Annemarie O’Connor, MSN, FNP-BC, APN, CNP, Nurse Practitioner at the University of Chicago Medicine Burn Center, discusses the Introduction to Burn Care: Priorities and Pitfalls.
[MUSIC PLAYING] ANNEMARIE O'CONNOR: For us, about 2 million people are burned annually. Of those, about 60,000 require admission to hospitals. And unfortunately, only about 27% are treated where there's a burn center. We have decreased our deaths from about 6,000 annually to about 5,000. And most people want to know when they come in and when they are going to be admitted, how long am I going to be there. So kind of an average, or something that we kind of use, particularly for our non-medical people, like our social workers, and things like that, it's about 1 to 1-1/2 days per percent burn. Now, that's not to say that if you are an 18-year-old who's otherwise healthy with a 20% burn, you're going to be there for 20 days. But if you're an 80-year-old with congestive heart failure and diabetes with a 20% burn, you're probably going to be there for 20 days. So it just depends on the patient, but it's sort of an average that we give to people. The important part is, is of the big burns that we see-- which luckily and thankfully we've seen a lot less of those in the last 10, 15 years-- the care that we give these patients in the acute care setting, whether that be the ICU, the step down, or the floor, is only 1/6 of their care. This is a life-changing event for these people and their families. Just a little bit of prevalence. The survival rate is terrific. And I think it's because of smoke detectors. It's because of education. Like Dr. Awad talked about with his stroke, is getting the word out there, it's the same thing with us. And I think we've done a great job of that in the burn community. Males get injured more than females. I don't think anybody's surprised by that. The ethnicity is more Caucasian than African Americans. In our community, we see more African American than Caucasians just because of where we are located. And this is a national database. About 43% are flame burns. About 34% are scalds. Of children, we see a lot higher prevalence of scalds. And they more commonly happen in the home. Some happen at work, but more commonly these injuries happen in the home or in a family environment. The most common cause of death in our patients is inhalation injury. So for the EMT and the paramedic and the pre-hospital people, if you get them to us, they have a pretty high rate of survival, because they haven't died from the inhalation injury. The very young and the very old don't do well. And I think Veena touched on this with sort of the depth of their skin, the thickness of their skin. And I'll talk about this again, but they don't do well because of the thickness of their skin. Again, prevention is key. She talked very eloquently about the 120 degrees for the hot water heater. Everybody knows about changing your clock, change your battery for the smoke detectors. You see when house fires happen in the communities, you see the firefighters and the EMTs going out there with smoke detectors to other families to prevent a house fire from happening again-- or, not necessarily a house fire, but injuries occurring during a house fire. And children with matches. I don't know about you, but I can't use a lighter that's a child-proof, but I can tell you most children can. So they will set things on fire like you would not believe. And boys are, again, pretty much worse at starting fires than girls are. And we really, really try to push not necessarily transfers to a burn center-- meaning that they would be admitted-- but to be seen where there's somebody who knows what they're looking at. This is my one and only attempt at a joke. So this just says, what really happened at Mrs. O'Leary's on the night of the Great Chicago fire? So, what it talks about is being smart, right? So Veena talked about most of the cases that she sees are neglect. Most of the burn cases that she sees are neglect. It's just all about being smart. Whether you're adult or you're caring for a child, it's all about being smart. This is a good slide that actually I got from Dr. Glick, who is Dr. Ramaiah's partner, to talk about why we should set the hot water heater at 120 degrees. So all I'm going to show you here is that at a hundred and-- oh, boy. All right. I'm going to do this. At 127, when the hot water heater's set at 127, you can sustain an injury in less than a hundred seconds. And when I say injury, I mean redness. I don't know about you all, but when I get out of the shower, I'm pretty red. I like nice, hot shower. But a child or an elderly person who's in contact with that, like Veena said, you move around if it's 112 degrees, and we're moving around. If someone can't move around, that's when they sustain an injury. But you see at 120 degrees, all the way up here, it takes about 600 seconds for anything to happen. So that change is ginormous. We teach, if anybody calls from a group home or some kind of a facility, we always tell them we think that it should be set at 120 degrees, and it's for this reason. Because burns are all about time versus temperature. How long were they in contact with the offending agent, whether it's the flame, the liquid, the chemical, the electricity, whatever it might be. And Veena also touched on the fact that grease burns are always deeper. And the reason for that is it holds that temperature in. Just some very basic functions of the skin. I think we all know that it protects us from injury and infection. It prevents fluid loss. It regulates our body temperature along with our hypothalamus. But if you think about it, it's also your personal identity, and it's what people see. So it's very important. We have one of the very, very few centers in the entire country that has a plastic surgeon running our center. And so he thinks about that. We all think about the cosmesis and what we would do to help this patient look better, because you saw what our survival rate is. So we really want them to be able to get back into community. So enough of that. So the anatomy of the skin. So it varies in depth. We've got four levels to our skin. We have the epidermis, we have the dermis, we have the subcu, and then we go down to muscle, and fat, and bone, and things like that. The epidermis is that first layer. That second layer is the dermis, right here. It's broken down into-- I've never used a pointer for this, so that's why I'm kind of-- it's broken down into two slides, two pieces, right here. You have the superficial dermis, and you have the deeper dermis. Depending on what level of the skin is involved, will depend on what the injury is. The anatomy of the skin. It is the largest organ in our body. It comprises 15% of our total body weight. It has multiple structures. It varies in thickness from 1.5 to 4 millimeters. The thickest skin we have-- palms of our hands, soles of our feet, our scalp, and our back. The thinnest skin that we have-- the inner arm, the inner thighs. And the reason that this is important for children and for adults is that rarely do we see full-thickness burns on the hand. The reason for that? The thickness of the skin. As Veena described, kids pulling things down on themselves, we see the depth of the injury being worse when they-- where the contact comes in. But if it runs down their back, usually their back does OK. The reason for that is the thickness of the skin. And I think that Veena and I both have driven this home, is that there's some critical reasons for the depth of the injury. It's