Good afternoon everyone, my name is Jong Lee. I'm actually a pinch hitter for the first talk today, so it can kind of go bad, or maybe really bad, but hopefully not. So this is a little bit about myself. And I don't have any financial disclosures. This talk contains some photos of our burn injuries. In 2017, there was a big fire at the government-run local shelter in Guatemala, and we went down to triage patients. 19 died in the fire, 33 were taken to local hospitals. 21 more died, out of 12 that survived, nine were transferred to Shriners Hospitals in Galveston, Boston, and Cincinnati. In 2018, unfortunately, they had another disaster. Guatemala had volcano eruption, and many people got burned. This overwhelmed the resource. They did a good job of initial care, including intubation, putting lines in, and resuscitation. And they put dressings on, but in terms of more definitive care, they were stuck because of the limited resources. Shriners Hospital took six kids to Galveston, and thanks to our military service, they actually helped us transport six kids to Galveston. I think the major question becomes, do you have enough resources and experienced staff to do the definitive care, burn care, at an austere environment or a resource-limited environment? If the answer is no, then provide temporary care until you can get patient transferred somewhere where they can get a definitive care. And so, of course, that can be difficult. Burn care is labor-intensive and resource-intensive for optimal care. Burn care needs a multidisciplinary team, just like trauma service and cardiothoracic service. With major burns, many different disciplines work together like an orchestra. You need surgeons, nursing, techs, pharmacy, rehab, dietary, respiratory, speech, psychiatry, psychology, social work, anesthesia, plastics. Care concept is simple, but it's a complex care. It's a long-term care, and that's what makes burn care very difficult, especially with major burns. Not much you can do in terms of definitive care of 80% burn in an austere environment other than evacuate because lengths of stay can be extremely prolonged. We had a child about 10 years ago that was transferred to Shriners Hospital in Galveston from another country who was staying in ICU for about two months. She had 80% third-degree burn, and they did a good job of critical care and wound care for two months, but they were not able to do the definitive care, which is excision and skin grafting. They were doing their best with wound care, but unfortunately that wasn't enough. There are things you can do to help the patient while you are waiting for a transfer, such as good resuscitation and wound care, and things you can do if necessary, escharotomies and fasciotomies, which I'll touch on at the end of the. So, there are guidelines out there, but the practical bottom line is stated by Teddy Roosevelt many years ago, do what you can with what you have where you are. Basic principles of critical care management of burn injury is similar to trauma patients, so I'll focus more on the wound and general burn management today. First thing is treat burn patients as trauma patients. There may be concurrent trauma, you want to rule out any other injuries because a lot of times it's not just burns. I'll briefly touch on inhalation injury. If true inhalation injury is present, airway may continue to swell and early intubation may be prudent. With severe edema, if you can't intubate, then obviously you need to consider surgical airway. Things I want to focus on are resuscitation, burn size estimation, and wound management today. And in order to estimate fluid requirement, obviously you need to calculate the burn size. Burn size can be estimated by the rule of nines, lumbar chart, and the use of patient's hand. Rule of nines divide each body part into multiples of nines. Lumbar chart divides each body region based on the age group. And of course if the burn is relatively small, then you can use patient's hand, and you have to use the whole hand, so it's the palm and the fingers. That's 1% for the patient, and of course you have to use the patient's hand. Major wound defined by greater than 20% will require significant fluid administration, particularly in the first 24 hours after injury. Once you have the burn size, you can figure out the fluid requirement. Parkland formula is probably the most well-known formula for burn resuscitation. I think everybody knows Parkland formula. Even though original Parkland formula used 4 milliliters per kilogram per percent burn, currently we typically start at 2 milliliters per kilogram per percent burn over 24 hours to avoid over-resuscitation, and that's what ABA, which is American Burn Association, and ATLS, Advanced Trauma Licensing Support, recommend. And half of the volume is given in the first 8 hours, and the remainder is given in the subsequent 16 hours. There is also a rule of tens, it was developed by the military. You estimate the burn size to the nearest 10%, and 10% times 10 is the initial IV fluid rate. So for every 10 kilogram of over 80 kilogram, you increase the rate by 100. Ultimately, though, it doesn't matter what formula you use. The formula is just an estimate and starting guide. Idea is to titrate your fluid resuscitation to a target goal. Typically we use urine output. Fluid should be adjusted to maintain urine output of approximately 0.5 ml per kilogram per hour for adults, but for simplicity, you can target 30 to 50 cc an hour. And titrate IV fluid to stay within the target range to avoid over and under resuscitation. IV resuscitation may be difficult in resource-constrained environment. IV fluids and supplies, even a simple thing as alcohol swap, may be limited and could be easily depleted. After the first 24 hours, the fluid requirement decreases, but are still above maintenance due to eruptive losses through the burn wound until wounds are completely closed. Hence the prolonged need for fluids even though you may no longer need a formal resuscitation. There is an oral resuscitation you can consider, which is an option especially if burn is small, typically up to 20%. But some patients with burns up to 40% can also be resuscitated successfully. We receive burn patients from Mexico, Central America, at our hospital. Some get to us after 24 to 48 hours, so they pass the initial resuscitation phase. But their fluid requirement