Management of Acute Burns

Presentation Outline

IntroductionTypes of burnsClassificationEstimation of extentABCs, incl. DEFFurther managementCommon PitfallsFurther Rx and PrognosisChemical and Electrical Burns

Introduction

2/3 of all burns happen at homeThe skin: Largest organ 15% of total body weight 1.7 m2

USA Statistics 1.2mil cases per year require attention 50 000 admitted 10 000 fatal

Types of Burns

Thermal burns Vast majority >80%

Chemical burns About 10-15%

Electrical burns About 1%

Classification

•Degrees vs Thickness

•1st, 2nd, 3rd degree

•Partial and full-thickness

•Moved away from Degree Classification

Classification

•Superficial Partial Thickness

•old 1st degree

•Epidermis only

•Resembles Sunburn

•No blistering

•Capacity to heal completely

Classification

•Deep Partial Thickness

•old 2nd degree

•Through epidermis, into dermis

•Pink, moist, blisters, very painful

•Some capacity to heal

Classification

•Full thickness burn

•old 3rd degree (and 4th)

•Through epidermis, dermis and connective tissue

•Appears leathery and dry and is not painful

•Has various colours

Estimation of Extent

• Adults

•Rule of Nines

•Head and Neck - 9%

•Thorax – 2x9% + 2x9%

•Arms – 9% + 9%

•Legs – 2x9% + 2x9%

•Perineum – 1%

•Children

•Palm surface = 1%

A is for Airway

Make sure the patient has an open airwayLook out for signs of inhalation injury Singed nasal hairs Hoarse voice Burns to lips and nose Soot in mouth/nose

May need early intubation/surgical airway due to airway oedemaPoor prognosis

B is for Breathing

Ensure adequate ventilationCircumferential burns may need escharotomyWatch for Carbon Monoxide poisoning Classic cherry-red but often not Ventilate with 100% O2

Pulse oximeter is not reliable (drop in 3% for up to 40% carboxyhaemoglobin)

C is for Circulation

Vast amounts of fluid loss from skinMonitor BP If shocked or >15% BSA partial thickness burns, or

>5% full thickness burns then give IV fluid boluses of Ringer’s Lactate (1litre over first hour minimum)

For children, >10% partial thickness burns require IV

Can get IV access through burnsPut 2 large bore IVsSecure Secure Secure the lines

D is for Dressings

Cover all burns with clean dry cloth initially Stops air drafts which are painful and increase fluid loss If possible, remove all dead tissue, incl burst blisters Don’t burst blisters Don’t apply cold water or cold gel burn-shield to extensive

burns

Flamazine is excellent with absorbent dressings Only needs changing every 1-2 days Can use cling-wrap over the dressings

…and D is for Drugs

Analgesia Morphine 1-2mg shots on as required IVI

Tetanus ToxoidMay require Ranitidine/OmeprazoleNO prophylactic topical or systemic antibiotics

E is for Exposure

Prevent Hypothermia Warm IV Fluids Use thermal blanket

Prevent Infection Regular handwashing with

hibitane/alcohol Don’t fiddle with dressings Insert NG tube due to gastro-colic stasis

(especially if over 20% BSA burns)

F is for Fluids

Calculate fluid resuscitation requirements Many formulas out there

Parkland formula 4ml x weight (kg) x %burn = ml of Ringer’s over 24 hr Half over first 8hrs (after burn, not arrival). Remainder

over next 16hrs Day 2 requires half the amount over 24hrs If NPO then must add normal daily requirements on

top (2-3 litres for an adult, calculate for children’s weight)

Only a guideline – must monitor response

Monitor response by urine output Pass catheter if necessary

Adults must pass >30ml / hour Paeds must pass >1ml / kg / hour

Further Management

Admit if: any burn over 10% in area, IV fluids for burns over 15% burns in special areas face, neck, hands, feet, perineum (need

referral to specialist ASAP) electrical burns any burn with history of smoke inhalation chemical burns full thickness burns where grafting is indicated (needs referral)

Laboratory investigations (where available) Electrolytes Blood gases Glucose Protein Haemoglobin (must be kept >12 g%)

Common Pitfalls

Pulmonary injury Needs early intubation

and ventilation

HypothermiaInadequate fluid resuscitationCircumferential burns

Compartment syndrome requires emergency fasciotomy

Further Rx and Prognosis

Wound debridementSkin graftingNeed nutritional supportRehabilitation

Prevent contractures Physiotherapy Psychological support

Bad prognosis Mortality rises exponentially above 30% burns If Age + Burn % >100 then survival unlikely ARDS Other injuries such as head injury Secondary infection

Chemical and Electrical Burns

Chemical Burns Copius irrigation >10 minutes Hydrofluoric acid – wet dressing with magnesium sulphate

paste and injection of calcium gluconate limits pain and damage

Phenol – Polyethyl alcohol to remove traces Phosphorous – Cover with petroleum jelly to exclude air, then

excise under GA ASAP

Electrical Burns Cause deep necrosis of muscle and thrombosis of vessels Can cause arrhythmias Watch for compartment syndrome Remove dead tissue as appropriate

“IN CASE YOU’RE FIRED”