Burns

Question 1

Learning Points

Answer 1

By reading this article you should be able to:

1. Describe the epidemiology of major burn injuries and the possible mechanisms of injury.
2. Recall the structure and function of the skin.
3. Use burn depth classification and surface area to assess a patient’s burn wound.
4. Describe the initial management of a major burn.

Question 2

Key Points

Answer 2

1. An adult with a major burn, defined as >15% of total body surface area burned,
   will require resuscitation and care at a specialised burns service.
2. Depth of burn is assessed by the degree that the dermis has been affected
   and determines subsequent surgical management.

3.Major burns have local tissue and wider systemic effects.
In burns >25% total body surface area,
a systemic inflammatory response occurs.

4. Timely but safe transfer to a specialist centre is often required
   with attention to airway, invasive catheters,
   fluids and temperature maintenance
5. Early surgical management with
   total or near-total burn wound excision in <48 h of injury
   has been shown to decrease blood loss,
   burn wound sepsis and length of stay.

Question 3

Epidemiology
Risk factors

Risk prediction

Answer 3

Low socioeconomic status;
overcrowding; households where young girls have domestic roles;

kerosene;
generalised poor health; and poor safety practices

Burns are a preventable injury and strategies to decrease the incidence focus on awareness,
education and health and safety legislation.

revised Baux score, which takes into account age, %TBSA burned and the presence of inhalation injury.

The point of futility with 21st century burn care is now 160 and the Baux50 (the Baux score at which predicted mortality is 50%) is 109.6

Question 4

Pathophysiology

Answer 4

The epidermis cannot regenerate without the presence of dermal tissue

Epidermis
1. Fluid Loss
2. Barrier to micoorganisms
3. Immune system activity
4. Neurosensory

Dermis
Rregulation Body temp
-dermal vascular plexus
-Sweating
- Piloerection

Responsible for skin druability and flexibility

Question 5

Classifcation

Answer 5

1. Superficial
   Upper Dermis damaged -
   Vascular plexus and adnexal structures intact
2. Deep partial
   Deep dermis
   affecting vascular plexus
   not all dermis destroyed
   Deep adnexal intact
3. FUll thickness
   Extended entire thickness of dermis
   no dermal tissue remains

Question 6

Clinical characteisitcs

Answer 6

1. Superficial Partial thickness
   Pale pink moist
   Blisters form fluid leak because blood vessel damage
   Very painful exposed nerve endings
2. Deep partial thickness - Drier, Red, Non blanching
   dermal plexus coagulated by heat
   less sensate
3. Full thickness burns waxy and white
   Charred and not painful

Question 7

Local and systemic effects of major burns

Answer 7

CVS
Hypovolaemia
Myocardial depression
reduced Co

Vascular
Increased cap permeability
Na and protein leak
Tissue Oedema

Resp effects
Bronchoconstriction
ARDS

Periperhal and splanchnic vasocon
AKI
Ileus
GI Stress ulcer

Fluid resus
Tissue oedema
Oedema
ACS

Systemic inflammatory response
HPA Activation
ADH
SNS RAA
Hypercoag

Question 8

Initial management

Answer 8

First aid
1. First aid at the scene is vitally important in burns and can prevent more severe injury. In particular there is a strong evidence base that a burn should be managed under cool or tepid running water for 20 min even up to 4 h after the injury is sustained

2. By arresting tissue damage, wounds are not as deep as they otherwise would have been, with subsequent improvement in healing and decreased scar formation
3. op the burning process, cool the burn and then cover in a non-adherent dressing
4. Burn must be cooled, the rest of the patient must be warmed to prevent hypothermia.

For chemical burns the patient should be removed from the area of exposure and all contaminated clothing removed. Chemical burns should be irrigated with running water or sterile fluids

. Irrigation is key in such burns as removing the chemicals stops the burning process. It is recommended that acid burns be irrigated for 45 min and alkali burns for 1 h.

