Ver el código de «Burns»

==Background==
{{Skin anatomy background images}}
[[File:Dermatology - Burns - Combined - Copy.png|thumb|Crossectional anatomy of burns, from left to right: first, second, and third degree.]]
*Any burns involving the dermis, superficial partial-thickness, or deeper allow for significant transdermal fluid losses
*Burns >60% BSA often associated with cardiac output depression unresponsive to fluids
*Inhalation injury is main cause of mortality
**Half of patients admitted to burn centers develop [[ARDS]]

{{Jackson’s Burn Wound Model}}

===Pre-Hospital Care===
*Cold running water for 20 minutes
**Most effective if done within 3 hours.<ref>Griffin, B., Cabilan, C., Ayoub, B., Xu, H., Palmieri, T., Kimble, R., & Singer, Y. (2022). The effect of 20 minutes of cool running water first aid within three hours of thermal burn injury on patient outcomes: A systematic review and meta-analysis. Australasian Emergency Care, 25(4), 367–376. https://doi.org/10.1016/j.auec.2022.05.004</ref>
**No direct ice to wound
**Do not apply creams or ointments
*Remove all burned/burning clothing, jewelry
**Also remove rings or jewelry distal to injury due to anticipated swelling
*Assess for signs of inhalational injury
**Hoarse voice, soot in nose or mouth, stridor, wheezing
**Start humidified [[O2]] 
**[[Intubate]] if necessary (see below) 
*[[Intravenous fluid]] (see below)

==Clinical Features==
{{Burn thickness chart}}

==Differential Diagnosis==
{{Burn DDX}}
{{Bullous rashes DDX}}

==Evaluation==
[[File:Wallace Rule of Nines-png.png|thumb|[[Rule of Nines]]]]
===Workup===
*Carboxyhemoglobin level
*[[Carbon monoxide]] and [[cyanide]] levels
*[[VBG]], CBC, chem, total CK
*[[CXR]]
*[[ECG]]
*[[Urinalysis]] (assess for myoglobinuria)
*[[Coagulation studies]] (severe burn patients can suffer from coagulopathies such as DIC)
*[[Lactate]] (higher lactate levels suggest increase mortality rate and inadequate resuscitation)
*Serial assessments for compartment syndrome

===Diagnosis===
*Normally a clinical diagnosis
**See [[estimating body surface area]]

==Management==
*Consider empirically treating for [[cyanide toxicity]] especially if fire was in an enclosed place

===Not Severe (Outpatient)===
*Cold running water for 20 minutes if within 3 hours.<ref>Griffin, B., Cabilan, C., Ayoub, B., Xu, H., Palmieri, T., Kimble, R., & Singer, Y. (2022). The effect of 20 minutes of cool running water first aid within three hours of thermal burn injury on patient outcomes: A systematic review and meta-analysis. Australasian Emergency Care, 25(4), 367–376. https://doi.org/10.1016/j.auec.2022.05.004</ref>
*Cleanse burn with mild soap and water or dilute antiseptic solution
*Debride wound as needed
*Consider a topical antimicrobial:
**[[Bacitracin]], [[neomycin]], or [[mupirocin]]
**''AVOID Silver Sulfadiazine as it may interfere with partial thickness healing and offers no healing advantage (inhibits keratinocytes) <ref>Hussain S et al. Best evidence topic report: Silver sulphadiazine cream in burns. Emerg Med J. 2006 Dec;23(12):929-32.</ref><ref>Atiyeh B et al. Effect of silver on burn wound infection control and healing: Review of the literature. Burns. 2007 Mar;33(2):139-48</ref>''
*Consider use of synthetic occlusive dressings (see [[burn dressings]])
*Blisters
**Leave blisters intact unless they cross a joint or if a large blisters precludes application of a dressing
**Aspiration is preferred to deroofing<ref>29703044</ref>
*[[Tetanus vaccine]] (if 2nd degree or higher)

===Severe (Inpatient)===
*IVF (see below) 
*[[Analgesia]]
*Remove all rings, watches, jewelry, belts
*Local burn care ([[burn dressing]])
**Contact burn center BEFORE applying any antiseptic dressings
**Small wound: moist saline-soaked dressing
**Large wound: sterile drape
*[[Antibiotics]]
**Administer in coordination with burn physician
**Prophylactic antibiotics have been abandoned - debridement is paramount to prevent infection
**Maintain glucose control to prevent infection<ref>Jeschke MG. Clinical review: Glucose control in severely burned patients - current best practice. Crit Care. 2013; 17(4): 232.</ref>
**Core temperature is usually "reset" to 38-39°C, so fever in the absence of other symptoms of sepsis does not indicate infection<ref>Weber J and McManus A. Infection Control in Burn Patients. http://www.worldburn.org/documents/infectioncontrol.pdf</ref>
**If [[sepsis|septic]], start broad spectrum antimicrobials - be sure to assess for need for antifungals in addition to antibiotics
*[[Nasogastric Tube]]
**Consider if partial-thickness burn >20% BSA ([[ileus]] frequently occurs)<ref>Herndon DN (Ed): Total Burn Care. Philadelphia, Elsevier Saunders, 2007</ref>
**Definite NG tubes in burns > 30% in adults and 25% in children
*Early GI prophylaxis ([[PPI]]/[[H2 blocker]])
**evidence of stress ulceration even within hours after major burns<ref>DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med. 1995;98(4):159.</ref>
*[[Tetanus vaccine]]

