What is important in the Hx of burns
Time injury occurred Circumstances e.g. open or closed fire, RTA, explosion Co-existing injury - e.g. if jumped to escape Any first aid received How long in water Date of last tetanus PMH e.g. DM DH e.g. steroid / anti-coagulant Allergies Any analgesia given
What do you do as first aid
Stop burning process
Cool the burn
Cover the burn
How do you stop burning
Extinguish flame
Switch of power
Remove clothing
Diluate acid or alkali
How do you cool the burn
Cold running water for 20 minutes
Not ice cold as will cause vasoconstriction worsening
How do you cover burn
Wrap in cling film or place limb in plastic bag
How do you assess
Primary survey
ABCDE
A
Airway and C-spine
Low threshold for intubation esp if suspect inhalation as swelling will obstruct quickly
B -
Breathing
High flow O2 applied
Look for evidence of CO poisoning - cherry pink skin
Assess chest for circumferential burns
C
Direct pressure if bleeding Ensure limb perfusion / any eschar Pulse IV access 2 large bore cannula through unburned skin Start fluid resus - bolus immediate Catheter to monitor FBC, U+E, clotting, G+S, X-match, glucose Carboxy-Hb if suspect CO bHCG in female to ensure not pregnant Haematocrit - if high suggests more fluid needed ABG
D
AVPU GCS PEARL Consider head injury if any abnormal Beware of hypoxaemia / shock - causing restlessness and reduced GCS
E
Remove clothing and fully expose
Remove jewellery / piercing
Maintain temp as skin not working
Log roll
What is a big risk in burns
Hypothermia
Heat is lost as blister evaporates and normal capillary control is lost
F
FLUIDS
- Parkland formula
What are extra’s
X-ray for injury / bilateral infiltrate in ARDS May get trauma CT if blast injury Tetanus immunisation PPI for stress ulcers Mannitol / diuretic - excrete myoglobin NG Catheter to monitor UO Ax Arterial line for invasive BP monitoring
What is given as tetanus immunisation
Full 3 doses
Human IM Ig if never had before
Why is PPI given
Reduce risk of stress ulcer
What is mannitol / diuretic given for
Increase myoglobin excretion and prevent renal damage
When do you give Ax
If look infected
NOT in acute phase
What is NG for
If gastroporesis
What happens in secondary survey
AMPLE - Allergies - Medication - Past illness - Last meal - Events leading up to Examine for evidence of smoke inhalation Full body exam
What do you do think of after resus
Managemen to Burns
What are options for burns not going to 2nd care
Analgesia
Leave open + cover with emollient
Dress with non-adherent gauze and review in 24 hours
Cover with silver sulfadiazine
When do you leave open
Epidermal
When do you use non-adherent gauze
Superficial partial thickness
What should you do with ulcers
Leave
When do you refer to 2 care
All deep dermal and full thickness
All circumferential
If superficial partial >3% or >2% in children
If involved face, hands, feet or genitalia
Any inhalation
Any chemical or eletrical
If suspect NAI
When do you refer to Burn;s unit
Complex burns
Involves hand, perineum or face
>10% adults or >5% in children
What surgery can be done
Excision of non-viable tissue
Closure of wound with autograft
Escharotomy
Dressing changes under GA
What does Echarotomy do
Incision through burnt tissue to Improves ventilation Relive compartment syndrome Improve circulation Beware of damaging nerve
When do you do immediate surgery
If eyelids If circumferential If Escharotomy needed If debridement needed Closure of defects Skin graft
What is early surgery within 2-3 days for
Excision of non-viable tissue
Graft
What is late surgery usually for
Release of contractures
Post burn reconstruction
What type of excision
All necrotic
Tangential which shaves away non-viable tissue until viable is reached
General principles
Maintain core temp to prevent hypothermia
Avoid hypo or hypervolaemia
Minimse blood loss
What occurs post op
Splint to prevent contracture
Physio
When requires frequent adjustment to fluid balance
First 24-48 hours
What formula is used
Parkland
3-4ml x % BSA x weight (kg) = amount of fluid to be given in 24 hours
How do you give the fluid
Give 1/2 in 1st 8 hours from time of burn
Then give over half over next 16 hours
What is most commonly used fluid in burns
Hartmann’s
Human albumin
- Look at local trust
When do you give resus fluids
If>10% burn children
>15% in adults
What may be required if haemorrhaging
Transfusion
What do you do for kids
Modified Parkland 2ml instead of 4 Use 4,2,1, surgical fluid If <30kg will also need to add maintenance at constant rate (albumin / 5% glucose 0.45% saline) First 10kg = 100ml / kg Next 10kg = 50ml/kg Next 10kg = 20ml / kg
What fluid
Normal saline +- 5% dextrose
What should you monitor
Capillary glucose every 4-6 hours
How do you monitor fluid
Catheter for UO Central venous line BP HR ABG - if acidotic or high lactate suggests poor perfusion
Aim of UO
0.5-1ml / kg/. h
What is important to remember with Parkland
Only replaces the fluid lost by burns
Can still be dehydrated if no oral intake
Give fluid bolus
Review
When is escharotomy indicated
Any circumferential burns
Deep burns causing resp or vascular compromise
What bedside tests
Obs BP Urinanalysis - no protein Blood glucose May want ECG if electrical ABG if electrical
What tests
FBC, U+E, LFT
G+S + clotting if theatre
Bone profile if electrolyte / worry arrhythmia
CK and cardiac enzyme if thinking compartment / rhabdo
What is typically given for analgesia
Morphine
