Hello, good morning everybody. So out of everybody here, I am the only person that does not currently practice at a burn center in this talk this morning. So we should have some housekeeping slides, and I was just telling them at the table up front, I said for the first time in the history of any talk I've ever given, I forgot to put the title of my talk on my opening slide. So anyway, it is multi-system trauma and burns. So going forward, this is the TCA educational statement, some housekeeping things for physician CME, nursing CE, you can read through that. Disclosures, looking at this, we've got no disclosures for anyone that's talking this morning. If you're going to claim credit, this is the site that you can go to, the survey, SoGoLytics.com. I'll give you a second there if anybody needs to take a picture or anything of that, so you have it. All right, handouts. If you go into the feed loop app, I know we have copies of the handouts for all of us in there. This is the other one. You'll want to take this number down or get into your phone. We're using Poll Everywhere this morning. So if you can go into your phone and text to, the number will be 37607, and then text TCAA1431. And if you go ahead and do that now, then your phone will be activated, ready to go, and as we have any of the polling questions up, you can just go ahead and text your answer whenever those happen. So now we'll dive into it. So objectives for my talk were to understand resuscitation and management priorities for multisystem patients with trauma. At a burn center, or at a center like mine, we are not a burn center, but we are one of the busiest level one trauma centers in the country. So we are getting a combination of both, and so, right, you don't just have to have one injury pattern. And as you go through this, I'll use an example of a patient that I really, really cared for several years ago that was a younger guy in his 20s driving a gas taker truck that got into a crash, and the gas tank truck exploded. So all of a sudden, I'm looking at everything, multisystem trauma in combination with a really, really, really devastating burn. And then discuss considerations for your trauma systems and the management of your patients with these traumatic injuries and your burns. So if you look, the most important thing, and what I always stress to our team, is you have to adhere to your trauma resuscitation process and guidelines. I equate it to the mangled extremity that comes in. Yeah, it looks terrible, but it's incredibly distracting, and make sure you stay focused on your normal processes so you don't miss anything. Still the same thing, A, B, C, D, E. And with burns, one of the caveats is we go through, and we always have early exposure, right? E is always exposure, but with burns especially, look for jewelry. If it's there, make sure you get it off, because especially if you start getting extremities that swell and everything else, you're going to be looking for ring cutters and everything else. So as soon as these patients come in, make sure you remember to get all the jewelry off. And then obtain an admission weight. We usually do this with all our patients anyway, but in these patients, it's especially important, given the fluid shifts and the volumes and everything else you're going to be doing with resuscitations. And then, of course, everything starts with airway, right? So you're looking for signs of significant smoke inhalation and immediate indications for inhibition. So you're looking for that horse cough, stride, or wheezing. Those are the easy ones, right? But then you get down, and are they horse? Is that how they normally sound? And if they're awake and able to talk to you, ask them, right? If I've got somebody that's a 30-year smoker, that may be exactly where he normally is. And then look for deep facial burns, carbonaceous sputum, all the blistering edema and the oropharynx. This is the big one for me, right? When I see the burns to the face, every single one of them, what I'll do, even above my resident fellow, whoever's in there, is I want to go right up there, and I tell them to open up and say ah, and get a good look. And if it's all up here, even if they've got some singed nose hairs, I know I'm pretty good. If I look in the back, and I already see that the back of their throat is red, or inside their mouth, at that point, I'll usually pull the trigger and say, say, intubate them now. But it's, you have to know your comfort level and what you're dealing with. Depressed mental status, that's an easy one, especially in multisystem trauma, right? GCS intubate. We're following all our standard protocols there. And then hypoxemia or hypercapnia, and one thing to consider, and this goes back to the kit I had with the gas tank truck, is do you need a reinforced ET tube? Do you have reinforced ET tubes available in your facility? And I say this because we intubated him with an ADT tube, and then his swelling and everything got so bad that he was actually occluding the ET tube because it was, his edema was so bad it was collapsing