Emergency medicine: Approach to Burns

Question 1

types of burn

Answer 1

thermal
chemical
electrical
radiation
cold injury

Question 2

types of thermal injury

Answer 2

• scald - hot liquids and steam
• flame- direct exposure to fire
• flash- exposure to flame
• contact- exposure to a very hot stimulus for a very short amount of time e.g. industrial accident or expsoure to host surface for abnormally long amount of time e.g. uconscious patient and radiator

Question 3

chemical burns can be

Answer 3

• acid
• alkali (worse- result in deeper and mroe severe burns due to protein denaturation and fat saponification)

Question 4

electrical burn

Answer 4

usually hand and feet - can look like minor burns but cause a significant injury

Types
- Direct contact
- Electrical arc

Question 5

electrical: direct contact

Answer 5

current from an electrical source passes directly through the body (Can cause extensive internal damage)
- Burn conducts through organs
- Rhabdomyolysis
- Cardiac arrhythmias

Question 6

electrical arc

Answer 6

flash thermal burn occurs due to an electrical arc coming briefly into contact with skin
- An arc is an electrical breakdown of a gas that produces a prolonged electrical discharge.

Question 7

radiation burn example

Answer 7

• UV e.g. sunburn
• X-ray e.g. radiotherapy

Question 8

Approach to Burns in A & E

Answer 8

A- E

Question 9

A

Answer 9

Airway

Look for: Nasal soot, singeing, stridor, hoarseness of voice

Management
- Pre-emptive intubation may be considered
- Protect cervical spine until clinically cleared

Question 10

burn and airway

Answer 10

if a person has been in a fire they may have an inhalation injury

Question 11

inhalatin injury

Answer 11

• Damage to airway secondary to inhalation of hot air
• Increases mortality by 20%
• Causes erythema or oedema
• Features
  o Stridor
  o Hoar voice
  o Soot
  o Singed nasal hairs
  o Respiratory compromise
• Management: earlt involvement of anaesthetics to secure definitive airway e.g. intubation

Question 12

B

Answer 12

Breathing

Look for: Circumferential burns, inhalation burns

Management
- 100% oxygen via on-rebreathe mask
- In more extensive burns, evaluate the need for escharotomy (emergency procedure which involves incising through areas of burnt skin to release the eschar and constrictive effects -> allows distal circulation and a equate ventilation
- Obtain ABG and check carboxyhaemoglobin levels (CO poisoning)
- CXR

Question 13

C

Answer 13

Circulation

Look for: fluid depletion signs (pulse, cold peripheries etc, slow CRT)

Manaegemnt
- 2 wide bore cannulas (avoid inserting through burns)
- Take routine bloods, G&S, clotting, CK
- Aggressive IV fluid therapy
- Insert Urinary catheter (fluid balance monitoring)
- ECG

Question 14

D

Answer 14

Disability

Look for: associated trauma (bone etc), GCS, BM, temp

Management
- prevent hypothermia (warm room)

Question 15

E

Answer 15

Exposure and environment

• Fully expose patient to get accurate estimation of % total body surface area (TBSA) burned and check for concomitant injury
• Give tetanus booster

Question 16

why is assessing burn severity important?

Answer 16

Assessment determines whether: patient should be transferred to specialist centre and initial volume of fluid resus

Ongoing care
* 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 17

how is burn severity measured

Answer 17

percentage total body surface area burned and burn depth

% TBSA is a critically step in guiding appropriate burns management as it determines the initial fluid volume requirements for resus and whether or not the patient should be considered for transfer

Question 18

techniques used to estimate %TBSA

Answer 18

• Wallace’s rule of nines
• Rule of palm – where patients palm area represents 1% of their TBSA
• Lund and Browder Chart- paediatric cases

Question 19

Wallace’s rule of nines

Answer 19

each arm is worth 9
front and back torso worth 18 each

Question 20

Assessing burn dept

Answer 20

• More superficial burns may heal spontaneously (albeit are often more painful)
• Deeper burns may require further interventions, deeper burns also carry a higher risk of complications
• Does not guide initial resus effortss

Question 21

images of different depths of burns

Answer 21

Question 22

Basic management of all burns

Answer 22

• IV morphine
• Wound dressing
  o Initially dress wound with clingfilm to allow full evaluation of wound depth, whilst minimising fluid loss
• Hypothermia
  o Warmed room
  o Warmed fluids
  o Reduce wound exposure time

Question 23

management of minor burns

Answer 23

• Remove source of burn
• Any non-adherent clothing should be removed
• Wound cooled under running water for 20 mins as soon as possible as this promote re-epithelialisation

Question 24

which patients should be referred to specialist burn service

Answer 24

• Children >2% TSA or 3% in adults
• Full thickness burns
• All circumferential burns
• Any burs not healed in 2 weeks
• Any burn with suspicion of non-accidental injury should be referred to a burns unit/centre for expert assessment within 24 h

Question 25

management of more severe bruns should start with

Answer 25

1) The initial aim is to stop the burning process and resuscitate the patient. 2) The airway should be assessed first as with any emergency * smoke inhalation can result in airway oedema * early intubation should be considered e.g. if deep burns to the face or neck, blisters or oedema of the oropharynx, stridor etc 3) Intravenous fluids 4) A urinary catheter should be inserted. 5) Analgesia should be given. 6) Complex burns, burns involving the hand perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit. 7) Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue. 8) Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection. 9) There is no evidence to support the use of anti microbial prophylaxis or topical antibiotics in burn patients.