Question 9

Airway and breathing

Answer 9

Indications for intubation are:

1. reduced conscious level requiring airway protection
   (e.g. because of head trauma during escape from a fire also requiring c-spine immobilisation,
2. systemic toxicity from inhalation injury, medical or substance use causing collapse);
3. actual or impending upper airway obstruction owing to deep neck,
4. perioral or intra-oral burns and oedema;
5. respiratory distress from inhalation injury requiring ventilatory support; or to facilitate safe transfer to a burns centre.

Question 10

Inhalation injury

+

Intubation

Answer 10

Hot gas causes direct burn injury to the upper airway, particulate matter and chemicals enter the lower airways causing acute lung injury and carbon monoxide and hydrogen cyanide cause systemic toxicity. Inhalation injury is more common if facial burns are present, but not all patients with facial burns have an inhalation injury.

Signs and symptoms include cough, soot in the nose, mouth and sputum and singed eyebrows and nasal hair, but in the absence of a facial burn these are unlikely to signal an airway emergency.

Voice changes, hoarseness and stridor, however, are particularly concerning as these signs may not develop until swelling is already obstructing the airway

plan for a difficult intubation including a surgical airway as the tissues may be erythematous, ulcerated and distorted by oedema.

A videolaryngoscope should be used if available and an uncut tracheal tube is vital to allow for further soft tissue swelling that might otherwise make a cut tube recede into the mouth. A larger-diameter tracheal tube is preferable to facilitate bronchoscopy and respiratory toilet.

Question 11

Ventilation

Answer 11

In full thickness burns the dead tissue or ‘eschar’ is non-compliant and may prevent adequate ventilation and adversely affect cardiac pre-load, necessitating escharotomies to the chest before transfer

Impaired gas exchange may also be the result of inhalation injury and associated carbon monoxide poisoning.

Hypoxaemia will persist despite adequate oxygen saturation by pulse oximetry, so it is important to check the co-oximetry results on an arterial blood gas

The time to carbon monoxide washout is reduced by ventilation in 100% oxygen, but hyperbaric oxygen therapy is not currently recommended.22 Patients’ lungs should be ventilated with 100% oxygen until the carboxyhaemoglobin level is <3%,

Hydrogen cyanide poisoning should be considered in patients with inhalation injury, cardiovascular instability and increasing blood lactate levels not responding to treatment, and the specific antidote – hydroxycobalamin – should be given

Question 12

Circulation

Answer 12

Burns and burn shock are not an immediate cause of hypovolaemia. Any haemodynamic instability must be assessed as possible bleeding in the first instance

Ideally, access is not placed through burned tissue but this may be unavoidable and if unable, intraosseous access must be gained before proceeding to definitive central venous access.

The Parkland formula guides resuscitation

fluids in the first 24 h for burns of >15% TBSA.

The principles are as follows:

Parkland formula: 2–4 ml × actual body weight (kg) × %TBSA burned

Question 13

Parkland formula

Answer 13

The Parkland formula guides resuscitation

fluids in the first 24 h for burns of >15% TBSA.

The principles are as follows:

Parkland formula: 2–4 ml × actual body weight (kg) × %TBSA burned

–
From the time burn sustained
–
½ in first 8 h, ½ in subsequent 16 h
–
Subtract any fluid already given
–
Use warm, isotonic balanced crystalloid

Question 14

Disability

Answer 14

Disability
Reduced Glasgow Coma Scale at presentation in major burns is not caused by the burn itself and must lead to a search for the cause and appropriate management. As described previously, these include poisoning by inhaled toxins (carbon monoxide and hydrogen cyanide); overdose; trauma including head injury and medical comorbidities leading to collapse.

Question 15

Exposure and estimation of % TBSA burned

Answer 15

All clothing and jewellery must be removed; however, exposure of the patient must be kept to a minimum as almost all major burns patients become hypothermic.

