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1 Role of the Anaesthesiologists in the management of Burns ---Dr.T.Venkatachalam.MD.

, DA A burn injury may result from dry heat, wet heat, Chemicals, Electricity, Sun, or any other means which generates heat. When it happens the emergency department receives these patients as in the case of Trauma victims. Also the burns and trauma may co-exist in a number of situations. All these implies that the anaesthesiologist may have to be involved in the management of these patients from the moment they are admitted to many years after that in their corrective and rehabilitative surgeries. The anesthesiologists role may be required during: 1. 2. 3. 4. 5. 6. Early resuscitation during burn shock Airway intubation and Ventilation. Pain relief Anaesthesia for Surgical procedures for burns like escharotomy or fasciotomy. Anaesthetic management of associated injuries. Anaesthesia for Surgical management for corrective and cosmetic surgeries etc.

The burning of skin causes local and systemic inflammatory responses with the release of a number of mediators like histamine, serotonin, prostaglandins, platelet products, complement components, and members of the kinin family.These occur not only in the burned tissues but also to a lesser extent, in the unburned tissues because of pouring in of neutrophils, macrophages, and lymphocytes into these areas, which affect both local and systemic capillary permeability. This results in rapid transcapillary equilibration of the components of the intravascular compartment with interstitium with a similar proportion of proteins and plasma fluid including all whole blood elements up to the size of RBCs(350,000 MW). As a result of this continued capillary leak, about of the infused crystalloid solution is lost to the interstitium with a continued accumulation of edema. When the size of the burnt area is more than 10 to 15% of Total Body Surface Area (TBSA), the excessive leak of the intravascular elements leads to the development of shock. The maximum effect of this leak occurs at about 6 to 12 hours post burns period. After this time the capillary integrity starts to return leading to a reduction in the fluid requirement for the patient. The second mechanism which favors the edema formation is due to the denaturing of the collagen fibers of the interstitium which results in the physical expansion of the potential third space with a development of a transient interstitial negative pressure of up to -20 to -30 mmHg. This favors the extravasation of the fluid and edema. In adults when the burnt area approach 25-30% TBSA, damage to cell membranes also occurs,as in the case of hypovolemic shock, which is associated with a decrease in trans membrane potential and the accumulation of intracellular sodium and water, with resultant swelling at the cellular level. When these patients are resuscitated properly, the transmembrane potential is restored back towards normal. But unlike hemorrhagic shock the restoration is only partial in these patients since the edema formation is due to various other factors also. If the volume deficit is not properly replaced it leads on to progressively deteriorating membrane potential and eventual cellular death.

2 When the burn wound is examined the following zones or areas can be identified: 1. Zone of coagulation Coagulated non-viable central area of the burnt tissues. 2. Zone of ischemia or stasis - Surrounding tissues (both deep and peripheral) to the coagulated areas, which are not devitalized initially but, due to micro vascular injury, can progress irreversibly to necrosis over several days if not resuscitated properly 3. Zone of hyperemia - Peripheral tissues that undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable The tissues in ischemic areas may be salvaged if proper resuscitation in the initial stages is carried out and followed by proper burn wound excision and antibiotic therapy when indicated. Underresuscitation can convert this area into deep dermal or full-thickness burns in areas not initially injured to that extent. Initial evaluation and management: Organizing the evaluation of a burn patient in a manner similar to that of a trauma patient, beginning with the ABCDE assessment (i.e., airway, breathing, circulation, disability, exposure) of the primary advanced trauma life support survey. Pay special and immediate attention to the presence of an ongoing thermal insult by way of either smoldering clothing or surface contact with a chemical irritant. Minor uncomplicated burns can be treated as out patients in most of the hospitals while major complicated burns need expert management in specialized burns unit. The American Burn Association (ABA) has established recommended criteria for transfer to burn centers. These criteria recognize the factors that are associated poorer outcomes, such as advanced age, electrical burns, smoke inhalation and age of the victims. The following list is adapted from Guidelines for the Operation of Burns Centers (p 79-86), Resources for Optimal Care of the Injured Patient 2006, Committee on Trauma, American College of Surgeons.

