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Burn Triage and Treatment of Thermal Injuries in a Radiation Emergency

 

Caveats:

 

Note:

  • Content on this version of the REMM burn page was created in collaboration with the American Burn Association.
  • The key consultants include: Drs. Joshua Carson, Rachel Williams, Colleen M. Ryan, William Hickerson, and James C. Jeng, with assistance from Annette Matherly, R.N.
  • See entire List of REMM consultants which includes list of burn consultants from prior versions of REMM.

 

Introduction

  • Following a radiation mass casualty emergency, especially a nuclear detonation, physical trauma with or without thermal burns (flash burns or flame burns) will be an immediate concern.
    • An air burst type of  nuclear detonation, will likely result in more burn victims than will a ground burst detonation of equal magnitude. 
  • Patients with combined injuries (radiation and trauma ± thermal burns) are known to have increased mortality compared to those who have a single type of injury. 
  • The increased mortality could be due many factors including the following
    • Local and systemic radiation effects complicating other injuries
    • Medical specialists in one area (e.g. burn, trauma or radiation injury) being less familiar with sophisticated, emergency diagnosis and treatment of other injury types.
    • Conjoint multispecialty teams having little experience working together in large mass casualty incidents that involve radiation
    • Temporary austere conditions, where the usual personnel, equipment, space, medications are not available
    • Uncertainly about optimal ways to implement temporary “crisis standards of care” in a complex, austere environment
  • The medical response to the thermal-injury aspect of radiological/nuclear mass casualty incidents will require immense resources to comprehensively manage patients’ burns.
  • The management of seriously burned patients in the first few hours can significantly affect their long-term outcome.
    • It is important that the patient be managed optimally in the early hours after injury to optimize the outcome.
    • The complexity, intensity, multidisciplinary character and expense of the care required by an extensively burned patient have led to the development of specialty care burn centers. 
  • With the limited number of available and dedicated burn beds and burn specialists in any one region of the US, transfer of patients to specialized burn centers throughout the country will likely be needed.
    • Consultation with an American Burn Association-verified burn center is recommended.
      • Until patients can be transferred to burn centers (pre-existing or improvised) with a complete burn team, immediate care of the burned patients will require significant real-time guidance and training from burn experts remotely and/or via mobile burn core-medical teams.

 

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Basics of Burn Injuries

  • Key concepts
    • Thermal trauma and cutaneous radiation burns are complex disease processes with
      • Direct tissue injury (e.g. skin and/or respiratory systems for thermal burns and cutaneous damage (but non-thermal injury) for radiation burns
      • Pathologic systemic inflammatory response
      • Multitude of potential secondary complications
    • Systemic response to effects of burn injury and burn shock
      • Systemic inflammatory response to burn injury
        • Large burns generate a very intense systemic inflammatory response
        • Massive burns generate one of the most intense inflammatory states seen in clinical medicine
      • Burn Shock and Resuscitation
        • Burn shock results principally from a combination of hypovolemic and vasodilatory shock.
        • Treatment/avoidance of burn shock requires fluid resuscitation carefully titrated to maintain perfusion
          • Inadequate volumes of fluid resuscitation will allow hypoperfusion, resulting in both secondary end organ damage as well as further expansion of the initial burn injury
          • “Over-resuscitation” (administration of excessive volumes of fluids) can also cause serious injury and mortality via the life- and limb-threatening complications of edema
  • Burn depth: key descriptor and prognostic factor for burn injuries

    Burn injury depth

    Source of graphic above:  D’Arpa P, Leung KP, Toll-Like Receptor Signaling in burn Wound Healing and Scaring. Adv Wound Care (New Rochelle). 2017 Oct 1;6(10):330-343.
    Note:  The injury depths shown above are superficial, partial-thickness, deep partial-thickness (DPT), and full-thickness cutaneous burns which extend to hypodermis, shown by dotted line, or deeper than the dotted line.