it. So we had to switch it out for a reinforced ET tube with metal wires inside so he couldn't collapse it, just to be able to protect his airway. Now that's a scary situation, right, when you get that much edema. So the thing is, if you need to intubate, intubate early, right? Because once they go and the swelling really, really starts, then you're going to be in a mess trying to intubate them, and the last thing you want to do is have a difficult intubation that would have been much easier an hour earlier. And then the estimation of your total body surface area, right, we like to keep this nice and simple, is the rule of nines or the Palmer method. So rule of nines, you can see adult and pediatric there, everything's basically broken down into it's either a nine or an 18 or a four and a half. And so that keeps it pretty simple, or the Palmer method. And the rule is it's not your palm, it's the patient's palm for each percentage, right? Because my palm on a kid, this is not one percent on a one-year-old torso, right? So this is actually from the Wake Forest, which is now in the atrium system, and that's one of the two burn centers that we refer to. And so this is in their burn algorithm guideline, and if you look, so the ones to really focus on are the partial thickness, full thickness, and so hot liquids, burns, flame, chemicals, and this is where I always tell my residents that you go and you may look at a burn, and I want to know what it is, because especially if they were cooking in the kitchen, a skull burn from hot water is very different than a grease burn. And that's what I'll tell them is, is when the patient tells me, all right, it's a skull burn from hot water, okay, that's what it's going to look like and probably be able to treat it, probably won't have to debride it, skin graft. But if they tell me it was a grease burn, that's very different. And that's what I always tell them, I'm like, that is going to convert, every single time. It's going to fool you, you're going to sit there and go, well, maybe, no, it will convert. So just keep that in mind as to the nature of the burn. And then we get into the full thickness, right? These are the ones that are pretty easy to pick out. These are white, leathery, black, charred, and usually very devastating and insensate because you killed all the nerve endings in the skin at that point. So this will be our first question, if everybody can go to your phones. According to the American Burn Association, at what burn percentage should fluid resuscitation by formulaic standards be initiated? So we got 80% is C, or 80% chose C, which is 20%, and that is the correct answer. So if you look at the ABA consensus formula, it's resuscitation for burns greater than 20% of total body surface area because that's where you really start seeing the volume losses and shifts. And I'm not going to go through every one of these formulas. We know in the past, for us, it used to just be reflex Parkland, right? It was always 4 times kilograms times total body surface area. Well, over time, and this is no different than our resuscitation with blood and blood products and getting away from crystalloid, it's you start here and look at 2 to 4, and then you're going to cater your resuscitation to urine output and what the patient is actually doing. Because I know whenever I was in training, we would get burn patients, and then next thing you know, we'd blow them up like the Michelin man or woman, and then we were probably hurting ourselves more than we were helping. So you definitely want to catch up, but then at that point, start really catering to your urine output, blood pressure, and what the patient's actually doing. So for me, this is the big thing, because if I get what I would call a real burn in, I'm transferring those out. So what does my team need to do on the front end? What's important for us? So as always, treat your life-threatening trauma, medical conditions first. We're going to treat this patient just like we would any other multisystem trauma. And as I said, this isn't a patient that we know is just a burn. This is a car crash, car caught on fire. We've got multisystem issues. And then follow your institutional resuscitation protocols. As with everything, when we deviate, we make mistakes. And then the question is, do I need to go to the operating room to deal with traumatic injuries and then stabilize your orthopedic injuries? It's just because they have burns, I've got to go and take care of everything else before we can deal with the burn on the back end. And then what is your need for imaging? And I would say you're going to image these patients and get whatever you have to get, the same as you are for any other patient. Once again, make sure you don't miss anything, take care of the patient. Do we need carboxyhemoglobin? Were they contained, you know, within a contained space or especially a car crash with a fire and everything? And then the thing is, what do we do if we have an elevated carboxyhemoglobin? What are you going to treat it with? Oxygen, just oxygen. So