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Koenig_and_Schultz_s_Disaster_Medicine_Ch_27.pdf

Burn Patient Management

John McManus and Ruben Gomez

OVER V IEW

Geopolitical events in the last several years have sparked the interests of governments and medical organizations in disas- ters, terrorism, disaster planning, and evaluation and treatment of patients resulting from disaster or terrorist acts. Arson has not typically been included in the terrorist’s agenda.1 Terror- ists usually aim their attacks at human beings directly, whereas fires usually destroy property primarily and injure people only in passing. Hence, injuries from burn disasters are not typically different from injuries from burn nondisasters, except that the number of burn patients is larger in the former than in the latter. Some of the newer explosive devices used in terrorist attacks have led to casualties with severe combined penetrating, blunt, and burn trauma.

This chapter builds on principles of disaster management to highlight the key features of a regional burn disaster plan. Typical injuries that are best treated in the burn center facility will be highlighted. Burn rehabilitation, although an integral part of burn care, is beyond the scope of this chapter.

STATE OF THE AR T DISASTER PLANNING

A review of burn disasters in the United States over the past 100 years2 shows that these events are local disasters, and the most common scenario is a large group of people caught in some type of structure that catches fire and is either land based or sea based. The number of burn victims has steadily decreased over the years so that typical numbers of burn victims requiring hospi- talization in the late 1990s seldom exceeded 20–50 patients. The majority of patients in a burn disaster die at the scene or in trans- port, but there are a very large number of victims with minor burns requiring minimal medical care. These casualties usually self-present early to on-scene care facilities or to local emergency departments often overwhelming the medical resources or the outpatient system. When casualties present to the treatment cen- ter in small numbers over a longer time, this can be termed an insidious disaster, whereas when the patients arrive at the same

time in one large group, the situation can be termed a sudden dis- aster. A combination of both patterns can occur.3 A burn disaster of national or international magnitude would likely only result from a thermonuclear detonation of the magnitude of Nagasaki or Hiroshima, Japan during WWII. The critical issue, however, is not the exact number of casualties, but whether the needs of the patients exceed the resources of the healthcare entity at the time they are required. If the facility, materiel, or personnel are hindered or destroyed, there may be insufficient surge capacity to manage the casualties. Another important concept proposed by the American Burn Association is that of a surge capacity state,4

occurring when the number of casualties reaches 50% more than the maximum number of patients that the healthcare facility can manage under standard operating conditions. When capacity is reached and no further capacity can be created, patients should be transported to an alternate hospital or center with burn patient care capacity as designated in the facility’s disaster plan.

The number of burn centers in Europe and North America has slightly declined over the last several years. In addition, the patient care capacity of some burn centers has declined.5 Hence, in many cases, a single burn center would not have sufficient resources to manage the number of patients generated by a burn disaster. A regional system is needed to coordinate transfer and treatment of burn disaster victims. Hence, in times of disaster, cooperation among burn centers in a region must be effected for all victims to receive appropriate treatment. One example of regional coordination for burn care is the U.S. Southern Region Burn Disaster Plan.6 This plan is designed to provide a commu- nications network among burn centers in the southern region of the United States and to facilitate and coordinate the move- ment of patients among burn centers during a regional burn disaster. The system establishes a central command center that is staffed by experienced burn center providers during times of disaster. The burn center director of the nearest burn center to the disaster triages the burn victims and establishes direct com- munication with the central command center. Via this channel of communication, the front line burn center requests treat- ment and transport aid from the central command as needed. The central command, in turn, has an established grid of all the

423 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:39:40.