    • Severity of burn injury is significantly correlated to the depth of injury
      • Other key prognostic factors include total body surface area involved with burn, location of the injury (including pulmonary), age of the patient, and selected complicating, pre-existing systemic illnesses. 
    • Levels of burn injuries
      • Superficial burns (aka first-degree burns)
        • Dry, red, painful ("sunburn"), blanches.
        • Akin to sunburn
        • NOT counted in calculations of total burn surface area (TBSA)
      • Partial Thickness Burns (Superficial Partial and Deep Partial thickness)
        • The deeper the burn (aka second-degree), the slower the healing
          • This outcome is thought to be related to fewer skin adnexa (appendages) for re-epithelialization
          • Skin adnexa include: hair follicles, sebaceous glands, apocrine sweat glands, eccrine sweat glands
        • Superficial Partial Thickness Burns
          • Moist, red, blanching, blisters, extremely painful
        • Deep Partial Thickness Burns
          • Pale to white, drier, less blanching, less pain
          • Takes up to 3 weeks or longer to heal via secondary intention.
      • Full Thickness Burns (aka third-degree)
        • Destruction/death throughout the dermis
        • Leathery texture, color varies, loss of sensation
  • Inhalation Injury and Pulmonary Complications
    • Airway deformity and compromise are potential severe complications
      • Swelling to airway (vocal cords) either from local injury or as a component of the global body edema in large burns can eventually occlude airway
    • Inhaled poisons may accompany burns
      • Carbon monoxide (CO) poisoning
        • Disables transport by binding to hemoglobin, resulting in anoxic injury
      • Hydrogen cyanide poisoning
        • Hydrogen cyanide is another product of incomplete combustion that may be inhaled in enclosed space fires. It occurs primarily from the combustion of synthetic products such as carpeting, plastics, upholstered furniture, vinyl
        • and draperies. Hydrogen cyanide is a potent and rapid cellular poison.
    • Smoke inhalation injury
      • Smoke particles damage mucosal lining of proximal and distal airways.
      • Sloughing mucosa collects in distal airway-- cast formation causes distal atelectasis or even bronchial obstruction (“mucosal plugging”)
      • Note: pulmonary symptoms rarely grossly manifest within first 24hrs -- generally evolves over 48-72hrs
  • Secondary Injuries / Early Complications
    • Extremity circulatory complications
      • Limb Strangulation – “Eschar Syndrome”
        • Circumferential (or near-circumferential) deep-partial- or full-thickness burns can create a functional tourniquet around the extremity as swelling limbs are cut off by noncompliant scar tissue
      • Extremity compartment syndrome
        • Extensive muscular swelling can overwhelm the limited volume capacity of extremity fascial compartments, leading to compromise of perfusion and ischemic injury
    • Thoraco-abdominal restriction and cardiopulmonary compromise
      • Burns involving large segments of the thorax can create restrictive respiratory failure
      • Burns involving large segments of the abdomen, when coupled with aggressive fluid resuscitation, can create an abdominal compartment syndrome, cardiovascular collapse refractory to fluid resuscitation.
      • In both cases, immediate relief is accomplished by releasing the tension through escharotomy—incision of scar that allows separation and functional expansion
  • Prognosis and triage of burn injuries
    • Significant prognostic indicators
      • Increasing burn size (Prognosis worsens with increasing total body surface area affected by burn.)
      • Age: mortality for any given burn size increases with age after childhood
      • Concurrent non-thermal trauma
      • Presence of Inhalation Injury
      • Selected pre-existing chronic diseases
    • CAUTION: Progressive injury and risk of progression
      • Patients with injuries that appear to be larger than 5% TBSA should be monitored and reassessed for 8-to-24 hours before finalizing triage
    • NOTE: Very little is known about the mechanisms by which radiation injury effects burn prognosis and vice versa. It is clear, however, that combined injury worsens prognosis.

