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Residents need to discuss each inhalation patient with the attending on-call 

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Residents need to discuss each inhalation patient with the attending on-call 

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Is the damage to the respiratory tract or lung tissue from heat, smoke, or chemical irritants carried into the airway during inspiration

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Patient should always be on (2L oxygen) and pulse ox monitoring

Bronchoscopy/lavage

Mouth/nare care

Aggressive pulmonary toileting

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Management of Smoke Inhalation in Adult and Pediatric Patients

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Management of Smoke Inhalation in Adult and Pediatric Patients

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Derek Bell

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Emily Bruckel

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Different every month

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Taylor McEachon

Megan Barbato

Shauna Cole

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Taylor McEachon

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Kaylee Maynard

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Matt Humphery

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Caitlin Kloss

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Renee Madathil

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Tonia Canty-Mckinney

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Lydia Ciranni

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Marijana Koropanovska

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8AM rounds

Clinic 10:30AM-4:00PM

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Residents coordinate dressing time with nursing

Multidisciplinary rounds at 1pm via zoom or in person in the 328 classroom

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OR day

Residents defer wound care coordination to APP

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OR day

Residents defer wound care to APP

Multidisciplinary rounds via zoom 3:00PM

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Clinic 8:00AM-Noon

Doctor Bell and APPs off site in afternoon

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Burn team rounds Monday mornings at 8AM

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Monday Morning Instructions:

Charge nurse to coordinate ETA of Dr. Bell

If ETA 8AM:

Pre medicate patient's at 7:30AM with PO pain medication (if wanted by patient)

Have dressings down by 8AM

Surgical dressings to be taken down by burn team

Nursing can take down non-surgical dressings

Nursing can take out staples if instructed

Nursing in charge of redressing

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Charge RN to page covering provider regarding all patients to coordinate a time to see dressings down

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Consults:

OT/PT (ordered on admission),

Nutrition (ordered on admission)

Social work (ordered on admission)

APS (if needed)

Psych (if needed)

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Pain medication:

PRN PO Oxycodone

PRN IV Dilaudid

APS consult for better pain control (ketamine/PCA)

Adjunct pain regimen may include:

Tylenol, Advil, Gabapentin (standing or PRN)

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Labs:

Prealbumin & CRP 12-24 hours (Monday & Thursdays)

Not necessary to draw pre-op labs unless there has been a problem with the HCT or bleeding

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Monitoring:

Telemetry and continuous pulse oximetry if needed (Q1 interventions for 8 hours only).

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Best practice for patients with swollen extremities

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Post op dressing stays in place for 5 days

Begin graft care after take down

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Post op dressing stays in place for 5 days

Begin graft care after take down (see below)

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Do Not Use Water or Saline to loosen dressing during removal

Post op dressing stays in place for 7 days

Rylon (mesh) to stay in place

Reapply kerlix and ace wrap – tell patient to leave in place for an additional 7 days

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Post op dressing stays in place for 7 days.

Water can be used to loosen dressing. The removal should be atraumatic

Telfa clear should also be removed

Wash and rinse wound very gently with baby shampoo before reapplying dressing

Dress with Polysporin, xeroform, kerlix and acewrap if on a limb

Change dressing every day after initial dressing change

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Face/head care: TID, baby soap and warm water, moisturize with Vaseline. If facial hair present, shave daily.

Once facial burns are re-keratinized, Eucerin may be applied instead of Vaseline

Ear care: BID, baby soap and warm water, moisturize with Sulfamylon cream, wrap with gauzes or Vaseline gauzes

Ensure ear is dressed at all times, reapply cream as needed

Hands: Wash with Chlorhexidine and rinse with warm water, apply a generous amount of Polysporin followed by edema gloves, reapply Polysporin throughout the shift to keep hands moist

Body: Wash with Chlorhexidine and rinse with warm water, apply Polysporin, xeroform, kerlix, gauze, ACE wrap/surgilast

Remove all dead/ excess skin to promote faster wound healing and prevent scarring

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Clean area with mild soap antimicrobial soap (chlorhexidine to body or baby shampoo for face) and water

Gently dab grafts. DO NOT SCRUB. This will prevent lifting of the graft.