about time versus temperature, as I've already said. It's about the thickness of that dermis. Where did the injury occur? Was it the hand? Was it the inner thigh? Was it the inner arm? What is the blood supply to that area? The face has a tremendous blood supply. So we usually don't see too deep of injuries on the face, and we usually don't graft those anymore. Years ago we used to do those, and that used to be our first operation. But now we're finding that they actually heal better, and we have a better cosmetic outcome, if we leave the face alone and just do great wound care, and good nutrition, and things like that. And again, I'm going to drive this home-- the special considerations for the very young and the elderly. And I think for the EMTs this is really important that what these look like when you guys see them may not be at all the same as what we're going to see the next day. And the reason for that is the age or the thickness of the skin. So the local response to an injury is burns are initially sterile. When we were all in chemistry in high school, or whatever, what did we use to sterilize things? Heat, right? So initially these injuries are sterile, which is why we talk to EMS and pre-hospital people and tell them to cover them with a clean, dry sheet. I can't tell you the amount of calls that I get. Kelly might call and say, somebody's calling, and they want to know if they should use a gel pack sheets that costs $200. No. You should use a clean, dry sheet that you have in your rig, or that you have in the ER. And the reason for that is this-- initially they're sterile. We contaminate them when they get to us, but initially they're sterile. If you have a 20% burn, or greater, you will have a systemic response to the injury. And a 20% burn is my chest to my abdomen. So I can't tell you the amount of people that come into my clinic that are like, oh, they didn't think it was anything. It was just on my chest and my abdomen. We will have a systemic response from this, which is why they should be seen where there's a burn center, and they will become rapidly hypothermic. And what we see in this first 24 to 48 hours is this hypermetabolic state. This is where they start to get sick, in the first 24 to 48 hours. Back in the day, when I first started in the unit, Chicago used to bring the patients directly to us, which I'm sure there's a couple people in the room that will remember that. And they were talking, and they may not have an IV, or they may have an IV, but they're not intubated yet, and they don't have a Foley, and they're talking to the firefighters, and everybody works the 24 on, 48 off. And so after their 48, they might come back to see the patient. And they'll be like, that's not the same patient I brought in. It is the same patient you brought in. It's just this whole hypermetabolic response that you see in that first 24 to 48 hours. This is where their lungs start to get bad. This is where they have a loss of GI barrier, which is why we want to feed them immediately. And this is where that we start to see a high fever. And the reason for that is that hypothalamus is resetting, and it's also their body's response to the injury. And then they have this systemic edema, which is tremendous, which is what usually makes them look not like the same patient. So when we talk about burns, there's something called the zone of burn injury. There's three zones of burn injury-- coagulation, stasis, and hyperemia. I always hated this slide. I always hated this concept. But if you think about it, as health care providers, whether you're a pre-hospital, in the emergency room, or working in the unit, this is a great slide to show what we can make a difference with. This white stuff in the center, that's stasis. We can't do anything about that. That's a full-thickness injury. We need to do something. But all of this other injury out here, with good wound care and good nutrition, and if it's on the lower extremity, keeping them off of it, we can prevent them from having to go to the hospital-- or, go to the operating room. We can prevent them from having horrible scars. So this is where we can make the biggest difference as health care providers. You can also get something called thrombosed veins. And this is just an example of some thrombosed veins inside the stasis portion of the coagulation. In the pre-hospital setting, I mean, I think you guys could probably tell me this better than I can tell you this, but common sense, right? Get them away from whatever the offending agent is, whether they're in the house and it's on fire, whether they're in the bathtub and it's hot water, whatever it might be, the chemical-- and from this last polar vortex 2014-- cold exposure. We had so many frostbites this year. I've been doing this for a long time, and I have never seen anything quite like this. And these were people-- we're doing this study right now on it. We're looking at all of our numbers, and you think, right, most of them are homeless, right? Is that what everybody thinks? Like it's the homeless people who get frostbite. Only 4% of our patients were homeless. Everyone else had their protective gear on and were doing the right things, and it was just so cold. So it's again, cold exposure is another thing. Actually, I threw this in recently, because we saw much of it this year. And then, keep the patient warm. I know I've heard from my colleagues in UCAN who say, people get freaked out if we ask for warm blankets, or warm this, because they're burned. But that's the only way to keep them warm. In the middle of the summer at 102 degrees outside, these patients will drop their temperature. And if they drop their temperature, we can't get at them. So we want you to keep them warm. Whatever means you need to do to do that, keep them warm. Too large-bore IVs. Scott used to say-- I don't if anybody knows Scott DeBoer, but he and I used to lecture. And he used to say size doesn't matter. And you know what, it's true. It does not. You just need to have access, because you need to be able to give these patients fluid. And it has no bearing whether they have burns in that area or not. You can put it through a burned area. The thing you have to think about is, how are you going to keep it secure? Because you're not going to be able to put tape on it. So you have to think about those things. But you can put it through a burned area. The other thing you have to think about is associated traumas. This is like, like Veena said, where you guys come into play to tell us what the scene looked like, what was out there. We had a kid one time who was outside with his brothers trying to light a barbecue. It kind of exploded because they put gasoline on it. And he came in to us, and he had this huge bump on his noggin. I mean, he was outside, he didn't fall, no one could figure out. And finally, one of the EMTs said there was a hard hat next to the grill. And he said, oh, yeah, that's what we were using for the gasoline, to pour it in. So when it exploded, it threw it up in the air, and it hit this kid in the head. So that was super important to us, because, you know, the whole million dollar workup for a head CT, and all that other. We knew exactly what the injury was and how it occurred. So it's real important for us to know-- what did the scene look like? And you have to think about these things. We are not an adult trauma center, but we are a pediatric trauma center. And when I say that we're not an adult trauma center, that doesn't mean that we don't get traumas. So we have to look at the whole patient. We