===Fluid Resuscitation===
====General====
*The Parkland formula (4mL*kg × % TBSA of burns, not including superficial burns) and modified Brooke formula (2ml/kg/%[[TBSA]]) are the two most widely used resuscitation formulas.<ref>American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249</ref>
**There is general agreement that there is an increasing tendency to over-resuscitate during burn shock.<ref>American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249</ref>
**Resuscitation recommendations are only a guide; must titrate to patient's urine output, clear sensorium, and HR less than 110
**Give '''least''' amount of fluid necessary to sustain organ perfusion (avoid "fluid creep")
**Patients with inhalation injury and/or multi-system trauma may require more fluid. 
*Goal directed therapy with Swan-Ganz catheters, inotropes, and fluid support have shown no superiority to standard clinical parameters, and have increased over-resuscitation and incidence of abdominal compartment syndrome (see below)<ref>Saffle JI. The phenomenon of "fluid creep" in acute burn resuscitation. J Burn Care Res. 2007 May-Jun;28(3):382-95.</ref>

====Indications based on Total Body Surface Area ([[TBSA]]) of Burn====
*Definite IV: Adults > 20%, Peds > 15%
*Perhaps IV: Adults 15-20%, Peds 10-15%
*Oral adequate: Adults < 15%, Peds < 10%

=====Types of fluids=====
*Many burn centers prefer lactated ringers unless shock liver or hepatic failure suspected
*Colloids generally not used unless burns > 40% [[TBSA]]
*Do not use dextrose in adults (false UOP), but children should receive small amounts due to small glycogen stores

=====Fluid Quantity=====
*2-4mL x weight (kg) x %[[TBSA]] ('''2nd and 3rd degree only''') = mL NS (or LR) over 24hr 
*Give 1/2 in first 8hr, remainder in next 16hr

=====Peds=====
*Give Parkland + maintenance fluid (2-4cc/kg x %BSA) if age < 5 yrs old
*Give 1/2 in first 8 hr, remainder in next 16 hr
*Can consider giving D5 1/2 NS if patient < 20 kg to prevent hypoglycemia

====Goal UOP====
*If UOP is greater than expected, consider glycosuria and reactive [[hyperglycemia]] as cause.
*Maintain urine output of ''0.5-1 mL/kg/hr''' urine in adults and''' 1-2 mL/kg/hr in children''' weighing < 30 kg<ref>Singer AJ, Lee CC. Thermal burns. In: Walls RM, Hockberger RS, Gausche-Hill M, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. Philadelphia, PA: Elsevier Saunders; 2018:715–724.</ref>
*If myoglobinuria seen, double expected UOP until urine grossly clears (consider mannitol diuresis)

===[[Intubation]] Guidelines===
*Full-thickness burns of the face or perioral region
*Circumferential neck burns
*Acute [[respiratory distress]]
*Progressive hoarseness or air hunger
*Respiratory depression
*[[Altered mental status]]
*Supraglottic edema and inflammation on bronchoscopy

{{Escharotomy burn indications}}

==Special Cases==
*In burns > 40% in adults and > 30% in children < 5 yo, consider colloids which reduce abdominal compartment syndrome<ref>MetroHealth Burn ICU Handbook (Not a policy manual), Cleveland, OH </ref><ref>Lawrence, A et Al. Colloid Administration Normalizes Resuscitatin Ratio and Ameliorates "Fluid Creep." Journal of Burn Care & Research: January/February 2010 - Volume 31 - Issue 1 - pp 40-47.</ref>
**Consider replacing 25% of IVF with [[FFP]], so that total IV rate is unaltered through the 24 hrs post-burn
**In children, give 1/2 of total volume as FFP and 1/2 as LR throughout 24 hrs
**For infants < 2 yrs with > 30%, use 5% dextrose in LRs with the FFP
*Burns > 50% or SEVERE [[metabolic acidosis]] may require 44 mEq of bicarb to each 1 L of LR in first 24 hrs, maintain bicarb > 18
*Vitamin C to reduce fluid volume requirements and prevent capillary leak<ref>Dubick MA, Williams C, et al. High-dose Vitamin C infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139-144.</ref>
**Consider infusion of 66 mg/kg/hr for 24 hours of Vitamin C infusion for > 30% [[TBSA]]
**To be started within 6 hours of burn injury

===Beyond 24 hrs===
*24-48 hrs - patients require ~1/2 total volume given in first 24 hrs; change LRs to D5,1/2NS; give FFP 2 units for every liter of crystalloid
*48-72 hrs - no formula; take into account [[TBSA]]/depth of burns (open partial thickness loss > full thickness with thick eschar), re-mobilization of 3rd space fluid beginning at this time

==Disposition==
===Outpatient Treatment===
''24-48hr follow-up''
*Partial thickness <10% BSA, age 10–50y
*Partial thickness <5% BSA, age <10y or >50y
*Full thickness <2% in anyone
*No major burn characteristics present

===Hospital admission===
*Partial thickness 10-20% BSA 10-50 yrs old
*Partial thickness 5-10% BSA in <10 or > 50 yrs old
*Full thickness burns 2-5% BSA in anyone
*High voltage injury
*Circumferential burns of an extremity
*Burns complicated by suspected inhalation injury
*significant comorbidities
*No major burn characteristics present

{{Burn center transfer criteria}}

==See Also==
*[[Caustic burns]]
*[[Electrical Injuries]]
*[[Lightning Injuries]]
*[[Burn dressings]]
*[[Estimating body surface area]]
*[[Carbon monoxide toxicity]]
*[[Cyanide toxicity]]
*[[Hydrogen fluoride toxicity]]
*[[Escharotomy]]

==External Links==
*https://www.racgp.org.au/afp/2017/march/burns-dressings/

==References==
<references/>

[[Category:Trauma]]
[[Category:Dermatology]]
[[Category:Symptoms]]