Written by: Van Wall, EM3

HPI: 40 yo M BIB EMS with report of 100% burns from a butane fire.  He was reportedly making BHO (Butane Hash Oil) when the room lit up.  He was intubated in the field, given a Cyanokit, 1L NS via IO to L humerus and transferred to the ED.

Questionable history that the patient was pulled from a meth house so he was decontaminated prior to being brought in to the trauma bay.  Important not to forget this.

HR 150, BP 140/90, O2 100% on 15L, BVM at 12

IMG_2631

Primary Survey: 

  • Airway – Condensation in the tube, secured in place
  • Breathing -Bilateral breath sounds, some rise/fall of the chest
  • Circulation – Difficult to assess, some perfusion peripherally

Don’t forget the basics. It is easy to get distracted by the severity of the wounds.

Give adequate pain control.  This patient was sedated on the vent at this point, but give lots of morphine.  I would also consider Ketamine.

Burn team paged immediately, estimated to have 80% TBSA burns.

Consider other injuries such as head trauma, ptx, etc from blast injury. US was helpful in this case to assess cardiac function, central line placement, FAST exam.

Keys:

  • Consider early airway management – pt’s can become severely edematous quickly and with ongoing fluid administration.
  • On the same note, remove all jewelry or items that can become constrictive.
  • Sedation/pain meds.
  • These patients will have severe volume loss. Have some kind of plan.
  • Parkland formula is a good guideline but fluids will need to be adjusted often and titrated to urine output (shoot for a minimum of 0.7mL/kg/hr).
  • 3-4mL x weight in kg x %TBSA (This estimates fluid needed in first 24 hours. Give 1/2 over the first 8 hours and 1/2 over next 16 hours.)  That’s 20-25L over 24 hrs! LR probably best to start with.  You should probably not give more than 2L/hr. The rule of nines for adults, slightly different for peds because of their big heads.
  • Assess for circumferential burns and be very concerned about compartment syndrome.
  • They often need escarotomies.
  • Cover with sterile, dry sheets.
  • Very susceptible to infections.
  • Assess for need to burn center.

Additional Resources:

Great GR lecture – about 50 min. http://maryland.ccproject.com/2013/11/21/managing-burn-patient/

Modern-Day Burn Resuscitation: Moving Beyond the Parkland Formula

http://crashingpatient.com/trauma/thermal-burns.htm/

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