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424 ■ JO H N MCMA N U S A N D RU B E N GO M E Z

Table 27.1: Triage Decision Table for Burn Victims Based on Anticipated Outcomes Compared with Resource Allocation

Burn Size (%TBSA)

Age in years 0–10 11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91+

< 2 Very high Very high Very high High Medium Medium Medium Low Low Low

≥ 2 and < 5 Outpatient Very high Very high High High High Medium Medium Low Low

≥ 5 and < 20 Outpatient Very high Very high High High High Medium Medium Medium Low

≥ 20 and < 30 Outpatient Very high Very high High High Medium Medium Medium Low Low

≥ 30 and < 40 Outpatient Very high Very high High Medium Medium Medium Medium Low Low

≥ 40 and < 50 Outpatient Very high Very high Medium Medium Medium Medium II Low Low Low

≥ 50 and < 60 Outpatient Very high Very high Medium Medium Medium Low Low Low Low

≥ 60 and < 70 Very high Very high Medium Medium Low Low Low (Low/ Low/ Low/ Expectant Expectant Expectant

> 70 Very high Medium Medium Low Low Low/ Expectant Expectant Expectant Expectant Expectant

1) Outpatient: survival and good outcome expected without requiring initial admission; 2) Very high: survival and good outcome expected (survival > 90%) with limited/short-term initial admission and resource allocation (straightforward resuscitation, duration of stay 14–21 days, 1–2 surgical procedures); 3) High: survival and good outcome expected (survival > 90%) with aggressive care and comprehensive resource allocation, including aggressive fluid resuscitation, admission 14–21 days, multiple surgeries, prolonged rehabilitation; 4) Medium: survival 50%–90% and/or aggressive care and comprehensive resource allocation required, including aggressive resuscitation, initial admission 14–21 days, multiple surgeries, prolonged rehabilitation; 5) Low: survival < 50% even with long-term, aggressive treatment and resource allocation; and 6) Expectant: predicted survival > 10% or less even with unlimited, aggressive treatment.

burn centers in the region, the distances between the centers, and awareness of medical personnel and resources. If the burn center director who primarily receives the disaster patients (i.e., the closest center) determines that the number or acuity of the burn patients presenting is overwhelming the center’s capacity, the director notifies the central command. The central command coordinates transfer of excess patients to other appropriate facil- ities. This system also allows for mutual aid with burn centers outside the region. By agreement among the burn centers partic- ipating in the system, the receiving burn center provides trans- portation assets and patient care funding. In addition to moving patients out, burn care specialists can also be transferred in to the front line burn center to assist in patient management and treatment.

PRELIMINAR Y TREATMENT

As with any mass casualty situation, casualty triage is an ini- tial action with a burn disaster. One well-described method consists of combining the Simple Triage and Rapid Treatment (START) system7 with the Age/Total Body Surface Area (TBSA) Survival Grid from the American Burn Association.4 The sur- vival grid segregates patients into different categories based on age and TBSA burned. The categories represent different bene- fit to resource ratios: a high ratio predicting a greater than 90% chance of survival, a medium ratio predicting a greater than 50% chance of survival, a low ratio predicting a less than 50% chance of survival, and an expectant category predicting a less than 10% chance of survival. This analysis assumes relatively infinite resources and the availability of state-of-the-art burn care; hence, survival rates would be expected to be lower in a scarce resource environment. Table 27.1 outlines the LD50 percentage TBSA ver- sus the age of the patient based on an age/TBSA survival grid. The

LD50 percentage TBSA is the percentage burn size that is pre- dicted to result in death in 50% of patients in a given age group. Nonthermal injuries are usually considered to be more critical than thermal injuries. During an event with a large number of casualties that exceeds resources, however, patients with extensive TBSA burns and underlying factors that portend a poor progno- sis (for example, an 80-year-old patient with an 80% TBSA full thickness burn) would likely be placed in the expectant category, even if the nonthermal injuries were of a trivial nature. Nonther- mal injuries should first be assessed by standard triage methods such as START before addressing thermal injuries. Regardless of the triage system used, three problems unique to the burn patient should be concomitantly addressed with the nonther- mal injuries in the early treatment phase. First, any suspicion of inhalation injury with airway compromise mandates immediate endotracheal intubation before airway edema makes intubation or the establishment of a surgical airway impossible. Next, the patient with deep circumferential burns of the extremities or the chest with compromise of the distal circulation or respiratory function, respectively, requires escharotomies. Finally, providers should initiate fluid resuscitation for shock from burns of 15%– 20% TBSA or greater early in the patient care course.8 Numer- ous formulas and recipes exist for determining fluid needs. Most involve administration of a balanced salt solution at an initial rate based on TBSA and the patient’s weight. The fluid rate is titrated based on the patient’s clinical response and hourly urine output. After field triage, burn injury patients would be trans- ferred in order of priority to the next higher level of care. On arrival, reassessment of the patient includes the following.

