/clinical/,/clinical/references/,/clinical/references/burn/,/clinical/references/burn/admission/,

/clinical/references/burn/admission/

201606158

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UWHC,UWMF,

Patient Care,

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Clinical Hub,References,Burn Basics

Admission

Admission - Clinical Hub, References, Burn Basics

Focus

General Admission Plans

We are a regional burn center and we will accept all burn transfers at any time. Valid reasons to be in the hospital include pain control, washing of wounds, PT/OT and so forth. If any of these reasons pertain to the patient he or she should be admitted, at least long enough for arrangements to be made for appropriate care at home. We have a low (but not zero) threshold for admitting children unless the family is very motivated to do the burn cares at home. Of course, if the circumstances of the burn are in any way suspicious, the child must be admitted and Child Protective Services notified. 

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Resuscitation

The goal of burn resuscitation is to have, 48 hours after the burn, an alert patient who is not in cardiac, pulmonary or renal failure. Capillary permeability is caused by a number of acute inflammatory mediators released by cellular destruction. The symptoms are limited to the area of the burn as long as the total burn is less than about 20% TBSA. When the burn is larger, local reactions become systemic and capillaries become permeable to molecules up to 500,000 Daltons. It is because of this capillary leaking that albumin is avoided during the first 12–24 hours after a burn occurs (See Fluids section for details). Fortunately, the capillary leak begins to seal at about 12 hours. The deeper the burn, the more acute inflammatory mediators that are made, and therefore, the worse the capillary leak. Smoke inhalation aggravates the capillary leak in the lungs, and significantly increases the fluid requirements during resuscitation.

Most patients with burns less than 20% can be resuscitated orally. Children younger than 10 years old and adults over 50 probably need intravenous resuscitation above 10% TBSA. For IV resuscitation, use the Cincinnati Shriners’ formula for children (4 mL/kg × % TBSA burn per 24 h + 1500 cc/m2 BSA per 24 h) and the Parkland formula (4 mL/kg × % TBSA burn per 24 h) for adults as a rough estimate. Remember that these formulas were based on retrospective observations only, are averages, and may not apply to your patient. The best monitor of adequate fluid resuscitation is urine output, at least during the first 24 hours. Our biggest initial fluid assessment problem is that pre-hospital and ER personnel know that the patient is supposed to get a lot of fluid, so they run large IVs wide open from the time of injury. This practice is perhaps better than giving too little fluid, but you really cannot subtract this extra fluid from the resuscitation totals because the excess fluid has already leaked into the interstitium. Pretend the correct amount was given and initiate resuscitation at the calculated rate.

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Fluids

Use the Parkland formula to calculate initial rate (4ml/kg/% TBSA burn over the first 24 hours after injury; half over the first 8 hours and half over the next 16 hours). This is a guideline. All fluids should be titrated to urine output guidelines listed below. Albumin may be considered if the rate of fluid administration is greater than 2X the calculated rate. Begin 25% albumin at 10mL/hr and continue until fluid requirements return to normal.

Adults: Administer Lactated Ringers IV following urine output guidelines listed below. If myoglobinuria present ensure urine output is >100ml/hr.

Children: Need a basal rate along with their fluid resuscitation. Use D51/2 NS for this fluid if very young (<20kg).

URINE OUTPUT

Patient less than 1 year of age

1 year of age to 60 kg

Greater than 60 kg

2mL/kg/hr

1mL/kg/hr

0.5mL/kg/hr

(30-50 ml/hr)

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Inhalation Injury

% CO level

Symptoms

0-10 %

Normal

10-20 %

Headache, confusion

20-40 %

Disorientation fatigue, nausea/visual changes

40-60 %

Hallucination, convulsion, combativeness, coma

60-70 %

Convulsion, coma, weak respiration and pulse

70-80 %

Decreasing respiration to agonal

80-90 %

Death in <1 hr

90-100 %

Death within few minutes

Oxygen treatment

Half-life of CO

Room air

240 -360 minutes

100% oxygen

40 -80 minutes

Hyperbaric oxygen

15 -30 minutes

Arterial Carbon monoxide levels should be drawn in all patients involved in closed space fires. CO has an affinity for hemoglobin 200 times that of oxygen and CNS damage can be quite severe from the resulting hypoxia. Levels of CO 30% or greater portend significant CNS dysfunction that may be permanent. Most patients with smoke inhalation and CO poisoning will be intubated by the time they get to the ER whether they needed it or not. The half-life of CO in the blood on 100% oxygen is about 40-80 minutes. Thus if someone has a CO of 15% in our ER one hour after the incident, their initial CO level was probably 30%. For your information, you can generate a level of >30% CO in about 3 minutes in a moderately smoky fire. Of note, chronic smokers can have anywhere from 5-20% CO levels depending on their pack per day intake.There are no controlled data to prove that hyperbaric oxygen has any long-term effect on outcome.

