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Burns
Sept 2015East of England CT3 Days
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Burns - aims
♦ Skin♦ Types of burns♦ Management
♦ Burns♦ Associated bits
♦ Tips for children
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What difference does skin make?
♦ Function of skin♦ Thermoregulation♦ Fluid conservation♦ Protection
♦ Immune♦Physical
♦ Flexibility / movement
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Skin thickness
Superficial
Partial Thickness
Full...
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What is a burn?
♦ Burn ♦ Scald♦ Chemical♦ Electrical♦ Inhalation
♦ Other injuries
♦ Tetanus
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Superficial –
erythema (sunburn)
Partial thickness –
Pink
Blistered
White - sensate
Full thickness –
Charred
Waxy white
Insensate
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Treatment (First Aid)
A Airway
B Ventilation
C Fluid replacement
DE
Special considerations
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Airway & BreathingLoss of hair & eyebrows
Singed nasal hairs
Soot stained nose / lips
Confinement with fire
Blistered lips
Circumferential neck burns
Mucosal erythema
Hoarse voice / stridor
COHb
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Carbon Monoxide♦ Unexplained obtundation♦ “Cherry Red Lips”♦ Toxicity
♦ Varies♦ >10% indicates toxicity♦ Chronis vs Acute
♦ ?HBO
♦ Cyanide?
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C - Fluid loss
♦ Replace fluid loss from time of injury♦ Adults and children♦ Hartman’s solution
♦ Equation...♦ BSA♦ Parkland formula…
♦ Maintenance fluids
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♦ Shock♦>15% (Adult)♦>10% (Child)
♦ Resuscitation
♦ Maintenance
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Parkland formula4ml / kg / %burn over 24hrs…
=
2 ml x kg x %burn over 8hrs+
2ml x kg x %burn over 16hrs
Add in maintenance fluids4ml / kg / hr for first 10kg
2 ml / kg / hr for next 10 kg1 ml / kg / hr for rest of weight
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Example
♦ 10kg child with 8% burns
♦ 60ml / hr for 8 hrs= 20ml / hr plus 40 ml/hr maintenance
♦ 50ml / hr for 16 hrs = 10ml / hr plus 40 ml/hr maintenance
♦ Clinical parameters
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Treatment (First Aid)
A Airway
B Ventilation
C Fluid replacement
D Other injuries
E Exposure
Simultaneously
♦ Stop the burn / constriction
♦ Pain management♦ Dressings... ♦ Tetanus??
♦ Safeguarding
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Analgesia♦ Assessment and reassessment♦ Pain ladder…
♦ Opiates♦ Intra-nasal diamorphine♦ Intravenous morphine
♦ Oramorph?
♦ Oral analgesia♦ Non-drug methods
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Debridement?♦ Deroofing
♦ Smaller than patient’s little fingernail♦ Aseptic technique: Forceps & scissors♦ Clean with dilute chlorhexidine♦ Dressing
♦ Why♦ Decreases infection♦ Analgesia♦ Fluid lost in a controlled way
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Dressings?
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Special Considerations
♦ Joints♦ Circumferential burns♦ Hands / Feet / Perineum / Face
♦ Other Injuries♦ Inhalation of CO / CN
♦ Cyanokit♦ HBO?
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Follow-Up♦ “Major Burns” – Referral to 3° centre
♦ “Consider” if >1% partial thickness♦ Special considerations
♦ Minor Burns♦ By local arrangement♦ Less than 10% BSA♦ Demarcation / Healing
♦ Late referral♦ Not healing (> 2 weeks)♦ Depth♦ Unwell
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Referral criteria
Referral criteria – unwell patients
Fluid management
Sepsis / TSS
Useful telephone numbers
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Tetanus
♦ Tet Tox♦ Basic course ♦ Boosters♦ Exceptions
♦ Tetanus prone wounds
♦ Immunoglobulin
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Immunisation status
Clean Wound Tetanus Prone Wound (see definition below)
Vaccine Vaccine Human tetanus immunoglobulin (TIG) Alternative normal immunoglobulin product if TIGis unavailable
Fully immunised i.e. has received a total of 5 doses of tetanus vaccine at appropriate intervals
None required None required Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue)500 units (2ml) TIG IM
Normal immunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites.
Primary immunisation complete, boosters incomplete but up to date
None required (unless next dose due soon and convenient to give now)
None required (unless next dose due soon and convenient to give now)
Only if high risk(heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue)500 units (2ml) TIG IM
Normal ImmunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites.
Primary immunisation incomplete or boosters not up to date
A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)
A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)
Yes: one dose TIG at a different site.250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns
Normal immunoglobulinSubgam ® brand only 750mg IMorNormal ImmunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites
Not immunised or immunisation status not known or uncertain
An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity
An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity
Yes: one dose of TIG at a different site.250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns
Normal immunoglobulinSubgam ® brand 750mg IMorNormal immunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites
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Sepsis♦ Toxic Shock
♦ Staph aureus or strep pyogenes♦ Temperature>38°C♦ Rash♦ D&V♦ Unwell
♦ What are the subtle signs?♦ Poor appetite♦ Listless♦ “just not right”
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Safeguarding♦ Red flags
♦ Multiple ages / delay to presentation♦ Changing or bizarre history♦ Child’s history♦ Multiple presentations♦ Parental “pathology”♦ Interaction♦ Register
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Safeguarding
♦ Patterns of injury♦ Clear imprints♦ Cig burns♦ Dunking♦ Depth inconsistent with history
♦ Who do you inform?
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Questions?
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Summary
Treat first, question laterABCAnalgesia & fluidsSpecial considerationsTetanusSafeguarding
http://www.lsebn.nhs.uk/