Good morning, everyone. I'm Angela in Washington, the trauma program manager of Alaska Native Medical Center in Anchorage, Alaska. A&MC has benefited from being a TCAA institutional member since 2016 and I currently serve on the TCAA membership committee. It is my great pleasure to introduce today's speaker, Dr. Alicia Brownson. She is the trauma medical director at Alaska Native Medical Center in Anchorage, Alaska. She, which is a level two adult and pediatric trauma and center with burn capabilities. She completed her general surgery residency at Boston Medical Center, as well as a surgical care fellowship focusing on trauma and burn care at Harborview Medical Center in Seattle, Washington. Dr. Bronson is involved in the care of traumatic and thermal injuries throughout the state of Alaska and serves as the ACS committee on trauma for the state of Alaska and is the state chair. She keeps very busy outside of work with her husband as they raise three very active boys and twin toddler girls. Excuse me. So I turn it over to Dr. Bronson. Thank you, Angie, and thank you to TCAA for this opportunity to speak today. I think this is a great topic to talk to trauma centers around the country and our capabilities for burn care. Today we'll be going through the stabilization transfer and how to build local capacity for caring for injured patients with burn injuries. I will be showing a lot of pictures because this is a lecture about burns. If you're signing in you are likely within the healthcare field, and so these images may be familiar to you. We'll be discussing the need for trauma centers to stabilize and manage burn patients, which sometimes is a high acuity but low frequency event for trauma centers. So it's important to make sure that everyone is familiar with guidelines and best recommendations. We'll be reviewing the initial burn care guidelines for those first few hours of managing a burn patient. And then we'll give some of our Alaskan experience and help other centers explore options for telemedicine and regional referrals so that you can build your trauma system within the regional burn network. So the question is, are you ready? If you're signing into this lecture, then you're probably having a smiley face if you hear the full trauma activation at 845 a.m. at your center, because we all love trauma and we all really want to take care of patients well. So then you hear it's a 24 year old man who is the restrained driver at a motor vehicle crash. So if you're well educated in trauma, you're starting to get worried. This patient could be really sick and you're trying to prepare for any potential injuries the patient may have. And if you have this face when you hear that it was a car fire and the patient was extricated with an estimated 30% total body surface area burns, then this webinar is for you. Because we want to make sure that you don't have that melty face and that you're really ready and prepared for that patient. So all the emotions are kind of going through rapidly. So trauma centers and burn care. Again, trauma centers are going to be the front line for critically injured patients. We want to remember that initial burn management will focus on the same things that trauma care does. The rapid stabilization of patients, the recognition of patients that need to be transferred, providing optimal care each step of the way, and preventing secondary injury. Does that sound like anything that you've learned in ATLS or that you manage in your trauma hospital? Of course it does. And so this is how we want to make sure that our trauma centers, regardless of burn status, are ready for burn patients. This is becoming increasingly important because there's a real scarcity of burn centers. And so there may not be a burn center within your trauma center for hundreds of miles. This was a now older study that showed the travel time for burn centers with rotary air transport. And so you can see in figure A, the verified burn centers, and then in figure B, any centers that declared themselves as burn centers. And you can see a lot of white areas where you're over two hours away from rotary air transport to get to a burn center. So it's not unthinkable to imagine that your trauma center is going to have to initially stabilize and care for these patients before they can get to a regional burn center. We also know in a post-COVID world that transfer can be really difficult. Hospitals are very full. There's a lack of ICU beds. And so you may be sitting with a patient and have to stabilize them for a prolonged period of time. We also know that the American Burn Association has some guidelines for who should be referred to a burn center. The newest guidelines were released in December of 2022, and they changed the title from referral criteria to advice on transfer and consultation. And that's very intentional, meaning that a center should be able to recognize which burns are able to be handled locally and which burns might need some expert consultation or might require a transfer. Just because a patient falls within this very large list of what a burn injury might be does not mandate a transfer to a burn center. And so we have to think wisely about our resources and our local capacity to be able to care for small and moderate burn cases so we don't overwhelm our regional burn centers. In Alaska, this is a really common thing that we deal with every day in trauma. We have a lot of barriers to getting patients to definitive care. And one of those is really transportation. Our medical evacuation distances can be up to 1,500 miles and even greater if we're shipping a patient down to Seattle, which is the closest verified burn center in Alaska. We sometimes have transport distances that are equivalent of transferring a trauma patient from Orlando, Florida to Washington, D.C. Additionally, medevacs are a finite