Management of Acute Burns

Dr Stephen Oakey

Consultant in Anaesthesiaand Burns Intensive Care

St Andrew’s CentreApril 2014

St Andrew’s Centre for Plastic Surgery and Burns

Broomfield Hospital,Chelmsford, Essex.

Overview

Pathophysiology of Burns First Aid and Safety A&E Management

Assessment and Stabilisation Transfer to Regional Burns Unit (RBU) ‘Specialist’ Treatment

Incidence Of Burn Injury

250 000 burn injuries in UK per year 16 000 admissions in UK per year 300 deaths in hospital following burn in

UK per year (most >60 years) National Burn Care Review, 2000

700 admissions to St. Andrews per year 100 shocked patients 60 ventilated patients (15 paediatric) Length of stay 1 day/ % burn

Aetiology

Pathophysiology

3 Zones of a Cutaneous Burn (Jackson 1947) Coagulation

Coagulation of proteins Irreversible tissue loss

Stasis Decreased perfusion Can convert to complete tissue loss

Hypoperfusion Infection Oedema

Hyperaemia Increased perfusion Usually recovers

Pathophysiology

Systemic response to burn injury

First Aid and Safety

Common causes of major burns House Fires

Fire Alarms Don’t smoke in bed

RTC Bonfires and Barbeques

Petrol Self Immolation

Drop and roll!

Prehospital Management

Remove source of heat ABC

Exclude non-burn causes of shock Cool (if burn is localised)

Cold running water Ambulance ‘gel’ dressings are designed for 15

minute use Cover with clingfilm Keep warm!

Prehospital Management(HEMS)

Airway Burn Hoarse voice, stridor, soot in mouth/nose

Low threshold for intubation If burn in oropharynx, will always get worse Normal looking airway deteriorates rapidly Unable to assess in back of ambulance Easier to intubate on scene

Scalds to face with no intra-oral component rarely need intubating

Prehospital Management(HEMS)

Expect difficult intubation if face burnt Inability to open jaw Surgical airway not easy either!

Escharotomy? To chest only if ventilation significantly

impaired

A&E Management

A&E Management

Identify inhalation injury?

Carbonaceous sputum

Face and neck burns

Inflamed oropharynx and hoarseness

Carbon deposits

Hair singeing

CO Hgb > 10%

A&E Management

Airway Including C-Spine control Assessment by

appropriate person Anaesthetic SpR or higher Experience of burnt

airways Early intubation

May be very difficult C-Spine immobilisation Sux OK to 18 hours

Use UNCUT tube

A&E Department

Breathing 100 % Oxygen via reservoir mask Nebulised salbutamol as needed Exclude chest wall trauma/pneumothorax Escharotomies if compliance high

Bleeding!

A&E Department

Breathing Inhalation Injury

Exposure to hot gases and products of combustion Thermal and chemical

injury History

Burn in enclosed space Loss of consciousness at

scene Drugs, alcohol, head

injury, hypoxia Cyanokit?

Breathing Inhalation Injury Protocol for 5-7 days

Salbutamol 2.5 – 5.0 mg Neb 2-hourly

20% Acetylcysteine 3mls Neb 4-hourly

Heparin 5000iu in 3mls Saline Neb 4-hourly

A&E Department

A&E Department

Circulation If shocked, look for causes other than burn! 2 x 14g cannulae – through burn is OK Avoid repeated attempts at central access

Precious sites Treat hypotension empirically Start a burn resuscitation fluid regime

In addition to maintenance and resus fluids Backdate to time of burn

Fluids

Fluids

Fluid Resuscitation Formulae

Parkland 4 ml/kg/% burn balanced salt.½ over 8 hrs, ½ over 16 hrs

Muir Barclay 0.5 ml/kg/% burn 4.5% HASeach in periods of 4-4-4-6-6 hrs

Galveston 24 5000 ml/m2/day PLUS2000 ml/m2 of burn/day.½ over 8h and ½ over 16h

Galveston 48 1500 ml/ m2/day PLUS3750 ml/m2 burn/day½ over 8h and ½ over 16h

Fluid Resuscitation Formulae

Modified Parkland(St Andrew’s)

1st 8 hrs:0.25 ml/kg/% burn/hour of Hartmann’s

Next 16 hrs0.1 ml/kg/% burn/hour of Hartmann’s

Fluid Resuscitation Formulae

Example: 80kg patient with 50% TBSA Burn First 8 hours:

0.25 x 80 x 50 = 1000 mls/hr! 8 – 24 hours:

0.1 x 80 x 50 = 400 mls/hr!

Children get maintenance fluid in addition to calculated burn resuscitation fluid!