 

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Emergency Burn Care

  • Rescue
    • Before addressing the injuries present, first priority is to prevent any additional injuries.
      • This means protecting bystanders, rescuers, and providers from injury, and halting ongoing trauma (burns, bleeding) in the patient.
    • Rescuer and provider safety must be addressed before engaging the patient (for rescue or care)
      • Fire-compromised structures may be at risk for collapse
      • Prolonged exposure to smoke-filled confines can be harmful to enter without proper breathing equipment.
      • Patients or their clothing may on flames or still hot enough to burn on contact.
    • Rescue from ongoing injury
      • Extinguish/smother flames, remove patient from path of fire, smoke or any mechanical threats. Put out any flames in patient.
      • If any possibility for carbon-monoxide poisoning (burned and trapped in an enclosed space), apply supplemental oxygen to flush out CO.
    • Cooling
      • Small burns: may be cooled gently with cool water (recommend at least 20 min)
      • Large burns: only actively cool tissue that is still at burning temperatures.
      • Be aware of the risk of hypothermia from cooling.
  • Primary Survey
    • Once ongoing harm/injury has been arrested, the burned patient should be immediately assessed and stabilized from a mechanical trauma standpoint using principles of Advanced Trauma Life Support.
    • The Primary survey includes
      • Airway maintenance with cervical spine protection
      • Breathing and ventilation
      • Circulation and Cardiac Status with hemorrhage control
      • Disability, Neurological Deficit and Gross Deformity
      • Exposure (Completely undress the patient, examine for associated injuries and maintain a warm environment.)
    • Danger of distraction
      • Survivable thermal injuries do not represent a mortal threat within the first “golden” hour from injury.
      • By far, the most likely cause of death within the first hour from injury is a missed/ignored traumatic injury
      • Providers with limited burn experience must take care not to allow the novelty of the burn injury to distract them from adhering to the basic principles of trauma management
  • Initiating Resuscitation with fluids
    • In large burns, significant intravascular fluid loss begins shortly after injury.
    • Initiating resuscitation as soon as possible helps minimize the ultimate severity of burn by maintaining perfusion to the viable portions of injured tissue.
    • What to do
      • Insert a large bore intravenous catheter (through unburned skin, if possible). Burns greater than 20% should have 2 large bore, indwelling venous catheters, especially during transport.
      • In the pre-hospital and early hospital settings, prior to formally calculating the Total Body Surface Area (TBSA) burned, the initial fluid rates for patients with visibly large burns are based on a rough estimate of TBSA burned. [See below in secondary survey for fluid rate formula]
      • Hourly fluid rates (termed “adjusted fluid rates”) should be adjusted to reflect updated TBSA estimate once formal assessment of burn surface area is perfomed in the Secondary Survey.
  • Warming of the patient may be needed
    • Measures should be taken to protect patients from hypothermia due to compromised skin protection.
    • Hypothermia can drastically complicate burn shock, and it is far easier to prevent then it is to reverse

 

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Secondary Survey and Resuscitation

  • About the Secondary Survey
    • The secondary survey does not begin until the primary survey is completed and after initial fluids are started.
    • A secondary survey includes the following elements
      • History (injury circumstances and medical history)
      • Accurate pre-injury patient weight
      • Complete head-to-toe evaluation of the patient
      • Determination of percent Total Body Surface Area burned (see below)
      • Apply adjusted fluid rates after TBSA determination (see below)
      • Obtain indicated labs, X-rays and studies
      • Monitor fluid resuscitation (see below)
      • Pain and anxiety management
      • Psychosocial support
  • Determination of percent total body surface area (TBSA) burned
    • In adults: "Rule of Nines" is used as a rough indicator of % TBSA; see table and diagram below. 

      Anatomic Surface

      % of total body surface

      Head and neck

      9%

      Anterior trunk

      18%

      Posterior trunk

      18%

      Arms, including hands

      9% each

      Legs, including feet

      18% each

      Genitalia

      1%
    • In children: use the Lund-Browder diagram below to modify the rule of nines and assign percent TBSA.
      • Children have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults
      • Palmar hand surface of the child is approximately 1% TBSA

    Estimating Percent Total Body Surface Area Affected by Burns 
    Lund-Browder diagram for estimating extent of burns in children (Print Lund-Browder diagram):
    % Total Body Surface Area
    (Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969)

  • Adjusting, monitoring and titrating fluid resuscitation
    • Once burn size (TBSA) has been formally estimated, initial fluid rate should be adjusted to reflect the size of injury.
    • The adjusted fluid rates are calculated according to the table below.