Apply a generous amount of Polysporin

Dress with xeroform, kerlix and ace wrap if on a limb

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A microbial colony encased in a polysaccharide matrix which can become attached to a wound surface

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This can affect the healing potential of wounds

Scrub off biofilm from burns to promote wound healing

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Mepilex Ag: Leave in place 10-14 days reinforce dressing if needed.

Contact provider if dressing falls off or unable to reinforce.

Xeroform: Provider needs to remove ace wrap 24 hours post op and non-adherent dressing (considered a surgical dressing). It should be stapled in place over the donor site, do not remove staples until post op day 5. Lifted/ dried xeroform can be trimmed but never removed in full.

Allow xeroform to air dry. Instruct patients to have legs open to air at all times, can use fan to help air dry.

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All burn patients should have a nutrition consult

Supplements: Juven, Liquacel, Ensure, Vitamins

Educate patients on need for increase protein intake

Potential DHT placement/tube feed order if prealbumin is trending down or <13

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Renee Madathil, PhD: Attending Psychologist for the inpatient burn unit

Sub-Specialties: Rehab Neuropsychology

Faculty Appointment: Associate Professor of Psychiatry and Surgery

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Assesses and recommends treatments for psychological issues encountered by burn patients and their families

Addresses a range of concerns, such as:

Pain control

Behavioral issues

Mood/Anxiety

Health care engagement

Cognitive functioning

Integrated member of the Multidisciplinary Team

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Typically conducts initial evaluations on primary burn patients automatically, without a formal consult

Decides when psychiatry consultation and medication may be necessary

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Leads a research program related to psychological adaptation to illness, injury, and disability

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DO NOT Enter a Patient's Room for Painful Procedure Without a Plan

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DO NOT Enter a Patient's Room for Painful Procedure Without a Plan

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Premedication is a must: Always create a game plan with the nurse for premedication before any painful procedure (e.g., post-op dressing change).

Check-in with the Bedside Nurse: Once on the unit, confirm with the bedside nurse that the patient has been pre-medicated.

Collaborate on Pain Management: Discuss any other approaches the patients may need beyond medication. Our burn nurses know the patient's pain tolerance better than anyone on the team.

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Burns Hurt- No Need to "Tough It Out"

Burn patients don't need to prove their toughness- burns and treatments are incredibly painful and distressing

Always assume that burn patients will experience substantial pain and prepare accordingly

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Physiologically, pain transmission is the same across all patients, regardless of age or health status

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Individual responses to pain differ based on factors such as:

Psychological makeup

Ethno-cultural background

Personal meaning of the injury

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A stoic individual or an infant doesn't experience less pain- they just express it differently

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It can occur in burn patients while hospitalized. The CNS becomes hyperresponsive to both nociceptive (painful) and non-nociceptive stimuli, leading to heightened pain perception.

For burn patients, this is a significant concern because:

Repetitive Painful Stimuli: Frequent procedures like dressing changes and physical therapy can worsen sensitization.

Prolonged Hospitalization: Longer stays increase the risk.

Psychological Factors: Stress and emotional impact can intensify pain perception.

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Beyond Medications: If a patient struggles with pain, consult the psychologist for an additional approach.