■ Address the airway immediately. If the patient was intu- bated in the field, ensure tube position with carbon dioxide detector and auscultation. Ensure tube security with cotton umbilical ribbon. DO NOT USE ADHESIVE TAPE on the

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-08 07:39:40.

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BU R N PAT I E N T MA NAG E M E N T ■ 425

9%9%

18% 18%

Anterior 18%

Posterior 18%

Figure 27.1. The “Rule of Nines” used to estimate the percentage of total body surface area burned (%TBSA).

endotracheal tube or any other important device or tube in the burn patient. The patient will become very edematous, the skin will fall off and the endotracheal tube will fall out if secured only with tape. If this happens, the patient will usually die from airway obstruction because it is extremely difficult to establish a surgical airway in a patient with a very swollen face and neck. If the patient is not intubated, closely observe for signs of airway obstruction and intubate the patient immediately if these signs appear.

■ Remove clothes and jewelry. These items may have melted onto the skin. If this is the case, the burn team may need to excise these items along with the burned skin. Jewelry may have to be cut off with wire cutters or other similar devices.

■ Insert two large bore peripheral or central femoral intra- venous lines if these have not already been placed in the field. Rapidly infuse intravenous fluids.

■ Insert a naso- or orogastric tube because patients with large burns (usually 20% TBSA or larger) will have an associated ileus.

■ Insert a Foley catheter to monitor the hourly urine output. ■ Estimate the percentage of total body surface that has partial

thickness and full thickness burns and either estimate the patient’s weight or weigh the patient. Use these numbers to calculate an initial fluid resuscitation rate. Figure 27.1 illustrates the “Rule of Nines.”

■ For adults, the total volume to be infused in the first 24 hours postburn is calculated as follows: 2 mL × %TBSA × weight in kilograms. One-half of the total volume is administered using lactated Ringers in the first 8 hours postinjury and the second half over the next 16 hours postinjury. For children (or patients weighing less than 30 kg), use 3 mL instead of 2 mL in the formula. In addition, in children, administer a maintenance rate of 5% dextrose one-half normal saline at 4 mL/kg/hour for the first 10 kg, 2 mL/kg/hour for the second 10 kg, and 1 mL/kg/hour for every kilogram thereafter.

■ During the second 24-hour period, start albumin in normal saline at a total volume of 0.5 mL/%TBSA/kg to be admin- istered over 24 hours. Replace the lactated Ringers infusion with 5% dextrose in water at one-half the last lactated Ringers hourly rate.

■ Discontinue the albumin infusion at the end of the second 24-hour period. Continue 5% dextrose in water and adjust the rate based on the serum sodium level if available and esti- mates of evaporative losses of 1 mL/%TBSA/kg/day. Follow the same guidelines for children.

■ The rate should be increased or decreased in increments of 20%–30% of the previous hour’s rate with the goal to maintain a urinary output of 30–50 mL/hour in the adult, and approximately 1 mL/kg/hour in the child or in a patient weighing less than 30 kg.

■ In all cases, glycosuria should be sought because this can lead to a spuriously high urine output in the face of inadequate fluid administration rates. Similarly, osmotic diuretics and certain other agents, such as ethylene glycol, may cause a high urine output in the face of inadequate fluid administration.

■ Wrap the patient in dry clean linens. Do not put ointments or ice on burns. Do not give the patient prophylactic antibi- otics.9 Give small amounts of intravenous opioids as needed.

