Burns
14/12/10
FANZCA Part II Notes
OHOA
Data Interpretation - Venkatesh
-
adults = fire
children = scalding
maybe associated with ET-OH, abuse, epilepsy or psychiatric problem
mortality is related to age (>50yrs), TBSA (40%) burnt and burn depth
CLASSIFICATION
Superficial – epidermis only
Partial – superficial (epidermis and upper layer of dermis), deep (extends to deeper layer of
dermis)
Full – all layers of dermis and may involve underlying tissue
METHODS OF ASSESSING EXTENT
Rules of 9’s
Palm of patient = 1% TBSA burn
Lund-Browder Chart
OTHER IMPORTANT ASPECTS
Resuscitation – airway patency, breathing, circulation, LOC
Adequacy of resuscitation to date – HR, BP, urine output, fluid received
Associated trauma
Airway burn or inhalational injury – stridor, burns to face, nose and mouth, carbonaceous
sputum
Facial and/or corneal burns, perineal burns
Circumferential burns – extremities -> compartment syndrome, ventilator inadequacy ->
escharotomy
Rhabdomyolysis
Inhalation of toxic gases – CO
Temperature
Adequacy of analgesia
Problems with vascular access
Evidence of drug/alcohol ingestion
Co-morbid conditions
MANAGEMENT
EMST/ATLS protocol – primary and secondary survey
Burn assessment and management – debridement by 48 hours
Transfer to definitive care facility
Jeremy Fernando (2011)
Primary Survey
Airway with C-spine control
- may need ETT quickly (use an uncut tube + wire to maxilla)
- warning signs include = singed nasal hairs, horse voice, productive brassy cough, soot in
sputum, stridor, facial burns, breathed fire, voice change.
- maximum wound oedema takes place @ 12-36hrs after injury
- FOB or nasoendoscopy
- Bronchoscopy - soot, charring, mucosal erythema, necrosis, airway oedema
- RSI
- sux ok for 24-48hrs then none for 2 days -> 2 yrs
- may need AFOI or surgical airway
Breathing with O2
- 15L/min + resevior bag
- may require ETT + IPPV because of other injuries, major resusication, sedation, ARDS &
analgesia, decreased pulmonary compliance
- protective lung injury
- NAC & heparin nebs
- suction
Circulation with haemorrhage control
-
>25% -> SIRS with oedema
IV access through intact skin where possible
IVF for >15% in adults & >10% in children
Hartmans is preferred
x-match units
may have to stop surgery to catch up
aim for PCV 0.3
Disability with assessment of neurological function
-
CHI
CO poisoning
ET-OH poisioning
analgesia
Exposure with temperature control
- remove all clothes
- if stuck to patient, cut around adherent areas
- keep warm
- assess %TBSA
- 1% = patients palm and fingers
- assess burn depth -> superficial = red and painful
deep = no capillary refill and not painful
- warm theatre (32 C)
- humidify (70-80%)
Jeremy Fernando (2011)
Secondary Survey
-
cool with running cold water (20min)
bronchoscopy for evidence of an inhalational injury (nebulized heparin and NAC)
watch for hypothermia
cover with clingfilm (limits evaporation, heats loss & pain)
IV morphine
escharotomy - limbs & chest wall
have lots of blood ready
watch for COHb -> will need 100% O2 or hyperbaric O2
ICU MANAGEMENT
Fluid replacement
- required in adult > 15%, children >10%
- Modified Parklands Formulae
-> Adults - 4mL/kg/%
-> Children - 3-4mL/kg/%
- give 1/2 in first 8hrs since injury
- give 1/2 in next 16hrs
+ normal maintenance!!!
- aim for urine output of 0.5mL/kg/hr and normal cardiovascular parameters
- then albumin after first 24 hours (keep albumin > 20)
- test for myoglobinuria -> if +ve then
(1) aim 1-2mL/kg/hr
(2) alkalinise urine with 25mmol of HCO3- for each litre of Hartmans
(3) promote diuresis with 12.5g mannitol to each litre of Hartmans
Dressings
- biobrane: superficial
- acticoat: partial
- subcut infusions: hypertonic saline + acetic acid (anti-pseudomonal)
Other issues
- N\J tube -> feed
- strict asepsis
- vigilance for nosocomial infections: line changes every 7 days
- tetanus
- antibiotics in initial period if dirty (frequently cooled at scene with dirty water)
- family discussion
- prognosis: age + TBSA burn should be less than 100.
- monitor for post burn leukopenia (cease silver sulfadiazine and use mafenide acetate, stop
cimetidine, consider G-CSF if doesn’t improve in 3 days)
Jeremy Fernando (2011)
Chemical Burns
- protect self with gloves, apron & facemask
- remove contaminated clothing
- neutralize or dilute with H2O (1hr)
Hyrdroflouric acid - topical calcuim gluconate burn gel + Biers block with 10-15mL of 10%
calcium gluconate + 5000U of heparin in 40mL 5 % dextrose
Phosphorus - copper sulphate solution
Bitumen - cool with H2O, remove with vegetable or parafil oil
Electrical Burns
- low voltage (<1000V) -> local contact burn
- high voltage (>1000V) -> entrance & exit wound -> may require fasciotomy
-> side flash = nearby lightening strike -> superficial burns, entry & exit burns +/respiratory arrest
- direct lightening strike -> often fatal
Jeremy Fernando (2011)