Additional Techniques Include:

Psychological Intervention

Virtual Reality

Music Therapy

Psychiatry Consults

Acute Pain Service Consults

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PT/OT needs to be reordered post-op with updated weight-bearing status and ROM limitations

Use figure 8 technique and elevate burned extremities to decrease swelling

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Usually no restrictions, gentle ROM okay

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Usually WBAT, gentle ROM

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NWB, very cautious with touch to extremity

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Depends on severity/location for WBing and ROM

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Depends on location

If splinted, assume NWB (page covering to clarify)

Shoulders/proximal UE: Usually WBAT

Hands/wrists/elbows: Usually splinted and NWB

Thighs/knees: Usually WBAT

Feet/ankles: NWB if spinted

With VACs: Usually WBAT but may NWB if crosses a joint

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Come down post op day 5 with burn attending present to assess graft take

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Grafted areas are then redressed with polysporin, xeroform, kerlix and ace

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Once keratinized, eucerin is all that's needed

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24 hours without IV dilaudid

Able to tolerate burn care with PO medications

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Patient able to demonstrate competency in burn care

If not able to do burn care on own, someone reliable needs to demonstrate competency in burn care

Send patients home with enough wound care supplies until follow up appointment is established

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Social work and care coordinator involved regarding social issues

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Patients who have had grafting and going home need a scheduled appointment made prior to discharge for POD 5

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Upon discharge, educate your patients on community burn resources

Finger Lakes Regional Burn Association (FLRBA)

https://www.flrba.com/

Phoenix SOAR

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Phoenix SOAR (Survivors Offering Assistance in Recovery) connects survivors and loved ones with others who have experienced similar trauma.

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Clarify with team which recs should be followed (burn vs. derm)

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Description:

Involves detachment of >30 percent of the body surface area (BSA)

Mucous membranes are also involved in 90 percent of patients

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Description:

Rare skin condition that causes large, fluid-filled blisters

They develop on the areas of the skin that often flex, such as lower abdomen, upper thighs or armpits

Most common in older adults

Occurs when your immune system attacks a thin layer of tissue below your outer layer of skin, this abnormal immune response is unknown

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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

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Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

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Description:

Can have a broad range of symptoms: fever, rash, facial swelling, enlarged lymph nodes, kidney or liver injury

Most will have an abnormal level of blood cells called eosinophils

Thought to be caused by an allopurinol metabolite called oxypurinol

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Description:

Skin detachment is <10 percent of the body surface

Mucous membranes are affected in over 90 percent patients, usually at two or more distinct sites (ocular, oral, and genital)

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Click on link to learn more about Electrical Burns and what to watch out for!

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What is an electrical burn? - This is a skin burn that happens when electricity comes in contact with the body.

When electricity comes in contact with the body, it can travel through the body. When this happens, the electricity can damage tissues and organs. This damage can be mild or severe, and it can even cause death. Organs that are commonly damaged include the:

●Heart - People can get abnormal heart rhythms. The heart can also suddenly stop beating, which is called "cardiac arrest."

●Bones and muscles - If the muscles are severely injured, substances from inside damaged muscle cells can leak into the blood. This is called "rhabdomyolysis." In some cases, it can cause injury to other organs. People can also get an abnormal buildup of pressure in a group of muscles, called "acute compartment syndrome."

●Nervous system - People can pass out, stop breathing, have nerve damage, or have muscle weakness.

What are the symptoms of an electrical burn? - The symptoms depend on the type and how much electricity came in contact with the body and how long the contact lasted.

Electricity can cause different types of skin burns, depending on which skin layers are affected. The terms doctors use to describe different types of burns are:

●Superficial burn - This affects only the top layer of the skin. The skin is red, dry, and painful. When you press on the burn, it turns white.

●Partial-thickness burn - This affects the top 2 layers of the skin. The skin is red and can leak fluid or form blisters.

●Full-thickness burn - This affects all of the layers of the skin. The burn doesn't usually hurt, because the burned skin can't feel anything. The skin can be white, gray, or black.

Other symptoms depend on whether or not you have damage to your internal organs.

Should I see a doctor or nurse? - Yes. If you get an electrical burn, see your doctor or nurse right away. That's because an electrical burn sometimes causes mild skin damage, but there can still be severe internal organ and tissue damage.

Sometimes, children get a burn on the side of their mouth from chewing an electrical or extension cord. This type of burn needs to be seen by a doctor right away. It can bleed a lot, even days to weeks after the burn first happens, and leave a scar.

