Thermal injuries Flashcards
Principles of thermal injury management
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)
Primary survey and resus in burns
Stop burning process
Ensure airway and ventilatory adequacy
Manage circulation
Stop the burning process in burns patients
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
Airway compromise in burns patients
Direct injury
Massive oedema
Factors increasing risk of upper airway obstruction
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
Causes of hypoxia in burns patients
Inhalation injury
Circumferential chest burns
Thoracic trauma unrelated to thermal injury
In patients who were burned in enclosed areas, always assume
Carbon monoxide exposure
Manage inhalation (smoke) injury
CXR and ABG
Supportive treatment
Intubate if significant burns
Elevate head and chest 30 degrees to reduce oedema when appropriate
Fluid rate for 2nd and 3rd degree burns
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
History in burns patient
Associated injuries whilst escaping fire
Explosions (internal injuries, fractures)
Time of burn injury
Enclosed space (inhalation risk)
LOC
Superficial burn description
Erythema
Pain
No blisters, no fluid replacement necessary
Superficial partial-thickness burn description
Moist
Painfully hypersensitive
Possible blisters
Pink
Blanches to touch
Deep partial thickness burn
Dry
Not painful
Possible blisters
Red/mottled
Does not blanch to touch
Full thickness burn description
Leathery appearance
Translucent/waxy skin
Painless
Dry
Escharotomy
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
Secondary survey in thermal injuries
Document
Baseline bloods including carboxyhaemoglobin
Maintain peripheral circulation in circumferential extremity burns
Gastric tube
Narcotic analgesia and sedatives
Wound care
Tetanus immunisation
Bloods for thermal injury
FBC
Cross match
ABG with carboxyhaemoglobin
Glucose
U&Es
pregnancy test if appropriate
CXR in intubated pts or suspected inhalation injury
Risk in circumferential extremity burns
Compartment syndrome
(dec skin elasticity and increased soft tissue oedema)
Possible indications for fasciotomy (as opposed to escharotomy) in thermal injuries
Skeletal trauma
Crush injury
High voltage electrical injury
Indications for gastric tube in thermal injuries
Nausea, vomiting or abdominal distension
Burns >20% body surface area
(Insert and attach suction prior to transfer)
Before administering narcotic analgesics or sedatives in thermal injury patients, first manage
Hypoxemia and inadequate fluid resus
- do small frequent IV doses only
- cover wounds to help decrease pain
Wound covering for partial thickness burn wounds
Cover with clean sheets
You should break blisters in burns patients, true or false
False
Before using antibacterial topical agents on burns wounds, you should
Remove any previously applied medication
How to clean dirty burns wounds
Sterile saline
Cold compresses or cold water should not be applied to patients with extensive burns, true or false
True
(risk of hypothermia)
Should antibiotics be used early post burn period
no
Irrigation to wash off chemicals in a patient with chemical burn injury should not occur until
the airway has been assessed and secured
Interventions for treating rhabdomyolysis
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
Effect on muscles of electrical burns
Contracture
Management of electrical burns
Therapy for suspected myoglobinuria
4ml/kg/%TBSA to ensure urinary output of 100ml/hr
Suspicious burn injuries for abuse
Circular burns
Clear edges and unique patterns
Burns on soles of feet
Burns to buttocks
Old burns seen with new traumatic injury
Criteria for transfer to a burns centre
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)
Passive rewarming
Environment that reduces heat loss
- dry clothing, blankets etc
Active rewarming
Additional sources of heat energy
- warmed IV solution
- warmed packs to areas of high vascular flow eg groin/axilla
Signs of non freezing injury
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
Manage frostbite and nonfreezing cold injury
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
Wound care for frostbite
Prevent infection
Avoid opening uninfected vesicles
Elevate injured area
Leave wound open to air
Keep wound clean
Withhold vasoconstrictive agents
Severe hypothermia
Core temp below 32