■ If the patient has circumferential burns of either the extremi- ties or the chest, these two areas should be monitored closely for the need for escharotomy and for the development of compartment syndrome. Burn eschar on the chest may inter- fere with ventilation and if this is the case, chest escharot- omy should be performed without delay. For the extremi- ties, eschar will act as constricting bands first occluding the venous return, then the arterial inflow. If available, Doppler signals should be followed hourly. Diminution of the signal or a change in its character is an indication for escharot- omy (Figure 27.2). Escharotomy is performed with a scalpel or with electrocautery. If performed properly, there will be minimal bleeding because the incision remains just below

Figure 27.2. Location of escharotomy incisions for eschars on the extremities and chest. Note that the incisions cross the joints.

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Table 27.2: Skin Characteristics of Partial versus Full Thickness Burns

Partial Thickness Burn Full Thickness Burn

Sensate Insensate

Blanches with pressure Does not blanch with pressure

Moist, pliable, and blisters Dry, leathery, sometimes with visible thrombosed vessels

the burn within the subcutaneous tissues. If much bleeding is encountered, the incision is too deep. Patients receiving massive amounts of fluid may also develop compartment syndrome. This results from an increase in the tissue pressure within an inexpansible compartment of the body. The com- partment may be within the skull, the chest, the abdomen, or the extremities. If compartment syndrome is suspected in the extremities, compartment pressures should be mea- sured unless escharotomy has been performed and compart- ments are decompressed. The pressures are measured with an 18-gauge needle connected to an arterial pressure transducer. The absolute intramuscular pressure is measured in each compartment. A difference between diastolic blood pres- sure and intramuscular pressure of less than 10–20 mm Hg in any one compartment is suggestive of compartment syn- drome. In addition, the muscles in the compartment being measured should be squeezed. A sluggish rise in the pres- sure tracing with this maneuver is nearly pathognomonic of compartment hypertension. In all cases, to prevent tissue death and the systemic crush syndrome, the key treatment principle if compartment syndrome develops is to decom- press the involved compartments immediately. The patient should undergo appropriate fasciotomies, when possible in the operating room by an experienced team.10

■ Update patient’s tetanus immunization. ■ Perform adequate fluid resuscitation. Formulas for fluid

requirements are based on the partial and full thickness burn size. Differentiating between partial and full thickness burns may prove difficult. An assessment of skin characteristics assists in the differentiation (Table 27.2).

■ If high rates of fluid are required for resuscitation (more than 1 L/h), check bladder pressures hourly. The patient may have to be temporarily paralyzed to obtain an accurate reading. A reading of greater than 20 mm Hg in the context of a low urine output, or high ventilation pressure heralds the abdominal compartment syndrome with the need for an abdominal decompression.

■ If the urine output is inadequate despite large rates of fluid infusion and a normal bladder pressure, acute renal fail- ure should be suspected. In addition, the patient should be reassessed for other injuries. If renal failure or undetected internal hemorrhage fail to explain the low urine output, other resuscitation endpoints, such as lactate, base excess, bicarbonate, or central venous pressure measurements, may be useful.

After initial stabilization, if capacity exists, evacuate the patient to the next higher level of care, a burn center, or an equiva- lent. Person-to-person communication with the receiving center including written documentation is crucial for patient continuity

of care. A sample documentation form is provided from the U.S. Army Institute of Surgical Research Burn Center (Figure 27.3).

EVACUATION TO A BURN CENTER

The next higher level of care should have personnel experienced with burn surgery and postoperative burn care. There should also be blood-banking and microbiological testing capabilities. Rehabilitation should be available at burn centers, but during a disaster, these services may need to be performed at another location. If this is the case, the patient may be transferred else- where for rehabilitation after recovery from the acute burn care injuries. Transportation methods must be carefully considered. The Institute of Surgical Research Burn Center has developed transportation guidelines that include contraindications and rel- ative contraindications for air evacuation.

■ Ground transportation should be used if it is available and deemed equally as rapid and safe as air transportation.

■ Air transportation should not be used if the patient’s condi- tion at the time of transfer suggests the patient is unlikely to survive the transport.