if they're not intubated, doesn't matter. You're going to, right, give them oxygen, crank it up, let them sit there and then that way blow off your carboxyhemoglobin. But you're going to treat it with oxygen. If they're intubated, they're intubated, right? You're already giving them oxygen anyway, just turn the level up for a while. And then pain control. I can't reiterate this enough. They are going to hurt, especially these large second degree burns. So make sure you're giving them adequate pain control. And one of the other things that can be tricky is adequate IV access, right? So if I've got somebody, bilateral upper extremity circumferential burns, I've got to find a place to try and put an IV. And the thing is, you look and you don't want to go through the burns, but if you have nothing else, there have been situations where we've had to go. This kid with the gas tanker, right, it was central lines, IV, everything, everywhere, anywhere we could get it. So the burn transfer criteria, and this is according to ABA, and what we follow for the most part at our institution is greater than 10% total body surface area partial thickness. Burns involving critical areas that are difficult to treat. Any full thickness burns. And for us, I would say, right, if you're 10% or less full thickness burns, a place like us, we do skin grafts and everything on our trauma patients. We can take care of those. Electrical burns in general, we'll take care of those too. But according to the ABA, if it's beyond your scope, send them. Chemical burns, inhalation injury. I can tell you the isolated inhalation injury, a place like us, we don't send any of these. We take care of all these because what do we do? We do trauma and critical care all the time. So if I don't have a big burn and it's isolated inhalational injury, that's right up, you know, within our scope of practice. And then, right, the burns with extreme medical comorbidities, and then in patients that require social, emotional, or rehab intervention. And when you look, that's one of the big things that separates the trauma centers that are not burn centers from the burn centers. It's all the other resources for these patients because in general, all our physicians were trained to take care of burns. And then care prior to transfer. So if you look for, you know, and for us, this is what we go by. If you're immediately transferring, then cover the burns with a clean dry sheet wrapped in dry gauze. You don't have to get fancy with all your dressings and creams and everything else. Just take it, dry it, pack them up, and try and get them out of there. And don't rupture or debride blisters, especially, right, if we're debriding these in the ED, that's probably one of the least sterile environments in the entire hospital. And then elevate your extremities, right. That's one thing that's always really important to remember. While we're sitting there, do anything we can while we're waiting on the transfer to keep extremities elevated so they don't get, especially circumferentially, don't get edema. And then wrap the patient in your blankets. Keep them normothermic. If intubated or total body surface area greater than 20 percent, the ABA would say place in GOG tube, tetanus, just like any other trauma patient. Make sure you've got your pain control. And then, you know, you're always watching those extremity burns, indications for escharotomies, fasciotomies, et cetera, especially, you know, if I've got a burn and tib-fib fractures that are crushed, I could be running into some real problems looking at escharotomies and fasciotomies before I have to get them out of there. And then if your transfer is going to be delayed, especially in the current environment, we know everybody's been at capacity, you're trying to get beds, then it falls on us to start that treatment in the emergency department and do whatever we need. If we have to go to the ICU, start dressing the burns, taking care of them until we can get a bed to get them there. And then for nursing and everyone, it's use sterile exam gloves when wrapping your burns. It'd be really devastating if you go and then you, you know, when you see burns convert, that just really stinks. It's, you go and you're able to dress it, you keep it sterile, and then all of a sudden, because as soon as one of them gets infected, they all seem to get infected and create some real problems. For really large burns, just cover with clean, dry linens. And then the importance of normothermy in these patients can't be underestimated, right? They're going to lose, lose temperature real easily. And especially with your EMS transport, whenever you're getting them ready, EMS, you're going to be telling them, but remind them, warm the rig, the copper, whatever they're doing, and consider Mylar rescue blankets, everything else you can to, to try and maintain your body heat. And then as a general rule for us, if their transfer or referral is going to be delayed until the next day or whatever, then begin taking care of them, right? Go and debride your