resource. And so if we take a medevac for a pediatric hand burn, then that will take that medevac away from that community who might have a really severe trauma, an obstetrical hemorrhage, or a patient with sepsis. The cost for medevac is very high, and although I have the listed costs from any of the rural villages to Anchorage, which is our hub, from $20,000 to $90,000, that's about double or even higher when we're transferring patients to Seattle. There's a real lack of specialty care in Alaska, and so getting a patient to surgical services or to burn or trauma centers exacerbates these care distances. So we have to make sure that trauma centers are prepared. You should be ready to care for a burn-injured patient for up to 24 hours, sometimes even longer, but I think for the purposes of our webinar today, we're really talking about those initial hours and maintaining stabilization. But if you're waiting for a bed, this could be a prolonged time. The resources you should consider for your center is how are you going to transport the patient, what personnel do you have, and what supplies do you have ready? So you should make sure that your personnel and your hospital feel comfortable initially identifying burns, being able to do the initial resuscitation, but then also supplies. The picture I have shown here is our blue burn cart that gets rolled up to the trauma bay when we have a known burn patient in the trauma bay. Again, when we approach our burn patients, we're going to use the standard trauma evaluation principles. We're going to keep with the same principles that we use for any patient that rolls through the doors by using our primary survey. I've bolded E because that's an important one for burn care. And then our secondary survey, which in this head-to-toe evaluation, we're going to at that time do our initial thermal injury assessment, including a total body surface area calculated at that time. So let's go through some of the principles of burn care. First things first, you have to stop the burning. Often this is something that occurs pre-hospital, and so this may not be something that you're dealing with in a trauma bay if it's a flame burn, but you may have something like a chemical burn. Again, remember that powdered chemicals should be brushed off before irrigated, and then again, the solution to pollution is dilution, and this should be copious irrigation to get the chemical off the surface to stop the burning process. For small burns, you can consider cooling burns with tap water irrigation. That may limit the depth and extent of burns, but you should not consider this for anything bigger than 10% TBSA and no more than 15 minutes. You really need to be sure in the early minutes and hours to avoid hypothermia in the burn-injured patient. So let's go on with the ABCs. Airway. Again, the airway in a burn-injured patient can be very variable. So there's a real spectrum of what that burn injury looks like. There's, again, this pediatric burn patient that's already intubated. We're really nervous about that. In the middle picture, we have a young man who threw propane on a campfire and has singed hairs. So less concern, but still is going to have some of those signs that you might be looking for. And then in the elderly gentleman, that patient is a COPD patient who is smoking while on oxygen. Again, those patients sometimes will have signs of respiratory distress, but because that's more of a flash burn than a true inhalational injury, they may actually have respiratory distress from a COPD exacerbation rather than inhalational alone. So how do we evaluate the airway? Well, I will remind you to assess frequently. The burn-injured patient's airway will rapidly change. You want to look for changes in mental status, hypoxia, hoarse voice, and stridor. You can use basic maneuvers by opening the airway, administering high-flow oxygen, maintain the patient in a sitting or upright position if there's no concern for spinal injury, and, of course, use other adjuncts for getting the patient oxygen as necessary. If you suspect any inhalational injury, you should administer 100% FiO2 oxygen immediately. The patients that you're considering intubating right away are going to be patients that are unconscious or unresponsive, hypoxic without correction on supplemental oxygen, upper airway burns, hoarseness or stridor, respiratory fatigue, and then large burns that you anticipate with a prolonged transport will often require intubation so that you don't have an intubation en route. Again, the burn patient is going to have a lot of progressive edema from the burn injury, but also from the massive volume resuscitation. And so their airway that looks stable may change over the first hour, so you really have to reevaluate frequently. We also have to consider true inhalational injury. This is due to the aspiration of not only really hot gases, steams, or hot liquids, but also noxious products of combustion. If a patient has inhalational injury, it does increase their mortality, and it can occur with or without cutaneous burns. So just because a person doesn't have any skin evidence of burns doesn't mean that they don't have inhalational injury. When you think of true inhalational injury, you really have to think about the pre-hospital condition of the burn. You're looking specifically for patients who have sustained burns in enclosed spaces for a prolonged exposure. This is really important in the history taking. So again, that young man that threw propane on the campfire, he's not at a high risk for inhalational injury. He was outdoors, and the flames would have dissipated in a really wide area. But if patients are stuck in an enclosed space, then they are getting that direct heat to their airways, as well as those noxious products. On physical exam, they'll have hoarseness and stridor, deep facial