder Chart
    11. Figure 4. Rule of Nines
    12. Figure 5. Escharotomy
    13. Figure 6. Accidental Versus Intentional Scald
  21. References
 
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Abstract

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries. Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes. This article reviews thermal burn classification and evidence-based treatment strategies.

 

Case Presentations

A 35-year-old chef presents to the ED after burning his right hand on a cooking surface at work. His vital signs are normal and his hand is blistered over half of the palmar surface. You place a nursing order for pain medication and a tetanus booster. As you leave the bedside, you try to recall whether he should be referred to a burn center and whether there are any evidence-based guidelines to help you select a dressing…

As you put down his chart, the nurse calls you to the resuscitation bay for a 22-year-old woman brought in by EMS from a house fire. Paramedics report that she required extrication from the collapsed house. She is minimally responsive, with soot visible in her oropharynx and extensive burns to her abdomen, back, and right upper extremity. Her vital signs are: temperature, 37.5°C (99.5°F); heart rate, 140 beats/min; blood pressure, 85/40 mm Hg; respiratory rate, 35 breaths/min; and oxygen saturation, 88% on room air. As you prepare to intubate her and start IV fluid resuscitation for her hypotension, you wonder which resuscitation fluid you should select and how to best monitor the patient’s response. You wonder whether anything other than her extensive burns may be causing her hypotension and altered mental status…

Your next patient is a 3-year-old boy brought in by his mother for scald burns to his feet. The mother says that yesterday the child picked up a bowl of hot soup and accidentally spilled its contents. He appears fussy and has symmetric, well-demarcated, full-thickness burns to both feet from the ankles down. His vital signs are: temperature, 37°C (98.6°F); heart rate, 120 beats/min; blood pressure, 90/55 mm Hg; respiratory rate, 22 breaths/min; and oxygen saturation, 98% on room air. You are concerned about the delay in seeking care and wonder whether this might be more than an accidental burn…

 

Introduction

The American Burn Association (ABA) reports that nearly half a million people suffer thermal burns each year in the United States.1 According to World Health Organization estimates, as many as 265,000 people worldwide die annually of thermal burns.2 The economic burden of thermal burn injury is also substantial: In the United States in 2000, the annual direct-care cost of treating pediatric burns alone was $211 million.2 This does not take into account the economic impact of rehabilitation and long-term disability. Efforts to prevent thermal burns through regulation and public health initiatives have reduced the incidence in developed countries; however, burn injuries still account for approximately 0.5% of all United States emergency department (ED) visits annually.3 This issue of Emergency Medicine Practice reviews the guidelines on assessment of burns and how these assessments are used for optimal management of fluid resuscitation, in addition to the latest evidence on burn-wound care, pain control, and the criteria for referral to specialized care.

 

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms burn, burns, and inhalation burn. The search identified approximately 4600 original articles that were screened and narrowed to articles of highest quality evidence and relevance. Only articles with abstracts available in English were included.

The Cochrane Database was searched for systematic reviews using the key term burn, which identified 11 articles. A search of the Database of Abstracts of Reviews of Effects (DARE) and Center for Reviews and Dissemination (CRD) databases did not reveal any unique publications not previously identified in the PubMed search. A search of the National Guidelines Clearinghouse identified 1 relevant guideline. The ABA Consensus Guidelines (2012) and ABA Practice Guidelines: Burn Shock Resuscitation (2008) were also reviewed. The former is a consensus statement, whereas the latter identifies the level and category of evidence upon which each of its recommendations is based. International guidelines from the World Health Organization and the European Burn Association were also reviewed.

Overall, the clinical evidence on thermal burns is of moderate strength, consisting of relatively few large, well-designed clinical trials and many smaller trials and observational studies. When possible, recommendations in this article are evidence-based. Recommendations based on common practice or expert consensus are explicitly noted as such.