Erythema alone is not counted in the estimation of burn surface area. All areas of superficial partial thickness burn or deeper are included

Lund and Browder chart or the Wallace Rule of Nines,

but more recently the

Mersey Burns app has gained popularity for ease of use and accuracy

Question 16

Wallace’s rule of 9s

Answer 16

Head and Neck

Upper limbs 9

Trunk 36 (18 front + 18 Back)

Lower limbs 18 each

Genitals 1

Question 17

Indications for escharotomy

Answer 17

1. Initial surgical management at the referring centre
   should be either life or limb saving.
2. Escharotomies are surgical incisions through
   non-compliant full thickness burn,
3. which restricts ventilation on the
   chest and abdomen or
4. causes significantly reduced perfusion in
   circumferential burns to the limbs
5. Escharotomies to produce decompression should be performed as soon as they are required for ventilation or perfusion;
6. the incision is longitudinal from unburned skin to unburned skin if possible, and deep enough to reach subcutaneous fat and release the eschar
7. Anaesthesia will be required,
   diathermy is usually used so blood loss should be minimal
   and prophylactic antibiotics should be given.

Question 18

Secondary survey

Answer 18

1. Other common areas of injury in major burns include
   corneal damage and
   examination with fluorescein stain is required.
2. Risk of rhabdomyolysis, and a creatine kinase level should be measured.
3. Pain relief using intravenous opioid titrated to effect should be given
4. Decompression with NG
5. Routine abx - not required

Question 19

Criteria for referral to a specialist unit and initial management

Answer 19

1. All major burns will need referral and transfer to specialist services.
2. Severe burns thought to be non-survivable should also be discussed as accurate estimation of burn size, site of donor areas, age and comorbidities are essential in making this decision, which is best done using the expertise of the burns centre.

Question 20

Goals

Answer 20

1. Occurs after resus + stabilisation
2. Scure airway - resus oedema - worsens
   NG
3. Not intubated - sat up - oedema
4. Invasive monitoring
5. Lines secured w/ sithces
6. Provision for large volumes
   COnsider vasopressor
7. Active warming - lose heat / severe hypothermic / acidotic
   Probably shouldnt delay to heat an already cool
8. Cling film - not too tight for blood flow

Question 21

Acceptance flow sheet

Answer 21

Place
Admission room
burns theatre
Burns ICU

People
Burn teams members

Plan
Shared decision

Prep space admission
Warmed room
Equipment / Monitor / Machine checks
Drugs + Fluids
Dressings
Theatre equipment + diathermy
PPE

Team leader
Introducition transfer team
Confirm weight
Move to warm room
Exchange of monitor / infusion
Stability
Handover
questions to complete

Question 22

Transfer complete

Answer 22

Primary survey - surgical team

Emergenecy resus / interventions PRN

Secondary survery + interventions

Anaesthetic
Airway secure
Monitoring
Vascular access
Plan for ongoing anes / sedation
warming devices
Infusions check
Bronch
Feeding tubes
cyano kit

Surgery
Complete surveys
Confirm TBSA + depth
Surgical plan
Consent
Eyes
Photographs
Cathter
shave
eschartomy
Dressigs

BICU
Hopsital id
admit
Height
bands
Bloods
Swabs
Infusions
Blood alcohol / Tox
Dressings as appropriate
GP summary

ALL
Confirm Resus plan
Surgical plan
WHO checklist

Huddle + Transfer
Burn and crit care needs - all members
WHO sign out
Prep transfer
Notes
radiology
update familly

Question 23

Early surgical Mx

Answer 23

Debrieded

Deep and partial - tissue excision
wound closure grats

Removal within 5 days
Reducing nectrotic load
drives SIRS

Decreases Blood loss / sespis + LOS

Improved cosmetic outcome

Wound closure
decrease fluid loss
Prevent dessiccation
infection

Temporay
covering allogtraft
synthetic skin subs
Perm autology SSG

SSG - gold strandard

Ability cover all permanent -
size area
availibity donor sites

Major burn undergo repeated ops
dressing changes

Specialist ICU care

Question 24

Burns 2

By reading this article you should be able to:

Answer 24

*
Describe the main challenges of caring for a patient with major burns in the operating theatre or ICU.
*
Explain the ways for optimising intravenous fluid therapy to avoid under- and over-resuscitation.
*
Outline how to recognise and manage infectious complications in patients with major burns.
*
Illustrate the pharmacological and non-pharmacological techniques available to mitigate the hypermetabolic response to burn injury.