Partial-thickness burns greater than 10% of total body surface area in patients who are younger than 10 years or older than 50 years Partial-thickness burns over more than 20% of total body surface area in other age groups Burns that involve the face, hands, feet, genitalia, perineum, or major joints Third-degree burns in any age group Electrical burns, including lightning injury. Chemical burns Smoke inhalation injury - Smoke particles settle in distal bronchioles and the mucosal cells die leading sloughing and distal atelectasis. Burns in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality rate Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or death Burn injury in children at hospitals without qualified personnel or equipment for the care of children Burn injury in patients who will require special social, emotional or long-term rehabilitative intervention

3 Airway management: Airway management of burns is an extremely important consideration and can lead to severe complications if not properly managed. Fire consumes oxygen and patient may have hypoxic injury. Ascertain whether inhalation components of the burns are present or not. Incomplete combustion produces carbon monoxide (CO). It has 200 times more affinity for oxygen and interferes with proper oxygenation. History of smoke inhalation, accident taking place in a closed space, presence of singed facial hairs and production of carbonaceous sputum all may indicate the presence of an inhalational injury. Edema formation during resuscitation does not spare the airway. All the patients should be administered supplemental oxygen to keep the O2 saturation at least >90%. Almost all patients with large burns require immediate intubation and ventilator support. The patients with small- to- mediumsized burns can initially have a stable airway but may develop stridor over the next few hours as the edema increases, requiring a difficult and urgent intubation under less-than-ideal conditions. In addition, the large amounts of narcotics administered for pain relief also contribute for the respiratory depression. Investigations like ABGA, Chest radiographs and carboxyhemoglobin levels are useful investigations as part of secondary assessment of these patients. Patients may benefit by bronchoscopy to clear mucous and fibrin clots from the airway. Also bronchodilators may be useful in patients with smoke inhalation injury Intravenous access Next to airway management the second important thing in the management is establishing a good wide bore IV access in all but simple burns. This is very essential for the fluid replacement therapy from the initial stages of management. Ideally, place IV lines away from burned tissues because of the difficulty in isolating veins and problems of securing the IV line to burned skin. Also the IV lines in burned areas can dislodge from the vein, due to the development of edema and a tourniquet effect if the IV line is secured improperly with circumferential dressings. If central lines are essential for the management, then they need to be placed early in the management before edema develops and make the landmarks disappear. Central lines, like peripheral lines, can become dislodged secondary to massive edema and hence longer catheters to be preferred. In burn patients who require IV resuscitation, the bladder is to be catheterized to monitor the urine out put which is a guide for assessing the volume status. A Nasogastric tube may be useful to decompress the stomach as well as to start early oral feeding. All the peripheral pulses should be assessed and also examine the chest and abdomen to rule out potential compartment syndromes. Weak pulses may be due to shock or edema.Hence proper assessment is to be done to take appropriate action. Edema formation can make a well-perfused limb to go in for ischemia. Myoglobinuria may be present which may lead on to renal failure if not recognized and managed properly.The affected limb may be raised above the heart level to encourage Gravity-dependent drainage. Close monitoring of the peripheral pulsed are essential for at least first 48 hours after a burn injury. Patients with circumferential burns have the highest risk of developing a compartment syndrome.

4 The loss of peripheral pulses may be due to: 1. Inadequate fluid resuscitation 2. Associated trauma with a probable vascular injury. 3. Development of a compartment syndrome. There are methods available to measure the compartment pressures and pressures more than 40mm Hg may need relief by doing an escharotomy or fasciotomy. Escharotomy can be performed with IV sedation in the ward itself if warranted (Electrocautery) and is not a very painful procedure as nerves supplying those areas will be destroyed by the burns. If the patient experiences severe pain, then it may not be a compartment syndrome, but the loss of pulse may be due to inadequate volume resuscitation. Estimation of Burn Size and Depth The first step in assessing a burn and planning resuscitation involves a careful examination of all body surfaces. A standard Lund-Browder chart is useful for a quick assessment of TBSA burns.

If the Lund-Browder chart is not available, the "rule of nines" is fairly accurate in adult patients. See the rule of nines as follows. Note that a patient's palm is approximately 1% TBSA and can be used for estimating patchy areas. Rule of nines.

Head/neck - 9% TBSA Each arm - 9% TBSA Anterior thorax - 18% TBSA Posterior thorax - 18% TBSA Each leg - 18% TBSA Perineum - 1% TBSA

The other important aspect of burns assessment is assessing the depth of the burnt area.In the pediatric patients, the head has a proportionally larger surface area while the upper legs have less. This difference is reflected in the slight differences noted in the pediatric Lund-Browder diagram. Only second-degree burns or greater should be included in the TBSA determination for burn fluid calculations.

