Case Study – Burn Management
Early last winter the LIFE STAR crew was requested to transport a critically ill burn patient from a local emergency department to the regional burn center. The patient, Mr. X, was approximately 60 years old and had sustained full thickness burns to approximately 80% of his body surface area. He was in a confined space inside a building when a fire ignited. It is unclear how long he was inside the burning building.EMS transported the patient via ambulance to the local emergency department. Prior to arrival of the flight crew the patient was intubated using rapid sequence induction. Endotracheal intubation was performed to protect his airway and to provide oxygenation and ventilation. He was noted to have carbonaceous sputum, soot in mouth and nares, head is charred and he has no hair. The patient has full thickness burns throughout his body with the exception of his posterior chest. Two tibia IOs were in place and IVF was infusing. The emergency physician was performing anterior axillary and extremity escharotomy and fasciotomies. The fasciotomies had been performed on each extremity secondary to full thickness circumferential burns. The anterior chest escharotomy was initiated to allow for increased chest expansion to improve ability to ventilate. Systolic blood pressure was 80-100 and 3,600ml IVF had been infused. He had received pain medications, sedation and antibiotics. Prior to transport the anterior chest escharotomy was completed. He was mechanically ventilated, covered with sterile blankets, central line placed, IVF continued and additional sedation and pain medication. The emergency physician also placed a suprapubic tube with 15ml output.
Care for Mr. X during transport includes: Mechanical ventilation with 100% FiO2 and tidal volumes equal to 7ml/kg. Fluid resuscitation, additional sedation and pain medication, blankets and cabin heat to maintain body temperature. OGT placed to suction. Urine output was monitored and there was 50ml urine output during transport.
During his stay in the burn center Mr. X was diagnosed with 80% third degree burn, acute inhalation injury with acute respiratory failure, sever lactic acidosis, hypotension secondary to burn shock and rhabdomylosis. He continues to receive fluid resuscitation and went to the OR for more extensive vasculotomies and fasciotomies. His hemoglobin and hematocrit were critically low at 6.3 and 17.1 he then received PRBCs and FFP. Unfortunately he passed away later that day.
Per the Journal of Burn Care Research (J Burn Care Res 2009;30:759-768) the following are guidelines for escharotomy and decompression therapies in burns.
- Extremities or anterior trunk that have circumferential burns
- Absence of doppler pulses
- Compartment pressures > 40mmHg
- Escharotomy incisions are made through the burned skin and should avoid neurovascular structures. Goal is to recover blood flow to extremities and relieve respiratory and hemodynamic dysfunctions
- Intra-abdominal hypertension can lead to abdominal compartment syndrome
- Intra-ocular pressures should be measured for burns in eyes.
Initial care of the burn patient should include oxygen and airway management, removal of clothes and jewelry, fluid resuscitation, pain medication and maintenance of body temperature. The Parkland Formula is commonly used as a guideline for fluid resuscitation.Parkland: 4ml x weight in kg x % Burned BSA = amount of fluid to be infused in the first 24 hours. The first half of that amount is to be infused in the first 8 hours. Although the Parkland Formula is often used it is imperative that the caregiver monitor urine output as well as vital signs, level of consciousness and skin color of non-burned skin. Normal urine output = 0.5-1ml/kg/hour.
In review of LIFE STAR transports form April 1, 2010 through March 31, 2011 the LIFE STAR program transported 22 critically ill burn patients to regional burn centers. Of the 22 patients transport all received IVF, 15 required airway protection with endotracheal intubation, all but one received pain medication and the patient who did not refused the offer of pain medication. Only 2 required escharotomy.
American Burn Association statistics: 450,000 burn injuries receive medical treatment annually. There are 3,500 fire and burn deaths per year. 45,000 hospitalizations for burn injuries annually including 25,000 at burn centers. The survival rate for patients admitted to burn centers = 94.8%. An article in the Journal of Burn Care Rehabilitation shows that early burn center transfer shortens the length of hospitalization and reduces complications in children with serious burn injuries J Burn Care Rehabil 1999 Sep-Oct;20(5):347-50.