12 - Burns Flashcards
What are the different types of burns and how is the severity of a burn assessed?
- Thermal
- Inhalational
- Electrical
- Cold contact
- Radiation
ALWAYS MASH REFER IN CHILDRNE BURNS IN CASE OF NAI
TBSA and Depth of burn
What is the steps of management in burns?
- Wound management
- Fluid resus
- Analgesia
- Referral to burns unit
What is the management of minor thermal burns?
- Cool
- Clean (inc deroofand debride dead skin if >1cm)
- Analgesia
- Dress
- Tetanus jab if needed
- Give advice e.g fluids, analgesia, elevate
- Reassess for infeection and redress
What is the initial management of the following burns:
- Thermal
- Electrical
- Chemical
A to E!!!
Heat: remove source. Within 3 hours of injury irrigate the burn with cool (not iced) water for 20 minutes. Cover the burn using cling film, layered, rather than wrapped around
Electrical: switch off power supply, remove from source, find entry and exit point
Chemical: brush any powder off then irrigate with water to neutralise, use pH strips
What are the different ways of assessing the extent of a burn? (TBSA)
- Lund and Browder Chart: most accurate
- Wallace’s Rule of Nine’s: different chart in infants
- Palmar Surface of Pt: 1% TBSA. Not accurate if >15%
Erythema is not included in TBSA
How do you assess the depth of a burn?
Superficial Epidermal: Skin red and painful, but not blistered. Cap refill blanches then rapidly refills
Superficial dermal (partial thickness): Skin is red or pale pink and painful with blistering. Cap refill blanches but regains colour slowly
Deep dermal (partial thickness): Skin dry, blotchy or mottled, and red, and typically painful There may be blisters. Cap refill does not blanch
Full-thickness: (into subcut tissue e.g muscle/bone Skin white, brown, or black with no blisters. It may appear dry, leathery, or waxy and is painless. Cap refill does not blanch
What are the key factors to use in assessing the depth of a burn?
- Colour
- Presence/absence of pain
- Blanching
- Blistering
What could be soon signs of inhalation injury, prompting you to consider intubation due to risk of airway oedema?
- Singed eyebrows or nasal hairs
- Sore throat
- Black carbon in sputum
- Hoarse voice
- Stridor
- Wheeze
- Signs of carbon in the oropharynx
TREAT ANY CO POISONING WITH 100% OXYGEN
Which burns need referral to secondary care?
- All deep dermal and full-thickness burns
- Superficial dermal burns >3% TBSA in adults, or >2% TBSA in children
- Superficial dermal burns involving face, hands, feet, perineum, genitalia, or any flexure
- Circumferential burns of the limbs, torso, or neck
- Any inhalation injury
- Any electrical or chemical burn
- Suspicion of NAI
Which burns need a referral to a burns unit?
What is the pathophysiology of why severe burns can be fatal?
- Following burn, there is a local response with progressive tissue loss and release of inflammatory cytokines so there is third spacing of fluids and hypovolemia
- Marked hypermetabolic response e.g increased cardiac output
-Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death
After initial A to E for severe burns (cool and cover), what are the next steps?
- High flow oxygenif not already given
- Fluid resuswith 2 large bore cannulas
- Catheter for fluid balance
- Monitor temperature
- Early debridement of dead tissue
- Admit to burns unit
When do patients need fluid resuscitation with burns?
- Burns >10% TBSA in children, >15% TBSA in adults
- Careful not to over resuscitate
- Insert a urinary catheter for fluid balance
What is the formula for calculating fluid resuscitation in burns patients and what fluid should you use?
2-4ml x Body Weight (kg) x Total Body Surface Area Affected (TBSA) (%)
Hartman’s or Ringer’s lactate
Needs to be done due to third spacing and hypovolemia
After 24 hours of fluid resuscitation in burns, what is the way to work the furthe resuscitation to do?
Colloid infusion: 0.5 ml x TBSA % x body weight (kg)
Maintenance crystalloid (usually dextrose-saline): 1.5 ml x TBSA x weight
Colloids used include albumin and FFP
What are the local complications with burns?
- Scarring (hypertrophic, and keloid)
- Contractures
- Infection
- Circumferential eschars
What are the systemic complications with burns?
- Haemolysis and anaemia
- Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after injury)
- AKI
- Protein loss
- Hypothermia
- Sepsis
- Secondary infection e.g. Staphylococcus aureus and TSS
- ARDS
- Curlings ulcer (acute peptic stress ulcers)
- Compartment syndrome
- DVT
- Psychological effects
What is the issue with circumferential burns and how may they be treated?
- Compartment syndrome
- Impede respiration
May require escharotomy to divide burnt tissue
What do you need to be careful of in burns with children?
Toxic shock syndrome
Usually 2-3 days after burn with viral symptoms
Why do we need to debride dead tissue from burns?
Prevent sepsis
What rehabilitation is done following major burns?
- High-calorie diet
- Physiotherapy
- Scar massage
- Change dressing every 48 hours and check for infection
- Psychological support
If a child becomes unwell after a burn (even minor ones) what do you need to consider?
TOXIC SHOCK SYNDROME
Will have flu/cold like symptoms
If a person has burns from a fire, what do you need to consider?
Inhalational injury and laryngeal oedema
Take ABG to check carboxyhaemoglobin
What is eschar?
Tight and leathery dead tissue caused by deep partial or full-thickness burns
When a constrictive eschar forms around the circumference of a limb it may constrict distal circulation causing limb ischaemia. If eschar forms around the chest it may prevent adequate chest expansion and cause respiratory distress
How can you assess perfusion in the area of a burn?
- Cap refill time
- Doppler US
What status do you need to check in all burns patients?
Tetanus and decide if need booster jab
How do different burns tend to heal (time-course)?
Superficial and superficial partial-thickness burns usually heal naturally within three weeks
Deep partial and full-thickness burns often require early excision of the necrotic tissue followed by a skin graft to aid healing and prevent hypertrophic scar tissue forming
When scars and contractures have matured from a burn, how can they be treated to improve the scarring/contracture?
How do acidic and alkali burns cause damage?
Acidic substances: coagulative
Alkaline chemicals: more extensive burns secondary to liquefactive necrosis
WILL KEEP BURNING UNTIL NEUTRALISED BY IRRIGATION
In electrical burns what are 3 important things to consider that may happen?
- Arrhythmias so do ECG
- Compartment syndrome as may have burnt whole limb
- Rhabdomyolysisso check CK levels
