Burn Injury An Update with focus on Oil and Gas Industry
Current Management of Major Burns Cocoanut Grove Fire Nov. 28 1942 422 died 166 injured Boston City Hospital 300 dead on arrival; 127 alive - 39 deaths after admission, (23 within 48) MGH 75 dead on arrival; 39 alive - 8 deaths after admission, (7 within 72)
Current Management of Major Burns Cocoanut Grove Fire 20 yr male Boston City Hospital 60-65% TBSA burn 30% full thickness 25,000 skin grafts Discharged PBD 363 Surgeons = Charles Lund & Newton Browder
Current Management of Major Burns Incidence Injuries requiring medical Rx - 450,000 Deaths/yr - 3,400 Inpatient/year - 40,000 69% - Males 59% Caucasian, 20% AA, 14% Hispanic 72% Home, 9% work, 5% Rec. Source ABA National Burn Registry (2013)
Current Management of Major Burns Hospitals Caring for Burn Patients US Hospitals that advertise - 125 Verified Regional Burn Centers - 65 ¾ of admissions cared for in verified ctrs
Whom we serve Nearest regional burn centers are Dallas, TX Oklahoma City, OK and Phoenix, AZ
Burn Center 2000 total patients cared for at TJH Burn Center 750 patients admitted to hospital/yr 175 patients need operations to heal Each patient needs an avg. of 3.5 operations to recover
Current Management of Major Burns Improved outcomes Last 10 years Mortality 2012 3.4% (2003 5.3%) LOS 15% (1.5 days) Scar reconstruction procedures 50-75% Source: National Burn Repository Report 2012
Current Management of Major Burns Mortality Traditional - age + % TBSA = % risk of death Current 60 yr + 30% TBSA = 40% chance of death Many Regional Burn Centers report patients 80 & 90 yrs old with >10% TBSA discharged in functional state
Current Management of Major Burns Disaster Management Sarin gas attack Tokyo; Car bomb US Embassy, Nairobi; Train bomb Madrid; Station night club Rhode island What we know - ~1/3 who survive will be burned Avg. 10-20 major burn patients admitted to the hospital Average length of stay 2 months
Current Management of Major Burns Changes in Resuscitation Field delays to determine TBSA Confusion over the Parkland formula (2-4 cc LRxKgxTBSA) Fluid creep
Current Management of Major Burns Changes in Resuscitation Prehospital: <5 yrs 125 cc LR/hr (prior to accurate 6 yrs 13 yrs 250 cc LR/hr TBSA) 14 yrs 500 cc LR/hr Once accurate TBSA determined 1 st half over 1 st 8 hours 2 nd half of remaining 16 hours 14 yrs 2cc LRxKgX TBSA chemical or thermal <14 yrs 3cc LRxKgx TBSA any cause 14 yrs 4cc LRxKgx TBSA electrical
Example Resuscitation Formula 50 % TBSA (2 nd and 3 rd degree burns only) Age 28, 70 Kg. 2 ml X 80kg X 50 % TBSA = 8,000 cc Give 4,000 ml over the 1 st 8 hours (500cc/hr Give the other 4,00 ml over the next 16 hours (250cc/hr)
Oil Field Burns Up to 75% will have other types of injuries TBI, Long bone FX, Internal bleeding 1/3 of those will be discovered several days to weeks later Joint injury, dislocations, sprains
Oil Field Burns Last 12 months Injuries patients admitted (West Texas and Eastern New Mexico) Total pts. Received 173 Trauma 82 Burn 37 Trauma plus Burn 54
Oil Field Burns Electrical Contact
Oil Field Burns Electrical Up to 15% of oil field injuries Both Direct and Alternating Currents Small surface wounds may be associated with devastating internal injuries
Tissue conduction Flash Arc (burn or blast) Secondary ignition Thermal Contact Associated injuries Oil Field Burns Electrical - Types
Oil Field Burns Arc Burns
Oil Field Burns Electrical Tissue Damage Energy change due to resistance Highest dry epidermis Second Bone Electroporation cell wall damage
Oil Field Burns Electrical - Findings Loss of consciousness Paralysis or mummified ext. Loss of peripheral pulses Contact charring-jewelry, zippers, buckles Myoglobin pigment seen in urine
Oil Field Burns Myoglobin
Oil Field Burns Electrical Knowing voltage critical low vs high 1000 volts Arc injury can be very deceiving multisystem injury risk Secondary ignition immediate surrounding up to 4000 o Ass. Injuries tetanic contractions, cataracts
Oil Field Burns Lightening 80 to 100 deaths/yr in US Extremely powerful current Direct strike Side strike Flash over - feathering
Oil Field Burns Electrical - Unique Aspects Cardiac arrest potential Pigment release (myoglobin) Dark color of urine High urine output 1cc/kg/hr. alkalinizing urine or diuretics contraindicated
Oil Field Burns Chemical Enhanced Oil Recovery (EOR) Polymer flooding Surfactant polymer flooding Alkali surfactant polymer floodings up to 10% burned will have chemical component
Oil Field Burns Chemical cause of injury Skin injury with possible systemic absorption Ingestion Inhalation combination
Oil Field Burns Chemical Alkalis (high ph) liquefaction necrosis protein denaturation leads to continued damage Acids (low ph) coagulation necrosis protein precipitation thick leathery eschar
OIL FIELD BURNS CHEMICAL - SEVERITY Composition Concentration Temperature Volume Duration of contact
Oil Field Burns Chemical - Unique aspects Polyacrylamide neurotoxicity Sodium bicarbonate, sodium hydroxide Alkali potentiates absorption Surfactants phenols, alcohols, petroleum based, betains all highly absorbable and tissue toxic Especially liver, lung, kidney
Oil Field Burns Chemicals PROTECT YOURSELF
Oil Field Burns Chemical - treatment Dilution dilution dilution Avoid hypothermia Brush away powders
Oil Field Burns Chemical - special Anhydrous Ammonia Fertilizers, methamphetamine very strong Alkali Hydrofluoric Acid Fluoride = Calcium binder Severe pain RX Calcium - gels, injection, IV
Current Management of Major Burns NSTI Mortality reported to be over 20% Can be reduced by half with aggressive RX - Immediate recognition - Aggressive wide debridement - Repeat OR every day until wound clean - Skin graft once patient and wound bed healthy
Current Management of Major Burns SJS (TEN) Mortality should be extremely low with appropriate therapy Early DX with skin BX Biologic dressings Aggressive Critical Care NO steroids or prophylactic antibiotics