6 Burn depth can be classified in many different ways but the following one is a fairly common one: 1. Superficial (first-degree) burns are limited to epidermal layers and are equivalent to superficial sunburn without blister formation. 2. Partial-thickness (second-degree) burns are also called dermal burns and can be superficial partial-thickness burns or deep partial-thickness burns. Superficial partial-thickness burns involve the superficial papillary dermal elements and are pink and moist with exquisite pain upon examination. Blister formation appears with the level of the burn. This type of burn is expected to heal well within a few weeks, without skin grafting.

Superficial partial-thickness burn

Deep partial-thickness burns involve the deeper reticular dermis. They can have a variable appearance ranging from pink to white with a dry surface. Sensation may be present but is usually somewhat diminished, and capillary refill is sluggish or absent. Burns of this depth routinely require excision and grafting for satisfactory healing.

Deep partial-thickness burn

Full-thickness (third-degree) burns extend into the subcutaneous tissues and have a firm, leathery texture and complete anesthesia upon examination. Clotted vessels can be observed through the Escher.

Full-thickness burn

Fourth-degree burns are devastating full-thickness burns that extend into muscle and bone. Estimating burn depth at the either end of the severity is easier than differentiating between the dermal level burns.However; this differentiation is more important for planning excision and grafting of the burn than for resuscitation. Some burns that initially appear to be limited to epidermal layers (i.e., firstdegree burns), and thus are not included in resuscitation calculations, may develop the blisters of dermal level burns after a few hours. When evaluating burn depth, factors like temperature, causative factors like electrical or chemical, vascularity of the area affected and anatomical location of the wound. The keratinized epidermal depth can vary very much in different areas of the body, (from less than 1 mm in the thinnest areas (eyelids, genitals) to 5 mm (palms and plantar surfaces), offering varying degrees of thermal protection. In addition, the dermal elements of young children and geriatric patients are relatively thinner than those of healthy adults, which explain the observation that burns in persons of these age groups, are usually more severe than similar injuries in other patients. Resuscitative Fluid Management Formulas and solutions: The modern concept of resuscitating the burns victim emerged from the observations made after the large fires at the Rialto Theatre in New Haven, Conn-USA in the year 1921 and later in the year 1942, another one at Coconut Grove Nightclub at Boston, Mass USA. At the time, physicians noted that some patients with large burns survived the event but died from shock in the observation periods.Underhill and Moore identified the concept of thermal injuryinduced intravascular fluid deficits in the 1930s and 1940s, and Evans soon followed with the earliest fluid resuscitation formulas in 1952. After the introduction of the concept of fluid resuscitation, there is a dramatic improvement in the survival of even severely burnt victims.