 

Risk Management Pitfalls for Management of Burn Patients in the Emergency Department

2. “I gave prophylactic oral antibiotics to a patient with a partial-thickness burn. The patient had an allergic reaction, and now my colleagues are saying that I should have never given the antibiotic in the first place.”

Systemic prophylactic antibiotics do not benefit burn patients. Use topical dressings for local wound care. Treat with systemic antibiotics only if a clinically apparent infection develops.

5. “I thought that fluid-resuscitating the patient according to the Parkland formula during the 8 hours he was awaiting transfer in my ED was enough. I didn’t realize he wasn’t making any urine.”

Use clinical endpoints, such as urine output, to assess and guide IV fluid administration. Formulas are merely a guideline, and IV fluid administration may need to be decreased or increased depending on how the patient responds.

6. “I assumed the patient was hypotensive due to the extensive burns he sustained in the house fire. I didn’t consider that he might have intra-abdominal hemorrhage.”

Burn patients are at risk for traumatic injuries and should undergo a comprehensive trauma survey and diagnostic testing per Advanced Trauma Life Support guidelines.

 

Tables and Figures

Burn - First Degree Burn - Burn Treatment - Thermal Burn - Trauma CME - Table 1. Classification of Burns by Depth

 

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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  2. World Health Organization. Burns: fact sheet. 2016. Available at: http://www.who.int/mediacentre/factsheets/fs365/en/. Accessed January 10, 2018. (WHO website fact sheet)
  3. United States Centers for Disease Control National Hospital Ambulatory Medical Care Survey: 2011 emergency department summary tables. Available at: https://www.cdc.gov/nchs/data/ahcd/nh
    amcs_emergency/2011_ed_web_tables.pdf
    . Accessed January 10, 2018. (Government survey database)
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  8. Walker PF, Buehner MF, Wood LA, et al. Diagnosis and management of inhalation injury: an updated review. Crit Care. 2015;19:351. (Review)
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  11. Nguyen NL, Gun RT, Sparnon AL, et al. The importance of immediate cooling--a case series of childhood burns in Vietnam. Burns. 2002;28(2):173-176. (Retrospective review; 695 patients)
  12. Yuan J, Wu C, Holland AJ, et al. Assessment of cooling on an acute scald burn injury in a porcine model. J Burn Care Res. 2007;28(3):514-520. (Randomized controlled animal study; 10 subjects)
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  16. Ikonomidis C, Lang F, Radu A, et al. Standardizing the diagnosis of inhalation injury using a descriptive score based on mucosal injury criteria. Burns. 2012;38(4):513-519. (Prospective observational study; 100 patients)
  17. Palmieri TL. Inhalation injury: research progress and needs. J Burn Care Res. 2007;28(4):549-554. (Review)
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  21. Agarwal P, Sahu S. Determination of hand and palm area as a ratio of body surface area in Indian population. Indian J Plast Surg. 2010;43(1):49-53. (Prospective study; 600 patients)
  22. American Burn Association. Advance Burn Life Support Provider Manual. 2007. Available at: https://evidencebasedpractice.osumc.edu/Documents/Guidelines
    /ABLSProviderManual_20101018.pdf
    . Accessed January 10, 2018. (Consensus guideline)
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  24. Baud FJ, Barriot P, Toffis V, et al. Elevated blood cyanide concentrations in victims of smoke inhalation. N Engl J Med. 1991;325(25):1761-1766. (Case control series; 109 patients)
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  26. Yamamura H, Morioka T, Hagawa N, et al. Computed tomographic assessment of airflow obstruction in smoke inhalation injury: relationship with the development of pneumonia and injury severity. Burns. 2015;41(7):1428-1434. (Prospective observational study; 40 patients)