had a patient one time who was in a house explosion. And the patient was sitting on the curb when paramedics and firefighters got there, so everyone assumed he walked out of the house. He was actually thrown out of the house, and he had a spinal cord injury. He just happened to have landed on the curb, which was lucky or unlucky, I'm not sure what it is. But our medical student found it by doing a rectal exam. So it's important to look at the whole patient, and to look at everything. They could still have a pneumothorax. They could still have a brain injury. Even though we are not an adult trauma center, we look at all of those things, as well, and things that you guys should be thinking about, as well. So, what happens when they are in pre-hospital or in the emergency department? Always remember the ABCs. I teach a class called Advanced Burn Life Support. And one of the things that we talk about is always remember the A. Because if you have a 100% burn or a 1% burn, if you don't have an airway, it makes no difference. So you always want to be thinking about the airway. So whether to intubate or not, you are looking at that patient. So you need to tell us whether the patient needs to be intubated. Years ago we used to think, oh, just intubate them, and we'll extubate them. Well, it's not really all that easy to extubate them, we found, by accident. So it really needs to be a thought process as to whether you want to intubate. Clearly, you don't want to be emergently intubating as you're driving down the street, or in the emergency room, or in the helicopter. So you want to do it early, but you do want to have it thoughtful and think about it. And then, the complete history. I think I've driven that point home enough, how important it is to know what the scene looks like. I think Dr. Ramaiah did, as well, when she talked about the temperature. Like we have to check the temperatures, we have to do all these things, because we want to know what the scene looks like. And this comes from the patient, it comes from the family, and it comes from personnel like you. Estimating the burn size. I get this question a lot. How do you estimate it? Everybody knows the rule of nines? Pretty standard. Yeah. So we've kind of broken it down into big parts get 18 and little parts get 9. So if my entire arm is burned, what percent burn do I have? 9%. If my whole leg is burned, what percent burn do I have? 18% right. So let me ask you this-- does it matter if it's 18% or 20%? No. Because you're always looking at the patient, right? You're always making sure. So if you have-- now, does it matter if the patient has a 1% burn and they have a 90% burn? Yeah, that makes a difference. But these little averages-- so just on average, if the whole arm is burned, you have about a 9% burn, and you can call it that. Kids have what we call big head syndrome, right? We all know that. Their heads are a little bigger. And as they start to grow, their limbs get longer and their heads get smaller. So it's a little bit of a different calculation, but again, on average, their whole arm is burned. OK. That's what we need to know. There is this concept of palmar surface area. That 1% of your body surface area is your palm. I've seen residents do it on babies. Like, oh, it's only 1%. Well, yeah, it's 1% if it's on you. But if it's on a 3-month-old, it's probably more like 4% or 5%. And again, that comes into play with fluid resuscitation and things like that. We have just recently done a study at the University of Chicago, and we just presented it, that for obese patients the polymer surface area, your palm doesn't change if you gain weight, but your body surface area does. So actually, if you have a BMI greater than 40%-- this is an aside, by the way, this isn't standard. We just looked at this on our own-- it's about 1.6% of your body surface area. So it's not exactly 1%, but on average it's about 1%. Just an interesting little thing. This is the [INAUDIBLE] that we use when they come to the unit, to get a little bit more exact. Again, for us, it also doesn't make a difference. Sometimes in billing it might make a difference. But, I mean, looking at the patient, we're always looking at the patient. So how do we know what depth the injury is? What kind of injury is this? So is it a-- people always want to know-- is it a third-degree burn? Is it a first-degree burn? We use thicknesses now, but the old standard was superficial injuries, that means you just involve the epidermis, so just this first dotted line here. Give me an example of a superficial injury. [INAUDIBLE] Sunburn. Exactly. Does anybody need to be admitted for sunburn? Has anybody had a bad sunburn they wanted to get admitted for? Yes. Please, please. We had a lady who was taking sulfa drugs, and she went into a tanning bed. And we all know those are photosensitive, right? So she ended up with, like, a 100% burn, but it was all superficial. She looked 10 years younger afterwards, because everything just sort of sloughed off. But we admitted her for pain control, for IV fluids, for-- she wasn't eating. You can imagine how sick you feel. Imagine when you get that sunburn, imagine it everywhere. So normally, no, we don't need to admit these patients. Partial-thickness injuries. And they are broken down, as I said, into superficial, which is the upper layer, and deep dermis. These are the hardest ones to evaluate right away. You know what a sunburn looks like, right? And I'm going to show you what a full-thickness injury looks like. Those are just clear-cut. This area right here, and you can see that it's the biggest area of our skin, is where we can make the biggest difference. Good wound care, good nutrition will make a huge difference in this patient that sustains this type of injury. Full-thickness injury. Has to go to the operating room. It is what it is. You've got to do something with it. Fourth-degree. There's no term for it, other than that it's bad. And you usually see it in electrical traumas. So what do they look like? So did this patient need to be intubated? He was one of those ones early on. So it's a little red. Again, you guys described it as a sunburn, caused by a flash flame, brief scald injury. They're erythematous and painful. So this little girl came in, and the mom's like, oh, what is this going to look like, and how is she going to look later on? So you see that-- and no one comes in with just a superficial or just a partial thickness. It's always kind of a mixed bag. So you can see-- can you see the blister? There's one here, and there's one right here. All the rest of the skin is intact. It's a superficial injury. This is what she looked like five days later. So the areas that were deeper or involved more of the dermis were the areas that reddened These types of injuries we just treat superficial burns, keep them moist, ibuprofen, things like that. As you go into a partial-thickness injury, as soon as you have a blister, you have a partial-thickness injury. Because when you have a blister, you have involved the dermis. And definition-wise, as soon as you involve the dermis, you have a partial-thickness injury. Whether to open them, aspirate them, or leave them alone, depends on who's looking at them. I am nosy. I like to see what's underneath there. But I don't deroof it all the way, because it can cause a lot of pain. You may just want to take a peek underneath and see what it looks like. As Dr. Ramaiah described, kids grabbing hot irons, or curling irons, or flat irons, or anything like that, where they freeze for a while, they have this