Burns

Question 1

Types of Burn

Answer 1

Thermal
Chemical
Electrical

Question 2

Electrical Burns

Answer 2

Can have small entry and exit points even when there is severe internal damage
Cardiac conductivity may be effected - if ECG abnormal 24hr monitoring
Exclude compartment syndrome if limb effected
Exclude Rhabdomyolysis and myoglobinuria

Question 3

Rhabdomyolysis

Answer 3

Death and breakdown of skeletal muscle causing release of muscle components (myoglobin) into the blood, which can be toxic to the kidneys and cause renal failure - check for myoglobulinuria

Question 4

Chemical Burns

Answer 4

Burns continue as long as agent is in contact with skin
Alkali burns are much more penetrating than acids so require more irrigation - Cement/lime burns are alkali, deep and present late – always check pH of skin

Question 5

Epidemiology of Burns

Answer 5

150,000 burns attend AnE/yr in the UK –> 10% require admission –> 600 deaths in 1996 –> more men
2 million in US –> 80,000 admissions –> 8000 deaths

Question 6

Anatomy of the skin

Answer 6

2 layers - dermis (blood vessels, nerves, pili muscles, sebacceous glands) and the epidermis (keratinized, stratified, squamous epithelium + hair, sweat glands, nails)

Question 7

Pathology of burns

Answer 7

Thermal damage causes protein & enzyme denaturation
Locally causes inflammatory response and fluid/ion loss
Greatest at 8hrs and normalises over 36-48hrs

Question 8

Inhalational damage in burns

Answer 8

Damage can occur when breathing in toxic chemicals or products of combustion –> laryngeal oedema, bronchorrhoea, bronchospasm and pulmonary oedema

Question 9

Problems with burns (7)

Answer 9

Respiratory damage Fluid loss
Hypothermia Haemolysis
Infection Multiorgan failure
Circumferential burns leading to contraction of skin

Question 10

Which parameters are used to classify burns?

Answer 10

Depth –> First, second, third and fourth degree

Extent –> rule of nines

Question 11

First degree burns

Answer 11

Superficial, partial thickness –> only effecting the epidermis
Erythema and redness, hyperalgesia and alldyonia, no blistering. capillary function normal. will heal in 24hrs, no scarring

Question 12

Second degree burns

Answer 12

Deep partial thickness -> epidermis to the superficial dermis -> most painful. Erythema, swelling and colour changes, blistering and weeping, extreme hyperalgesia and alldyonia, capillaries impaired, will heal in 1-14 days

Question 13

Third degree burns

Answer 13

Full thickness –> All layers into the hypodermis and subcut tissue
No erythema, swelling or redness, black or white colour, no blistering or weeping, loss of pain and sensation, protracted healing time and scarring

Question 14

Fourth degree burns

Answer 14

Into deep tissues such as muscle, fascia, bone and tendons

Question 15

Rule of nines (adult)

Answer 15

Head (front and back) - 9%
Front of chest - 9% Back of chest - 9%
Front of abdomen - 9% Back of abdomen - 9%
Each arm - 9% Each leg - 18%
Genitals - 1% The patients’ Palm is about 1%

Question 16

Rule of nines (child)

Answer 16

Head (front and back) - 18%
Front of chest - 9% Back of chest - 9%
Front of abdomen - 9% Back of abdomen - 9%
Each arm - 9% Each leg - 14%
Genitals - 1% The patients’ Palm is about 1%

Question 17

First Aid for a person with burns

Answer 17

Ensure you and other staff are safe
Stop the burning process
Primary survey –> resuscitation –> estimation of burn extent –> secondary survery

Question 18

Primary Survey in burns

Answer 18

Airway with C spine control –> consider risks of inhalation burns
Breathing & Oxygen –> consider risk of pulmonary damage/oedema
Circulation –> consider haemorrhage and fluid loss/replacement
Disability –> risks of organ/brain damage
Exposure –> consider hypothermia risk

Question 19

Respiratory complications of Burns (4)

Answer 19

Airway burns can lead to oedema and obstruction
Ventilation perfusion mismatching can lead to hypoxia
Lung parenchymal damage and swelling
Carbon monoxide poisoning

Question 20

Clinical signs of inhalational burns

Answer 20

Facial burns or Singeing of the eyebrows and nasal vibrissae
Carbon deposition and inflammatory changes to the oro-pharynx
Breathlessness, coughing and carbonaceous sputum

Question 21

Investigations in a burns patient

Answer 21

Blood tests –> FBC, U+E, ABG, COHb, group and save
Urine/blood pregnancy test
ECG
Chest or other Xrays

Question 22

Fluid resuscitation in burns

Answer 22

Start if burn covers 10-15% or more of the body
Can use Parkland formula of 24hrs
Aiming to achieve urine output >0.5ml/kg/hr
pulse below 120, lucid and calm patient

Question 23

Parkland formula of 24hrs

Answer 23

Volume of crystalloid to give in first 24hr = 4 x kg x % burnt in mls
Eg 75kg man with 20% burns get 4x75x20=6000ml
Half in first 8hrs, half in the next 16hrs

Question 24

Examination of burns

Answer 24

Depth –> is it all the same? Are there any circumferential burns?
Extent –> use the rule of nines, if there any risk of internal burns?
Oxygen stats, pulse, BP and urine output should be taken into account

Question 25

Treatment of Burns

Answer 25

ABC with particular care to possible complications of burns
Monitoring HR, BP, urine output and GCS to watch for change
Analgesia, particularly in second degree + wound care
Antibiotic if signs of infection + tetanus vaccination if needed
Contact burns unit

Question 26

Analgesia in burns

Answer 26

Intravenous mainly - should be strong enough
Cover burns and cool skin
May need to anesthetize the patient

Question 27

Wound care for burns

Answer 27

Cover the burn with cling film, but do not wrap
Arguments over whether to pop blisters – reduce size and pain but increase infection risk
Aim to reduce pain and fluid loss and to prevent hypothermia

Question 28

When to transfer to specialist centre

Answer 28

Partial thickness >20% or >10% if child or elderly
Full thickness >5% at any age
Any burns involving the face/eyes, ears, palms, soles, perineum or skin over joints or circumferential burns or inhalational burns
Significant chemical or electrical burns including lightning
Burns in patients with pre-existing illness or special circumstances

Question 29

Stages of healing in burns

Answer 29

Inflammatory
Destructive
Reparative
Maturation

Question 30

Methods used to cover skin

Answer 30

Skin grafting or possible in future cell cultures

Question 31

Psychological care

Answer 31

Counselling about healing process and scarring risk

Rehabilitation and retraining if needed