Question 25

1Key points 2

Answer 25

1 Involvement of the multidisciplinary burns team is vital for the care of patients with major burns.
*

2. Thermoregulation, blood loss and coagulopathy are key considerations for the anaesthetist during surgery for major burns.
   *
3. The Parkland formula should be used to guide resuscitation and fluids titrated to urine output, haemodynamic and laboratory variables.
   *
4. Human albumin solution, given in addition to crystalloids, may reduce fluid requirements.
   *

5.The hypermetabolic response to major burns can be attenuated by early excision, appropriate nutrition and specific pharmacotherapy.

Question 26

Conclusions

Answer 26

As a result of vast improvements in burn care in recent decades,

clinicians are now responsible for managing patients
who have suffered burn injuries of increasing severity and complexity.

It is challenging to provide high-quality anaesthetic and intensive care.

These patients often require numerous and complex surgical interventions.

Areas that require special focus include

airway management,
management of blood and fluid loss,
thermoregulation and
overcoming monitoring difficulties.

Patients who have suffered major burns are

also at high risk of infection,
excessive catabolism,
significant pain and psychological distress,

all of which are associated with adverse long-term consequences.

Managing this myriad of complex issues
requires expert input from a wide multidisciplinary team.

Question 27

Anaesthesia and burn surgery

Answer 27

Subsequent operations including temporising

cadaveric autografts,

xenografts (such as pig skin) or

synthetic dermal substitutes until

skin coverage with autografts is possible
(using unburned patient donor skin)

elective surgical procedures are frequently required to help restore function and improve cosmesis

Question 28

Location of surgery

Answer 28

Burns surgery should be carried out in a
dedicated burns operating theatre,
ideally in close proximity to intensive care facilities.

appropriately warmed in order to reduce heat loss

Question 29

Preoperative assessment

Answer 29

Should include knowledge of the extent of the burn,
associated injuries and details of the planned surgery,
including positioning needed a
nd estimated blood loss

Given the large volumes of i.v. fluids often required
and the potential for associated renal injury,

a thorough assessment of circulating volume status
and electrolyte abnormalities should also be made

Nutritional support should generally be continued
throughout the operative period in patients who have
been mechanically ventilated before surgery,

and fasting times kept to a minimum in those requiring airway intervention.

Question 30

Airway

Answer 30

1. Airway assessment should include clinical examination and a careful review of previous anaesthetics
2. ventilation may have already been established before transfer to the operating theatre, particular care is required to prevent accidental extubation,
3. Formation of a tracheostomy may be indicated for various reasons and is commonly required for patients with complex facial burns in order to maintain skin health around the mouth and nose
4. Burns involving the face or neck may not present any airway difficulties initially, subsequent contractures may severely limit neck extension and mouth opening.
5. Advanced techniques such as awake fibreoptic intubation may be indicated. A difficult airway trolley with equipment for emergency front of neck access should always be immediately available.

Question 31

Intraoperative management

Monitoring

Temp

Answer 31

1. Monitoring can prove challenging.

Electrocardiogram electrodes sometimes require sutures or skin clips for reliable contact.

2. Pulse oximetry and blood pressure cuff positioning may also be difficult, and suitable sites for i.v. access and direct arterial monitoring may be limited
3. It is mandatory to monitor the patient’s core temperature.
4. Methods to minimise heat loss include minimising exposure,
   using forced air warmers and heat lamps,
   humidifying anaesthetic gases,
   infusing warmed i.v. fluids and maintaining
   an ambient temperature in theatre of 28–33°C.

Question 32

Ventilation

Answer 32

Care should be taken to assess a patient’s ventilatory requirements preoperatively and lung protective ventilation should be continued throughout the intraoperative period.

Patients who have also suffered an inhalation injury may have increased requirements for oxygen and PEEP.

particularly important to avoid alveolar derecruitment with the loss of PEEP during transfer to a transport or theatre ventilator

increased oxygen consumption and carbon dioxide production, higher than expected oxygen concentrations and minute volumes may be required.