pattern of blisters all around, because they're holding onto something circular. We kind of open those up and take a look at them, but pretty much leave them alone. Superficial partial. You see this is moist. It's pink. It's red. It blanches. This is another example of a superficial partial. You see it's kind of moist. It would blanch if we touched it. There's a little bit of bleeding there on the edge. This wound is going to be just fine. But then you have a deep partial-thickness injury. These are kind of mixed in color. You see how it's kind of moist here, a little pinkish here? This is a partial thickness, but this whitish area here is a little bit deeper. You see where that is, right? It's in the medial thigh. Like I said, those are the deeper injuries. Same offending agent-- oh, sorry. Did I hit something? Same offending agent, but it caused a deeper injury because of the thickness of the skin. Another example of a deep partial-thickness injury. This woman came in with this injury, and you can see-- can you see these white areas here? One, two, three. All the rest of this is nice and pink. So this is a partial-thickness and a deep partial-thickness injury. And this is what it looked like about two weeks later. And you see the areas that are a little bit more pronounced in their scarring are these darker areas, or the deeper areas of the skin. We treat these with topical antimicrobials. We look at these frequently. We use hydrotherapy for this type of injury. We expect them to heal in about one to three weeks. And I always say that they should be seen where there's a burn center. And the reason I say that is, is this is the injury where we can make a big difference. We can prevent them from having horrible scarring and things like that, if we do good wound care, and good nutrition, and things like that. This is a full-thickness injury. As I described, dry, leathery, white, fixed pigment. These patients need to go to the operating room. This little slit that you see here in the middle of the wound is our attending, Dr. Gottlieb, taking a blade and just cutting into that. And you see it doesn't bleed. It doesn't do anything. It's pretty much a dead hand. It's his right hand, that we see a lot of these types of injuries in people who are working. So for the nurses in the audience, when does the discharge begin? On admission, right? So we're thinking about, how are we getting this 30-something, 40-something-year-old male back to work and back to function when we see an injury like this? One of the things that Dr. Gottlieb talks about is the fact that live tissue swells and dead tissue shrinks. This is a lady who had a seizure and landed on the stove. And you can see this depression right here. That is full thickness. That is a dead injury right there. So this is the operating room is where you see her now. Now, full-thickness injuries can be really kind of tricky. So this injury to the right is the right hand before we went to the OR. And I apologize it's the whole arm, but this is the hand after we went to the OR. So you see it's kind of-- I'm sorry-- it's kind of that pink and moist and it's got those little white specks in it? This is where you kind of get fooled into thinking this might be not so bad of an injury. But from the history, we knew that this was going to be a significant injury. And the slits that you see are escharotomies. These injuries will take more than three weeks to heal, they're are high risk for infection and contracture, and they require a surgical debridement. People ask whether we should start fluids or not. Who do we know to start fluids on? Patients who have greater than 10% or 20% burn, or if they can't autoregulate their fluids status, should have IV fluids started. If you're putting in an IV anyway-- and why would you be putting in IV in a burn patient? For pain medicine, right? So put the IV, and you let the IV run. If they're at our institution, we talk about it with the ER and try to decide whether we're going to start the fluids or not. We use now-- everybody's familiar with the Parkland formula? The only difference between the Parkland formula and the Consensus formula-- which is what we use now-- the Parkland formula is 4 cc's per kilo per percent burn, period. The Consensus formula gives you a little bit more leeway where you can start with 2 to 3 to 4 cc's per kilo per percent burn. We give half of that in the first eight hours. And the reason for that is that's when they have the biggest loss. The largest loss that we see of fluids is in their first eight hours. So we want to give them those fluids up front. Again, I said I've been doing this for a long time, and I usually will not use the word never or always, but I have never given the entire Parkland formula. And those who have worked in the burn unit with me who are here will probably tell you the same thing. Because we are always looking at the patient. This is a place to start. It's a place where we say, this is where we're going to start the fluids. But the patient is not peeing enough, so what are we going to do with those fluids? Increase them. If they're peeing enough, what do we do with the fluids? We decrease them. Exactly. So this is a place to start. Our goal always is end-organ perfusion. And for adults, we want to see 0.5 to 1 cc per kilo per hour. So if you have an otherwise healthy 30-year-old male who has a 20% burn, and he put out 200 cc's in one hour, are you doing a good job with that? You are over resuscitating that patient. But does that mean you turn those fluids off? No. What it means is you turn them down. If that patient peed 10 cc's, are you doing a good job? You're right at that borderline, because it's 0.5 to 1 cc. So right at the borderline. So you just really want to see that you have enough end-organ perfusion. For pediatric patients-- and I'm only going to touch on this briefly-- the way that we look at it-- children who are less than 1 are infants, and we want to see a higher urine output on them. So we want to see 2 cc's per kilo per hour. And children greater than 1, we want to see 1 cc per kilo per hour. They also have a very immature glomeruli system, and they have a tendency to get hypoglycemic. So we will use D5LR on children. On adults, we use LR. I know most people carry 0.9. Is that right? Yeah. On your rigs, yeah. So it's fluid, right? We want to get it in. The reason we use LR is it's the fluid that most commonly mimics the intravascular fluid that we have. But if you have 0.9, that's what you should use. I heard that one time when I was talking, and I had no idea. What happens when they come to us? We reevaluate their injuries. We look at the pattern. We talk to our CPS people. We look at the depth of the injury. We decide if this patient needs to go to the unit, if they need to go to the operating room. We recalculate out their percentages. Again, we look for other injuries, as I talked about. Just because they came from someplace who said they're not a trauma, we still go ahead and look at the entire patient. And unfortunately-- and I think that Veena did a great job in talking about abuse-- anybody under the age of 3 in our unit gets an automatic consult to CPS. And what I tell the residents, that doesn't mean that if they're 4 you shouldn't call CPS if you're concerned. We almost always go through CPS for all of our abuse and neglect, but we are, as she stated, mandated reporters. So that I tell people if you feel strongly about this, and you need to do this, you should go ahead and do that. But our CPS department does such a great job of going