Burns Flashcards by Andrew Gan

Define a burn.

Thermal coagulative injury to the skin. Causes physical and psychological trauma

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What are the types of burns

Scald, Flame, flash , contact , chemical, electrical, friction

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Predisposing factors of burns

Elderly - mobility issues, visual impairments
ALSO CHILDREN
Medical conditions such as epilepsy
Alcohol misuse
Carelessness

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Effects of burns on the skin?

Wipe out functions of protection, thermoregulation, sensation, metabolic.
Will have difficulty controlling their temperature

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Which systems of the body do major burns trigger?

Cardiovascular system - reduced myocardial contractility
Respiratory system - bronchoconstriction
Immune response - losing skin barrier which means… MORE VULNERABLE TO INFECTION (SEPSIS is largest cause of death in major burns)
Hypermetabolic - metabolic response
Increasing capillary permeability - causes oedema

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First Aid for burns

A lot of burns are minor and can be attended with first aid
Stop the burning process: Remove the heat e.g. stop drop and roll
Cool the burn: e.g. cool running water for 20 mins
Cover the burn
Keep patient warm

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General principles when dealing with patients with major burn:

Rescue patient from the burning process
Resuscitate: Give patients fluids and deal with their injuries
Resurface: Repair and replace damaged skin - can take months to years
Rehabilitate: Return the patient to preinjury state 🡪 normal way of living, job hobbies etc.
This starts on admission so should run in parallel to all other parts.

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Assessment of Burns

ABCDE approach very important to follow
Size of burn
Depth of burn
Other injuries

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What is Intubation?

process of inserting a endotracheal tube through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing during anaesthesia

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What can make it difficult after a burn to intubate a patient?

Swollen face and lips after a burn

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What is an arterial blood gas?

A blood test which assesses oxygen levels
Look for carboxyhaemoglobin levels 🡪 sign of inhalation injury

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What does a ‘Look and listen’ to chest help you see?

Assess bilateral air entry
Look for signs of chest injury

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Assessment of airway burns

History – If the burn happened in an enclosed space you are more likely to have airway burn than if it happened outside
Facial burns - considered to have airway burn until proven otherwise
Common signs of airway burns
Singed nasal hair
Hoarse voice
Stridor - a high-pitched, wheezing sound caused by disrupted airflow.
Coughing up Carbonaceous sputum
Altered consciousness
Respiratory distress

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A prolonged capillary refill time indicates:

Dehydration

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What is the best way to measure urine output?

Urine catheter

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What is an escharotomy?

Surgical procedure used to treat full-thickness circumferential burn (CB) (e.g chest, neck ,limb, digit)
As CB restricts peripheral perfusion, escharotomy releases the tightness

What imaging would be used to check injuries?

CT Scan

How do you measure the size of the burn in terms of TBSA?

Size of burn as a percentage of the total body surface area (TBSA + Age (+17 if inhalation injury = % mortality)
Revised bow score - chance of mortality
E.g if you are 80 and have a 20% burn you are expected to die
Flaw: patients who have a score of 130 can still survive

How do you measure size of burns (Rule of 9, Lund and Browder chart, Palm of hand method)?

Rough estimate
Less accurate in children

Blanching

Press the reddened area if it blanches white (as blood is pushed out of capillaries) then goes red again.

Types of burns based on depth [4]

Superficial - epidermis only
Superficial dermal - Epidermis and top of dermis
Deep dermal - Epidermis and most of dermis
Full thickness - Full thickness of skin, subcutaneous fat and potentially muscle or bone

Methods for assessing depth of burn

Clinical features: appearance, capillary refill and sensation
Clinical examination: Reliable 75% of cases
Other methods: biopsy, ultrasound, laser doppler

Superficial burn examples (first degree)

Only affects epidermis
Sunburn
Red
Blanching
Very painful - nerve endings exposed
Excluded from TBSA
Heals rapidly within 5-10 days without scarring

Superficial partial thickness (second degree)

Effects whole epidermis and papillary dermis (skin loss)
Red
Blanches with pressure
Blistering
Painful (nerve endings exposed and damaged)

Deep partial thickness (second degree burn)

Effects whole epidermis and extends to reticular dermis Cherry red appearance or yellow/white Fixed staining - does not blanch Blistering Possible reduced sensation Contracture (muscle stiffness) Drier and paler than superficial partial thickness

Full thickness burn

Effects all skin and subcutaneous fat and potentially muscle or bone Flame burns - black and charred Scald - white waxy appearance No capillary refill Painless - nerve endings destroyed Dry - leathery appearance

Why are burns a dynamic wound?

Change and evolve over 48 Hr, may look superficial then after 48h it may look deeper

Fluid Resuscitation

Determine size of burn to assess how to replace fluid and electrolytes lost Fluid resuscitation: Adults > 15% TBSA Children > 10% TBSA (plus maintenance fluid)

What is the parkland formula?

Fluid (24 hrs) = 4 x weight (Kg) x TBSA (%) Fluid volume divided in half (first half given in first 8 hrs, next half in next 16 hrs) Calculated from time of burn not time of arrival

Apply the parkland formula: 70 Kg man, 45% TBSA Burn What is his requirement? How much to give in first 8 hrs? /hour Next 16 hrs? /hour

4 x 70 x 45 = 12600ml 12600/2 = 6300ml 6300mls in first 8hrs = 787ml/hr 6300mls in next 16hrs = 393 ml/hr Adjust depending on urine output

Jackson's burn model. What are the distinct zones?

Zone of coagulation - centre, initial site of injury, tissue is irreversibly damaged Zone of stasis - tissue in shcok Zone of hyperaemia - most distant zone, tissue is red due to dilated blood vessels, major burn over 30% zone of hyperaemia becomes the whole body

Why do we need to estimate the size of burn correctly?

To give right amount of fluid and preserve zone of stasis and minimise damage to skin

Management of burns

Size and depth Minor - dressing Major - excision, scarring. Burns that take longer than 3 weeks to heal lead hypertrophic scars

Why might infection burnt tissue be excised?

Skin lost barrier so patient risks of sepsis is higher

Why have early excision and grafting?

Better recovery of scars

Why might burn surgery be hazardous?

Blood loss, become cold and hyperthermic, etc. Leaves additional wound

How does burn excision work?

Shaving layers of burnt tissue until you get to healthy tissue. Healthy tissue then covered with patient own skin graft of with cadaver skin or skin substitues if you don't have enough donor sites

Long-term management of burns?

Hypertrophic scars (keloid scar) Scar contractures Psychological support Burns camps for children Surgical procedures - release scar contractures to allow for better range of movements Tissue expanders - expanding skin to release contracture Free flap - tissue, skin and fatty tissue disconnected from blood supply from one part of body joined to cover unstable scarring tissue