Question 33

EBL

Answer 33

Blood loss can be as much as 3.4% of
total blood volume for each per cent TBSA excised

Rsks are increased in patients with infected burn tissue, deeper thickness burns and by prolonged operative time

Reduced
Tourniquests
Topical adrenaline
compression

TEG

Question 34

General vs regional anaesthesia

Answer 34

Most patients with major burn injuries will require general anaesthesia for surgical interventions. However, regional anaesthesia, either alone or in combination with general anaesthesia, may be suitable

Question 35

Intensive care management

Fluids

Answer 35

Fluid management

1. Under-resuscitation may lead to
   impaired tissue perfusion,
   end organ damage and
   extension of burn depth

Risks excess

electrolyte disturbances such as hyponatraemia,

exacerbation of tissue oedema,

pulmonary and cerebral oedema,

abdominal and limb compartment syndromes.

Question 36

Fluids formulae

Answer 36

The Parkland formula remains the most commonly used tool to calculate fluid requirements

May overestimate

Suggestions Initial calculation by Parkland
then regular reassess - de esclation
based on physiology

Question 37

Goal-directed fluid therapy

Answer 37

The most common and easy method of ensuring appropriate fluid resuscitation is by targeting an hourly urine output of 0.5–1 ml kg−1 ideal body weight.

< 0.5ml/kg/hr
Fluid challenged 250 x3
Increased norad
Increased baseline 10%

1-2
Reduce by 10%

> 2
Reduce 25%

Consider Colloid resucse
if >6ml/kg TBSA
1/3 crystalloid w/ 4.5 Albumin

Question 38

Persiste low urine out

Answer 38

Other than under-resus

Renal failure from
acute tubular necrosis or
rhabdomyolysis can result in
oliguria, as can
increased anti-diuretic hormone release in response to injury

asoplegia, low cardiac output and abdominal compartment syndrome should also be considered.

Reassess

1. peripheral perfusion
   MAP
   PPV
2. BLood lac
   HCT
   BE
3. Cardiac Output monitor
4. Measure IAP

Question 39

Choice of fluid

Answer 39

Choice of fluid

Balanced crystalloids such as Hartmann’s solution are the mainstay of fluid resuscitation in major burn injuries.

reduce the incidence of significant electrolyte disturbances such as hyperchloraemic metabolic acidosis

Fluid Creep
colloids such as human albumin solution in combination with crystalloids may reduce overall fluid volume requirements, mitigate against ‘fluid creep’ and lessen increases in intra-abdominal pressures compared with crystalloids alone

Question 40

Thermoregulation

Answer 40

thermodysregulation, with an initial propensity to hypothermia driven by heat and fluid loss from the burn wounds themselves

Most patients with major burns will subsequently develop a raised core temperature.

<-
hypothalamic setpoint for thermoregulation by pyrogens such as interleukin-1 (IL-1) and tumour necrosis factor.

Temperatures exceeding 40°C, can occasionally occur
and may lead to multiorgan failure

Techniques include debulking dressings, giving antipyretics such as paracetamol, applying ice to non-burned areas, infusion of cooled i.v. fluids, and irrigating the bladder and stomach with cold fluids. More invasive approaches such as intravascular heat exchange catheters or extracorporeal circuits may also need to be considered.

Question 41

Nutrition

Answer 41

Basal metabolic rate can increase significantly after a burn injury, more than doubling in patients with burns >40% TBSA

2. loss of lean body mass, immune compromise and impaired healing.

= loss of lean body mass and adverse events, including infectious complications and death

Question 42

Timing of nutritional support

Benefits Early

Answer 42

1. enteral nutrition in the hours immediately after injury

has been shown to have

beneficial effects on stress hormones,
improve gut integrity,
reduce intensive care length of stay,
improve wound healing and
reduce wound infections.

2. Enteral nutrition should be started as soon as possible
   in major burns, ideally within 6–12 h after the injury.
3. Total body weight loss should not exceed 10% of the patient’s weight at admission.