through these cases that we're pretty lucky, is all I'm going to say. We're very lucky to have them. How to tie the ET tubes, I have a great picture to show you that. And then we do the same things any other ICU does-- put in a Foley, put in a feeding tube. We check their pulse ox. Everything that other ICUs do, we do the same thing. We're constantly monitoring their urine output. That's what we talked about, right? That's what we're looking at. That's our golden standard, is how much are they urinating, to be able to tell that we're giving them enough fluid. There are damages for under resuscitating, and there are damages for under resuscitate-- over resuscitating and under resuscitating. So we want to make sure that we're right at that threshold. We do ABGs to check their gas exchange. We have a lot of insensible loss, so we see a lot of electrolyte abnormalities. Hourly Dopplers. That's just to make sure that the limbs are-- everything is being perfused appropriately. Burn patients have a specific ulcer that I have seen one time, and it was on a 6-year-old girl. It's called a Curling's ulcer. It's specific to burn patients. I think we've sort of eradicated it by using the H2 blockades that we use nowadays. DVT prophylaxis is big in our unit. Eye lubricants, if there's any eye or facial involvement. Splinting. Our occupational therapist plays a big role in our unit. Specialty beds that we put them on to make sure that they don't get any pressure sores or pressure ulcers. And then, clearly, tetanus, if it hasn't already been given. Pain control is huge in our unit. We have two attendings in our unit. We have a critical care attending who's usually the anesthesiologist, and we have a surgery attending. We also have an anesthesia resident, again, who's well-versed in pain, and a surgery resident. We tend to used Dilaudid these days. But whatever it is that you guys use, either in your emergency room or your rigs, you can use morphine, Dilaudid, fentanyl. I'm not sure whatever other things are out there that's common for people. But whatever you need to use, you always give it IV. The reason for that is we have no idea, if you give it IM, how they're going to be able to absorb that because of their fluid exchange. If you give it p.o., we have no idea what their gut is doing. So you really want to give it IV. We use morphine because it's easily reversible. But again, whatever it is that you have on your rigs is what you should use, or in your emergency room. And it really should be titrated for comfort. And I'm going to briefly talk about this, just the surgical priorities. And there's a couple of definitions. Debridement is when we remove the loose tissue that's already there, and excision is when we cut something out, so we surgically cut that out. So as I'm talking, those are the definitions that we use. So early excision or early debridement is what we've learned in the last 15 years is what helps. And I think people could back me up who've been in the units and have been to the burn unit, that we used to wait for, like, 24 to 48 hours to take them to the operating room. And I don't know what we were waiting for. I think we were waiting for their lungs to look terrible. I'm not sure what we were waiting for. But now we know that we want to get them to the operating room early. So we do early excision. Get the dead stuff off. That's the most important thing. Then we have to cover them with their own skin, which is autologous coverage, or autograft. Restoring function, whether it be a hand, a limb, a hip, a knee, an ankle. And then cosmesis. We think about that. We don't use meshed grafts on anything. And I have some examples of meshed grafts. So this is an example of debridement. You see we're just taking that blister off. We're getting rid of that first layer. The autograft that we use is skin taken from the patient and put on the patient. Allograft is usually cadaver skin that we use, and that's a temporizing coverage, because the only thing that's going to stay on you is your own skin. Xenograft is just from a different-- like a pig skin, perhaps. We don't use that very often. And then a biological dressing. We use a lot of Biobrane, which is a synthetic material that has silicone in it that helps the wounds heal. So these are some of the coverages that we use. We use what's called split-thickness skin grafts, which is the most common type that we use. We use the epidermis, and the dermis. So if you think about that, what we've created now is a partial-thickness injury, right? Because we've taken off the epidermis and the dermis. So you really want to make sure that that bed is a good bed, because if you put an autograft on an infected bed, you've now created another wound, and you have to do it again. So you really have to make sure that your wound is clean, and that you're free of infection to be able to have that wound take. We use mesh grafts in split-thickness skin grafts, which is just a sheet graft. Meshed grafts, if you can imagine why we would use a mesh graft? To cover a larger body surface area, because you can sort of open up that mesh. A full-thickness graft is something that includes the dermis, and the hair follicles, and the nerve endings. Those are for a little bit-- that lady that I showed you with the deep injury to her shoulder, she needed a full-thickness graft. Because really-- we went down into the fat when we took that, so we really needed to replace that to make sure that it looked OK. You can use this for small, cosmetically important or functional areas. Her shoulder, we wanted to make sure that worked. This is an example of a meshed allograft. You see it's kind of whitish in color. It's kind of what we call rejecting, but that's probably not a really good word, but it's not going to stay because it's not her skin. This is an example of a meshed autograft. This is one that's healing. This is one that's meshed and healed. But you see that meshing pattern, right? I'm going to use the word never again. We never use meshed grafts on the hands or the face, ever, no matter how much skin we have. We have a patient who has about a 95% to 100% burn in our unit right now. And we will not use meshed skin, even though we will get a larger [INAUDIBLE] surface area on his face or his hands. And the reason for that is you always see this meshing pattern. Sheet graft. This was a left-handed social worker who had a seizure disorder and was cooking spaghetti. And the only reason I remember her so well is she was like the most compliant patient we had. She did everything we told her to do. And I think it's probably hard for you guys to see her entire sheet graft, but it goes all the way to all of her fingers and comes all the way down here. This is a patient who did extremely well, clearly. The pot that she was cooking in, her hand went into, clearly, and she sustained a pretty significant injury, but did really well. She's functional. She's back at work, doing great. So I touched on escharotomies, and I'm going to touch on fasciotomies. Why do we do these? I mean, they're so disfiguring, if you've ever seen them. We use these for patients who have circumferential injuries, because we don't want people to lose limbs. When I was a kid, if I broke a limb, my mom took me to the ER, and what did they-- first thing they did? [INAUDIBLE] Put a cast on. What happened 24 hours later? [INAUDIBLE] Right. So what did I do? Go back to the ER, and what did the ER do? Cut it off. Cut it off. We're cutting off the cast. You can think of the eschar as the cast. So how did your mom know that