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Resident
Orientation Manual (Feb. 2000)
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, Janet A
Marvin RN, MSN,
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.
Next - Section 2:
Acute Burn Management
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