MANAGEMENT OF BURNS

Scald Flame Contact Electrical Chemical Friction Radiation Frost burns

CAUSES OF BURNS

High incidence of burns in children under 5

Second peak in young men 15 – 35 years

Rising incidence in elderly population

AGE DISTRIBUTION

Jackson’s model of burn

Zone of Coagulation

Zone of Stasis

Zone of Hyperaemia

BURN PATHOPHYSIOLOGY

BURN WOUND CONVERSION

Over 48 hours

Immediate treatment given

First aidTotal Body Surface

AreaResuscitation

DepthLocation of BurnAgentAgePast Medical History

FACTORS DETERMINING THE SEVERITY OF THE BURN

First Aid Primary SurveySecondary Survey

INITIAL MANAGEMENT

Stop the burning process

Stop, drop, and roll

Remove clothing and jewellery

Remove from source of heat

FIRST AID

Cool the burn surface

Immediate cool running water

For 20 minutes

Within 3 hours of injury

No ice

First aid for ALL burns

FIRST AID

A. Airway management with C spine controlB. Breathing and ventilationC. Circulation with haemorrhage controlD. Disability / neurological statusE. Exposure + environmental controlF. Fluid resuscitation

PRIMARY SURVEY

Cervical spine protectionAirway Compromise

May not be initially obvious

Rapidly changingPotentially fatal

Consequence of direct injury or oedema

PRIMARY SURVEY – AIRWAY

Classification

1. Airway injury above larynx

2. Airway injury below larynx

3. Systemic Intoxication Injuries

INHALATION INJURY

Increases mortality by ~ 1.7 times

Flame burns

History of burns in enclosed space

Explosions

Burns to face, neck or upper torso

Unconscious patient

SUSPECT AN INHALATIONAL INJURY

Singed nasal hairCarbonaceous sputum or soot in

oropharynxSwelling of oropharynxChange in voice – hoarsenessCoughStridorDyspnoeaTachypnoeaReduced GCS

SIGNS OF AIRWAY INJURY

If potential compromise: Sit patient upright

Reduce oedema

Careful fluid administration High flow humidified oxygen Frequent reassessment Discuss with Burns unit

Intubate if airway compromised

AIRWAY COMPROMISED

Examine the chestPossible other injuries

Provide high flow oxygen Measure respiratory rateDeep Circumferential chest

burnsDo they need an escharotomy?

PRIMARY SURVEY – BREATHING

Carbon monoxide has greater affinity for haemoglobin than oxygen

Reduces oxygen carrying capacity of blood

Patients are classically “cherry red”

Often confused and disorientated

Pulse oximetry normalTreat with high flow O2

CARBON MONOXIDE POISONING

Carboxyhaemoglobin %

Symptoms

0 - 15 None15 -20 Headache

Confusion20 -40 Nausea

FatigueDisorientationIrritability

40 - 60 HallucinationAtaxiaSyncopeConvulsionsComa

> 60 Death

Inhaled products of combustionPlastics, wool, silk, nylon, nitriles, rubber, paper

20 times more toxic than Carbon Monoxide

Can cause immediate respiratory arrestCan result in reduced GCS

Treat with high flow oxygen

CYANIDE

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Assess circulation and perfusion Unburnt skin colour, temperature and

capillary refill Pulse and Blood Pressure

Obtain IV accessInsert 2 large bore cannulaeIdeally through unburnt skinCommence IV fluids