burns or intraoral burns, hypoxia, loss of consciousness, carbonaceous sputum, and singed hairs will be present, although it's not very specific for inhalational injury. For laboratory data, you'll want to make sure that you get an arterial blood gas with lactate, as well as a carboxyhemoglobin level. When we think of the airway for inhalational injury, we have airway that's above the vocal cords. This will be an injury that is due to direct heat or chemicals to the mucosal edema. But if we have an injury that's below the vocal cords, then that is due to the inhaled chemicals, and that becomes an inflammatory injury to the bronchi and small airways. Basically, you have an injury to all those mucosal surfaces, and you get sloughing and bleeding of the airway, which clogs those very small airways and can lead to hypoxia and respiratory failure. And then we have poisonous gases, and the two that we'll talk about today are carbon monoxide and cyanide. For carbon monoxide, this is where the carboxyhemoglobin level will come in. Just remember that under 10 is normal, and even if you live in a really urban area or smokers, they might be low teens, but pretty much under 10 is going to be normal. After that, symptoms include headache, nausea, and vomiting. Then you start to get to some vital signs, compromise, and a very severe will lead to altered mental status, seizures, and even death. So the treatment for carbon monoxide is simply oxygen. Carbon monoxide has a 200-time affinity to hemoglobin than oxygen, so you just have to flood the body with oxygen. The half-life of carbon monoxide is about four hours if you were just to be breathing in a room, and so if you put someone on 100% FiO2, that reduces that half-life to an hour. So if your carboxyhemoglobin was 40 and you have someone on 100% FiO2, it will be down to 20 the next hour. There's always questions about hyperbaric oxygen, but it doesn't reduce that half-life by that much, and often these patients are really unstable and it would be unsafe to put them in a hyperbaric oxygen tank, and often that's not something that's readily available. If you stick with 100% FiO2, either on a non-rebreather or if the patient's intubated, you should be able to clear that carbon monoxide pretty quickly. Cyanide is a byproduct from synthetic materials that are burned, so couches, fabrics, curtains will produce cyanide. The way that cyanide poisons you is that it shuts down that Krebs cycle and leads to lactic acidosis. Blood tests for cyanide take a long time and may be a send-out at your hospital, and so lactate is what we use as a surrogate for cyanide poisoning. You also may be able to see some differences in the physical symptoms, so if someone is abtunded, that may be prolonged if they have cyanide poisoning. They can get hypotension, and again, that lactate level will be very high, like over 7, a really high lactate that you wouldn't explain with a normal trauma or high alcohol levels. The treatment for cyanide poisoning is basically a hydroxylcobalamin, which will stop that cyanide from blocking normal metabolic cycle. It's usually given, some places will have this pre-hospital, given in two vials. It's a very quick 15-minute infusion, and there's very few side effects to giving it. It will turn the patient purple, so you can see this patient was kind of seeping out with purple sweat, and it will change the urine to purple, so you lose that ability to monitor someone's urine, but it can be very helpful for patients with very severe inhalational injury. Those patients that we recommend, either pre-hospital or in the trauma bay, would be if you have that history that makes you very suspicious for inhalational injury, and they either have altered mental status, hypotension, or cardiac arrest. We've talked about airway and breathing, and we're going to move on to circulation, which will really go into the resuscitation of the burn patient. In order to do that, we have to be on the same page about how to assess the burn wound. We'll talk about how to describe burn wounds using size, depth, location, and mechanism. This really is a common language for communicating with providers. If I'm talking to you over the phone, and I see this child in front of me, I can say that I have a partial thickness, 8% TBSA, scald burn to the anterior chest. That really gives you a better picture of what I'm seeing than if I'm describing in centimeters and not sure what the depth is. It really will help you have that conversation when you're giving your assessment to other providers or even transferring patients out. When we talk about size for burns, this is in TBSA or total body surface area percent. There are several ways that we calculate TBSA. For large burns, we often use the rule of nines, which divides the human body into integrals of nine. It's really important to remember that kids are different. Their heads are going to be bigger, and their extremities are going to be smaller. For smaller burns, a good way to do it is to use the Palmer method, which takes the hand from wrist crease to fingertips of the patient. That should represent 1% of that patient's TBSA. If you have a real patchy burn, or even if you have an extremity burn that's nearly full, you could subtract even that way. Using the Palmer method is a nice way for scattered burns, or for smaller burns. To help you remember that kids are different, I've been able to collect images to show that you don't think about it, but again, babies' heads are bigger, and their extremities are smaller. You can really see this difference that as the human grows, they're able to put their hands over their head, something that babies actually can't do. You will need to use some kind of chart to help you remember, because again, you're going to be really stressed when this patient rolls through your trauma bay. Often, when we get