Burns

Question 1

Pt presents with a burn, what is your imediate management?

Answer 1

• ABC
• Heat burn- remove from source, within 20 mins. Irrigate with cool water for 10-30 mins. Cover using cling film, rather than wrapped around limb
• Electrical burn- switch off power supply, remove the person from the source
• Chemical burns- brush any powder off and irrigate the burn

Question 2

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What are serious burns that need to be referred to a burn centre?

Answer 2

• Partial thickness burns of > 10 % total body surface area
• circumfrential burns
• involving face, hands, feet, genitalia, perineum or major joints
• full thickness burns in any age group
• electrical burns
• chemical burns
• inhalation injury
• burns + concomitant trauma where the burn injury is a greater risk of mortality or morbitity
• Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality
• Burned children in hospitals without qualified personnel or equipment for the care of children
• Burn injury in patients who will require special social, emotional, or rehabilitative intervention

Question 3

How to assess the extent of the burn?

Answer 3

• Rule of 9s
• Lund and Browder chart- most accurate method
• Palm of patients hand is roughly equivalent to 1% of total body surface area- not accurate for burns > 15% TBSA

Question 4

What is the rule of 9s?

Answer 4

• head and neck= 9%
• each arm= 9%
• each anterior part of the leg= 9%
• each posterior part of the leg= 9%
• anterior chest= 9%
• posterior chest= 9 %
• anterior abdomen= 9%
• posterior abdomen= 9%

Question 5

How to assess the burn depth?

Answer 5

• Superficial epidermal: red and painful, dry, no blisters
• partial thickness (superficial thickness): pale pink, painful, blistered, slow cap refill
• paritial thickness (deep dermal): typically white, may have patches of non- blanching erythema. Reduced sensation, painful to deep pressure
• Full thickness: white/ brown/ black in colour, no blisters, no pain

Question 6

What is an escharotomy?

Answer 6

• Indicated in circumferential full thickness burns to the torso or limbs.
• Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Question 7

Management of severe burns?

Answer 7

• AIRWAY: smoke inhalation can cause airway oedema, early intubation should be considered e.g. if deep burns to face or neck, blisters or oedema of the oropharynx, stridor
• IV fluids: in paeds if the burn is > 10% of TBSA and adults > 15 % of the TBSA
• Fluids calculated using parklands formula
• Urinary catheter should be inserted
• Analgesia should be given
• Complex burns should be transferred to burns unit
• Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

Question 8

When do you use conservative management for burns?

Answer 8

• superficial burns and mixed superficial burns
• will heal in 2 weeks

Question 9

Definitive treatment of complex burns?

Answer 9

• excision and skin grafting
• Excision and primary closure is not generally practised as there is a high risk of infection.

Question 10

Pathophysiology of severe burns?

Answer 10

• local response with progressive tissue loss and release of inflammatory cytokines
• Systemically- cardiovascular effects resulting from fluid loss and sequestration of fluid into the 3rd space
• marked catabolic response
• immunosupression is common with large burns and bacteral translocation from the gut lumen is a recognised event

Question 11

Complications of burns?

Answer 11

• immunosupression and resultant infection
• sepsis
• fluid loss/ hypovolaemia
• compartment syndrome (where a limb is involved)

Question 12

What is parklands formula?

Answer 12

4ml x total body weight x total body surface area affected
* 50% to be given in the first 8 hours SINCE BURN e.g. if they present 1 hour post injury, then the fluid is given over 7 hours
* 50% to be given in the next 16 hours

Question 13

What is the use of the Parkland formula?

Answer 13

• calculate fluid resuscitations

Question 14

Indications of fluid resusctiation in burns?

Answer 14

> 15% total body area burns in adults (>10% children)

Question 15

What is the aim of fluid resus in burns?

Answer 15

• prevent the burn deepening
• Most fluid is lost 24h after injury
• First 8-12h fluid shifts from intravascular to interstitial fluid compartments
• Therefore circulatory volume can be compromised. However fluid resuscitation causes more fluid into the interstitial compartment especially colloid (therefore avoided in first 8-24h)
• Protein loss occurs

Question 16

When do you stop fluid resuscitating a pt with burns?

Answer 16

• urine output is 0.5-1.0 ml/kg/hr in adults

Question 17

How to treat burns 24 hours post fluid resus?

Answer 17

• Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg))
• Maintenance crystalloid (usually dextrose-saline) is continued at a rate of 1.5 ml x(burn area)x(body weight)
• Colloids used include albumin and FFP
• Antioxidants, such as vitamin C, can be used to minimize oxidant-mediated contributions to the inflammatory cascade in burns
• High tension electrical injuries and inhalation injuries require more fluid
• Monitor: packed cell volume, plasma sodium, base excess, and lactate
  *

Question 18

Lightening learning: AR burn depths and their
classifications ?

Answer 18

Question 20

Pass med: Burns pathology
(Extensive burns) and some complications because of these

Answer 20

• Haemolysis due to damage of erythrocytes by heat and microangiopathy
• Loss of capillary membrane integrity causing plasma leakage into interstitial space
• Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after injury)- decreased blood volume and increased haematocrit
• Protein loss
• Secondary infection e.g. Staphylococcus aureus
• ARDS
• Risk of Curlings ulcer (acute peptic stress ulcers)
• Danger of full thickness circumferential burns in an extremity as these may develop compartment syndrome

Question 21

Pathophysiology of how burns heal

Answer 21

Superficial burns:
* keratinocytes migrate to form a new layer over the burn site

Full thickness burns:
* dermal scarring. Usually need keratinocytes from skin grafts to provide optimal coverage.

Question 22

What would be a clinical marker of when you can stop resusing a burns pt with fluids?

PASS MED

Answer 22

Resuscitation endpoint:Urine output of 0.5-1.0 ml/kg/hour in adults (increase rate of fluid to achieve this)