Burn Class for ICU Nurses

For 2014

Objectives for Today’s ClassBasics on Burn ResuscitationICU Interventions to prevent Burn

ComplicationsICU Standards to Advocate for Burn PatientsLabs and Markers to NoteAdjunct Care Practices specific for Burn

PatientsPlan of Care for ICU Burn PatientInhalation Injury Dressings and Burn Netting

Resuscitation – It’s GoodGoal is to anticipate and prevent burn shock,

not to play catch up and treat it. Cell death is not an event that is eligible for resurrection.

Everyone agrees fluid resuscitation is the primary factor in determining survivability of burns with TBSA >20%. [Holm C: Resuscitation in shock associated with burns:

Tradition or evidence-based medicine? Resuscitation 2000; 44:157–164]

Consensus formula is not set in stone – it is a guideline. The two consensus formulas endorsed by the ABA are: Parkland & Modified Brooke

Resuscitation – It’s GoodDelay in fluid resuscitation beyond 2 hours

of the burn injury complicates resuscitation and increases mortality. [Klein MB, Hayden D, Elson C, et al: The association

between fluid administration and outcome following major burn: A multicenter study. Ann Surg 2007; 245:622–628]

High dose ascorbic acid in first 24 hours leads to 40% reduced fluid volume requirement, 50% reduced burn tissue water content and decreased vent days. (but not standard practice or in ABA guideline)[Dubick MA,

Williams C, Elgjo GI, et al: High-dose vitamin c infusion reduces fluid requirements in the resuscitation of burn-injured sheep. Shock 2005; 24:139–144; Tanaka H, Matsuda T, Miyagantani Y, et al: Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration. Arch Surg 2000; 135:326–331]

Resuscitation – It’s BadOver-resuscitation leads to pulmonary edema,

myocardial edema, conversion of superficial into deep burns, the need for fasciotomies in unburned limbs, and abdominal compartment syndrome.[Fodor L, Fodor

A, Ramon Y, et al: Controversies in fluid resuscitation for burn management: Literature review and our experience. Injury, Int J Care Injured 2006; 37:374–379]

Initial rates are based on accurate calculation of TBSA and most first responders and providers not specialized in burns inaccurately calculate TBSA.[Bhat S, Humphries YM, Gulati S, et al: The problems of burn resuscitation formulas: A need for a simplified guideline. Available at: 

http://www.journalofburnsandwounds.com. Accessed February 8, 2009]

Aggressive fluid resuscitation potentiates edema and decreases tissue perfusion. [Saffle JR: The phenomenon of "fluid creep" in acute burn

resuscitation. J Burn Care Res 2007; 28:382–392]

Resuscitation – It’s UglyNo “agreed upon standards” exist for the

approach to resuscitation of burn patients from current data. Review American Burn Association practice guidelines burn

shock resuscitation.Pham TN, Cancio LC, Gibran NS, American Burn Association J Burn Care Res. 2008 Jan-Feb; 29(1):257-66.

ABA Guidelines have not been updated since 2001.

Over-resuscitation vs. under-resuscitation studies are mixed. Blumetti J, Hunt JL, Arnoldo BD, et al. The Parkland formula under

fire: Is the criticism justified? J Burn Care Res. 2008;29:180–186. [PubMed]

Resuscitation – It’s UglyResuscitation failure increases with co-

morbidities of inhalation injury, electrical burns, those in whom resuscitation is delayed, and those using alcohol or illicit drugs.[Cancio LC, Reifenberg L, Barillo DJ, et al: Standard variables

fail to identify patients who will not respond to fluid resuscitation following thermal injury: Brief report. Burns 2005; 31:358–365]

Meth lab burns require 2-3x more fluid than standard resuscitation due to depth, size and mechanism of burn.[Burke BA, Lewis RW, Latenser BA, et al: Methamphetamine-related burns in the

cornbelt. J Burn Care Res 2008; 29:574–579]

Studies indicate that the gold standard of measuring urine output for adequate fluid resuscitation is not a good indicator. [Klein MB, Hayden D, Elson

C, et al: The association between fluid administration and outcome following major burn: A multicenter study. Ann Surg 2007; 245:622–628]

ICU Interventions that Lead to Successful ResuscitationThink fluids first: vascular access and foley

insertion for TBSA >20%. Under 20% TBSA burns with no airway involvement can be orally resuscitated.

Measure UO. The American Burn Association Practice Guidelines for Burn Shock Resuscitation recommend 0.5 mL/kg/hr urine output in adults.

You have a 100 kg patient. How much urine per hour should you expect for adequate resuscitation?

0.5 ml * 100 kg = ___________Decreased UO in first 48 hours indicates

inadequate reperfusion.

ICU Interventions that Lead to Successful ResuscitationA-line is more accurate than cuff for

pressuresOther measurements to consider for

adequate resuscitation are:HR <120. 110s are ideal. HR >120

indicative of hypo-resuscitation.