to that secondary survey, we're going to use a Lund and Browder chart. This really guides the evaluating provider through an exact calculation of burn size according to age. You basically just call things out and shade that patient on the sheet, and then you can go and do an exact calculation. That's size. Let's talk about depth. Again, there's three degrees we'll talk about. First degree is a superficial burn wound, and is not included in our calculations of total body surface area. The reason for this is that it's really not clinically significant. This type of burn injury isn't going to be something that a patient's going to be hospitalized on. The wound will be erythematous, but you will not see blistering. It's a common mistake to include that surrounding erythema in your burn size when you're evaluating a patient. Second degree is partial thickness. You can have a superficial partial thickness or deep partial thickness. That's going to be a little more nuanced when you look at the wound bed after the blisters are removed. If you have a pink moist area, that's going to be superficial and deep, will be moist with those blisterings, but have really pale or white wound bed. The real characteristic is blisters. If you see blisters, that's a second degree partial thickness burn wound. Then third degree is full thickness. Again, third degree burns can come in many colors. You can see they can be white, they can be dark brown, they can even be that cherry red. They are going to be very dry and leathery, so you do not see any blistering or wet weepy wounds here. They're going to have lack of sensation. If you see a large burn and a patient is sitting there comfortably, then that might be a patient that you're really concerned about having a full thickness injury, because you would expect them to be in a lot more pain. Location, location, location. We all know that that's really important. It will matter to you more if you burn one percent of your face than if you burn one percent of your thigh. We're looking specifically for location for specialty areas that might require some more expert consultation. Face, hands and feet, groins, and major joints should be of concern. If you have a hand burn, it's important to ask the patient if that's their dominant hand, and also if the burn is on the dorsal or palmar surface, that can change how we treat the burn. Then there's a lot of ways to get burned. We've talked about some of these already, contacts, gall burns, which is the most common in pediatric patients, flame and flash burns, electrical injury, grease, chemical, friction burns, and inhalational burns. Once we have our burn size, we're going to be able to calculate our resuscitation. We have to remember that acute burns greater than 20 percent TBSA will have increased fluid needs. If you have a small or moderate size burn, you probably won't need to utilize these resuscitation calculations. Why do we have to resuscitate? Patients with these large burn injuries will go into what's called burn shock. It's a type of hypovolemic shock, and the amount of fluid lost and the amount to be replaced are going to be proportional to the burn size and the weight of the patient. That's why it's important to make sure that you calculate an accurate TBSA. The hypovolemic shock is caused by inflammatory mediators that are released with that large burn injury. It makes the capillaries very leaky, and so fluid goes out of the blood volume into the interstitial tissues or third spacing. In effect, a patient becomes very hypovolemic while being massively edematous. This fluid shift is fastest in the first eight hours, but continues for 24 hours or longer. You have to replace the fluids that the patient is going to be losing from that intravascular space. This is something that was really new to me. I had trained in high-volume trauma center that did not take care of burns. I understood trauma resuscitation as if we're trying to fill the tin can and there's a big hole, aka hemorrhage, that if we patch the hole, aka stop the bleeding, I could fill that can. But in burn shock, it's as if that tin can is punctured with dozens of holes, and I can't patch them. The more I pour fluid into the can, the more fluid rapidly falls out of the can. You can never fill the can, and the faster you fill it, the more fluid exits. What we recommend for pre-hospital, and then this is also for your initial fluids to be hung in the trauma bay. We just want you to start a rate. If the patient is a large burn, you don't have to say exact TBSA at the first moment the patient rolls in. We should be able to identify if the patient is a large burn or not. Then we're going to give them a basic rate based on age. If they're less than five years old, we're going to do 125 cc's an hour. If they're school-aged children, 6-13, it'll be 250 milliliters an hour. If they're adolescent to adults, 14 years or older, it's going to be 500 milliliters an hour. We will calculate our TBSA as soon as possible. But again, this is probably going to occur in the secondary survey. We just want to start a rate. There's been a real pendulum swing on fluid resuscitation for burn patients. I think we all know that often when we see burns and we have in our minds that they need fluid, we bolus right away. We bolus one or two liters. But think of that tin can and as you pour that bolus in, you're pouring most of that into the third space. We just want an hourly rate that will match the needs of the patient, so we don't over resuscitate the patient. If you have that 24-year-old man who is in the car fire and he rolls into your trauma bay, you don't have an exact TBSA, just start him at 500 cc's an hour. I will prep everyone to grab your calculators because we're going to be doing some polling questions, and I'll have you do a calculation to make sure that everyone understands