8 There are a number of fluids and their combinations are used to resuscitate these patients. The pioneering study was done by Charles Baxter, MD, at Parkland Hospital at Southwestern University Medical Center (Dallas, Tex) in the 1960s from which emerged the Parkland formula. According to this formula, the 24 hour fluid requirement (Ringer Lactate solution) is calculated at the rate of 4 mL / kg body weight / % burn TBSA. Of this the calculated volume is given in the first 8 hours post burn, and the remaining is given during the following 16 hrs. The time-dependent variables for these formulas begin from the moment of injury, andnot from the time the patient is seen in the emergency department. All the formulae use the RL solution as the key component for at least the first 24 to 48 hours. RL is preferable over isotonic sodium chloride solution (i.e., normal saline [NS]) for large-volume resuscitations because its lower sodium concentration (130 mEq/L vs. 154 mEq/L) and higher pH concentration (6.5 vs. 5.0) are closer to physiologic levels. Another potential benefit of RL solution is the buffering effect of metabolized lactate on the associated metabolic acidosis. Regardless of the resuscitation formula or strategy used, the first 24-48 hours require frequent adjustments.Calculated volumes from all of the formulas should be viewed only as a guideline for the appropriate fluid load. Blind adherence to a derived number can lead to significant over resuscitation or under resuscitation if not interpreted within the clinical context. Over resuscitation can be a major source of morbidity for burn patients and can result in increased pulmonary complications and escharotomies of the chest or extremities.In addition, not all burns require use of the Parkland formula for resuscitation. Properly managed adult burns of less than 15-20% TBSA without inhalation injury are usually not enough to initiate the systemic inflammatory response, and these patients can be rehydrated successfully primarily via the oral route with IV fluid supplementation. Monitoring and interpretation of Vital signs: Routine vital signs, such as blood pressure and heart rate, can be very difficult to interpret in patients with large burns. Catecholamine release during the hours after the burn can support blood pressures despite the extensive intravascular depletion that exists. The formation of edema in the extremities can limit the usefulness of noninvasive blood pressure measurements. Evaluation of arterial line pressures likewise is subject to error from peripheral vasospasm from the high-catecholamine state. Tachycardia may occur due to hypovolemia, pain, or anxiety. Following a trend in the gradual normalization of vital signs is much more useful than any single reading. End points for resuscitation: Achieving the balance of fluid lost to the fluid replaced so that haemodynamic stability is maintained is the goal of the resuscitation. This can be monitored by monitoring the hourly urine out put and if possible by CVP measurements. A urine out put of 0.5mL/kg/h or approximately 30-50 mL/kg/h in adult and older children (>50kg) is a good indication for adequate replacement. In small children, the goal should be around 1 mL/kg/h. If the above levels are not reached, then a gradual increase in the rate of fluid administration can be done up to 25% of the calculated amount. It is better to increase the rate of administration gradually

9 rather than giving the deficit volume in boluses. This is because the transient increase in the hydrostatic pressure gradients will further increase the shift of fluids to the interstitium and worsen the edema. It is advisable not to increase the urine out put to more than 50mL/h because it can lead on to increase in edema formation including pulmonary edema. This may lead on to morbid escharotomies and prolonging the ventilator support. There may be a few fallacies with monitoring urine output as a single guide to determine the volume status of the patient. If the patients blood sugar level is high due to whatever reason, the osmotic diuresis which results can increase the urine out put despite a poor volume status. Many older patients may be on long time use of diuretics and they are dependent of these drugs to maintain a urine flow in spite of receiving an adequate volume for resuscitation. A central venous pressure monitor may be of use in these situations to correctly manage the fluid state in these patients. An improving base deficit may show the adequacy of the fluid resuscitation and can be routinely practiced if available. Apart from this many patients may require more than the calculated amount as above. 1. Patients with inhalation injuries may require 30 to 40 % (up to 5.7mL/kg/ % burn) 2. Delay in initiating the resuscitation may increase the fluid requirement up to 30 %, probably due to the accumulation of an increased inflammatory cascade. 3. Patients on long standing diuretic therapy may already have a contracted fluid volume over which the burn shock is imposed. 4. Electrical burn patients may require more fluids than calculated volume due under estimation of the burnt area. 5. Patients with escharotomy or fasciotomy wounds may lose free water from the exposed wounds which need to be replaced. 6. A patient with burns may also have associated trauma to bones and soft tissues. They will require more fluids according to their other injuries. Colloid and Hypertonic Saline High volume resuscitations may be associated with high morbidity rates. Substituting colloid solutions to some extent will reduce the total volume required. In the early hours of post burn period (up to 8 h) there is lose of capillary integrity but once the capillary integrity is regained substituting colloids may be useful by reducing the volume of fluid administered. A strategy for testing whether the capillary leak has begun to resolve is by substituting an equal volume of albumin solution for RL solution. An increase in urine output suggests that at least some of the leak has resolved and that the further introduction of colloid can help to decrease the fluid load. The following types of colloids solutions can be tried. 1. Albumin is the plasma protein that most contributes to intravascular Oncotic pressure. When administered intravenously as a 5% solution from pooled plasma product, approximately half the volume remains intravascularly, as opposed to 20-30% of crystalloid solutions. 2. Fresh frozen plasma has the theoretic advantage of replacing the whole range of plasma proteins that are lost rather than just the albumin fraction. (0.5-1 mL/kg per percentage burn during the first 24 hours, beginning 8-10 hours post burn as an adjuvant to RL solution resuscitation). 3. Dextran is a solution of polymerized, high molecular weight glucose chains with almost twice the Oncotic pressure of albumin. It can promote microcirculation by red cell de- aggregation.

