Burns

Question 1

A 59 year old man is brought to the ED with 30% full thickness burns to his body in an outdoor fire. How would you assess and manage him?

Answer 1

Impression
In this patient with significant full thickness burns, am also contemplating other potential complications/injuries including;
- airway burns and subsequent obstruction
- smoke inhalation and CO poisoning

Goals
- Call for senior help, rapid assessment taking A to E approach to ensure HD stability and initiate emergent management as required

Question 2

Burns - Assessment

Answer 2

Assessment
- Call for senior help, move to resus bay
- Consider ICU/retrieval to burns unit

A - patent, maintaining. Low threshold for intubation if indication of airway burns (increasing oedema makes it harder). Consider use of nasoendoscopy to assess upper airway for evidence of burns, otherwise any indication of burnt facial hair, cherry red lips (CO poisoning), other facial burns, eschars, or audible stridor then intubate to secure airway
o anaesthetics involvement for difficult intubation

B - Given low sats would be starting supplemental 02 at Fi02 of 100% (given ?CO poisoning), then via ventilator If intubated. Consider administering nebuliser salbutamol if bronchospasm involved.
o suction for any particulate debris

C - as usual plus ECG, 2xIVC access for fluids, and bloods: ABG/VBG (carboxyhaemaglobin, Pa02 level, acidosis, lactate), cyanide level, FBC/UEC/LFT (baseline, organ damage, etc). IDC to monitor urine output.
o Manage burns with fluid resus via 2x large for cannulas
o administer fluid according to modified brooks formula, taking into account the SA of the body that has been burnt

D - GCS, as per the rest.

E - Exposure: looking for other burn sites, assessing for % of body covered, calling burns unit/plastics for input
o escharotomy to release constricting and unyielding eschars
o remove any burnt clothing, cool burnt areas with cool running water
o estimate extent of burns using rule of 9’s, and gauge thickness

Other immediate management
- pain relief
- early nutrition to avoid TPN, also improves morbidity/mortality outcomes

Question 3

Burns - Hx

Answer 3

History
- MIST AMPLE
- mechanism of injury

Factors affecting wound healing
- diabetes, immunocompromised, steroid medications

Question 4

Burns - Ex

Answer 4

Examination
- Head to toe assessment for further injury, characterising the extent of the burns

Question 5

Burns - Ix

Answer 5

Investigations
As per A to E

Question 6

Burns - Management

Answer 6

Management
acute stabilisation and precautions as per A to E assessment.
- referral to burns unit/plastics

Supportive
- Analgesia
- Fluid resus as per Modified Brooks Formula for ongoing maintenance fluids OR
- Parklands formula for fluid resuscitation, use Hartmanns.
- Topical antibiotics, other antibiotics not indicated unless evidence of infection - pseudomonas colonisation of a burn
- Oxygen therapy (Fi02 100% if CO poisoning)
- Tetanus prophylaxis
- antiemetics
- VTE prophylaxis

Definitive - wound management
- shaving
- irrigation with cool water
- escharotomy to prevent constriction and vascular compromise
- cleansing and debridement
- regular dressings (high intensity nursing)
- Plastics referral +/- skin graft