Ep 124 Burn and Inhalation Injuries: ED Wound Care, Resuscitation and Airway Management

Burn and inhalation injury patients present to the ED more often than one might think, with a staggering half a million annual visits in the USA alone. It turns out that for all burn patients—from minor to severe—there is a lot of room for improvement in ED management, counselling and disposition. Things like inaccurate estimation of burn size, unnecessary endotracheal intubation, over- and under-estimation of fluid resuscitation volumes, inadequate analgesia and inappropriate wound dressings are just some of the issues where a small change to ED practice patterns could have a huge impact on patient care. In this EM Cases main episode podcast we have the director of the Burn Unit at Hospital for Sick Children, Dr. Joel Fish and EM educator Dr. Maria Ivankovic discuss dozens of pearls and pitfalls in the management of both pediatric and adult burn and inhalation injuries management with a special appearance by airway master George Kovacs to talk about awake intubation in the burn and inhalation injuries patient... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Shaun Mehta, edited by Anton Helman and Maria Ivankovic, May, 2019 Cite this podcast as: Helman, A. Fish, J. Ivankovic, M. Kovacs, G. Burn and Inhalation Injuries: ED Wound Care, Resuscitation and Airway Management. Emergency Medicine Cases. May, 2019. https://emergencymedicinecases.com/burn-inhalation-injuries/. Accessed [date] Go to part 2 of this 2-part podcast on burn, inhalational, and electrical injuries Always Consider Non-accidental Trauma in The Pediatric Burn Injury Patient For the pediatric patient presenting with burn and inhalation injuries, always consider non-accidental injury in your differential, particularly when: * Delayed presentation to care * Story and injury pattern mismatch * Burns with well-demarcated lines (e.g. immersion burn) * Patterned burns (feet, hands or buttocks) * Burns in a certain shape (e.g. iron, cigarette) Learn more about pediatric non-accidental trauma in Episode 108 First Aid for Burns What not to do: ice causes severe vasoconstriction and can even deepen the burn. Toothpaste is also harmful given the effects of fluoride. What to do: run cold water for at least 20 minutes. Evidence suggests that this can reduce pain and edema, reduce the depth of the burn, decrease the overall inflammatory response, improve the speed of wound healing, and minimize scarring. Managing Burn-Associated Pain Pediatric burn pain management Pain management should be a priority: Treating pain early and aggressively has been shown to prevent psychological trauma and even to improve healing. A multi-modal analgesic approach is recommended. Have a low threshold to include a narcotic given the severity of pain associated with burns. For pediatric burn patients, intranasal fentanyl and ketamine have similar analgesic effects, but fentanyl is preferred given greater rates of sedation and dizziness with ketamine. Burn Classification: Don't Use 1st, 2nd, 3rd Degree  The burn classification system has moved away from the traditional 1st, 2nd and 3rd degree nomenclature to a more physiologic classification: superficial thickness, partial thickness (superficial vs. deep) and full thickness. There are three anatomic layers of the skin important for burns: * Epidermis: <1 mm in most areas, very thin layer of protection against bacteria and moisture loss.