Burns Flashcards
What is the first aproach to managing a patient presenting with burns?
Immediate first aid - ABC, remove person from source
What is the immediate management of a patient presenting with burns caused by heat?
- remove person from the source
- within 20 minutes of the injury, irrigate the burn with cool (not iced) water for 10-30 minutes
- cover burn using clin film - layered rather than wrapped around a limb
Within what time and for how long should a burn caused by heat be irrigated?
within 20 minutes of the injury
for between 10-30 minutes
How should you cover a burn caused by heat?
with cling film, layered rather than wrapped around a limb
What is the immediate first aid for an electrical burn?
switch off power supply, remove the person from the source
What is the immediate management of chemical burns?
brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended
What is a useful rule to initially assess the extent of a burn?
Wallace’s rule of Nines
What are 8 aspects to Wallace’s rule of nines to assess the extent of a burn?
- 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%
What is the most accurate method for assessing the extent of a burn?
Lund and Browder chart
What proportion of the total body surface area is the palmar surface?
1%
What are the 4 classes of depth of burn? (modern and former terminology)
- Superficial epidermal (first degree)
- Partial thickness (superficial dermal) (second degree)
- Partial thickness (deep dermal) (second degree)
- Full thickness (third degree)
What will the appearance of a superficial epidermal (first degree) burn be?
Red and painful
What is the appearance of a partial thickness - superficial dermal (second degree) burn?
pale pink, painful, blistered
What is the appearance of a partial thickness - deep dermal (second degree) burn?
typically white, may have patches of non-blanching erythema. Reduced sensation
What is the appearance of a full-thickness (third degree) burn?
white/brown/black in colour, no blisters, no pain
What are 6 situations when you should refer burns to secondary care?
- 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
What are the 2 situations when you should refer superficial dermal burns to secondary care?
- >3% TBSA in adults or >2% in children
- involving face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso or neck
What is the management of superficial epidermal burns in primary care?
symptomatic relief - analgesia, emollients
What is the initial management of superficial dermal burns in primary care? 5 aspects
- cleanse wound
- leave blister intact
- non-adherent dressing
- avoid topical creams,
- review in 24h
After what time period should you review a superficial dermal burn in primary care?
24h
What is the pathophysiology following severe burns, locally at the site of the burn?
local response with progressive tissue loss and release of inflammatory cytokines
What is the systemic response to severe burns pathophysiologically?
- cardiovascular effects from fluid loss and sequestration of fluid into the third space
- marked catabolic response
- immunosuppression common with large burns
What effect is a recognised event in the gut following severe burns?
translocation of bacteria from gut lumen
What is a common cause of death following major burns?
sepsis
What is the initial aim in the management of severe burns?
stop the burning process and resuscitate the patient
In what 2 instances are IV fluids required in the management of severe burns?
- Children with burns >10% TBSA
- Adults with burns >15% TBSA
What is the formula used to calculate the IV fluids needed in severe burns management?
Pakland formula
volume of fluid = total body surface area % x weight (kg) x 4
What are 3 aspects of the initial management of severe burns?
- IV fluids: half of fluid is administered in first 8 hours
- Insert urinary catheter
- Analgesia
How should fluid, calculated using the Parkland formula, be given in severe burns?
50% of IV fluid administered in first 8 hours
50% given in next 16 hours
When should you transfer a patient with severe burns to a burns unit? 3 situations
- complex burns
- burns involving hand, perineum and face
- burns >10% TBSA in adults and >5% in children
What specific treatment may circumferential burns affecting a limb or severe torso burns impeding respiration require?
escharotomies: surgical procedure performed to allow greater circulation to that part of body
What is an escharotomy?
eschar is stiff, dead skin tissue caused by deep 2nd or 3rd degree burns. escharatomy is surgical incision through the eschar to release the constriction, restoring distal circulation and allowing for adequate ventilation
What are the 2 key situations when escharotomy is performed?
- circumferential burn around limb
- torso burn affecting respiration
When is conservative management of severe burns indicated?
superficial burns and mixed superficial burns that will heal in 2 weeks
What may the management of more complex, severe burns require?
excision and skin grafting
Is excision and primary closure of burns performed? Why/why not?
not generally practised as there is a high risk of infection
Is antibiotic prophylaxis/ topical antibiotic treatment given in burn patients?
no evidence to support their use
What is the benefit of escharotomy in a burn involving the torso?
careful division of encasing band of burn tissue will potential improve ventilation
What is the benefit of escharotomy in a circumferential burn involving a limb?
will relieve compartment syndrome and oedema
What happens blood in extensive burns and why?
haemolysis, due to damage of erythrocytes by heat and microangiopathy
What are 2 ways that dehydration/hypovolaemia follows burns?
- Loss of capillary membrane integrity causing plasma leakage into interstitial space
- Extravasation of fluids from the burn site causing hypovolaemic shock (up to 48h after injury) - decreased blood volume and increased haematocrit
Up to what time period following extensive burns can hypovolaemic shock occur due to extravasation of fluids from the burn site?
up to 48 hours after injury
What can happen to serum protein levels with burns?
protein less - levels decline
What type of infections are you particularly prone to following severe burns?
secondary infection e.g. Staphylococcus aureus
What are 4 problems secondary to extensive burns that patients are at risk of?
- Secondary infections e.g. Staph aureus
- ARDS
- Risk of Curlings ulcer (acute peptic stress ulcers)
- Danger of full thickness circumferential burns in an extremity as may develop compartment syndrome
How does healing occur in superficial burns?
keratinocytes migrate to form a new layer over the burn site
How does healing occur following full thickness burns?
dermal scarring
usually need keratinocytes from skin grafts to provide optimal coverage
What is the main aim of fluid resuscitation following burns?
to prevent the burn deepening
At what point following a burns injury is most fluid lost?
24 hours after the injury
What happens to fluid in the first 8-12 hours after a burns injury?
fluid shifts from intravascular to interstitial fluid compartments, therefore circulatory volume can be compromised
Why should colloids be avoided for fluid resuscitation following burns?
fluid resuscitation can result in more fluid moving into the interstitial compartment (rather than intravascular), especially colloid, so avoid in first 8-24h
What type of fluid should be given IV in burns injuries?
Crystalloid only e.g. Hartman’s solution/Ringers’ lactate
What does the Parkland formula calculated?
total fluid requirement in 24 hours;
fluid requirement = 4ml x total burn surface area (%) x body weight (kg)
What is considered the resuscitation endpoint following severe burns?
urine output of 0.5-1.0 ml/kg/hr in adults (increase rate of fluid to achieve this)
What is the starting point of fluid resuscitation following a burns injury?
the time of injury
What should you deduct when calculating IV fluids to give following a burns injury?
fluids already given
24hours after a burns injury, what is done next regarding IV fluid replacement? 2 aspects
- colloid infusion is begun at rate of 0.5ml x TBSA (%) x body weight (kg)
- maintenance crystalloid (usually dextrose-saline) continued at rate of 1.5ml x (TBSA) x body weight (kg)
What are 2 examples of colloids that can be given after 24hrs following a burns injury?
albumin
FFP (fresh frozen plasma)
What type of burns require more fluid that based on the traditional formulae?
high tension electrical injuries and inhalational injuries
In addition to fluids, what else can be supplemented in the treatment of burns?
antioxidants such as vitamin C - to minimise oxidant-mediated contributions to the inflammatory cascade in burns
What are 4 things to monitor whilst giving treatment for burns?
- Packed cell volume
- Plasma sodium
- Base excess
- Lactate