this principle. Once we have an exact TBSA, then we're going to use our consensus formula. It's agreed upon that somewhere between 2-4 milliliters per weight of the patient kilograms per percent TBSA will equal the amount of fluids, which we're going to give back in lactated ringers, that the burn patient will need in 24 hours. We're going to give the first half over the first eight hours because that's when that burn inflammatory mediator response is the greatest. Then we're going to give the second half over 16 hours. For the purposes of this webinar, we'll use the middle ground. We'll use three milliliters for our calculations. For kids, they're a little more sensitive to these needs, and so we are going to lower the threshold to 15% TBSA. We're going to start with that same consensus fluid rate, and then for small children, less than 30 kilograms, they will require an additional dextrose source. So those patients, again, they have immature livers. They cannot store long-term glucose as glycogen, and so they will become easily hypoglycemic with any major body stressor. So what does this look like? If we had a 25-year-old man with a scald injury, circumferential from the beltline down to the toes, and we knew he was 80 kilograms and about 45% TBSA. So our pre-hospital fluids, when this patient comes through the door, oh, now it's not going to let me advance, but that's okay. It's going to be 500 cc's, right? Because we know that that patient is a big burn and he's an adult, so we're going to give him 500 cc's. So now using that three cc's, can you calculate out the initial fluid rate for this patient? So remember that consensus formula. And we have the weight of the patient and the size of the burn being 45% TBSA. Okay, so I may have confused people because of the slide. So the pre-hospital or initial fluid rate is going to be 500 cc's, but the calculated fluid rate for the patient is going to be greater than that. So let's go through that calculation. So once we have our calculated initial rate, we do three cc's times 80 kilograms, times 45 for the TBSA. That number is going to get you 10,800. Now that's your total in the first 24 hours. To get our calculated initial hourly rate, we're going to divide it by two because we're dividing it in half and then divide it by eight for that hourly rate. And that's going to give us 675 milliliters per hour of lactated ringers. Okay. Now, this is the second poll question. And this is going to be, if you can tell me what pre-hospital fluids, so you can put up the poll question, and this one is correct. 16 month old boy with a scald injury, and you have 20 kilograms for your weight and about 30% TBSA. So what would be your initial fluid rate that you're going to start pre-hospital or on arrival to your trauma bay? Are you going to use 125 cc's, 250 cc's, 500 cc's, or start a two liter bolus? And again, I think that this is really important that we remember that that TBSA is going to be in that secondary survey, that we really are going to have this period of time, usually about 30 minutes, right? Before we get that exact TBSA. And so you really want to be ready and have your staff know, what are we going to hang when this patient rolls through the door? This is a big burn, we're expecting what is going to be that initial fluid that we're going to hang. All right, you guys did great. So 125 cc's is correct. So again, small children is going to be 125. For a child, we're also going to calculate our initial rate, just the same as we do an adult, three cc's times 20 times 30, that's 1800. And that divided by two, divided by eight will be 113 milliliters of lactated ringers. But what else does this child need? This child needs a dextrose form. Now this can be D5 half NS, D5 NS, D5 LR, I don't care, as long as it has a D in it for that dextrose source. So we're going to do a weight-based maintenance, which is 60 cc's. This is on top, it is not subtracted from your consensus formula. So you're going to have two lines running and this patient's actually going to get about 175 cc's an hour of fluid. Really quickly, we'll talk about some of the challenges of rural burn care. Often these patients have a delayed presentation. There may be multiple transfers, long distance and long times. And there's a real possibility for decompensation for the patient en route. And often rural clinics or even small hospitals might have limited resources. So they might not have enough fluid resuscitation to properly hydrate the patient. So what do we do in those cases? So same patient, okay, same patient we had before, we calculated that 675 cc's an hour of LR. But what if we know that the patient was hiking in rural Idaho and presents four hours after injury and hasn't received a drop of IV fluids? So we're going to start with that same rate of 675 an hour, because that's our calculated hourly need of the patient for that first eight hours. We're not going to bolus to catch up the lost time of 675. But we are going to know that that patient will be more prone to a, with problems from resuscitation and might be kind of dehydrated to start. And so we might need to adjust the rate hourly based on urine output. The choice of fluids for a resuscitation is lactated ringers. It's the most physiologic fluid and is closest to our plasma. And if you resuscitate a patient with normal saline, that high floor, the high sodium chloride may induce a hypochloremia induced metabolic acidosis. The lactate ringers will give you a hyponatremia for really large volume resuscitation. But it's typically lactate ringers is the most well tolerated. You want to make sure you have good vascular access. For your initial access, it's okay to place IVs through burn wounds, but you do have to remember that that person is going to have a lot of burn wound sweat. And so, or may have creams and ointments on. So