Will I need tests? - Probably. Your doctor or nurse will ask about your injury and do an exam. They might order tests to check for organ damage. Tests can include:

●Blood tests

●Urine tests

●Electrocardiogram ("ECG") - This measures the electrical activity in the heart ( figure 1).

How is an electrical burn treated? - Treatment depends on the type of skin burn you have and how serious it is.

Treatments for a mild skin burn can include:

●Cool the burn - You can put a cool cloth on your burn or soak it in cool (not ice) water. Do not put ice on a burn. Do not soak the burn for longer than 15 minutes.

●Cover the burn with a clean bandage - Your doctor might also recommend or prescribe a cream or ointment to soothe the skin or prevent an infection.

●Treat the pain - You can raise the burned part of your body above the level of your heart. For example, you can prop your foot or leg up on pillows. You can also take an over-the-counter pain medicine, such as acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin).

●Get a tetanus shot, if it has been too long since your last one.

A severe skin burn is usually treated in the hospital. Treatments can include:

●Strong pain medicines

●Special bandages

●Antibiotic and other types of creams or ointments

●Surgery to repair the burned area

Your doctor will also treat any problems you have from damage to internal organs.

How can I prevent an electrical burn? - To help prevent you or a family member from getting an electrical burn, you can:

●Put child safety covers on all electrical outlets.

●Keep electrical cords out of the reach of children.

●Follow the directions when using electrical appliances.

●Do not use electrical appliances in the shower or bath.

●Turn off the circuit breaker when you are working with electricity.

More on this topic

Patient education: Skin burns (The Basics)
Patient education: Sudden cardiac arrest (The Basics)
Patient education: Rhabdomyolysis (The Basics)
Patient education: Acute compartment syndrome (The Basics)

Patient education: Skin burns (Beyond the Basics)

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Patient education: Electrical burns (The Basics) - UpToDate

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All topics are updated as new evidence becomes available and our peer review process is complete.

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Burn should be consulted for extravasation injuries

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Prevention and Treatment of Intravenous Extravasation of Non- Antineoplastic Agents in Adult and Pediatric Patients

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Prevention and Treatment of Intravenous Extravasation of Non- Antineoplastic Agents in Adult and Pediatric Patients

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Early recognition and reporting signs and symptoms of sepsis

Strict aseptic technique when providing burn/wound care

Perform optimal level of burn care with maximal wound debridement

Early mobilization and pulmonary toileting to prevent lung infection

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Click on the link to learn more about inhalation injuries and what to watch out for!

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Inhalation injury from heat, smoke, or chemical irritants - UpToDate

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Inhalation injury or smoke inhalation injury remains one of the leading causes of death. The pathophysiology, clinical features, diagnosis, initial management, subsequent management, and special considerations of inhalation injury are reviewed here.

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>20% TBSA burn

Need fluid resuscitation (strict I&Os)

Hourly vital signs

Inhalation injury requiring intubation

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This is a two person procedure with one person securing the tube during the taping procedure (video illustrates procedure on a mannequin) 

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URMC Kessler Burn Center Adult Burn Resuscitation Protocol Fluid Calculation Sheet  

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URMC Kessler Burn Center Adult Burn Resuscitation Protocol Fluid Calculation Sheet  

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Adult Burn Resuscitation Protocol Worksheet

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Adult Burn Resuscitation Hourly Worksheet 

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Adult Burn Resuscitation Hourly Worksheet 

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Adult Burn Resuscitation Hourly Worksheet 2

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The body surface is divided into areas representing 9% or multiples 

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PolicyStat ID: 10202920

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Cassandra Davis

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CBRN Study Materials – American Burn Association

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Certified Burn Registered Nurse (CBRN) Notes

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Password: 32800

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Call Tracy Bissel x55931

Leave a message with patient name, DOB, and that it is placed in the soiled utility room on 318

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Jenn Frenzel

jfrenzel@solventum.com

585-978-6417

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Cleared by the multidisciplinary teams involved

GOAL: Safe discharge