10 The edema-reducing properties are maintained for as long as the infusion is continued, but upon withdrawal and subsequent metabolism of the glucose, rapid loss of fluid occurs back into the interstitium if the capillary leak is still present. 4. Hypertonic saline solutions, ranging in concentration from 180-300 mEq sodium per liter, have many theoretic benefits. These benefits are achieved by the reduction in volume requirements by mobilizing intracellular fluid into the vascular space by the increased osmotic gradient. The intracellular depletion of water that results is a debated issue, but it appears to be well tolerated. Close monitoring of serum sodium levels is mandatory, and serum sodium levels should not be allowed to increase to greater than 160 mEq/dL. 5. RL solution with 50 mEq amps of sodium bicarbonate (in 500 ml) Fluid approaching 180 mEq sodium per liter during the initial 8 hours of the resuscitation and changed to RL solution to complete the resuscitation. Hypertonic saline management must be titrated closely to both urine output and serum sodium checks, without which it should not be done. The patients who benefit the most from lower-volume resuscitations aided by colloid are those with larger burns (>40%), those with preexisting heart disease, geriatric patients, and those with burns with associated inhalation injuries At 24-30 hours after the insult, the patient should be resuscitated adequately, with near complete resolution of the transcapillary leak with fluid requirements. At this point, some recommend a change in fluid management from RL solution to a combination fluid infusion involving albumin and D5W. The rational for this is the massive protein losses that have occurred from the burn wound during the first 24 hours. Replacing this deficit with a steady infusion of 5% or 25% albumin solution can serve to maintain a serum albumin concentration greater than 2, which can help reduce tissue edema and improve gut function. Associated insensible losses of free water from the injured skin barrier can be met by replacing the deficit with an electrolyte-free fluid such as D5W solution, which also serves to restore the extracellular space to an isotonic state, especially if hypertonic solutions were used during the resuscitation. The formula for the estimate for 5% albumin infusion is as follows: 0.5 mL/kg per percentage burn = mL albumin for 24 hours The formula for the free water estimate is as follows: (25 + percentage burn) X BSA (m2) = mL/h of free water required The sodium-rich albumin solution can lead on to the development of Hypernatremia. Serum sodium levels should be checked at least once a day. The relative rate of albumin is titrated to adequate urine output with close monitoring of the serum sodium level. As the serum sodium level rises to unacceptable levels, simply increasing the D5W solution infusion rate corrects it toward normal or vice versa.

11 Wound Care During initial or emergent care, wound care is of secondary importance Advanced Burn Life Support recommendations 1. Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS. 2. Simple dressing if being transported to burn center (they will need to see the wound) 3. Sterile dressings are preferred but not necessary 4. Covering wounds improves pain 5. Elevate burned extremities 6. Maintain patient's temperature (keep patient warm) 7. While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will result in hypothermia. If providing prolonged care 1. Wash wounds with soap and water (sterility is not necessary) 2. Maintain temperature 3. Topical antimicrobials help prevent infection but do not eliminate bacteria 4. Non-sticky dressings for more superficial burns Skin grafting Deep burns require skin grafting. 1. Grafting may not be necessary for days. 2. Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, to others trained in surgical techniques. 3. Grafting of extensive areas may require significant amounts of blood. 4. Patient's temperature must be watched. 5. Anesthesia requires extra attention Difficulty in positioning the patient, Difficulty in establishing IV access, Difficulty in intubation, Contraindication of scoline, etc. Burns Pain Management Burn pain can be one of the most intense and prolonged types of pain. Burn pain is difficult to control because of its unique characteristics, its changing patterns, and its various components. In addition, there is pain involved in the treatment of burns as the wounds must be cleansed and the dressings changed. Superficial burs only require simple oral analgesics while the second degree burns may produce intense pain. Deeper level burns may not cause much of pains. Conclusion During the initial few hours of managing the burn patient the following things should be kept in mind. 1.0xygen administration. If needed intubation and ventilation as early as needed. 2.Assess the affected area using a standard protocol. 3.Prompt and effective fluid resuscitation 4.Pain management 5.Wound management 6.Corrective surgeries and rehabilitation Acknowledgement: The above discussion is extensively adopted from CHEMM, BMJ, Burns surgery.org, and American burns association Web pages and other standard referral works on burns management for the purpose of this lecture.

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