those IVs need to be really secured well. You can use IOs as well for your initial access, but you have to remember again to assess the patient frequently. So as that patient becomes massively edematous, you could lose a short peripheral or an IO. So you have to assess your access sites. And ultimately, once a patient gets large volume resuscitation is at a definitive care center, they're going to be getting central access due to those large volumes that they'll need and that the massive tissue edema. Oral rehydration therapy is feasible and is favored for small to moderate size burns. If you have a burn in kids less than 15% TBSA or adults less than 20% TBSA, they really can hydrate themselves with oral therapy alone. It's really been abandoned for larger burns, but can be something that's used in austere or remote environments or in mass casualty. But if you are doing oral rehydration, let's say that first little child that 8% skull burn is coming through, you wanna make sure that if you're sending that to another facility that you discuss NPO status, because that patient may require sedation for a burn wound deprivement on arrival. And so you can use oral rehydration therapy, but the patient may have to be NPO for other reasons. Once we start our burn fluid resuscitation, we want to monitor our response. Again, that fluid calculate is an estimate. It really is not gonna be a tailor custom for everybody. It's just our best starting point. And so we're gonna adjust the rate based on urine output. If you have a patient early in your burn resuscitation, this is really key. If you have a patient early in burn resuscitation that is hypotensive, it's likely not from the burn shock. Burn shock really is gonna affect hemodynamics a couple hours later. If you have a patient with a large burn in your trauma bay with hypotension, do not be fooled and do an appropriate trauma evaluation and look for sources of hemorrhage or other causes of shock. So if the patient is hypotensive, of course, bolus them or give them blood products according to kind of your local protocols and your assessment. But what I really don't want to do is have fluid boluses to catch up on patients that are not resuscitating well. We have patients that are going to be high risk for failed burn resuscitation. Those are patients with associated trauma injuries, electrical injuries, because that's a deeper kind of injury, inhalation injury, resuscitation delay, prior dehydration for pre-trauma characteristics, which may be alcohol or drug abuse. Sometimes elderly will fall in this category. And then also a very deep burn injury. So a full thickness, 30% TBSA will resuscitate differently than a partial thickness, 30% TBSA. The gold standard for urine output for resuscitation endpoint is urine output. So get a Foley catheter in early and check hourly volumes. Your CVP or PA catheters, any kind of invasive monitoring is not going to be accurate because then again, in burn shock, we know that they're always going to be hypovolemic. If you're using it on labs, it's going to be slow to correct. So it's really that hourly urine output. Our goal is a half to one CC per kg per hour in adults and one per kg per hour in children and also in electrical injury. If that urine output is excessive, you can decrease it. If it's inadequate, you can increase it. So you really have to make sure that you do this fine balance for maintaining tissue perfusion and organ function while avoiding your complications of over resuscitation. Fluid creep is kind of a social phenomenon, really common for patients that are transferred at multiple centers. But if we look at how much fluids patients get over the first 24 hours, they will actually receive five to seven CCs per kg per percent TBSA. So it's really important that when that patient gets to your trauma center, even if you're shipping them out to a burn center, that you do appropriate fluid management so that you don't contribute to over resuscitation. Over resuscitation with total body edema can lead to wound conversion, meaning that a partial thickness burn can be converted to a full thickness burn if the patient is massively edematous and can't get good skin perfusion. Elevated compartment pressures may have to be released for the extremity, abdominal compartment syndrome, or ocular, and pulmonary complications including pulmonary edema, ventilator-associated pneumonia, and ARDS. So remember, fluid management, don't bolus unless the patient's hypotensive or has other reasons. Start a rate. If it's a big burn and they're rolling in your trauma bay, start them at a pre-hospital rate and then adjust that rate based on urine output. Needs are individual. Needs will change over time. So you need to have that hourly urine output and make sure to avoid over resuscitation. For the ABCDEs, remember that E is very important in the burn-injured patient. Many materials can be used to conserve heat, clean sheets, blankets, and towels. If a patient has a large burn, they are going to soak through those towels or sheets and you may have to replace them. We're gonna avoid any kind of circumferential wraps because the patient's become edematous and that could be a tourniquet effect. And monitor that patient's temperature. Get an initial temperature and monitor that every few hours. If there's wound care for big burns, we don't really want you to do any large wound debridement, which would be painful. And the definitive burn care center is going to need to do their own assessment. So putting creams or ointments on will not be helpful. We definitely don't want like saline-soaked gauze because again, we wanna keep that patient nice and warm. If they're smaller burns, depending on your resources, you might start initial wound care at your center. But be sure again to avoid hypothermia. If you're performing a burn wound debridement