  27. Oh JS, Chung KK, Allen A, et al. Admission chest CT complements fiberoptic bronchoscopy in prediction of adverse outcomes in thermally injured patients. J Burn Care Res. 2012;33(4):532-538. (Retrospective review; 49 patients)
  28. Mosier MJ, Pham TN, Park DR, et al. Predictive value of bronchoscopy in assessing the severity of inhalation injury. J Burn Care Res. 2012;33(1):65-73. (Retrospective review; 32 patients)
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  30. Bittner EA, Shank E, Woodson L, et al. Acute and perioperative care of the burn-injured patient. Anesthesiology. 2015;122(2):448-464. (Review)
  31. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New Engl J Med. 2000;342(18):1301-1308. (Randomized controlled trial; 861 patients)
  32. Buckley NA, Juurlink DN, Isbister G, et al. Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD002041. (Systematic review; 1361 patients)
  33. Bebarta VS, Tanen DA, Lairet J, et al. Hydroxocobalamin and sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of acute cyanide toxicity in a swine (Sus scrofa) model. Ann Emerg Med. 2010;55(4):345-351. (Randomized controlled animal study; 24 swine)
  34. Nguyen L, Afshari A, Kahn SA, et al. Utility and outcomes of hydroxocobalamin use in smoke inhalation patients. Burns. 2016. (Retrospective review; 273 patients)
  35. MacLennan L, Moiemen N. Management of cyanide toxicity in patients with burns. Burns. 2015;41(1):18-24. (Review)
  36. Cyanokit® package insert. Available at: https://www.meridianmeds.com/sites/default/files/pi/CYANOKIT_PI.pdf. Accessed January 10, 2018. (Drug package insert)
  37. Rajan V, Bartlett N, Harvey JG, et al. Delayed cooling of an acute scald contact burn injury in a porcine model: is it worthwhile? J Burn Care Res. 2009;30(4):729-734. (Prospective controlled animal study)
  38. Raine TJ, Heggers JP, Robson MC, et al. Cooling the burn wound to maintain microcirculation. J Trauma. 1981;21(5):394-397. (Prospective randomized controlled animal study)
  39. Pham TN, Cancio LC, Gibran NS. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res. 2008;29(1):257-266. (Review and professional society guideline)
  40. Vlachou E, Gosling P, Moiemen NS. Hydroxyethylstarch supplementation in burn resuscitation--a prospective randomised controlled trial. Burns. 2010;36(7):984-991. (Randomized controlled trial; 26 patients)
  41. O’Mara MS, Slater H, Goldfarb IW, et al. A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients. J Trauma. 2005;58(5):1011-1018. (Randomized controlled trial; 31 patients)
  42. Cooper AB, Cohn SM, Zhang HS, et al. Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score. Transfusion. 2006;46(1):80-89. (Randomized controlled trial; 42 patients)
  43. Perel P, Roberts I, Ker K. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567. (Cochrane review and meta-analysis; 22,392 patients)
  44. Eljaiek R, Heylbroeck C, Dubois MJ. Albumin administration for fluid resuscitation in burn patients: a systematic review and meta-analysis. Burns. 2016. (Systematic review; 4 randomized clinical trials, 140 patients)
  45. Goodwin CW, Dorethy J, Lam V, et al. Randomized trial of efficacy of crystalloid and colloid resuscitation on hemodynamic response and lung water following thermal injury. Ann Surg. 1983;197(5):520-531. (Randomized controlled trial; 79 patients)
  46. Belba MK, Petrela EY, Belba GP. Comparison of hypertonic vs isotonic fluids during resuscitation of severely burned patients. Am J Emerg Med. 2009;27(9):1091-1096. (Prospective study; 110 patients)
  47. Oda J, Ueyama M, Yamashita K, et al. Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients. J Trauma. 2006;60(1):64-71. (Prospective observational study; 36 patients)
  48. Bechir M, Puhan MA, Neff SB, et al. Early fluid resuscitation with hyperoncotic hydroxyethyl starch 200/0.5 (10%) in severe burn injury. Crit Care. 2010;14(3):R123. (Randomized controlled trial; 30 patients)