you were having swelling? Because you said it hurt, or it was getting numb, or it was painful, more painful than it was before. And those are the signs and symptoms that we see of patients. Now, unfortunately, most of our patients who have this type of injury are probably not awake and not going to be able to tell us. So we have to use other signs. Some of it is just we know that this patient is going to need an escharotomy because of the extent of their injury. They have decreased pulses, which is why we do those Doppler pulses every hour. But the interesting thing is, is most of our nurses who have lots of experience will say to the resident, you need to do this escharotomy before I lose the pulse. Because what's the last thing to go? The pulse. If you've lost the pulse, it's a little bit too late. So the nurses play a huge role in this in saying to the residents-- who don't know, because they're there for a month-- we need to do these earlier rather than later. And this comes from all the fluid, it comes with a burn itself, and it's just a progressive thing. This is an example of an escharotomy. We do these emergently at the bedside. This is the left hand of the right hand that you saw before. So this is after we did the escharotomies on this patient, on his left hand. This is another example of an escharotomy done in the operating room, and done very nicely, to be able to open up. And you see that-- you see how demarcated that is there, and how you could get some swelling there and have some loss of limbs or fingertips. This is when you used to see burn patients who lost limbs. Fasciotomies I think of as a deeper escharotomy. We use these when the muscle is involved, when the muscle is swelling. We can see muscle swelling in unaffected areas. So we had a patient one time who literally was burned from his waist up. And we ended up doing fasciotomies to his calves. That was from all the fluid that we gave him. He was just too swollen, and we needed to go ahead and do those. It's to relieve vasoconstriction, to promote normal ventilation. You see this patient has fasciotomies, you see the muscle here. You see he has them on his chest here, to promote ventilation. You can imagine if you have a big cast around your chest that you just can't take-- the lungs are still OK. You just can't take that deep breath that you need to. And then you see the muscle in through here. So this is an example of fasciotomies. Burn wound infection is huge. Once they get to us, as I said, inhalational injury is what most likely will kill our patients. This is the next thing. So this is what we try to prevent. The mortality rate is high when we see this. Prevention is key. We use topical antimicrobials, gowns, gloves, masks. We used to do a lot of frequent line changes, but we found that that actually does not make that much of a difference. We still do it somewhat. Like if there's a-- we don't have a source if they have a high fever, we may change out the line just to make sure. And then that early excision and grafting, that makes a huge difference. I think I've stressed this enough-- nutrition is huge in our unit. We have our own dietitian. Protein is big in our unit. We rarely use T.P.N. We always want to feed enterally, whether that be p.o., or through an NG, or whatever it might be that the patient is getting fed through. Micronutrients, a lot of vitamins, glutamine-- we use all sorts of things to kind of buff these patient's nutrition up. And I only put this slide up here to show you all the people that we have on our team to take care of these patients and the specialized areas that we have. Specific injuries that we see are to the hands. I think I mentioned that rarely will you see a polymer surface burn that is full thickness on an adult. You might see it on a child. They haven't had a chance to get calloused and get thicker skin than we do. They still have thick skin there, but it's not quite as thick as ours. Splinting is big with these patients. Early and aggressive excision on these patients. We use sheet grafts, as I showed you with the lady with the hand injury. And post-op splinting, occupational therapies, plays a big role. I touched on the face. This is usually the-- if you need to graft, is the first operation you want to do, because it's best skin, because you want to have the best skin for the face. Ideally this is done from skin above the clavicle. I don't know many people who have a face burn without having a little bit on their neck, or a little bit on their shoulders. So it's pretty rare that we're able to get these type of donor sites. Because, right, when you see a burn patient, what do you see if you've ever seen a burn patient that has had grafts on their face? It's the color difference, right, that you see. So I'm telling you, you take the skin from my abdomen who hasn't seen sun in 20 years, and you put it on my face that sees sun every day, it's a color change. And that's what you see. You see that color difference. So if you can take it from someplace that is similar, you don't see that color difference as much. Ears have cartilage in them. Cartilage has zero blood supply to it. So if cartilage gets infected, they will lose their ears. So we try to prevent that. We use Sulfamylon, which is a cream that we use that has a little bit better penetration. And we treat the noses very similar to the ears because they also have cartilage in them. Eye injuries. So if we have a facial injury, we may suspect that they may have eye injuries. Rarely do we see corneal burns. The reason for that? Because our reaction is so quick, right? We close our eyes so fast when anything comes towards us. We have had patients in the past who have had corneal burns. And we had a gentleman one time who had a corneal burn on his left eye. And the reason for that was he was unable to close his left eye because during the house fire he had a stroke. And so he was unable to close that eyelid, so he ended up with a corneal burn to his eye. But the reason for that is because he was unable to close it. So it's pretty rare. Ophthalmology comes to our unit immediately when we have these. And the reason for that is they swell so much that, when they try to do the eye exam 24 hours later, it's extremely difficult. So they really do try to come to our unit fairly quickly. I touched on lower extremity injuries. Anything below the knee we consider a lower extremity injury. I get this question a lot, not from our ER anymore because they are like, yeah, you're right. They get worse injuries. I see it in my clinic a lot when they've been seen in another hospital. And it's like, oh, a little spot on the top of the foot. Oh, you can just go to the burn unit. And they give them our number, and they come to see us three days later, and they've been walking on it and going to school, or going to work, whatever it might be. And the injury, and they're like, oh, it didn't look like that before. Well, it's because of the swelling. It's because of the dependent edema. And they have a high risk for cellulitis. So we will always, if they come into our emergency room, admit. I always tell the residents, you cannot go wrong at 2 o'clock in the morning on a Saturday admitting somebody with a lower extremity burn for observation. And we do this for bed rest, because nobody stays on bed rest at home. I just got up to answer the phone. I just got up to go to the bathroom. I just got up to get something to drink. It's hard enough to keep them on bed rest in the hospital, so we really try to keep them in the hospital for this. And this is