at your center, remember that this can be performed by any healthcare provider. It's your local resources that determine who best to perform this debridement. It's usually performed at the definitive care site, but in delayed settings, it could be performed at a small clinic or outside hospital. It's important for wound evaluation and also allows you to get a topical on the actual burn wound. So you can see this picture below. We didn't really know how big that burn wound was and we couldn't really have a good assessment of the depth of the burn wound. And you can see you're kind of surprised in that picture on the right how big that burn wound is. And now we know that that is a mixed deep partial and full thickness burn wound. Wound care is not sterile. You can use regular gloves and use clean water and gentle soap. Prophylactic antibiotics are unnecessary. For the debridement, really avoid prolonged scrubbing. You're just gonna use a firm wipe of a washcloth, enough pressure to remove loose debris. And then loosely trim back any skin edges with suture scissors. If you are doing a dressing, make sure that you put creams and ointments onto your dressings and not spreading them on the wound bed, which is really painful. And you really only need wound care to be done daily and minimal wraps, not bulky, to allow for range of motion. This is the question I get probably the most is what to do with blisters. I recommend that blisters should be debrided if they're overlying a joint that would impair motion or if they're greater than two centimeters or about the size of a quarter. Flat blisters can remain in place and small blisters may be decompressed with a sterile needle. And you should expect blisters to worsen over the first 24 hours. So if you don't debride blisters, you may have the patient come back to the emergency department the next day to see if they need any further burn wound debridement. So I'll ask you to pop or not to pop. If we can have our polling question, which blister should be debrided? Patient A, patient B, both patients, or none of the patients? Again, remember you're looking for large size blisters or blisters overlying joints. All right. A lot of you said both of them. Now, I'll tell you kind of my perspective. So, again, you can see some blisters. So, A, I think it's pretty obvious. We would debride those. Those are large-sized fluid blisters. They're over an ankle. And those are probably going to pop on their own if you don't debride them. And so, it's better to just debride them and get a topical on that wound bed. For B, this is tricky. There are some blisters. I see flat blisters on the second through fifth digits. On the thumb, you can see some fluid-filled blisters. But those are smaller than a quarter. And I bet if I ask that patient to oppose his thumb, he'll be able to move that okay. So, I would say A. Here's some examples. Again, pop these on the left. Leave in place these flat blisters. This picture down low on the leave in place, that picture on that digit, now that fluid-filled blister is in between those knuckles. So, you could theoretically leave that in place. That would also be another good one to just puncture with a sterile needle and lay that blister flat. So, transfer and consultation. So, you've assessed and stabilized your burn patient. Now what? Well, if you have a small or moderate burn injury, you may be able to keep that local. But large and specialty burns are often going to require transfer to a burn center. We've tried to increase the capacity at our local center. Again, we're a level two adult and pediatric trauma center. And we've built a really formal relationship with our regional burn center, which is the UW Medicine Regional Burn Center at Harborview in Seattle, Washington. What are some of the ways that we can communicate our burn injuries to our sending center? Well, we use a lot of telemedicine and burns. A picture's worth a thousand words. And for burns, which are often skin deep, we can get a really good assessment of these. There's two types of telemedicine that we utilize for burn evaluation. One is a store and forward, which is a still picture that can be taken and sent to the provider. Or you can use video conferencing, which gives you a live feed either to the provider at the bedside or to the patient for burn follow-up needs. I would emphasize that you need to make sure that anything you use is on a HIPAA compliant platform. And also, telemedicine may involve licensure if you're going across state lines. There's some pros to store and forward. It can be sent in advance for a clinic follow-up. It's very high resolution, so you're getting a better picture of that burn wound. But the cons are that it can be taken out of context. If it's really zoomed in, I may not know what part of the body it is. And it's not very dynamic. Where video conferencing allows for that dynamic interaction, allows with discussion of the patient or provider. But there's some cons. You might not be able to do it if you're in an area where you don't have good connectivity. And there's really poor resolution of the actual images. Often we combine store and forward and video conferencing to get that holistic view. We've done a lot of burn education at our center. We held a statewide burn symposium that was kind of more tailored to the needs of Alaska. We've held ABLS classes up here. And we also do a every other month burn and soft tissue echo. This is a telemedicine statewide project that goes through burn cases, both a didactic and a case presentation, tracking the patient from initial care site all the way to the definitive care and follow-up. And it really builds capacity and networking. The Harborview burn director is on our panel. So everyone knows that we're all within the same network and all working together to make sure that burns go to the