blisters, start all your, you know, your treatment with the silver sulfodiazine, Bacitracin, whatever, to just try and keep the process moving. Don't let that patient, just because we are not a burn center, just sit there and, and linger. And then, you know, one of my personal pet peeves is you go in to see a dressing and you can tell that people just went, they took the dressing off, and then they just slapped more silvadene right on top of old, yellow-looking silvadene, right? So, but that's where it gets into nursing experience and how to take care of these patients that, that we don't necessarily get. So, extremity burns, monitor pulses, blood pressures every 15 minutes in these, especially if you've got circumferential burns, because these things can change and change quick. And use a Doppler as, as needed, just like anybody else with a, you know, question of a vascular status and an extremity. We do this in the trauma bay on all our other patients. And the same thing, monitor for compartment syndrome and 6Ps, pain, power, pulselessness, paresthesia, paralysis, and pressure. So, this brings us to next question. Patient presents with a circumferential third-degree burns to bilateral upper extremities with significant edema. Pulses are now diminished, and the extremities have become cold. What's your next step in the management? The answer is C, bilateral upper extremity escharotomies. And the reason it's not fasciotomies, fasciotomies are, are deeper. Your problem here is that all the swellings occurred in your skin subcutaneous tissues, and that is now what is impeding flow. You're not dealing with the fractures and everything as deep as, as the muscles. And so, the, the escharotomies, emergency, emergent surgical procedure to basically release your skin and just the constrictive effects, which will allow your, your flow to kick back in. It's often needed with circumferential third-degree burns. And what happens is, as these go, your, your extremities just become tight and non-distensible. So, so, it, you, you can't do anything, and, and the pressure isn't enough to, to maintain your blood flow. So, if you look at this with escharotomies, it's important to know how to do them. Because, especially when you start talking about arms and hands, it's not just as simple as, as the big cut all the way down your arm that you can see. But, when you start getting into your hands, you've got to make sure you release medial, lateral, your digits on each side and all the way down. Because, you don't want to have a great save and get this patient. And then, all of a sudden, you find out they've got muscle necrosis and everything else. Because you did an inadequate escharotomy. And so, you can see live picture right there of, of the hand on the bottom. And then, you can see arm and leg, or escharotomies when you go. And, you know, for us, if we're doing these, we're moving. And we will pull a, a bovie out in the, in the ED and release them. Because we are preparing for transport. Everything is moving, moving, moving. And I'm doing everything I can to just get them ready to go. And then, this one. When you start having patients, you'll start seeing high peak pressures. You're not able to oxygenate. You, you just can't push. And that's when you get to these patients. And this, you know, this kid that we, that we had was driving a tanker truck. And we ended up with this. We, we had everything ended up bilateral, upper, lower extremity escharotomies. And then, had to, had to release his chest as well. Just to be able to, to get enough pressure to be able to ventilate him. On top of having to switch out his ET tube. That it collapsed just because of the edema in his airway. And so, how many of you are at burn centers? All right. And I, you know, I'll, I'll throw this out there and say that, that for those of you that are at burn centers, just remember that while we may be extremely high functioning trauma centers, and most of our faculty are actually trained to manage burns, we don't have the supporting burn. The nursing units, the whirlpools, the burn ORs, the PT, the OT, the burn dressings, and, and all of that. And so, I know sometimes when we're talking to the burn center on the other end, there may sound like there's some frustration with the transfer, but you're going, yeah, I know, I'm one of the busiest trauma centers in the country. And yes, I could do this if I were at your place, and I had the skilled people and everybody around, but, but I don't. And so, similar to our referring trauma centers, or our referring outside hospitals that are sending things in, we're requesting transfer because this, the system is beyond its capabilities to provide optimal care for these, these patients, no matter how good we think we are. And here are just a couple of references that I threw in. And as we mentioned before, we will take questions at the end, and I will be here almost all week. So thank you very much for your time.

resuscitation priorities

multisystem trauma

burns

trauma resuscitation protocols

ABCDE sequence

early intubation