■ If inadequate or insufficient staff are available for air trans- port, then this mode should not be used.

■ Relative contraindications to air transport include the fol- lowing patient conditions: ■ active bleeding ■ sepsis ■ poor respiratory function as manifested by minute ven-

tilation of greater than 25 L/minute, a pO2 of less than 100% on an FiO2 of 0.6 or greater [a paO2/fraction of inspired oxygen (FiO2) (P to F ratio) of less than 166]

■ an uncontrolled dysrhythmia ■ chest or abdominal surgery within the last 24 hours ■ presence of intracranial or intraocular air ■ other conditions likely to worsen during air transport

(e.g., pneumothorax, compartment syndromes)

At the burn center, the work begun at the initial patient care site continues with greater emphasis on three injury types unique to burns: inhalation injury,11 chemical injury,12 and electrical injury.10

Inhalation injury usually occurs when the patient is trapped inside a burning structure. Inhalation injury should also be sus- pected when the patient is at the extremes of life or he has sus- tained very extensive burn injury. Physical findings suggestive of inhalation injury include disorientation, obtundation, stridor, dyspnea, grunting respirations, and voice changes. Inhalation injury results from a chemical burn extending from the bronchial lining down to the level of the alveoli. The chemical injury is caused by products of incomplete combustion carried on smoke particles. Small smoke particles carry the chemicals deeper into the lungs compared with large smoke particles. True thermal injury to the airways is rare, occurring most commonly with direct exposure to flame or superheated steam. Flash flames may injure the supraglottic respiratory tract leading to upper airway occlusion but seldom with injury to the infraglottic respiratory tree unless there is concomitant smoke inhalation. In addition to the supraglottic or infraglottic inhalation injury, inhalation of carbon monoxide is common in patients found in burning

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Figure 27.3. Transfer form used at the U.S. Army Institute of Surgical Research Burn Center.

structures. Carbon monoxide levels of 15%–40% usually pro- duce central nervous system symptoms. Levels greater than 40% usually produce coma.

The chemical reaction in inhalation injury produces in- creased lung vascular permeability and may lead to noncardio- genic pulmonary edema. Damage to type II alveolar cells leads to reduced surfactant levels and stiff lungs. The injury causes epi- thelial cell damage with desquamation of small airways with airway casts, bronchorrhea, and wheezing. The first phase of injury at 0–36 hours is characterized by acute asphyxia, carbon monoxide poisoning, bronchospasm, upper airway obstruction, and severe parenchymal damage. The second phase during 6–72 hours postburn is dominated by pulmonary edema. Bronchop- neumonia is common during the third phase occurring 3–10 days postburn (Table 27.3). As previously outlined, early intubation is essential in these cases because supraglottic and infraglottic edema may make delayed intubation impossible. In addition, the patient should be placed on 100% oxygen until carbon monoxide levels are less than 10%. Other treatment for inhalation injury is supportive and consists of nebulized bronchodilators and nebu- lized heparin to reduce cast formation. Bronchoscopy is neces-

sary to confirm the diagnosis of inhalation injury. Tracheostomy should be considered if endotracheal intubation is predicted to last more than 2 weeks. Prophylactic steroids and antibiotics are not indicated because they have not been shown to improve outcomes in inhalation injury.9,13

Another type of injury that should be managed at a burn center or equivalent institution is the electrical injury. A mass

Table 27.3: Pulmonary Clinical Characteristics at Different Time Points After Inhalation Injury

Time since Inhalation Injury Pulmonary Clinical Characteristics

0–36 Hours Acute asphyxia, carbon monoxide poisoning, bronchospasm, upper airway obstruction, severe parenchymal damage

36–72 Hours Pulmonary edema

3–10 Days Bronchopneumonia

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casualty event involving electrical injury would be extremely rare; however, a possible scenario is that a group of people could be simultaneously struck by lightening. The situation could lead to one or two patients with combined thermal and electrical injuries within a group of causalities with only thermal injury. Injury to tissues from electricity occurs because the electrical current is converted to heat. The amount of heat generated is directly proportional to the amperage, the resistance, and the time of exposure. Bone exhibits a high resistance, so that struc- tures nearest bone tend to incur more thermal damage than do structures away from bone. An electrical injury may appear superficial and small in size, but may extend to an extremely large area beneath the skin. Deep muscles may be necrotic while more superficial muscles may look intact. Overall assessment and management of electrical injury is similar to that of other injuries with a few exceptions.