where-- this is the injury where we're going to make the biggest difference. So if you're out there in the community and you see this type of injury, call us. We take care of other types of injuries, not just burns. These things are things that will start out maybe like as a rash. Our emergency room is great about calling us for these. Usually when they come from outside hospitals, they've been there for a few days, because nobody really knows what this is. It's called erythema multiforme. I don't know if anybody's ever heard of it. It's usually a drug reaction. You can also have some Stevens-Johnson syndrome. Staph-scalded skin is usually from a staph infection. Purpura fulminans is a clotting disease that we see on our patients. And necrotizing fasciitis the flesh-eating disease, or I think that's what they-- shark-- I don't know what they used to call it. But it's the necrotizing fasciitis where the fascia is actually involved with the infection. We also see inhalational injuries. So history is important with these. Were they in an enclosed space? Were they down for a period of time in an enclosed space? Were they in a blast injury? Did they have loss of consciousness? Do they have facial burns, carbonaceous sputum, singed hairs? There are some studies that we can do. But the most important thing is looking at the patient, and while the nurses are suctioning, hey, and we're seeing some black stuff coming out of their tubes. So it's important to note this. Is it important that they had an inhalational injury? Yes, it's important, because you really want to support them. But there really isn't much that we do with inhalational but support them. We watch them closely. It's the products of combustion that cause the injury when you have an inhalational injury. Carbon monoxide poisoning, carbon monoxide injuries. Carbon monoxide has an affinity to oxygen-- to hemoglobin 210 times that of oxygen. So if there's a carbon monoxide molecule and an oxygen molecule, the carbon monoxide is always going to win. So this is why we see these high levels in people who are asleep at night. But we can also-- it's also dose dependent. You can also get a headache in about 8% to 10%, if you're jogging down Lakeshore Drive, with your carbon monoxide. 10% to 20%, you can see nausea. From 30%, some confusion. 40% is unconscious. And greater than 50% is usually fatal. We talk about starting the patient on 100% oxygen, because you can eliminate the carbon monoxide in about 45 minutes. We used to have a hyperbaric chamber in our unit. We used to have a breakable wall between our treatment room and our admission room to hyperbaric, which we broke that wall down and brought that patient into it. And I think Liz can tell you, because she was our hyperbaric nurse, and myself, and Marianne, and any of the rest of us that took a patient from that treatment room with a 90% burn and put them into the chamber, how scary it was. Because it may shorten the CO2-- and we don't know if they have favorable outcomes. We've actually found that they don't have great favorable outcomes-- but there's so many more cons. The ototrauma that we see, the limited access to the patient. I mean, I'd be sitting on one side and Liz would be sitting on the other side, and it would be, should we bring them up? Do you think we should bring them up? Well, you can't bring them up too quick. What's their heart rate now? Or what's their-- how much morphine are we giving them? Are we giving them too much? Are we not giving them enough? Are they-- it's a very scary time to be in these chambers. If anybody's ever seen it, you know the Michael Jackson chamber? That's what we had, that glass chamber. You could literally see the patient, but you couldn't get at them. So clearly, currently, we do not recommend this for carbon monoxide or inhalational injuries. The closest hyperbaric chamber, I believe, is Lutheran General. And I've been told that it will take longer than 45 minutes for them to get from our emergency room to the chamber in Lutheran General, even if UCAN takes them-- the package, the air time, getting them to the chamber, getting the chamber started, and everything else. So in that amount of time, you've eliminated the carbon monoxide. So that's why we don't currently recommended it. Again, I talked about supportive care. Chemical injuries. The reason I have this water up here is because what you want to do is flush that injury. Do not wait for the neutralizing agent. If it's a powder, brush off that powder and start flushing that. We flooded our emergency room one time just using bottles and bottles of water just to flush these types of patients. We get into hydrotherapy now, but at the time we didn't have a key to that. You see alkali injuries, acid injuries, organic compounds. Gasoline is a big one. If somebody is in a motor vehicle accident and they might be laying for-- not being extricated right away, laying in the gasoline, you'll see a chemical injury from that. I talk about hydrofluoric acid injuries because they're very minor injuries. It's a weak chemical, but it causes life-threatening hypocalcemia. So if you're in the field, and someone is a jeweler and they sustained an injury and they have a hydrofluoric acid injury, think about their calcium. Put them on the monitor. Watch what their EKG is going to do. And you can give calcium for these types of injuries. Myoglobinuria is something that we usually see in electrical injuries. It's doesn't always have to be electrical, but that's usually where we see it. The treatment for this is to hydrate the patient. You want to give this patient-- the electrical injury is where you start at 4, not at 2, when you're doing your Consensus formula. The electrical injury is called the inside-out injury, or the tip of the iceberg, because what you see on the outside is not always what it's like on the inside. Our greatest barrier to electricity is our skin. Once that barrier is broken, the electricity will run along the path of least resistance. The path of least resistance is the bone. So anything adjacent to the bone will become injured. And you're not going to see that on the outside. So you can have pretty significant injury there. Long-term problems that we see are hypertrophic scarring-- we use pressure garments for those-- functional deficits, contractures, contour defects. And we have all different things that we do for those things. This is an example of a patient who's positioned really appropriately, except for that one hand right here. But everything else is what it should be. Early mobilization. This patient right here is that patient that you saw with all those really bad escharotomies and fasciotomies. He was in our unit for about seven months. And this is him when we took him outside for the first time. Do I have time to go through the case studies, or should I fly? [INAUDIBLE] Fly. [INAUDIBLE] I have 10 minutes? [INAUDIBLE] OK. So I just have a few pictures of our injuries, so that you guys can take a look at this. So this is a young girl who came home when they were moving from one apartment to another, and she smelled gas, so she went to turn the stove off. She thought it was on, and she turned-- she was going to turn it off, and she actually turned it on, and it exploded. So what did she have on? Anybody? What did she have on her head? [INAUDIBLE] Braids. Exactly. So you see the braids protected her scalp, but in between where the braids were, she sustained an injury. This is an example of a scald injury. I'm not going to ask the same question that Veena did, because that's