Question 43

Route of nutrition

Answer 43

As with most critically ill patients,
the enteral route is preferred.

Postpyloric feeding may be required if
gastric stasis is present and impairing calorie delivery

risk of aspiration, especially in patients requiring multiple interventions under general anaesthesia

Parenteral nutrition is rarely required, but when used, caution should be exercised because of the associated risks including infection, overfeeding and erratic blood glucose control.

Question 44

Aim nutrition

Overfeeding complications

Answer 44

The aim of nutritional support in patients with major burns
is to meet the substantially increased caloric requirements
in these patients while avoiding harmful overfeeding.

Complications of overfeeding include
1. hyperglycaemia,
2. hypertriglyceridaemia,
3. hepatic steatosis,
4. hypercapnoea and
5. prolonged duration of mechanical ventilation.

Question 45

How Assess Nutrition

Answer 45

specialist input from a dietician within the burns team is essential.

Most accurate method is indirect calorimetry,
but this remains mainly a research tool.

Formulae
Harris–Benedict
Toronto

Question 46

Harris Benedict

Answer 46

Men: 66.5 + 13.75 (weight in kg) + 5 (height in cm) – 6.76 (age in yrs)

Women: 66 + 9.56 (weight in kg) + 1.85 (height in cm) – 4.68 (age in yrs) Multiplied by factor determined by burn size:

<20% TBSA ×1.5

20–40% TBSA ×1.6

> 40% TBSA ×1.7

Question 47

Macronutrients

Answer 47

carbohydrates, proteins and lipids –

provide substrates

1. for adenosine triphosphate (ATP) biosynthesis,
2. wound repair,
   3.immune function and
3. maintenance of lean body mass
4. Carbs preferred
   Prevent reliance muscle proteolysis

Solely = hyperglycaemia

Insulin resistance in critically ill

Glucose 55% total energy requirement
Hyperglycaemia managed

*

2. Excess lipid
   Accum liver
   Impaired immune function
   15-30%
   (propofol)

*

3. Protein - wound repair
   maintenance LBM

Increasing protein intake - supraphysiological values - doesnt prvent catbolism
PRevents negative nitrogen balance

15-g-2g
Protein enriched feeds

Question 48

Micro nutrients

Answer 48

copper,
selenium, zinc and
vitamins B, C, D and E may become

depleted because of the intense inflammatory response,
exudative losses and haemodilution
resulting from resuscitation with i.v. fluids.

antioxidant defences, wound healing and immune function.

uce infectious complications, improve wound healing and reduce intensive care length of stay.17

Question 49

Infection

Answer 49

The loss of skin, the primary barrier to infection, coupled with relative immunosuppression in patients with major burns lead to an increased risk of infectious complications.

estimated 42–65% of deaths after burn injury.

Burn wound colonisation and infection
Patients can become colonised with multiple, often resistant, organisms.

Question 50

Consequently, specific criteria for the diagnosis of sepsis in patients with burns have been proposed

Answer 50

(i) Temperature >39°C or <36.5°C

(ii) Heart rate >110 beats min−1

(iii) Ventilatory frequency >25 bpm
(or minute ventilation >12 L min−1 if invasively ventilated)

(iv) Thrombocytopenia <100×109 L−1
(>3 days after initial resuscitation)

(v) Hyperglycaemia >11.1 mmol L−1 or
insulin infusion dose requirement >7 units h−1

(vi) Intolerance of enteral feed

Question 51

Biomarkers

Answer 51

With such difficulty in relying on clinical signs and traditional biomarkers such as C-reactive protein (CRP), other markers such as procalcitonin (PCT) may have better discriminatory capacity in diagnosing sepsis in patients with major burns

Question 52

Rx infection

Answer 52

Patients with infections should be treated with appropriate antibiotics, ideally as advised by the medical microbiology team and based on colonising organisms. Surgical debridement may be require