right places. All of these activities were grant sponsored. The echo, the continuation of that is now in our budget. So look for creative funding because it's really important to make sure that your trauma center is ready to take care of these burns. What we've done around the state of Alaska by building burn capacity is we've actually reduced our out-of-state transfers by 50%. And this has been sustained. And so it's really made a difference for travel patterns and cost. And we've been able to keep more Alaskans in Alaska for their burn care. We've also integrated with our region. So the American Burn Association divides the country into five regions. We are now a designated center that can receive burn patients or keep burn patients in a burn mass casualty event in the Western region. This was even something that was important with the recent fires in Maui. And so just making sure that we have a center set in our region to be able to help with the burn load. From a state perspective, we've now been able to, with our state trauma system, present guidelines for burn resuscitation and burn triage guidelines. Our burn triage guidelines are meant to make sure that patients go to the right center and we identify who can stay locally, regionally within our state or transfer out. So in summary, we've talked about the stabilization and care of the burn injured patient. And really these patients can be well managed by a non-burn trauma center. Burn care should follow your basic trauma assessment principles using the ABCDEs. And I encourage your center to utilize regional partnerships. This will help reduce unnecessary transfers and strengthen your local capacity. With that, I will end the lecture portion and we can move into some questions. Thank you. Thank you, Dr. Bronson. That was an excellent presentation. As always, I've heard this presentation in different iterations several times and each time I learned something new. So it's great. We don't have any questions in the chat yet, but I do have a question that is sometimes asked, which is other than turning the patient purple, are there any other side effects of using the cyano kit? No. So the cyano kit for cyanide poisoning, actually the one vital sign change that you might see is a little hypertension. And so it's actually a pretty safe medication to use. And often you don't see any abnormalities. That purple color will last for several hours, like four to eight hours. And so again, you're monitoring that urine output. You're looking, we really talked about the quantity of urine that you're getting, but you're also assessing that quality of urine. If you're seeing dark or reddened, especially with like electrical injury, you might be worried about myoglobin in urea. And you're going to lose the ability to monitor that early, but it's definitely worth it if you have a patient that's a high risk patient that needs it. And it can be repeated a second time. But at that point, I would make sure that you were in consultation with a burn specialist before administering a second time. Okay. Thank you. Oh, how do you determine how many, how much supplies to have on hand in your emergency department? I'm assuming. That's a really great question. There's a really, there's a lot of really good resources that you can look at when you're, most of them are kind of focused around burn mass casualty preparedness. Again, we're part of the Western Region Burn Disaster Consortium. And if you, if you look them up online, they have a lot of really quick, a lot of quick reference sheets, which can be useful. Remember how all you guys had to calculate that for that poll and you had to calculate out that thing. And you're thinking, oh my God, if I had to do that in the trauma bay, I would be really stressed and might not get that number. There's a lot of quick reference sheets for basic weight and TBSA charts to get you a calculated fluid rate. So those are great. And then there are also preparedness modules to talk about how many supplies you would need and how to evaluate. A lot of that is going to come from preparedness resources for burn mass casualty. Again, we have a basic cart that is restocked after every burn wound care, but it's mobile. So it just comes right up and then we can do our debridement right in the trauma bay, often with help of sedation needs from our emergency department as we need for those kind of small and moderate size burns. So, you know, I think that I would direct you to those resources that are super helpful when looking at needs for your center. And they also have a lot of free CEs and modules that you can go through as well. If you have a person's where my favorite IV site is a burn site and there's nothing else, can I place an IV or an IO on that site? Absolutely. You can place a peripheral or an IO through a burn wound. Again, it's burn patients are the only time when I've seen us actually have to suture in a peripheral IV because your usual, if you're doing it on a burn wound, your usual adhesive IV securing materials will not work. Same thing with endotracheal tubes. If you have a facial burn injury, you're going to have to be really creative about how to stabilize that endotracheal tube. Because again, they're going to be slippery, their skin's going to be very weepy. And so that's why it's really important, all your tube lines and drains should be looked at every hour when you're keeping a burn patient in your trauma bay and kind of waiting for that transport. You really need to make sure that you're evaluating those every hour. Thank you and great presentation. So, thank you everybody for attending. We appreciate your attention. And thank you, Dr. Bronson for your knowledge. Thank you.

burn injuries

trauma centers

management

high acuity

low frequency event

burn care guidelines

initial burn care

telemedicine

regional referrals