Getting Started / House Staff Manual

Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors: Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

Okay, so you wanna be a burn surgeon? Fortunately, the nurses and therapists are well-versed in the usual nuances of burn patient management, and an under-appreciated resource. They are friendly and helpful, so a little kindness and consideration on your part will be a worthwhile investment. If you stray from the path of righteousness in your patient care, the attending will happily (not for you) set you right again. Success in acute burn management hinges on diligence and attention to detail.

If you have a question, don't be afraid to ask. You will find our faculty very approachable and helpful. It's more embarrassing to be hammered in the morning than to wake up the faculty at night.

Taking Referrals
The Shriners Burns Hospital and the Blocker Burn Unit are tertiary burn care centers, and a large portion of our patients are transferred from other medical centers throughout the country. Patients can only be accepted after housestaff speak to the referring physicians as a "physician to physician referral" with approval of the attending surgeon. To assist in information gathering, referral sheets are available at the desk on both units. This sheet is a legal medical record and should be filled out legibly, carefully and completely. For Shriners Burns Hospital referrals the address of the prospective patient is essential to determine the supporting Shrine Temple, who generally will pay for patient transport. Once a data sheet is completed, the case is discussed with the appropriate attending physician. Once the transfer is accepted, the resource nurse (SBH) or transfer center (UTMB) will arrange for patient transport. For SBH transfers, the Baylor resident or fellow may accompany the flight team to retrieve the patient. After flight arrangements are initiated, a return call is made to the referring physician to help direct resuscitation and assure patient stability for patient transfer. Patients who are clearly preterminal are not appropriate candidates for transfer, including those with severe neurological compromise. For SBH transfers, the Anesthesiologist on call and the OR should be notified at all anticipated admissions. All contact with outside physicians should be done on a recorded phone line, both for the patient's and your safety.

The age of the patient is also essential, as SBH does not accept first time acute patient admissions after their 18th birthday. Older patients can be referred to the Blocker Burn Unit at UTMB. Acute referrals from the UTMB Emergency Room for hemodynamically stable patients meeting SBH admission criteria are sent over for evaluation and treatment without needing to obtain faculty approval prior to transfer.

It is not only courtesy to notify the faculty on-call of all admissions and transfers, but their responsibility to know of such happenings. The mode of transportation and any treatment recommendations should be relayed back to the referring facility.

Arrival Checklist:

ABC's of Trauma
   Establish Airway
   Check Breathing
   Administer Oxygen for Hypoxemia
   Control External Bleeding
   Insert IV's, Foley, NGT
   Initiate Fluid Resuscitation
   Search for Associated Injuries

Patient Evaluation
   AMPLE History
   Immunization Status - including Tetanus
   Check Accompanying Referral Paperwork
   Complete Physical Exam
   R/O Occult Injuries
   Labs: CBC, ABG's, Serum Electrolytes, Liver Function Panel, BUN, Cr, Glucose, Albumin, Ca, TP, U/A, CXR, EKG, CO-Hgb,
Type & Screen/Crossmatch
   X-rays if needed (e.g. long-bone films, C-spine, etc.) and Review with Radiologist
   Clean and Gently Debride Wounds (usually in tub room) - Culture (blood, urine, wound)
   Photographs
   Burn Diagrams: Size & Depth

Calculate Fluid Requirement
Measure Height and Weight
Determine Body Surface Area (BSA) and BSA Burned

Shriners Burns Hospital Resuscitation Formula
First 24 hours: 5000 ml/m²BSA burned/day plus
2000 ml/m²BSA (total)/day

Half of this calculated amount is given over the first eight hours from the time of burn injury, and the second half of this fluid requirement is given over the next 16 hours. This is only a predicted fluid requirement and actual needs are titrated to adequate urine output (0.5-1cc/kg/hr for patients older than 2 years of age and 1-2 cc/kg/hr for children under 2 years of age).
Fluid is given as LR (children under 2 years of age have less glycogen reserves and need a constant supply of glucose, so the maintenance IV is changed to D5LR).

Watch serum/urine glucose.

   After 24 hours:    3750 ml/m²BSA burned/day
                                  (evaporative loss from wound)   plus
                                  1500 ml/m²BSA/day (maintenance)
                                  1000 ml/m²BSA/day (evaporative loss if on clinitron bed)

This accounts for total fluid needs, including enteral feedings and IV's. IV solution is chosen to help maintain normal serum electrolyte, e.g. D51/3 NS + 20 mEq K + Phosphate

Blocker Burn Unit Resuscitation Formula
First 24 hours: 2 cc/kg/%TBSA burned. Half is given in the first 8 hours, 1/4 in the second 8 hours and 1/4 in the third 8 hours. Fluid is given as Lactated Ringers. Again, urine output at 0.5-1 cc/kg/hr is the target to assess adequacy of resuscitation, and fluids adjusted accordingly. Patients with inhalation injury generally require greater volumes of resuscitation (in general, more like 4 cc/kg/%TBSA).