Thermal damage to the lower airway is rare; however, the upper airway can be burned as it cools the hot gases from a fire. Patients at greatest risk of upper airway thermal damage are those in explosions (propane, natural gas, gasoline, etc.) who have face and upper torso burns. Other patients at risk include those who were unconscious in the fire. If the oral mucosa looks dry and red or has blisters, the patient will probably need to be intubated.

Smoke inhalation primarily effects the lower airways. One should have a high index of suspicion in those with 1) carboxyhemoglobin levels >10% on admission,2) history of a closed space fire, or 3) production of carbonaceous sputum. If all three are positive, the patient has a 90% chance of needing ventilator support. Without associated cutaneous burns, smoke inhalation has a low morbidity and mortality. With associated burns, the mortality rate for any given burn is increased by about 40. Inhalation injury may not be apparent on admission but usually is at its worst at five days after injury. Definitive diagnosis of inhalation can be done three ways: Xenon scan is the most accurate but rarely needed; Bronchoscopy may show inflamed mucosa with carbonaceous material present; Alternatively, if the P/F ratio (PaO2/FiO2) is less than 300, it is indicative if inhalation injury. The treatment is supportive only. Never use steroids or prophylactic antibiotics. Patients with smoke inhalation usually require a higher fluid resuscitation rate. Under resuscitation is probably as damaging as over-resuscitation in this setting. Bronchospasm and secretion control are essential adjuncts to ventilatory management.

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Stress Ulcer Prophylaxis

Curling ulcers (stress ulcers in burn patients) are a phenomenon of the past. This entity has probably been effectively treated by early enteral feedings, which protect the gut. Our Guidelines for treatment:

ADULTS

PEDS

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Nutrition

Burn patients who can eat normally should receive a general diet high in protein, high in calories. Patients with burns larger than 20% TBSA become hypermetabolic. It starts 36-48 hours after injury, persists at least until the patient is completely covered with skin, and may persist for the first 6 weeks to 3 months after major burns. Nutritional requirements increase proportional to burn size and reach a maximum of twice basal requirements in those with 50% burns. All patients with burns greater than 20% TBSA should have a feeding tube placed. Tube feeding is given continuously and is not stopped during dressing changes. If the feeding tube is post-pyloric and they are going to the OR with only supine positioning, the feeding is also continued.

The Curreri formula helps to predict necessary feedings in burn patients to prevent weight loss. For adults this is 25 Kcal/kg + 40 Kcal/%TBSA burn. For children this is 40 Kcal/kg + 40 Kcal/%TBSA burn. Formulas vary and are relatively equivalent, however high protein is definitely necessary. Weekly monitoring of the metabolic rate is to be done with indirect calorimetry and weekly nitrogen balance calculations help to fine-tune nutritional needs. For infants do not advance beyond 3/4 strength at 60 ml/hr unless discussed with attending and nutritionist.

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Laboratory Work

Large fluid and electrolyte shifts make frequent laboratory analysis necessary for large burns, but a decrease in frequency should occur when appropriate after discussion with the burn attending. Labs for burn patients should be reevaluated and ordered on a daily basis. UW Hospital does not encourage standing daily labs.  Preoperative labs should be drawn the day prior to OR (on Monday for Tuesday OR days) so that imbalances can be corrected in time so as not to delay OR. These labs should be BMP, Ca, Mg, Phos, CBC, and type &screen/cross as needed depending on anticipated blood loss.

