Thermal injuries

Question 1

Principles of thermal injury management

Answer 1

High index of suspicion for airway compromise
Identify and manage associated mechanical injuries
Maintain haemodynamic normality with volume resuscitation
Prevent hypothermia
Remove pt from injurious environment
Energy transfer and oedema may not be evident immediately (think about IV lines, tube ties, ID bands)

Question 2

Primary survey and resus in burns

Answer 2

Stop burning process
Ensure airway and ventilatory adequacy
Manage circulation

Question 3

Stop the burning process in burns patients

Answer 3

Completely remove patient’s clothing
Prevent overexposure and hypothermia
Think about possible wound contamination
Brush any dry chemical powders from the wound and then rinse

Question 4

Airway compromise in burns patients

Answer 4

Direct injury
Massive oedema

Question 5

Factors increasing risk of upper airway obstruction

Answer 5

Increasing burn size and depth
Burns to head and face
Inhalation injury
Burns inside the mouth
Age: children with burn injuries are at higher risk for airway problems

Question 6

Causes of hypoxia in burns patients

Answer 6

Inhalation injury
Circumferential chest burns
Thoracic trauma unrelated to thermal injury

Question 7

In patients who were burned in enclosed areas, always assume

Answer 7

Carbon monoxide exposure

Question 8

Manage inhalation (smoke) injury

Answer 8

CXR and ABG
Supportive treatment
Intubate if significant burns
Elevate head and chest 30 degrees to reduce oedema when appropriate

Question 9

Fluid rate for 2nd and 3rd degree burns

Answer 9

2 ml lactated ringer’s x body weight x % surface area in burns

• one half in first 8 hours
• one half over next 16 hours

3ml for paediatrics
- in children <30kg add maintenance fluids of 5% dextrose in water

Adjust according to urine output

Question 10

History in burns patient

Answer 10

Associated injuries whilst escaping fire
Explosions (internal injuries, fractures)
Time of burn injury
Enclosed space (inhalation risk)
LOC

Question 11

Superficial burn description

Answer 11

Erythema
Pain
No blisters, no fluid replacement necessary

Question 12

Superficial partial-thickness burn description

Answer 12

Moist
Painfully hypersensitive
Possible blisters
Pink
Blanches to touch

Question 13

Deep partial thickness burn

Answer 13

Dry
Not painful
Possible blisters
Red/mottled
Does not blanch to touch

Question 14

Full thickness burn description

Answer 14

Leathery appearance
Translucent/waxy skin
Painless
Dry

Question 15

Escharotomy

Answer 15

Incision in burn eschar that release pressure in underlying soft tissue

If oedema
+ reduced elasticity of burned skin

that results in increased pressure in underlying soft tissue

Question 16

Secondary survey in thermal injuries

Answer 16

Document
Baseline bloods including carboxyhaemoglobin
Maintain peripheral circulation in circumferential extremity burns
Gastric tube
Narcotic analgesia and sedatives
Wound care
Tetanus immunisation

Question 17

Bloods for thermal injury

Answer 17

FBC
Cross match
ABG with carboxyhaemoglobin
Glucose
U&Es
pregnancy test if appropriate
CXR in intubated pts or suspected inhalation injury

Question 18

Risk in circumferential extremity burns

Answer 18

Compartment syndrome
(dec skin elasticity and increased soft tissue oedema)

Question 19

Possible indications for fasciotomy (as opposed to escharotomy) in thermal injuries

Answer 19

Skeletal trauma
Crush injury
High voltage electrical injury

Question 20

Indications for gastric tube in thermal injuries

Answer 20

Nausea, vomiting or abdominal distension

Burns >20% body surface area

(Insert and attach suction prior to transfer)

Question 21

Before administering narcotic analgesics or sedatives in thermal injury patients, first manage

Answer 21

Hypoxemia and inadequate fluid resus

• do small frequent IV doses only
• cover wounds to help decrease pain

Question 22

Wound covering for partial thickness burn wounds

Answer 22

Cover with clean sheets

Question 23

You should break blisters in burns patients, true or false

Answer 23

False

Question 24

Before using antibacterial topical agents on burns wounds, you should

Answer 24

Remove any previously applied medication

Question 25

How to clean dirty burns wounds

Answer 25

Sterile saline

Question 26

Cold compresses or cold water should not be applied to patients with extensive burns, true or false

Answer 26

True

(risk of hypothermia)

Question 27

Should antibiotics be used early post burn period

Answer 27

no

Question 28

Irrigation to wash off chemicals in a patient with chemical burn injury should not occur until

Answer 28

the airway has been assessed and secured

Question 29

Interventions for treating rhabdomyolysis

Answer 29

Fluids to target urine output at 100mls/hr

Mannitol - free radical scavenger and osmotic diuretic, to increase urine output and therefore wash out of myoglobin

Question 30

Effect on muscles of electrical burns

Answer 30

Contracture

Question 31

Management of electrical burns

Answer 31

Therapy for suspected myoglobinuria

4ml/kg/%TBSA to ensure urinary output of 100ml/hr

Question 32

Suspicious burn injuries for abuse

Answer 32

Circular burns
Clear edges and unique patterns
Burns on soles of feet
Burns to buttocks
Old burns seen with new traumatic injury

Question 33

Criteria for transfer to a burns centre

Answer 33

Partial thickness burns on greater than 10% total body surface area
Burns involving face, hands, feet, genitalia, perineum and major joints
Third degree burns
Electrical burns
Chemical burns
Inhalation injury
Pre-existing medical disorders
Concomitant trauma
Children, when capabilities for children are not present
Special intervention required (social, emotional, rehab)

Question 34

Passive rewarming

Answer 34

Environment that reduces heat loss
- dry clothing, blankets etc

Question 35

Active rewarming

Answer 35

Additional sources of heat energy
- warmed IV solution
- warmed packs to areas of high vascular flow eg groin/axilla

Question 36

Signs of non freezing injury

Answer 36

Black appearance
Alternating arterial vasospasm and vasodilation

Affected tissue progresses from cold and numb to hyperemia with painful burning and dysesthesia
oedema, blistering, redness, ecchymosis, ulceration

Question 37

Manage frostbite and nonfreezing cold injury

Answer 37

Stop tissue freezing
Replace constricting, damp clothing with warm blankets
Hot fluids by mouth
Place injured part in circulating water at constant 40 degrees
Avoid excessive dry heat, do not rub area

Analgesia
monitor cardiac status and peripheral perfusion

Question 38

Wound care for frostbite

Answer 38

Prevent infection
Avoid opening uninfected vesicles
Elevate injured area
Leave wound open to air
Keep wound clean
Withhold vasoconstrictive agents

Question 39

Severe hypothermia

Answer 39

Core temp below 32