Question 26

which burns patients will require IV fluids

Answer 26

Children with burns >10% TBSA Adults >15%

Question 27

how are fluids calculated for burns patients

Answer 27

Parkland formula

Question 28

why fluid resus

Answer 28

- GOAL: adequate end -organ perfusion - Following burn injury allows for adequate intravascular volume and limits hypovolaemia, maintains organ perfusion and minimises tissue ischaemia in immediate post-burn period - Fluids are calculated from the time of the burn, not the patients hospital arrival time, if patient is clinically shocked on arrival, this should be corrected prior to calculating nay fluid requirements - Close urine output monitoring – marker of fluid balance status – should be maintained at 0.5mL/kg/hr

Question 29

urine output should be maintained at

Answer 29

0.5ml/kg/hr

Question 30

Modified parkland formula

Answer 30

The modified Parkland formula describes the volume of crystalloid fluid (ideally Hartmanns solution) to be administered in the first 24 hours post-burn: * Initial 24hrs (**Adults**): 4mL (Hartmann’s) x Weight (kg) x %TBSA burned * Initial 24hrs (**Children**): 3mL (Hartmann’s) x Weight (kg) x %TBSA burned **How is the fluid given:** - 50% of the calculated volume is given within the first **8 hours post-burn**, and the remaining 50% is given in the remaining 16 hours.

Question 31

Escharotomies

Answer 31

* 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 32

Reconstruction

Answer 32

- Early excision and grafting to prevent post-burn hypertrophic scarring and contracture - Thick sheet grafts can be used for important areas such as face, hands and neck - Pressure garments including face masks are applied as soon as scars are stable - For formed scars and contractures surgery is not attempted until scars have matured - Techniques o Excision and grafting o Scar release and join release o Local and regional flaps o Skin substitutes o Tissue expansion - Non-surgical o Intralesional corticosteroid injection o Cryotherapy o Laser treatment o Radiotherapy o 5- fluorouracil

Question 33

important support post burns

Answer 33

- Physiotherapy o Maintaining range of motion, preventing abnormal positioning and preventing predictable contractures o Regular chest physiotherapy - Nutritional support

Question 34

general complications of burns

Answer 34

Complications - Airway compromise - Respiratory failure - Fluid loss - Electrolyte imbalance (hyperkalaemia due to release of potassium from dead cells) - Rhabdomyolysis - Hypothermia - Compartment syndrome

Question 35

Systemic complications

Answer 35

Specific organ injuries that can occur include: * Acute lung injury – caused by a combination of burn and smoke inhalation, which can eventually lead to acute respiratory distress syndrome (ARDS) * Acute kidney injury – multifactorial from a combination of SIRS, hypotension, myoglobinuria, and any iatrogenic nephrotoxic agents o Treatment remains supportive, with careful fluid management; mannitol can be used in severe cases, especially with myoglobinuria * Endocrine complications – Direct fluid loss from the burns, third space losses, and kidney injury can lead to electrolyte imbalance, commonly results in initial hypernatraemia; subsequent hypokalaemia, hypomagnesaemia, hypocalcaemia, and hypophosphataemia * Gastrointestinal complications – these include paralytic ileus, Curling’s ulcer, and bacterial translocation o Early enteral feeding often mitigates complications, aiming to maintain body weight and endocrine homeostasis o Curlings ulcer- ulcer which forms due to signif reduction in plasma volume following injury which can lead to gastric mucosa ishcaemia, elading to ulcer formation

Question 36

Local complications

Answer 36

- Contractures - Keloid or hypertrophic scarring

Question 37

types of cold injury

Answer 37

freezing (frostbite) non-freezing (trench foot)

Question 38

Freezing (frostbite) management

Answer 38

* Remove wet clothing and replace with dry blankets, do not massage or rub area * Rewarming must be gradual to avoid reperfusion injury * Affected extremities need to be placed in a circulating bath of 37-39 degrees, until tissues soften and become a red/purple colour * Reperfusion can be very painful – IV analgesia , affected area should be demarcated to determine injury progression * Tetanus prophylaxis

Question 39

Non-freezing (trench foot)

Answer 39

* Washing * Airdrying * Rewarming * Elevating * Resting feet