After 24 hours: 1 cc/kg/%TBSA burned. In general, maintenance fluids are estimated to be similar to the above calculations. Mostly, they are determined by the volume of enteral feeds to meet caloric needs and monitored again by urine output.

Circulation Assessment
   Escharotomies (Faschiotomies) for suspected compartment syndrome
   Splint and Elevate - 'sky hook', collagenase if requested by faculty
   Serial Exams. Remember the 5 'P's: Pain, Palor, Parasthesias, Poikilothermia, Pulseness.
       Usually, the pulse is the last physical exam finding to be lost (keep in mind
       your CVP is 8-12 mmHg and Arterial pressure is 120 mmHg).

Infection Prevention
Tetanus Prophylaxis
Major Injuries (>30% TBSA) may receive prophylactic empiric antibiotics, usually Vancomycin, Imipenem and Levofloxin (check with Attending or Fellow for current drug choice).

Metabolic Support
   Prevent Hypothermia (warm room, warm fluids)
   Comfort Measures: Sedation, Analgesics
   Order Metabolic cart on admission orders to get baseline nutritional needs

Hormonal Manipulation (Usually as part of study protocol - check with Fellow/Attending)
   Growth Hormone
   Propranolol
   Oxandrolone

Nutritional Support
   Place dobhoff and nasogastric tube and start enteral feeds early.
   1500 Kcal/m²burned and 1500 Kcal/m²TBSA daily for children
   25 Kcal/kg/day and 40 Kcal/kg/%TBSA burned
   Feed with Vivonex (0.75 kcal/ml). Historically, milk (0.66 kcal/ml) was used and is a good choice if nothing else is available, such as referrals still in Mexico and other locations.

Burn Wound Treatment
   Gentle Debridement
   Remove or Aspirate Blisters
   Apply Burn Dressing (dealer's choice) - Check with Attending

Supportive Care
   Ventilatory Management
   Physical and Occupational Therapy
   Psychosocial Support - including Family

Surgical Wound Closure
   Notify OR and Anesthesia on-call of patient arrival for SBH transfers
   Notify Blood Bank to have 1cc blood/cm² skin to be excised. (1m² = 10,000cm² = 10 sq ft)
   Notify Skin Bank (homograft to cover excised TBSA)
   Major cases need 4 electrosurgical units, warmed OR and skin opened/ready at start of case.