Question 53

Common pathogens

Answer 53

1. Gram-positive bacteria such as
   Staphylococcus aureus,
   Streptococcus and Enterococcus species.
2. Gram-negative bacteria such as
   Pseudomonas aeruginosa can translocate from the
   gastrointestinal tract or the environment
   and thrive in the moist environment of a burn wound.
   typically green/yellow colour and foul smell and can lead to invasive infection with necrosis.
3. Resitance
   VRE

Recognised risk factors include the use of broad-spectrum antibiotics, colonisation at hospital admission, need for escharotomy, prolonged hospital or intensive care stay and multiple surgical procedures

4. Fungal colonisation and invasive fungal infections are also significant problems.
   Candida albicans is the most common pathogen

Question 54

Toxic shock syndromes

Answer 54

Toxin-producing strains of S. aureus can cause toxic shock syndrome (TSS)

group A Streptococcus, has a similar presentation

macular rash, vomiting and diarrhoea, thrombocytopenia, lymphopenia and deranged liver function tests.

reduce exotoxin production, such as clindamycin and linezolid, should be considered.

Question 55

Hypermetabolic and inflammatory response

Answer 55

Most pronounced in the acute phase,
some changes can persist for several years
after a burn injury has healed

(i) Increased resting energy expenditure

(ii) Increased serum and urine cortisol and catecholamines

(iii) Increased cytokines including
IL-6, IL-8 and granulocyte colony-stimulating factor (G-CSF)

Appropriate skin closure, nutritional support and analgesia are fundamental to mitigating this response. Several therapies have been proposed,

Question 56

Long-term effects of burn injuries.

Answer 56

1.Immune

Increased incidence of respiratory infections (influenza, pneumonia)

Increased hospital admissions with infective diseases

Increased mortality from infections

*

2. Cardiovascular

Increased risk of ischaemic heart disease,
hypertension,
heart failure and stroke

Reduced exercise tolerance

Myocardial fibrosis

*

3. Gastrointestinal

Increased risk of disease of alimentary tract,
gallbladder, biliary tract and pancreas

Increased hospital admissions with diabetes mellitus

4. Musculoskeletal

Increased fracture risk

Joint pain and stiffness

Reduced mobility

Increased hospital admissions with musculoskeletal disorders

*

5. Central Nervous
   Increased hospital admissions with epilepsy, migraine and nerve problem

*

6. Miscellaneous

Increased all-cause mortality

Increased cancer risk (perhaps worse in females)

Question 57

How to prevent long term effects?

Answer 57

Beta-blockers

Beta-adrenergic blockade with drugs, such as propranolol, suppress the catabolic effects of a burn by reducing energy expenditure, limiting insulin resistance, preventing muscle wasting and acting as anti-inflammatory agents
wound healing and reduced muscle catabolism

*

2. Oxandrolone

Oxandrolone is an androgen receptor agonist,
which stimulates protein synthesis and muscle growth
with much less virilising activity than testosterone,

making it more suitable for use in women and children

minimise weight loss, improve urinary nitrogen balance, increase muscle strength and reduce healing time.

Question 58

Pain management

Answer 58

Types of pain

Background pain

Breakthrough pain

Procedural pain

Pharmacological management
Opioids

Non-steroidal anti-inflammatory drugs

Ketamine

Gabapentinoids
Gabapentin and pregabalin

Dexmedetomidine

Psychological sequelae of burn injuries

Question 59

Pain management

Answer 59

Nurn injury can be excruciating and is often difficult to manage. Some studies suggest higher pain scores during hospital admission are associated with poorer long-term outcomes such as increased mental health problems

the complexities and challenges of effective pain management, a specialist pain service should be an integral part of the burns team

Question 60

Types of pain

Answer 60

Although the burn injury is usually the most significant source of pain,

there are many other causes.

These include pain from associated injuries,
tracheal tubes,
invasive lines and catheters,
skin autograft donor sites,
pressure areas and
interventions including position changes

hree main types of pain: background, breakthrough and procedural pain.

Question 61

Background pain

Answer 61

Patients will experience a degree of persistent pain after a burn injury and multimodal analgesia should be prescribed to maintain adequate control

. Infusions should be titrated to a targeted effect, maximising clinical benefit while avoiding unwanted adverse effects.