      Category Adjusted fluid rate

      Age and weight

      Adjusted fluid rate

      Flame or scald

      Adults and older children (≥14 years old)

      2 ml LR x kg x % TBSA

      Children (<14 years old)

      3 ml LR x kg x % TBSA

      Infants and young children (≤30kg)

      3 ml LR x kg x % TBSA

      PLUS D5LR at maintenance rate

      Electrical injury

      All ages

      		 4 ml LR x kg x % TBSA
    • Monitoring response to fluids
      • Check the patient’s urinary output and physiological response to decide further titration.
    • Titrating fluid resuscitation
      • It is better to increase fluids based on response than to attempt to remove excess fluids once given.
      • Some patients including those with a delayed start of fluid resuscitation prior dehydration, or inhalation injuries may require more than the estimated fluids. Again, the adjustments to fluid rates are based on patient response.
  • Wound Care
    • During initial or emergent care, wound care is of secondary importance
    • Advanced Burn Life Support recommendations from the American Burn Association
      • Cover wound with clean, dry sheet or dressing: NO WET DRESSINGS
        • Simple dressing if being transported to burn center (The burn care team will need to see the wound.)
        • Sterile dressings are preferred but not necessary
        • Covering wounds improves pain
    • Elevate burned extremities above heart level when possible.
      • This reduces edema, and thus increases perfusion to marginally viable skin while minimizing the risk of compressive ischemia or compartment syndrome
        • Maintain patient's temperature (keep patient warm)
    • Hypothermia is a constant threat in patients with medium to large burns
    • See Prototype /Template for Hospital Orders for Adults and Children for selected options wound care and burn therapies which should be directed by experts in burn diagnosis and treatment.

 

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Preventing, monitoring, and treating early burn complications including compartment syndromes and inhalation injury

  • Re-assessment of airway
    • Watch for emergence/progression of upper airway swelling.
  • Failure to resuscitate
    • Some patients will continue to manifest signs of poor perfusion or even hypotension.
    • Importantly, any failure of resuscitation should prompt comprehensive consideration of missed/evolving injury or new complication including
      • Reassessment of burn size for progression;
      • Reviewing trauma workup and
      • Reassessing for any missed mechanical-trauma injury
  • Extremity complications
    • Most effective measure in preventing or forestalling extremity complications is to limit swelling by
      • Elevating extremity
      • Avoiding excessive fluid administration
    • Constricting eschars / Eschar Syndrome
      • Most complications caused by constricting burn eschar develop several hours into resuscitation as progressive edema.
      • Any circumferential or near-circumferential burn scars should be noted and followed with serial exam for progressive constriction.
        • Involved limbs should be elevated.
      • Any indication of ischemia from constriction (eschar syndrome) should prompt escharotomy serious consideration of escharotomy, resources permitting.
        • Distal pulses are the last remaining sign of perfusion in eschar or compartment syndromes.
        • Deferring intervention until distal pulses are lost can result in loss of limb
      • Escharotomies may save limbs (
        • Maintain high index of suspicion in completely circumferential burns
        • Incisions are made laterally and medially splitting eschar along entire limb
          • Should be limited to burn eschar and limited space above and below (2-4cm in each direction).
          • No need to incise the entire length of an extremity for a burn scar that only involves a short segment
        • Will likely require surgical hemostasis
    • Compartment syndrome
      • Compartment syndrome develop when compartment tissue swells beyond the volume capacity of the compartment fascia
      • Eschar syndrome is a major predisposing factor
      • Fasciotomies are definitive management
        • Requires surgical expertise and awareness of anatomy
        • Surgical hemostasis is required
  • Trunk Compartment Syndromes
    • Chest Compartment Syndrome
      • Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
      • Escharotomies through mid-axillary line, horizontally across chest/abdominal junction
    • Abdominal Compartment Syndrome
      • Pressure in peritoneal cavity > 30 mmHg (measure via Foley catheter)
      • Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen
      • Treatment - decompression via escharotomy
  • Inhalation injury
    • Watch for late emergence of inhalation injury
      • Typically takes 24-48hrs to manifest
      • Patients show progressive decline in pulmonary function, with increasing requirements for support required to maintain adequate oxygenation and ventilation
    • Prior to pulmonary manifestations, inhalation injury is typically manifest via fluid requirements beyond those anticipated for a given size of burn