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Resident Orientation Manual Produced by Galveston Shriners Burn Hospital and The University of Texas Medical Branch Blocker Burn Unit. Contributors: Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD, Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD, Marsha Hildreth RD, Ray J Nichols Jr. MD GETTING STARTED Okay, so you wanna be a burn surgeon? Fortunately, the nurses and therapists are well-versed in the usual nuances of burn patient management, and an under-appreciated resource. They are friendly and helpful, so a little kindness and consideration on your part will be a worthwhile investment. If you stray from the path of righteousness in your patient care, the attending will happily (not for you) set you right again. Success in acute burn management hinges on diligence and attention to detail. If you have a question, don't be afraid to ask. You will find our faculty very approachable and helpful. It's more embarrassing to be hammered in the morning than to wake up the faculty at night. Taking Referrals The Shriners Burns Hospital and the Blocker Burn Unit are tertiary burn care centers, and a large portion of our patients are transferred from other medical centers throughout the country. Patients can only be accepted after housestaff speak to the referring physicians as a "physician to physician referral" with approval of the attending surgeon. To assist in information gathering, referral sheets are available at the desk on both units. This sheet is a legal medical record and should be filled out legibly, carefully and completely. For Shriners Burns Hospital referrals the address of the prospective patient is essential to determine the supporting Shrine Temple, who generally will pay for patient transport. Once a data sheet is completed, the case is discussed with the appropriate attending physician. Once the transfer is accepted, the resource nurse (SBH) or transfer center (UTMB) will arrange for patient transport. For SBH transfers, the Baylor resident or fellow may accompany the flight team to retrieve the patient. After flight arrangements are initiated, a return call is made to the referring physician to help direct resuscitation and assure patient stability for patient transfer. Patients who are clearly preterminal are not appropriate candidates for transfer, including those with severe neurological compromise. For SBH transfers, the Anesthesiologist on call and the OR should be notified at all anticipated admissions. All contact with outside physicians should be done on a recorded phone line, both for the patient's and your safety. The age of the patient is also essential, as SBH does not accept first time acute patient admissions after their 18th birthday. Older patients can be referred to the Blocker Burn Unit at UTMB. Acute referrals from the UTMB Emergency Room for hemodynamically stable patients meeting SBH admission criteria are sent over for evaluation and treatment without needing to obtain faculty approval prior to transfer. It is not only courtesy to notify the faculty on-call of all admissions and transfers, but their responsibility to know of such happenings. The mode of transportation and any treatment recommendations should be relayed back to the referring facility. Arrival Checklist: ABC's of Trauma Establish Airway Check Breathing Administer Oxygen for Hypoxemia Control External Bleeding Insert IV's, Foley, NGT Initiate Fluid Resuscitation Search for Associated Injuries Patient Evaluation AMPLE History Immunization Status - including Tetanus Check Accompanying Referral Paperwork Complete Physical Exam R/O Occult Injuries Labs: CBC, ABG's, Serum Electrolytes, Liver Function Panel, BUN, Cr, Glucose, Albumin, Ca, TP, U/A, CXR, EKG, CO-Hgb, Type & Screen/Crossmatch X-rays if needed (e.g. long-bone films, C-spine, etc.) and Review with Radiologist Clean and Gently Debride Wounds (usually in tub room) - Culture (blood, urine, wound) Photographs Burn Diagrams: Size & Depth Calculate Fluid Requirement Measure Height and Weight Determine Body Surface Area (BSA) and BSA Burned Shriners Burns Hospital Resuscitation Formula First 24 hours: 5000 ml/m²BSA burned/day plus 2000 ml/m²BSA (total)/day Half of this calculated amount is given over the first eight hours from the time of burn injury, and the second half of this fluid requirement is given over the next 16 hours. This is only a predicted fluid requirement and actual needs are titrated to adequate urine output (0.5-1cc/kg/hr for patients older than 2 years of age and 1-2 cc/kg/hr for children under 2 years of age). Fluid is given as LR (children under 2 years of age have less glycogen reserves and need a constant supply of glucose, so the maintenance IV is changed to D5LR). Watch serum/urine glucose. After 24 hours: 3750 ml/m²BSA burned/day (evaporative loss from wound) plus 1500 ml/m²BSA/day (maintenance) 1000 ml/m²BSA/day (evaporative loss if on clinitron bed) This accounts for total fluid needs, including enteral feedings and IV's. IV solution is chosen to help maintain normal serum electrolyte, e.g. D51/3 NS + 20 mEq K + Phosphate Blocker Burn Unit Resuscitation Formula First 24 hours: 2 cc/kg/%TBSA burned. Half is given in the first 8 hours, 1/4 in the second 8 hours and 1/4 in the third 8 hours. Fluid is given as Lactated Ringers. Again, urine output at 0.5-1 cc/kg/hr is the target to assess adequacy of resuscitation, and fluids adjusted accordingly. Patients with inhalation injury generally require greater volumes of resuscitation (in general, more like 4 cc/kg/%TBSA). After 24 hours: 1 cc/kg/%TBSA burned. In general, maintenance fluids are estimated to be similar to the above calculations. Mostly, they are determined by the volume of enteral feeds to meet caloric needs and monitored again by urine output. Circulation Assessment Escharotomies (Faschiotomies) for suspected compartment syndrome Splint and Elevate - 'sky hook', collagenase if requested by faculty Serial Exams. Remember the 5 'P's: Pain, Palor, Parasthesias, Poikilothermia, Pulseness. Usually, the pulse is the last physical exam finding to be lost (keep in mind your CVP is 8-12 mmHg and Arterial pressure is 120 mmHg). Infection Prevention Tetanus Prophylaxis Major Injuries (>30% TBSA) may receive prophylactic empiric antibiotics, usually Vancomycin, Imipenem and Levofloxin (check with Attending or Fellow for current drug choice). Metabolic Support Prevent Hypothermia (warm room, warm fluids) Comfort Measures: Sedation, Analgesics Order Metabolic cart on admission orders to get baseline nutritional needs Hormonal Manipulation (Usually as part of study protocol - check with Fellow/Attending) Growth Hormone Propranolol Oxandrolone Nutritional Support Place dobhoff and nasogastric tube and start enteral feeds early. 1500 Kcal/m²burned and 1500 Kcal/m²TBSA daily for children 25 Kcal/kg/day and 40 Kcal/kg/%TBSA burned Feed with Vivonex (0.75 kcal/ml). Historically, milk (0.66 kcal/ml) was used and is a good choice if nothing else is available, such as referrals still in Mexico and other locations. Burn Wound Treatment Gentle Debridement Remove or Aspirate Blisters Apply Burn Dressing (dealer's choice) - Check with Attending Supportive Care Ventilatory Management Physical and Occupational Therapy Psychosocial Support - including Family Surgical Wound Closure Notify OR and Anesthesia on-call of patient arrival for SBH transfers Notify Blood Bank to have 1cc blood/cm² skin to be excised. (1m² = 10,000cm² = 10 sq ft) Notify Skin Bank (homograft to cover excised TBSA) Major cases need 4 electrosurgical units, warmed OR and skin opened/ready at start of case. ↑ Top
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