may still be elevated because they have wounds and they have eruptive loss. And instead of giving IV fluid, we typically put a feeding tube in and give them feedings and fluid through that to resuscitate them. Because the resource of administering large volumes of IV fluid may be lacking in an osteo environment, fluid or a fluid resuscitation is an option and may be necessary. The GI tract has the ability to absorb large amounts of fluid up to 20 liters per day, and that's the only physiology I'm going to talk about today. Oral rehydration therapy is a well-established technique for preventing dehydration caused by diarrhea, particularly in developing countries. Since 1975, the WHO and UNICEF have provided packets of glucose and salts to be used in oral rehydration therapy for infectious diarrhea. If you're not pretty satisfactory, you can then decrease IV fluid as long as oral rehydration therapy can be continued. Patients should be allowed to take a sip from a cup frequently, and with the goal of continuing approximately about 8 to 10 ounces every 10 to 15 minutes, which comes out to about a liter an hour if they can tolerate it. So oral rehydration solution can be made with one liter of clean water, one teaspoon of table salt, and three tablespoons of sugar. And of course there is a commercially made package as well. Now there is a colonic resuscitation, which we won't talk about as much, but an additional approach that may be valued to remote or rural setting if oral intake is restricted is the rectal infusion therapy, proctocolitis. Colonic resuscitation has been tried and published in animal models, and rectal infusion of either tap water or saline has been tolerated at rate of up to about 400 ml per hour. Proctocolitis can be performed by boiling water to reduce risk of infection, warming the water to body temperature, formulating a balanced rehydration solution by the addition of salt and bicarbonate, inserting a urethral catheter into the rectum, attaching a reservoir to the catheter, and infusing fluid at a rate comfortable to the patient and consistent with clinical science. So it sounds great, and it's life-saving, but please don't try to do that to me if I'm needing a resuscitation, so try oral resuscitation or IV fluid first. So I'm going to move on to wound management. Some of the recommendations by ABA guidelines include identifying and training a wound care team. Of course, sometimes you may not have enough time to do that, and prepare a clean place for wound care, establish a process for daily wound care and inspection, and develop a consistency. Determine availability of topical antimicrobials and dressings or silver-based dressings, which I'm going to talk about, and plan their rational use. For wound dressing, you treat second-degree and third-degree burns or partial thickness or full thickness burns the same way. You want to use some kind of antimicrobial ointment daily and wrap. If you don't have enough ointment or dressings, every other day, dressing change is okay. If you don't have ointments, then just put clean dressings on. You don't have to put ACE wraps if you don't have it, and if that's the case, sometimes you just have to put gauze and even chucks, and that's sufficient. If you don't even have that, then you can put clean sheet until you get better equipment available. Because you do what you can with what you have. You may end up putting less dressings on and changing dressings less frequently due to limited resources. The most well-known topical ointment when we talk about burn wound is silver sulfadiazine because everybody knows the white burn cream, right? We typically don't use silver sulfadiazine as much anymore because it tends to be cytotoxic to the dermal cells and actually can slow down the healing process. It's great for infection, but after a while, it can actually slow down the healing process. So any topical antimicrobial ointment should do it. So Neosporin, Vastracin should be okay. Now there are silver-based dressings out there, which is very popular. Nano-crystalline silver impregnated into the dressings, whether it may be a foam or a sponge or silicon, and those are typically good for about seven days. So less dressing change, and that actually translates into less pain for the patient as well. So if you have that, that certainly is an option. But the bottom line is you want to be vigilant for infections and, of course, be flexible. Now one last thing I'm going to talk about is some of the complications or early complications that can happen with the burn and resuscitation. With resuscitation, you may develop compartment syndrome, anticipate need to perform escharotomy and fasciotomies. With circumferential burns, some may need escharotomy. If you have perfusion compromise because your circumferential burn may act like tourniquet or a blood pressure cuff that's constantly on and decrease the perfusion to your distal aspect of your limbs, and then you will need escharotomy. If that continues and you develop compartment syndrome, then obviously you're going to need fasciotomy. The most serious avoidable complications that we see coming from out of country transfer are typically dead muscles from compartment syndrome that was missed due to lack of escharotomy or fasciotomy. And these tend to be because of the too much fluids and not necessarily from the burn injury because we see patients coming from burns, but they have no burns in their lower extremities, but then they develop compartment syndromes and that gets missed. So it's important to be looking out for compartment syndromes in any body parts if they get too much fluid. If you have circumferential burns on the chest and have respiratory compromise or ventilatory difficulties, such as when somebody's on a ventilator, if they start having high peak airway pressures where you just can't get rid of CO2, then you have to wonder if the eschar on the chest is causing compromise of the ventilation and you may need escharotomy of the chest. And of course, you know, always look for abdominal compartment syndrome, which is a complication of burn resuscitation or any resuscitation if you get too much fluid. This is my email. If you have any questions, feel free to contact me and I'll be happy to answer your questions. Thank you.

burn care

resource-limited environments

burn injuries

fluid resuscitation

wound management