Burns

Question 1

What is a burn

Answer 1

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

Question 2

Types of burn

Answer 2

Scald -most common
Flame-most common
Flash
Contact
Chemical
Electrical
Friction

Question 3

Cost of burn

Answer 3

Acute hospital care
Out patient care
Rehabilitation care
Loss of vocational activities
Loss of recreational activities

Question 4

Effects of burns on skin

Answer 4

Functions of skin: protection, thermoregulation, sensation, metabolic
Having a major burn wipes out these functions

Question 5

Effects of burns systemic response

Answer 5

Major burns affects all body organs and systems
Cardiovascular- reduced myocardial contractility
Respiratory- bronchoconstriction
Reduced immune response in addition to losing skin barrier so very vulnerable to infection
Hyper metabolic response- metabolic rate increases threefold
Increased capillary permeability - cause oedema

Question 6

Predisposing factors of burns

Answer 6

elderly-usually have mobility issues, visual impairment, prone to falls
Medical conditions such as epilepsy
Alcohol misuse
Carelessness

Question 7

General principles

Answer 7

Rescue
Resuscitate
Resurface
Reconstruct
Rehabilitate

Question 8

First aid

Answer 8

Stop burning process
Cool the burn
Cover the burn
Keep patient warm

Question 9

Assessment of burns

Answer 9

ABC approach
Size of burn
Depth of burn
Other injuries

Question 10

ABC approach

Answer 10

Airway, breathing, circulation
Method: AB
Give high flow oxygen
Assess for possible airway burns
Anaesthetic review- consider intubation (process of inserting endotracheal tube through mouth into airway so a patient can be placed on a ventilator to assist with breathing during anaesthesia)
Look and listen to chest
Arterial blood gas- measure CO levels carboxyhaemoglobin
Chest X-ray

Question 11

Airway burns

Answer 11

History- enclosed space then very likely to have airway burns
Facial burns- very likely to have airway burns
Common signs:
Singed nasal hair
Carbonaceous sputum
Hoarse voice
Altered consciousness
Respiratory distress, stridor(high pitched wheezing sound)

Question 12

ABC
C method

Answer 12

Intravenous access and replacement of lost fluid
Peripheral pulses
Capillary refill- a prolonged capillary refill time indicates dehydration
Check for circumferential burns- go around limb, trunk chest, neck etc
Monitor- urine output, pulse, blood pressure

Question 13

Escharotomy

Answer 13

Circumferential deep burns: chest, neck, limb, digit
Restricts distal circulation
Mechanical effect on ventilation
Escharotomy is a surgical procedure used to treat full thickness circumferential burns, these burns restrict peripheral perfusion, releases the tightness
Cut into burn

Question 14

ABCDE secondary survey

Answer 14

Disability and exposure
Method:
Check for other injuries- top to toe examination
Imaging/investigations
Insert catheter, place arterial line and a central line
Burns dressings
Tetanus toxoid-vaccine
Keep patient warm

Question 15

Size of burns

Answer 15

Total body surface area TBSA- %
Affects treatment and outcome
TBSA+ age (+17 if inhalation injury)= % mortality
Rule of nines: leg is 18%, arm is 9, chest is 18
Rough estimate
Less accurate in children, proportions of body change with age
Lund and Browder chart: more accurate especially in children, standard method of assessing burns
Palm of hand method: patients hand 1%

Question 16

Assessing depth of burn

Answer 16

Clinical features
Appearance, sensation, capillary refill
Other methods: biopsy, ultrasound, laser Doppler

Question 17

Blanching

Answer 17

Gently press red area if it blanches white then goes red again this is a normal reaction
Capillary refill

Question 18

Erythema

Answer 18

Epidermis only- superficial
E.g sunburn
Red, blanching
Very painful- nerve endings exposed
Heals rapidly without scarring
Exclude from TBSA calculations

Question 19

Superficial partial thickness

Answer 19

Whole epidermis and part of dermis
Skin loss and blistering
Wet
Red
Blanches with pressure
Painful

Question 20

Deep partial thickness

Answer 20

Whole epidermis and most dermis
Cherry red appearance
Drier and paler
‘Fixed staining’ does not blanch with pressure
Sensation may be reduced

Question 21

Full thickness

Answer 21

All skin, subcutaneous fat and potentially muscle and bone
Dry leathery appearance and texture
Painless (nerve endings destroyed)
Stiff
Flame burns- black and charred
Scald- white and waxy appearance

Question 22

Assessing depth of burn

Answer 22

Easier when very superficial or very deep
Most burns are mixed depth- difficult to manage
Burn depth evolves over first 48 hours

Question 23

Fluid resuscitation

Answer 23

To replace fluid and electrolytes lost from major burns
Adults> 15% TBSA
Children >10% TBSA + maintenance fluid
Various different formulae
Parkland formula: most commonly used
Uses Hartmann’s fluid
Fluid ml(24 hours)= 4 times weight (kg) times TBSA%
Half given in first 8 hours and half in next 16 hours
Calculated from time of burn not time of arrival
Formula only used to start fluid replacement, needs to be regularly reviewed, urine output best indicator of fluid balance aim for 0.5ml/kg/h in adults more in children or electrical burns

Question 24

Jacksons burn model

Answer 24

Burns have 3 distinct zones:
Zone of coagulation: centre of wound, where thermal injury first hits skin, tissue is irreversible damage
Zone of stasis: tissue in shock has potential to recover or can progress to zone of coagulation with inadequate resuscitation
Zone of hyperaemia: most distant zone, tissue look red lots of dilated blood vessels

Question 25

Referral guidelines

Answer 25

Burns to face, hands, feet, perineum
Age <5 or >60
Inhalation injury
TBSA>10% (5% in children)
Full thickness burns >5% TBSA
“Complex” burns e.g. comorbidities, other injuries, pregnancy
Suspected non accidental injury

Question 26

Management of burns

Answer 26

Depends on size and depth
Small, superficial burns managed with dressings alone
Larger or deeper burns may require excision
Burns taking >3 weeks to heal more likely to leave hypertrophic scars (red and raised and uncomfortable)

Question 27

Why excise a burn

Answer 27

Pros: potential source of infection, burn stimulates inflammatory effects, early excision and grafting may leave better scars
Cons: non full thickness burns may heal spontaneously
Burn surgery can be hazardous, leaves additional wounds (donor sites)

Method: shave layers of burnt tissue until you get to healthy tissue to preserve viable remaining dermis, then covered in patient own skin graft or with donor skin or skin substitutes

Question 28

Surgical planning

Answer 28

Subtotal burn excision now standard of care
Priority areas: neck, central line sites, high functional importance e.g hands, protective e.g. eyelids
Ideally cover with autograft
Other options are allograft, xenograft, skin substitutes, biological dressings
Multidisciplinary burn team

Question 29

Long term management

Answer 29

Hypertrophic scars
Scar contractures- cause functional problems
Psychological support
Burn camps for children
Surgical procedures to release scar contractures to allow better range of movement
Tissue expanders- expanding skin to release contracture