PRIMARY SURVEY - CIRCULATION

Circumferential full thickness burns Is the circulation compromised or

likely to become compromised? Elevate the affected area

Reduces swelling Half hourly neurovascular

observations May require Escharotomies

Call Burns Consultant for advice

PRIMARY SURVEY - CIRCULATION

ESCHARATOMIES

Assess Consciousness AVPU GCS

Altered consciousness can be sign of

Hypoxia Hypovolaemia CO intoxication

Look at Pupillary Response

PRIMARY SURVEY - DISABILITY

Remove clothing and jewellery

Assess the Burn Size

Look for other injuries

Keep patient warm

PRIMARY SURVEY – EXPOSURE / ENVIRONMENTAL CONTROL

Rule of Nines for adults

Lund and Browder chart

Patients’ palm represents 1% TBSA

ESTIMATION OF THE AREA OF THE BURN

AREA AGE 0 1 5 10 15ADULT

A = ½ OF HEAD 9½ 8½ 6½ 5½4½ 3½

B = ½ OF ONE THIGH 2¾ 3¼ 4 4½ 4½4¾

C = ½ OF ONE LEG 2½ 2½ 2¾ 3 3¼3½

LUND AND BROWDER CHART

Clean skin before assessing the burn

EXAMINATION OF THE BURN

The same arm 30 minutes after debridement

What colour is the burn?

Does it have a capillary return? If so is it normal?

Is there sensation? Is it normal?

Are there blisters?

ASSESSMENT OF THE BURN

SUPERFICIAL BURNS

Assessment of Superficial BurnsAppearan

ceCapillary

RefillSensation Healing

timeScarring

Dry and RedNo Blisters

Blanches Yes Within 7 days

No

SUPERFICIAL DERMAL BURNS

Assessment of Superficial Dermal BurnsAppearanc

eCapillary

RefillSensatio

nHealing

timeScarring

Pale PinkBlisters

Blanches Very Painful

Within 14 days

Colour match defect

Low risk of scar

MID DERMAL BURNS

Assessment of Mid Dermal BurnsAppearanc

eCapillary

RefillSensatio

nHealing

timeScarring

Dark PinkLarge

Blisters

Sluggish Painful 14 – 21 days

Moderate risk of hypertrophic scarring

DEEP DERMAL BURNSAssessment of Deep Dermal Burns

Appearance

Capillary Refill

Sensation

Healing time

Scarring

Blotchy RedFixed Stained

No Maybe - reduced

Over 21 days

High chance of hypertrophic scar

FULL THICKNESS BURNS

Assessment of Full Thickness BurnsAppearance Capillary

RefillSensati

onWill it heal?

Scarring?

White/leatheryBlack/charred

No blisters

No No No Yes

When to start IV fluid resuscitation

In Adults > 15% tbsaIn Children 18 months and older >10% tbsaIn Children less than 18 months >8% tbsa

PRIMARY SURVEY – FLUID RESUSCIATION

2mls x % tbsa x weight (kg)

Hartmann’s solutionCalculated from time of burn First half over initial 8 hoursSecond half over next 16 hours

Plus daily maintenance fluids = 2000ml

PRIMARY SURVEY – FLUID RESUSCIATION

Closest isotonically to the burn fluid that is being lost

Sodium chloride 0.6% Sodium lactate 0.25% Potassium chloride 0.04% Calcium chloride 0.027%

Ultimately any crystalloid fluid will do

WHY HARTMANN’S?

Insert Urinary Catheter

Monitor urinary output

Aim for 0.5-1ml/kg/hour

Adjust fluids accordingly

Inhalation and electrical injury 2ml/kg/hour

PRIMARY SURVEY – FLUID RESUSCITATION

82 kg man sustains 50% TBSA flame burn at 2am admitted today to your hospital 8am. How much fluid does he require?

2 x 50 x 82 = 8200mls of Hartmann solution 4,100 mls in first 8 hours i.e. by 1000 am4,100 mls in next 16 hours i.e. by 0200am the next day

WORKING EXAMPLE

2mls x % tbsa x patients weight (kg)

Adult – 2000ml in 24 hours

Children1st 10kg – 100mls /kg2nd 20kg – 50mls /kgOver 20kg – 20mls /kg

MAINTANENCE FLUID

Burning agent

Burning circumstances

Duration of burning

Clothing alight

Inhalation injury

Immediate First aid

Type and length

Medical History

Medications

Allergies

Tetanus status

Alcohol and drug use

Smoking

Occupation

SECONDARY SURVEY: HISTORY, ASSESSMENT

Pulse Blood Pressure(CVP) Urine output – aiming for 0.5

ml / kgSpecific Gravity - 1020Electrolytes

Oxygen saturation if indicatedArterial blood gases if indicated

MONITORING OF PATIENT

Urinary CatheterNasogastric Tube Pain ReliefClean and Dress WoundKeep warmOedema Control – elevation and compression Tetanus

