Burns

Question 1

types of burns

Answer 1

thermal
contact
chemical
electrical

Question 2

what is inhalation injury

Answer 2

Damage to airways: stridor, hoarse voice, respiratory compromise

Secondary to inhalation of hot air

Intubation needed

Other features: singed nasal fairs, facial burns, soot deposits around nose

Nasoendoscopy: erythema or oedema of airway on direct visualisation

Question 3

definition of major burn

Answer 3

A major burn is any burn with >20% TBSA (>10% in children) of partial or full-thickness burns (i.e. not including superficial burns).

Major burns can result in profound inflammatory responses and large fluid shifts occurring, and aggressive fluid resuscitation is often required to mitigate burn shock.

Question 4

initial burns assessment

Answer 4

Assessment in warmed room

Giving warmed fluids

Reducing wound exposure time

Secondary survey

Question 5

airway burns

Answer 5

Inhalation injury: burn above vocal cords

Pre-emptive intubation may be required if suspected or high-risk

Protect c spine

Question 6

signs of inhalation injury

Answer 6

History of flame burns or burns in an enclosed space

Full thickness burns

Singed nasal hair

Carbonaceous sputum

Change in voice, with hoarseness or harsh cough

Stridor, tachypnoea, or dyspnoea

Erythema or swelling of oropharynx on direct visualisation

Question 7

breathing in burns

Answer 7

100% oxygen via non-rebreather mask

Evaluate need for escharotomy

Obtain ACG and check carboxyhaemoglobin levels

Question 8

circulation in burns

Answer 8

Two wide bore iv cannulas

IV fluid therapy

Insertion of urinary catheter

Question 9

disability in burns

Answer 9

Evaluate neurological status

GCS

Temperature check, increased risk of hypothermia

Question 10

exposure in burns

Answer 10

Body surface area percentage

Ensure patient is given tetanus booster

Question 11

history of burns

Answer 11

mechanism
timings
injury

Question 12

injury history of burns

Answer 12

Liquid

Solute in liquid

Voltage

Flash or arcing

Contact time

Chemical

Non accidental?

Question 13

mechanism history of burns

Answer 13

Type of burn agent: scald, flame, electrical, chemical

How did it come into contact with patient

What first aid was performed

What treatment has been started

Risk of concomitant injuries

Risk of inhalation injuries

Question 14

timings history of burns

Answer 14

When did the injury occur

How long was patient exposed to energy source

How long was cooling applied

When was fluid resuscitation started

Question 15

assessing burn severity

Answer 15

Severity of burn: percentage total body surface area burned and burn depth

Initial fluid volume requirements

Wallace’s Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%

Lund and Browder chart: the most accurate method

the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Question 16

superficial (first degree burn)

Answer 16

epidermis
dry, blanching, erythema
painful
heals without scarring, 5-10 days

Question 17

superficial partial thickness (second degree)

Answer 17

upper dermis
blisters, wet, blanching, erythema
painful
heals without scarring, <3 weeks

Question 18

deep partial thickness (second degree)

Answer 18

lower dermis
yellow or white, dry, non-blanching
decreased sensation
heals in 3-8 weeks, likely to scar if healing >3 weeks

Question 19

full thickness (third degree)

Answer 19

subcutaneous tissue
leathery or waxy white, non-blanching, dry
painless
heals by contraction, >8 weeks, will scar

Question 20

management of minor burns

Answer 20

First aid

Remove non-adherent clothing

Put wound under running water

Question 21

initial management of burns

Answer 21

initial first aid as above

review referral criteria to ensure can be managed in primary care

superficial epidermal: symptomatic relief - analgesia, emollients etc

superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours

Early intubation

Question 22

fluid resuscitation in burns

Answer 22

Limit hypovolaemia

Minimise tissue ischaemia in the immediate post-burn periods

Fluids are calculated from time of burn

Modified parkland formua: volume of crystalloid fluid (Hartmans)

50% of callculated volume given within first 8 hours post-burn, and the remaining 50% is given in the remaining 16 hours

Question 23

escharotomies management in burns

Answer 23

Indicated in circumferential full thickness burns to the torso or limbs.

Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Question 24

goal-directed therapy in burns management

Answer 24

The goal of fluid resuscitation is achieving adequate end-organ perfusion.

Due to the systemic inflammation seen in burns patients, conventional markers of fluid balance are not always feasible.

Urine output can be monitored closely as the main marker of fluid balance status, which should be maintained (in adults) at >0.5mL/kg/hr.

Other measures include use of mean arterial pressures (MAPs) and blood gas measurements.

Question 25

referral to secondary care in burns

Answer 25

all deep dermal and full-thickness burns.

superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children

superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck

any inhalation injury

any electrical or chemical burn injury

suspicion of non-accidental injury

Question 26

ongoing care management of burns

Answer 26

Depending on the injuries involved, patients with burns may require transfer to either a burns unit or a burns centre (see Appendix):

Burn Units are facilities that have a specialised burns ward staffed by skilled burns professionals, capable of caring for moderate level of injury complexity.

Burn Centres represent the highest level of inpatient burn care, with immediate operating theatre access and highly-skilled critical care staff, for the management of highly complex burn injuries.

Question 27

complications of burns

Answer 27

Airway compromise

Airway oedema from smoke inhalation

Respiratory failure

Fluid loss and electrolyte imbalance

Hypothermia

Compartment syndrome

Question 28

complications of penetrating injuries burns

Answer 28

tension pneumothoraces

lung contusions

alveolar trauma

ARDS

Question 29

complications of smoke inhalation in burns

Answer 29

Bronchospasm, inflammation and bronchorrhea

Ateletcasis or pneumonia

Non-invasive management: nebulisers and positive pressure ventilation

Question 30

complications of carboxyhaemoglobin in burns

Answer 30

Carbon monoxide

Hyperbaric therapy