Critical Care Pain Observation Tool (CPOT) for use in the ICU

Non-pharmacological measures such as

appropriate dressings,

comfortable positioning,
cutaneous stimulation,
acupuncture
and techniques such as

cognitive behavioural therapy and
music therapy may also help alleviate this form of pain

Question 62

Breakthrough pain

Answer 62

Breakthrough pain occurs on top of
well-controlled background pain,

either as an exacerbation of background pain
or originating from another source.

evoked, spontaneous, predictable or unpredictable

managed with boluses of rapid-acting agents, increases in the rate of opioid infusions or, if predictable, anticipatory doses of longer-acting agents.

Question 63

Procedural pain

Answer 63

Procedural interventions include
dressing changes and mobilisation.

Analgesic interventions should be timed appropriately
to gain the maximum benefit from the agent being used

Include opioid boluses,
inhaled agents including nitrous oxide and
methoxyflurane or analgosedative agents such as ketamine

Other non-pharmacological methods may be beneficial, including hypnosis, virtual reality systems and other distraction techniques

Question 64

Pharmacological management
Opioids

Answer 64

Opioids remain the mainstay of pain management in burn injuries.

patient factors including renal function and conscious level.

Patient-controlled analgesia (PCA) is commonly used
but relies on a conscious and alert patient

significant burn injuries often require large doses of opioids. Adverse effects include ileus, respiratory depression, delirium, hypotension and potentially dependence.

Question 65

Non-steroidal anti-inflammatory drugs

Answer 65

Non-steroidal anti-inflammatory drugs such as ibuprofen and diclofenac are infrequently used in critically ill patients because of the potential risks of gastrointestinal haemorrhage and renal impairment. Although they may be of benefit in selected patients, they should be used with caution.

Question 66

Ketamine

Answer 66

Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist

with potent analgesic effects.

Ketamine can be given as an i.v. infusion,
often to reduce opioid requirements,
or in sedative or anaesthetic doses for painful interventions.

Ketamine may also have a role in preventing the
development of neuropathic pain and

has been shown to reduce secondary hyperalgesia
and ‘wind-up’ phenomenon in healthy volunteers

Question 67

Wind up

Answer 67

Wind-up is a frequency-dependent increase in the excitability of spinal cord neurones, evoked by electrical stimulation of afferent C-fibres.

Question 68

Gabapentinoids

Answer 68

Gabapentin and pregabalin have been used in the
management of burn pain and pruritus,
both acutely and in those who develop chronic symptoms

improved pain scores and reduced opioid consumption.

g evidence of harm from dependence, abuse and overdose, they should be used with caution

Question 69

Dexmedetomidine

Answer 69

Dexmedetomidine is a highly selective
α2 receptor agonist with both analgesic and sedative effects.

It can be used in the ICU as part of an analgosedative regimen,

in combination general anaesthesia,
as a sedative for painful procedures and also as an adjunct in PCA

dexmedetomidine are bradycardia and hypotension

isk of pyrexia associated with dexmedetomidine use, caution is advised in the context of hypermetabolism after burns.

Question 70

Psychological sequelae of burn injuries

Answer 70

Survivors of burn injuries can be left with long-lasting mental health problems such as

depression,

anxiety,
suicidal ideation and

post-traumatic stress disorder (PTSD).

ognitive impairment, physical limitations, chronic pain and pruritus

post-intensive care syndrome (PICS

Question 71

Burns Risk factors

Answer 71

Patients with major burns often have a
prolonged hospital admission,
numerous invasive procedures,
multiple risk factors for developing delirium
and significant pain issues

Question 72

Rx

Answer 72

Psychological support staff should form part of the multidisciplinary team.

Routine psychological assessment is advised and

robust care pathways should be in

place in order to provide help and
support to burn victims and their families

support groups, charities, websites and opportunities for peer support

psychosocial screening may help identify patients at the highest risk of developing problems after burn injury, allowing prompt intervention to address the psychological, emotional and social challenges these patients may face.