■ The size of the surface burn is not predictive of the extent or size of a deeper burn.

■ Compartment syndrome can develop from necrotic subfas- cial muscle. A high index of suspicion must be maintained for compartment syndrome.

■ Fractures and dislocations may occur as a result of spasms and contractures produced by the electrical current.

■ Occult internal injuries in the chest or abdomen must be suspected.

■ Bizarre neurological symptoms may develop. Perform a detailed neurological examination on initial patient assess- ment and periodically thereafter.

■ Muscle injury may lead to pigments in the urine. Maintain a urine output of 75–100 mL/hour. This is a higher urine output than for thermal injuries in adults. Add sodium bicar- bonate to intravenous fluids to facilitate clearing pigments from the urine. Attain a urine pH above 6.

■ If the patient presents with cardiac arrest or dysrhythmia, assess for a primary cardiac event and initiate continuous cardiac monitoring for 24–48 hours.

■ Muscle necrosis may require multiple debridement proce- dures.

In contrast to electrical injuries, mass casualties are much more likely to present with chemical injuries. Many industrial and transportation accidents involve large quantities of harmful chemicals. Secondary contamination of medical providers from chemicals or vapors is of concern. The first priority in these disas- ters is to protect the healthcare provider by using appropriate lev- els of protective clothing. Once this is done, the same principles already established for other injuries apply for burns involving chemical injuries. Chemicals may be associated with irritating and noxious fumes and vapors that when inhaled lead to an inhalation injury to the lung. The airway and breathing must be protected with early intubation and then all other injuries are evaluated and addressed. Principles specific to chemical injury can be found in Chapter 28.

CONCLUSIONS

This chapter sets forth important concepts in disaster plan- ning for burn victims. A comprehensive plan should include a method of communication between a central command and the healthcare team at the front line and a robust triage and field

treatment system. Combination injuries such as concomitant thermal and nonthermal burns must be detected and treated. Considerations specific to thermal injury patients that require expeditious interventions include: circumferential eschars of the extremities and chest, and hypothermia.

Transportation criteria determine when air transport is appropriate to move patients from initial treatment areas to definitive burn care facilities. After arrival at the burn facility, three major types of injury (inhalation injury, chemical injury, and electrical injury) that are commonly found among burn victims require assessment and treatment. A discussion of spe- cific surgical procedures for burns and rehabilitation and phys- ical therapy of the burn victim are beyond the scope of this chapter.

RECOMMENDATIONS FOR FURTHER RESEARCH

Although an “all-hazard approach” is often advocated for disas- ter preparedness and response, many emergency response plans fail to consider burn casualties. Future comprehensive emer- gency management plans must account for burn patients. Due to the high incidence of burn-related casualties in U.S. com- bat operations, investigators are collecting data that will guide future referral and treatment guidelines. As described earlier in this chapter, guidelines provided by the American Burn Association recommend initiating crystalloid fluid resuscitation for burn patients at a rate of infusion derived by multiplying 2–4 mL/kg/%TBSA burned administered over the first 24 hours postburn, providing one-half of estimated fluid over the first 8 hours. Difficulty in remembering the appropriate formulas and how to apply them has led to a high rate of noncompliance with these guidelines at various levels, especially in the prehospital setting or other locations where burn patients are treated infre- quently. Future recommendations on appropriate fluid choice and rate of administration are currently being studied. Finally, additional study is urgently needed to guide triage and treat- ment decisions that would optimize outcomes for multiple burn patients when healthcare capacity is exceeded.

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