Laboratory Tests for the Differential Diagnosis of Hyponatremia

Laboratory Tests for the Differential Diagnosis of Hyponatremia

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Preliminary Tests

FeNa = (Urine Na x P creatinine) x 100 / (P Na x U creatinine)

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Differentiating Between Hypovolemia and SIADH

Hypothyroid → hyponatremia

Adrenal insufficiency → hyponatremia

 

Postural changes:

BP

HR

Hemoconcentration:

↑ Hct

↑ BUN:Cr

↑ Total Protein

Serum Tonicity*

Urine Osmolality

Urine Na

FeNa

Serum Uric Acid

Response to IV NS 1-2L/d x 1-2 days:

Serum Na

FeNa

Hypovolemia

 

yes

yes

 

yes

yes

yes

<280

>450

<20

<1%

>5mg/dL

 

↑ >5mmol/L

↑ <0.5%

SIADH

 

no

no

no

no

no

no

<280

<100

>40

>1%

<4mg/dL

 

↑ <5mmol/L

↑ >0.5%

*Serum Tonicity = Serum Osmolality – (BUN/2.8)

Treatment for Mild Hyponatremia

 SIADH

  1. Fluid restriction to induce a negative water balance:
  2. 800 mL/day (obligatory urinary excretion plus insensible losses are > 1L/day, so this should result in a negative fluid balance)
    -vs.-
  3. 15 mL/kg (35 ml/kg is normal adult requirements)
  4. Use 2-Cal for enteral nutrition
  5. Consider use of furosemide (e.g., 20 mg 1-2x/day)
  6. Conivaptan is a vasopressin antagonist (IV only). It is not on UWHC formulary.

Resistant hyponatremia: Hypertonic saline (see Rose article).

HYPOVOLEMIA (EXCLUDING CHF AND CIRRHOSIS)

  1. Use a 1-Cal/mL Enteral formula (e.g., Promote without Fiber )
  2. Supplement with 1 tsp NaCl / L formula (i.e., 6 g NaCl)
  3. Use IV 0.9 NS
  4. No dietary fluid restriction. Encourage salty foods.

REFERENCES

Ellison, D H and Berl, T. The syndrome of inappropriate antidiuresis, NEJM, 356;20, 2064-72. May 17, 2007.

Gross, P. Treatment of hyponatremia. Inter Med 47: 885-891. 2008.

Milionis, HJ, Liamis, GL, Elisaf, MS. The hyponatremic patient: a systematic approach to laboratory diagnosis. CMAJ 166(8):1056-62. 2002.

Rose, BD. Treatment of hyponatremia: SIADH and reset osmostat, UpToDate.com, accessed 9/3/08.

Whitmire, SJ. Nutrition-focused evaluation and management of dysnatremias. Nutrition in Clinical Practice23, 2, 108-121, Apr/May 2008.

Thermoregulation is also altered in large burn patients and it is unclear how to interpret fevers. It is reasonable to obtain blood cultures on patients for fevers >39 and not within two hours of dressing changes.

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Activity

Movement is encouraged to decrease edema, maintain muscle tone and minimize contractures. However, for the few days after surgery (5-7 days) grafted areas are immobilized to prevent shearing of the grafts. New burn patients, and those who have not had a recent skin grafting should be up to the chair and up walking in the halls at least 3 times per day. Patients who have received a skin graft below the knee cannot ambulate or have their legs dependent for 6 days postop. Some exceptions will be made at the discretion of the burn attending regarding postoperative ambulation with small upper leg grafts.

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Constipation Prophylaxis

Constipation is a significant problem in the burn population due to the significant amount of opioids used and decreased mobility. Complications related to constipation can range from mild ileus to bowel perforation due to extreme distention. Regardless of the degree of constipation, it ultimately will lead to inability to tolerate tube feedings which interferes with nutritional intake thus decreasing the wound healing capacity

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DVT Prophylaxis

All adult burn patients should be treated for DVT prophylaxis with LMWH (Enoxaparin 40mg daily) unless contraindicated. LMWH should be held the morning of surgery and can be resumed the following morning of there are no complications.

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Antibiotics

Extensive documentation exists for bacteremia following wound manipulations, which are unaltered by systemic antibiotics. It is the exception rather than the rule that a patient in our unit needs to be on systemic antibiotics. Prophylactic systemic antibiotics have been shown to be harmful, except for a single perioperative dose prior to surgery. Remember that dosing of antibiotics can be different for the hypermetabolic burn patient so discuss freely with the pharmacist.

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Reviewed by Burn Director, May 2016