her question to answer. But you might think about this, right? You might think this doesn't really-- I mean, what happened? What we see sometimes with kids is-- like that first case that she showed you-- they fall into things, and they're not able to get themselves up. They can't get themselves away from whatever the offending agent might be. So what are you thinking with this injury? I'm thinking occupational therapy, right? I'm thinking this patient needs splinting. And I'm thinking CPS is going to be called for this patient. This is another example of a scald injury. You see the pattern here, it stops right there. That stock in-- oh, gosh, sorry. The stocking, or the cutoff there that Veena described, this is what it looked like after we debrided the foot. That white, fixed pigment, right? You might think, oh, it's just a few blisters, or it's just a big blister. But that's what it looks like underneath. And you see that line even more right here. And another telltale sign-- I don't know if Veena touched on this. I don't think she did-- is this little crease right here. If you're standing up, you have creases there, right, in your ankles? That's the crease protecting that skin to skin that she talked about. Remember I talked about dead stuff shrinks. This is just a kid who was rolling round, that whole stop, drop, and roll. He did it right, so I put it in there just to give him some credit. But he landed on something. And you see how sort of shrunken that is there in the center, right? That part is dead. That's probably down to fat. The edge is not so bad, but right there in the center. This is how we tie our ET tubes, right? You can't use tape. They have those fancy covers-- no, what are they called? The ET tube hold, like the holders and stuff? [INAUDIBLE] Yeah. And they have those DuoDERM things on the side, and it kind of sticks to the face, then we can't do the dressing changes and all this other. So we use twill tape. And this is how we tie our ET tubes in the burn unit. This always freaks parents out, that we shave the head. And this is why-- this little girl's hairline is right here. And you see all that burn beyond that, right? So Dr. Gottlieb always says it has to be shaved an inch beyond the burn. You guys don't have to worry about this, EMS, but just something that if you're in the ED, you might tell the parents, they are probably going to shave the head here. So it kind of helps us out a little bit. Veena had this exact picture. And unfortunately, I'm sorry I put flame, because I tried to put all scald in here. I was doing it later in the evening. But remember how she said the mother threw, and-- I don't know if anybody saw her go like this when the water came at him? This here is the result of that, when he put his arm up like this. The reason I put this slide here is so that what would I be thinking about? I would be thinking about occupational therapy-- again, splinting this patient. How can we put this patient in a good position? Because if you heal, wounds heal by contracture. So if you heal the patient like this, it's going to be impossible to get their arm up. But if you heal them like this, it's going to be easier to get it down. So we will use occupational therapy for this patient. Grease burn. We talked about it being really deep. This little girl-- somebody explain to me why you deep fry pizza puffs. I mean, I don't understand it. But it was on the floor, and they were deep frying the pizza puff, and the kid's hand went right into it. The reason I show this slide is, is do you see her hand, the position that it's in? So if you lay your hand on the table right now, what happens to your hand? It goes flat, right? Hers is like this. The reason for that is all this muscle in here is invaded and it's dying. So we need to get at this. This is a patient we're going to do escharotomies at the bedside, emergently. Why do we do this? This is a patient of ours, this is a pediatric patient of ours who was treated. This is the firefighter who saved him. Lara Beauty used to use this as their greeting card, and they've been nice enough to let me use it for my presentation. American Burn Association, which is actually based here in Chicago, but is a national and international organization, have criteria for when to call a burn center. We always say just call and ask. But if they have greater than a 10% burn that's partial thickness, they should be called. Third-degree burns, if it involves a cosmetic or functional area-- hands, feet, face, perineum, over a major joint. If it's a circumferential burn, do they need escharotomies? So they really need to be where people know how to do escharotomies. Because you can imagine if you do an escharotomy in a round spot, what you can end up with is a nice big bleeder. So you really have to be careful of where you put those. If they have a chemical, electrical, or inhalational injury. If they have comorbidities-- I think this is really important. Imagine how difficult it is to heal a diabetic foot. Think about the diabetic foot without the burn. And if you try to heal it with a burn, it's difficult. And it's a management problem. You really have to get their sugars under control, and get them off of their feet, because it's usually their feet that they burn. Do they have a concomitant in trauma? And they added these two-- burn children in hospitals with qualified personnel and equipment, and where they can receive the special social, emotional, and rehabilitative assistance. In the State of Illinois, we have four burn centers. University Chicago and Loyola are the only two verified burn centers. We're verified by the American Burn Association and the American College of Surgeons. And for anybody who works in the medical profession, whether you be pre-hospital or in the hospital, we all know we have regulatory people who come in and say, you're not doing this right, or you're doing a great job with this. This is what this is. This is a pretty rigorous thing that we do. As Dr. Awad talked about, being the stroke center, we are the burn center for the south side and for Northwest Indiana. Stroger and Memorial are two other burn centers in the state. They are not verified burn centers. We have Advanced Burn Life Support. I think I touched on it very briefly. It's a course very similar to ATLS, ACLS, but it involves burns. We do one at University of Chicago about once, maybe twice, a year, but there's other courses that you can get throughout the entire country. So if you go on the website for the ABA, you can find those courses, if you're at all interested. There is CEUs, just so everybody knows, if you take the course. Here's some contact information. University of Chicago, the UCAN, and the burn center number. And then the clinic that I do with our occupational and physical therapist, we have clinic twice a week. Some additional resources. Here's the U of C's website. The American Burn Association website. And I put up the Illinois Fire Safety Alliance for anybody who might know a child who was injured in the State of Illinois with a burn injury, or treated in the State of Illinois with a burn injury, who might benefit from burn camp. Its children 8 to 16. It's free of charge for the children and their families. And it's a great way for the kids to see-- most kids that when they come to camp for the first time will say, I didn't know there was other people like me. I didn't there was other people who have burns, because they usually don't come in contact with them. And Indiana has their own burn camp, as well, for anybody who's from Indiana.