ADJUNCTS

Nanocrystalline impregnated silver mesh, sustained released

For ALL burns in first 48 hours

ACTICOAT

Moisten Acticoat with water

Can apply Flaminal or Intrasite under

Secondary dressing wet gauze, jelonet, dry gauzeORDuoderm

ACTICOAT DRESSINGS

AnatomyBody surface area

Skin thicknessAirway

PhysiologyFluid management

Nutrition

Psychology

Epidemiology IncidenceAetiologyAge distribution

Burn pattern

BURNS IN CHILDREN

Children are not small adults!

NON ACCIDENTAL INJURIES

Suspicious FeaturesDelay in presentationIncompatible historyInconsistent historyOther signs of trauma

Pattern of injuryDemeanor Interaction

Toxin mediated diseaseCommon from Staph aureus

or Group A StrepCan occur from small burnYoung children usually

affectedDue to lack of antibodies

TOXIC SHOCK SYNDROME

Symptoms often presents like childhood viral illness

Pyrexia Rash Vomiting or diarrhoea Poor peripheral perfusion Hypotension

TOXIC SHOCK SYNDROME

ELECTRICAL INJURIES

Low Voltage <1000V

High Voltage >1000V Lightning

Voltage Skin Deep Tissue Cardiac Arrhythmias

Low Voltage<1000V

Local entrance and exit wounds

Unlikely Immediate cardiac arrest possible,Otherwise nil

High Voltage>1000V

Flashover burnFull thickness entrance and exit wounds

Muscle damage with rhabdomyolysisCompartment syndrome

Transthoracic current may cause myocardial damage and delayed arrythmias

LightningSuperficial or dermal flashoverExit burns on feet

Ear drum perforation and corneal damage

Respiratory arrest

ELECTRICAL BURNS

Taken from EMSB course

Ensure you are wearing correct PPEFirst aidRemove contaminated

clothingBrush off dry powderCopious irrigation

Check pH Keep irrigating until pH

normal

CHEMICAL BURNS

Small burns (2%) can be fatalAction of fluoride ions

Bind to Magnesium and CalciumVery PainfulCause Cardiac Arrhythmias and death

Irrigate with waterApply Calcium Gluconate 10% to wound

HYDROFLUORIC ACID BURNS

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> 10% TBSA in adults > 5% TBSA in children Any full thickness burn Any circumferential burn Respiratory /inhalation burns Infected burns Electrical burns Chemical burns Special areas: hands, face, genitalia, feet Burns with concurrent injuries/co-morbidities

REFERRAL CRITERIA FOR IMMEDIATE TRANSFER

For Adults – Fiona Stanley Hospital

Walk in clinic Monday – Friday 10amfsh.burnstelehealth@health.wa.gov.au

For Children – Princess Margaret Hospital

Call Ward 5B for appointmentpmhburnstelehealth@health.wa.gov.au

HOW TO REFER

Ensure the patient is stabilised prior to departure

Airway: Consider need for intubation

Breathing: High flow oxygen Sit with head up

Circulation: IV access, IDCDress the wounds: ActicoatPain reliefNG tube

PREPARATION FOR TRANSFER

Document everything andsend with patientIncluding your contact details

MANAGEMENT OF THE SMALL BURN

First aid – cold

running water for 20

minutes

Remove jewellery

Pain management

Tetanus

MANAGEMENT OF THE SMALLER BURN

Clean wound and debride blisters

Dressings – Acticoat for 48 hours

Oedema management

No antibiotics unless infected

Follow up

MANAGEMENT OF THE SMALLER BURN

SUPERFICIAL BURNS

Emollient / Sorbolene Analgesia

FURTHER TRAINING

Emergency Management of Severe Burns Course (EMSB)1 day course – 14th May 2016

More details at www.anzba.org.au/education/emsb

ANY QUESTIONS?THANK

YOU