ICU Interventions that Lead to Successful ResuscitationMAP > 70. MAP <60 requires immediate

action and increase in fluid volume;Crystalloid of preference is LR; NS in large

quantities in large burns has increased risk for abdominal compartment syndrome

Arterial Pressure (systolic – diastolic) of 30-40. (Narrow arterial pressure indicative of hypo-resuscitation and poor outcome)

ICU Interventions that Lead to Successful Resuscitation

Avoid pressors; use of pressors within first 12 hours of resuscitation yielded an independent factor of 80% higher risk of mortality with a 2-fold increased risk if used in first 24 hours. [Sperry JL, Minei JP, Frankel HL et al. Early use of vasopressors

after injury: caution before constriction. J Trauma. 2008 Jan;64(1):9-14. doi: 10.1097/TA.0b013e31815dd029]

Avoid hypothermia. Keep room at 29○C (85○F) or greater; keep patient temperature between 37○C and 38○C ideally; start warming when 37.5

ICU Interventions that Lead to Successful Resuscitation

Monitor for ACS in abdomen, limbs and chest.

Bladder pressure is current indicator for determining abdominal acute compartment syndrome.

Cap refill is best indicator for limb perfusion.

ICU Interventions that Lead to Successful Resuscitation

Monitor bladder pressure for TBSA >30% and prepare for abdominal decompression. Patients who get more than 250ml/kg of crystolloids in first 24 hours will likely require abdominal decompression [Klein MB, Hayden D, Elson C, et al: The association between fluid

administration and outcome following major burn: A multicenter study. Ann Surg 2007; 245:622–628]

On admission: Ensure DVT prophylaxis is started. Burn patients are more susceptible to HIT; usually placed on LMWH weight-based therapy BID unless contraindicated

On admission: Ensure Stress-Ulcer prophylaxis is started.

Labs and Markers to NoteOn admission:

CMP, CBC with diff, Lactate, ABGEvery 6 hours during active resuscitationElectrolyte replacement protocol should

be standardValues to pay attention to -

BE/BD in ABG (Low BD values indicate poorer outcomes)

Serum lactate (values that are high on initial admission indicate poorer outcomes)

HCT of 55-66 is not uncommon in early post-burn resuscitation

Labs and Markers to NoteValues to pay attention to -

Thrombocytopenia in early post-burn is expected.

WBCs that trend down for 3 days post admission and then increase suddenly are normal for a burn patient – called transient neutropenia. Monitor when above 12 and consider cultures above 14.

Sudden decrease in WBCs may indicate AgSd induced neutropenia

Higher cortisol levels are normal for burn patients with large TBSAs

Adjunct Care Practices Specific to Burn Patients Nutritional support via enteral tube feeding

and protein supplements; insert NJ (tiger stripe) for feeding tube; consider OG for abdominal decompression; metabolic impact of burns

Nutritional consult on admission (assesses need for ascorbic acid, zinc, oxandralone, juven, tube feed formula and caloric needs, etc.)

Splints for hand burns within 24 hours – OT/PT evaluation orders on admission

Curos caps on ALL IV ports, including foley

Adjunct Care Practices Specific to Burn PatientsFoot drop splints (PRAFO type boots) within 7

days if ICU LOS is expected to be more than 1 weeks

GI Motility prophylaxis and consideration of fecal management tube for burns on buttocks and perineal areas

Elevate testicles and reposition frequentlyIncreased perineal care for burns in that area

(alternate every 2 hours with oral care schedule)

Pillows! (NO under head; YES under arms/legs)

Adjunct Care Practices Specific to Burn PatientsFacial Burns

Daily shavingFace care every 4 hoursIncreased frequency of oral suctioning Oral care every 2 hours

Elevate limbs and perform passive ROM every 2 hours, along with hand and finger manipulation every 4 hours if uninjured (combine with face care schedule)

Typical Plan of Care for ICU Burn PatientFluid resuscitation x72 hoursInitial burn dressing will be

bacitracin/adaptic for superficial burns and superficial partial-thickness (BID).

Deep partial thickness burns will be dressed with collagenase + bacitracin & adaptic (if Dr. Pharaon) or AgSd (Schulz/Cho). (BID)

Expect patient to be scheduled for OR within 5-7 days of initial burn injury. Longer delays result in higher risk for burn wound sepsis.

Typical Plan of Care for ICU Burn PatientSurgery will usually be TED with allo/auto

graft placementPost allo/autograft, patient will remain

occluded between 3 and 7 daysPost surgical surveillance of CBC (platelets,

Hgb, Hct, WBCs) and discoloration or sweet smell of dressings for post-surgical site infection is important

Continued burn dressings for non allo-autografted areas are maintained

Typical Plan of Care for ICU Burn PatientPatient ICU criteria include:Vent-dependentS/S sepsis requiring higher level of careAcuity Multiple drips and sedation

Vital Sign Normal values are redistributed in the burn patient.HR is typically tachycardicTemp is elevated (38.5 is normal for TBSA 40% or more)Low BP and MAP are expected (within range. 80/60 is concerning but

not alarming; MAP of 65 is concerning but not alarming)

Inhalation InjuryIncreases mortality riskRequires more fluids in resuscitation (up to

44% more) [Navar PD, Saffle JR, Warden GD. Effect of inhalation injury on fluid resuscitation requirements after thermal

injury. Am J Surg 1985; 150:716–720]

Early intubation indicated for patients with hx of being in enclosed space, facial burns, stridor, carbonaceous sputum, vocal change

Obtain carboxyhemoglobin on admission if inhalation injury is remotely suspected

Obtain bronchoscopy within 24 hours of admission

Questions?