  49. Csontos C, Foldi V, Fischer T, et al. Factors affecting fluid requirement on the first day after severe burn trauma. ANZ J Surg. 2007;77(9):745-748. (Retrospective review; 47 patients)
  50. Gibran NS, Wiechman S, Meyer W, et al. Summary of the 2012 ABA Burn Quality Consensus conference. J Burn Care Res. 2013;34(4):361-385. (Review)
  51. Caruso DM, Matthews MR. Monitoring end points of burn resuscitation. Crit Care Clin. 2016;32(4):525-537. (Review)
  52. Paratz JD, Stockton K, Paratz ED, et al. Burn resuscitation--hourly urine output versus alternative endpoints: a systematic review. Shock. 2014;42(4):295-306. (Systematic review; 20 studies)
  53. Holm C, Mayr M, Tegeler J, et al. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns. 2004;30(8):798-807. (Randomized controlled trial; 50 patients)
  54. Salinas J, Chung KK, Mann EA, et al. Computerized decision support system improves fluid resuscitation following severe burns: an original study. Crit Care Med. 2011;39(9):2031-2038. (Case-control study)
  55. Cancio LC, Salinas J, Kramer GC. Protocolized resuscitation of burn patients. Crit Care Clin. 2016;32(4):599-610. (Review)
  56. Saffle JI. The phenomenon of “fluid creep” in acute burn resuscitation. J Burn Care Res. 2007;28(3):382-395. (Review)
  57. Palmieri TL, Caruso DM, Foster KN, et al. Effect of blood transfusion on outcome after major burn injury: a multicenter study. Crit Care Med. 2006;34(6):1602-1607. (Multicenter retrospective review; 666 patients)
  58. Jamshidi R, Sato TT. Initial assessment and management of thermal burn injuries in children. Pediatr Rev. 2013;34(9):395-404. (Review)
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  68. Shaw J, Dibble C. Best evidence topic report. Management of burns blisters. Emerg Med J. 2006;23(8):648-649. (Review)
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  72. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am. 26(1):125-136. (Review)
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  79. Erickson EJ, Merrell SW, Saffle JR, et al. Differences in mortality from thermal injury between pediatric and adult patients. J Pediatr Surg. 1991;26(7):821-825. (Retrospective review; 1200 patients)
  80. Goverman J, Bittner EA, Friedstat JS, et al. Discrepancy in initial pediatric burn estimates and its impact on fluid resuscitation. J Burn Care Res. 2015;36(5):574-579. (Prospective observational study; 50 patients)
  81. Chan QE, Barzi F, Cheney L, et al. Burn size estimation in children: still a problem. Emerg Med Australas. 2012;24(2):181-186. (Retrospective review; 71 patients)
  82. Nagel TR, Schunk JE. Using the hand to estimate the surface area of a burn in children. Pediatr Emerg Care. 1997;13(4):254-255. (Propsective observational study; 91 patients)
  83. Graves TA, Cioffi WG, McManus WF, et al. Fluid resuscitation of infants and children with massive thermal injury. J Trauma. 1988;28(12):1656-1659. (Prospective study; 48 patients)
  84. Maguire S, Moynihan S, Mann M, et al. A systematic review of the features that indicate intentional scalds in children. Burns. 2008;34(8):1072-1081. (Systematic review; 26 studies)
  85. Wibbenmeyer L, Liao J, Heard J, et al. Factors related to child maltreatment in children presenting with burn injuries. J Burn Care Res. 2014;35(5):374-381. (Prospective observational study; 68 patients)
  86. Roderique EJ, Gebre-Giorgis AA, Stewart DH, et al. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. J Burn Care Res. 2012;33(5):624-633. (Review and case report)
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  CME Information

Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.

Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits, subject to your state and institutional approval.

Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Tolles, Dr. Burns, Dr. Palmer, Dr. Mishler, Dr. Toscano, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.

Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.

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