36. Burns

Question 1

What is a burn?

Answer 1

Tissue injury caused by thermal, chemical, electrical or radiation energy

Question 2

What is a scald?

Answer 2

A burn caused by contact with a hot liquid or steam

Question 3

Burns management.

a) A-E assessment
b) Further burns management

Answer 3

• Consider transfer to major burns centre if severe

Airway / Breathing.

• Protect airway - adjuncts as necessary
• High-flow 100% oxygen: 15L/min via NRB mask (especially if risk of CO poisoning)
• Assess for inhalation injury

Circulation.

• IV access
• Bloods: FBC, glucose, U+Es, carboxyhaemoglobin
• Assess for dehydration, hypotension, shock, etc.
• Assess cap refill, peripheral pulses, colour, neurology, etc.
• Monitor urine output
• Fluid deficit replacement indicated if BSA > 15% in adults and >10% in children (plus maintenance fluids)

Disability / Exposure.

• GCS
• ensure good temperature control (especially as cooling burns could result in hypothermia)
• ensure all body surface visible to assess extent of burns
• Pain relief (eg. opiates)

Further management

• Initiate cooling process
• Ensure clothing/adhesives removed
• Cleaning of wounds/burns
• Non-adhesive dressings applied
• ABx if any infections
• Tetanus status? - give IM tetanus vaccine if required

Question 4

Body surface area: rule of 9s

Answer 4

Adults:
- 9% each for the head and each upper limb; 18% each for each lower limb, front of trunk and back of trunk

Children:

• Cranium contributes 18% in < 1 year and leg only 14%
• Subtract 1% from head and add 0.5% for leg for each year above 1

Question 5

Depth of burn

• types
• for each: appearance, CRT/sensation, healing time/Rx

Answer 5

Superficial (epidermal)

• Layers involved: epidermis only
• Features: red, glistening, pain, absence of blisters and brisk capillary refill.
• Healing: Normally ~ 1 week, without scarring.

Superficial partial-thickness (superficial dermal)

• Layers involved: epidermis and SUPERFICIAL dermis
• Features: pale pink or mottled appearance with associated swelling and small blisters, may have a weeping, wet appearance, EXTREMELY SENSITIVE, brisk capillary refill.
• Healing: in 2-3 weeks with minimal scarring and full functional recovery.

Partial thickness (deep dermal)

• Layers involved: Epidermis and DEEP dermal:
• Features: blistering, dry, blotchy cherry red, doesn’t blanch, no capillary refill and REDUCED SENSATION.
• Healing: 3-8 weeks, with scarring; may require surgery

Full-thickness (third-degree).

• Layers involved: epidermis, entire dermis, touching subcutaneous layer
• Features: dry, white or black, no blisters, absent capillary refill and ABSENT SENSATION.
• Healing: requires surgical repair and grafting.

Fourth-degree.

• Layers: includes subcutaneous fat, muscle and perhaps bone.
• Requires reconstruction and, often, amputation.

Question 6

Burns: cooling process

Answer 6

• Remove any clothing and other chemicals, powders, etc.
• Cool the burn with running water from a cold tap for at least 20 minutes (avoid using ice or refrigerated water as this can cause further vasoconstriction and damage)
• Monitor for hypothermia (keep warm) and shock (keep hydrated)

Question 7

Inhalation injury.

a) Suspect in who?
b) Clinical features
c) Management

Answer 7

a) Anyone with:
- face/ neck burns, singeing of the eyebrows

b) - STRIDOR, hoarseness
- carbon deposits in sputum/oropharynx
- Carboxyhaemoglobin level greater than 10%

c) - Transfer to major burns centre
- A-E: early intubation and ventilation

Question 8

Carbon monoxide poisoning

a) Suspect in who?
b) Features
c) Investigations
d) Management

Answer 8

a) Anyone involved in a fire (especially in enclosed space)
b) Headache, nausea, confusion, coma, cherry red skin (note: skin changes are a very late sign: CO level > 20%)
c) - Serum carboxyhaemoglobin level
d) High-flow 100% oxygen: 15L/min via NRB mask