 

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Extended burn care to recovery: Burn excision and reconstruction

  • General principles
    • While small burns or medium burns that are superficial throughout can often be managed on an outpatient basis, deep burns and large represent an ongoing risk for morbidity and mortality until open wounds have healed and/or reconstructed.
      • This process can take anywhere from days to months, depending on the severity of burn and patient factors.
  • Early excision and reconstruction are major drivers of recovery in burn patients.
    • However, these operations are quite specialized and resource intensive.
    • When at all possible, excision and reconstruction of any large burns should be performed at a tertiary center.
    • Fortunately, the window for accomplishing early excision is flexible.
    • As such, in any situation where transfer to a burn center can be accomplished within a matter of days, excision should be deferred until after transfer.
  • Excision
    • Once a patient has been stabilized and resuscitated, the cornerstone of modern burn care is to get “source control” of the inflammatory nidus by excising all burned tissue from the body.
    • Early excision: cornerstone of modern burn care
      • “Early excision” refers to the practice of surgically excising burn wounds down to healthy tissue.
      • “Early” is invoked to distinguish this practice from the prior standard of care, which involved leaving the burned in place as they gradually demarcated and separated from the underlying viable tissue on their own.
      • The precise timeline for early excision is subject to care context, patient factors and surgeon preference.
  • Reconstruction
    • All wounds excised through full thickness of skin will require reconstruction, generally via autologous skin graft.
    • Many deep-partial thickness wounds benefit from grafting as well, as a means to expedite recovery and minimize scarring complications.
    • As with excision, autologous skin grafting large surface areas is an extremely resource-intensive process that entails significant physiologic stress and blood loss.

 

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Supportive Care and Burn Critical Care

  • Massive thermal injuries create a massive inflammatory and metabolic stress that renders the burn patient increasingly vulnerable to infection and other complications until burn wounds are healed.
  • Nutrition
    • Between the energy required to heal large wounds and the metabolic dysfunction induced by the inflammatory response to thermal injury, patients with large thermal injuries live in a state of functional malnutrition.
    • Aggressive nutritional support is essential to sustain the patient through the process of wound healing.
  • Infection
    • The compromised skin barriers, inflammatory dysregulation and malnutrition all predispose patients with massive thermal injuries to opportunistic infections.
    • The inflammatory response to burn complicates this infectious risk, as early signs and symptoms of sepsis are difficult to distinguish from basic burn response.
  • Rehabilitation
    • Regaining maximal function requires specialized, intensive physical and occupational therapy.
  • Pain control
    • Thermal injuries and their treatments are often tremendously painful.
    • Given the prolonged nature of burn care, sophisticated pain management strategies are required to achieve a reasonable modicum of pain control without creating crippling narcotic dependence.
  • Psycho-social support
    • The trauma of the initial injury and that associated with acute burn represent tremendous psychological stressors
    • In many cases, the injury event is associated with additional losses such as injury to or loss of love ones, loss of home or possessions, or public catastrophe
    • Social-psychiatric support systems and professional treatment during acute care and thereafter are often necessary to restore psychiatric and emotional function.

 

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Treatment of Burns in Austere, Mass Casualty Conditions

 

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American Burn Association