A&E Management

Disability Accurate GCS and history Suspect head injury Document all neurological abnormalities

Patients may be ventilated for weeks Legal considerations

A&E Management

Exposure …and environmental control Estimate burn size – rule of 9s Cover burn with Clingfilm Escharotomies if needed – but consider blood

loss KEEP WARM – blankets and hot air blowers

Est

imate

Siz

e o

f B

urn

Rule of 9s(Differs for Children)

Est

imate

Siz

e o

f B

urn

Lund and Browder Charts

Estimate Size of Burn

Palm + Fingers = approximately 1% BSA

Estimate Size ofBurn

Estimate Depth of Burn

Difficult Bleeding on pin-prick Sensation Appearance Blanching to pressure Laser Doppler

Superficial

Epidermis only

Partial Thickness

Superficial Dermal

Deep Dermal

Full Thickness

Involves subcutaneoustissues

Estimate Depth of Burn

Superficial - Erythema(1st Degree)

Soot (Not Burn)

Partial Thickness Burns(2nd Degree)

Full Thickness Burn(3rd Degree)

A&E Management

Secondary survey Head to toe Clarify history

When, Where, How, What type, Clothes, First aid? Past medical history, Tetanus prophylaxis? Nil by mouth (or start feed ?) NG and NJ tubes

Referral to RBU Adult > 15%, Child > 10% Significant areas (Hands, face, genitalia etc) Inhalation injury ANY other concerns

Transfer to RBU

Not always immediate priority – stabilise first

Most dangerous time for patient Right person Right kit Right mode of transport (Probably NOT

helicopter) Right communication

Bring notes, X-rays, scans, fluid charts, nursing obs. etc

Transfer to RBU

Transfer to RBU

Transfer to RBU

All interventions before entering transport Do not intubate on hard shoulder of A12

Keep warm Blankets, foil if already warm Temp high in vehicle – difficult Remove ‘cooling’ devices

Keep wet Fluids. If in doubt, give some more Clingfilm

Admissions Room

Airway Tube position and length

Breathing Adequate ventilation Bronchoscopy

Circulation IV-access Sterile central venous line and

sterile arterial line Maintenance and Resuscitation

fluids

Anaesthetists

Admissions Room Anaesthetists

Sedation and analgesia M&Ms (Morphine and Midazolam) Propofol and Remi if early extubation

predicted Feeding access

NG-tube for decompression NJ-tube for feeding

Monitors MAP, CVP, Temp, urine, ABG’s, CO

Admissions Room Surgeons

Admissions Room Surgeons

Swab All body areas

Clean Whole body with Betadine

Shave Hair of head

Photos Burn size and Depth

Accurate assessment +/- Laser Doppler Treatment plan

Escharotomies +/- immediate surgery

ITU ManagementThe Burn Wound

Skin Largest organ in the body

15% of the bodyweight Covers 1.7 m2 in the average adult

Problems arise from loss of organ function: Protection from infection Temperature Control Fluid homeostasis

ITU ManagementThe Burn Wound

Source of virtually all ill effects (local and systemic) seen in a burned patient

Early surgical removal of the burn wound results in a much improved survival and a decline in morbidity

ITU ManagementThe Burn Wound

Necrotic cells and denaturated proteins

Release of inflammatory mediators

Local and systemic response

Burn ShockHypodynamic Phase (First 24-48 hours)

Plasma volume Cardiac output Systemic vascular resistance (SVR)

Result: Blood pressure Perfusion Urine output Oxygen delivery

Some response to fluid challenge

Burn ShockHyperdynamic Phase (From 24-48 hours on)

SVR Pathological inability to respond to

hypovolaemia with vasoconstriction Energy expenditure Immune status Cardiac output Urine output Poor response to fluid

Easily overloaded, oedema formation

Fluid ResuscitationComplications

Too Little Hypovolaemia Shock Renal failure Multi-organ

failure (MOF)

Too Much Pulmonary oedema Cerebral oedema Gut/Liver oedema Compartment

syndrome Abdomen Limbs

Fluid ResuscitationIncreased Requirements

Delayed or inadequate resuscitation Deep burns Petrol burns Electrical burns Inhalation injury Child

Surgical ManagementEarly Excision

Team 4-6 surgeons 2 anaesthetists 1 ODA 4 nurses

Theatre Conditions 32C ambient temperature Radiant overhead heater Minibar

Drink every 30 min to prevent dehydration and headache

Surgical ManagementEarly Excision

Tangential excision of dead tissue Infiltration with saline/adrenaline or

saline/phenylephrine solution into donor areas To reduce bleeding

Tourniquets used for excision on arms and legs Often 2-3 teams simultaneously

Quicker Higher rate of blood loss!!

Surgical ManagementBlood Loss

Can be massive! > 2x circulating volume Insidious

No filling of suction bottles Blood in fridge on the Unit before knife to skin

Surgical ManagementAnaesthesia

Intensive care treatment concurrent with surgery Continue Analgesia and sedation Continue NJ-feeding if tube position confirmed Continue calculated fluid requirements through

pump Add intraoperative losses

Pharmacokinetics of all drugs changed significantly

Further ITU ManagementInfection in Burns

Up to 75% of mortality in burns patients is related to infection.

Contributory factors: Destruction of the skin or mucosal surface barrier

allows microbial access Presence of necrotic tissue and serosanguinous

exudate provides a medium to support growth of micro-organisms

Invasive monitoring provides portals for bacterial entry

Impaired immune function allows microbial proliferation

Ongoing Trauma in the ITU

Most trauma patients get single ‘hit’ followed by predictable recovery phase

Burns patients receive recurrent ‘hits’ from Hypermetabolic state Burn wound toxicity Repeated surgical procedures Repeated dressing changes and showers Massive fluid shifts

‘Having been hit by the bus, patients get repeatedly reversed over, until the burn wound is healed’

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Summary

Basic first aid pre-hospital ATLS trauma call for all burns Early intubation with uncut tube

Keep warm and give some fluids

Safe transfer to RBU

Summary

Stabilise and optimise cardiac/fluid status

Early total excision Watch for repeated pathophysiological insults

AnyQuestions….

…and the kitten gets it!