Thermal injuries Flashcards
When may energy transfer and oedema in thermal injuries present
Are not always immediately evident and may progress over time through progression of inflammatory response
Maintain suspicion regarding airway
Cause of hypovolaemia in burn injury
Inflammatory changes and capillary leak
Goal of resuscitation in thermal injuries
Stop burning process
Secure airway and ventilation
Maintain intravascular fluid in face of ongoing leak
(Rather than stopping the leak with haemorrhage)
Methods to stop burning process
Completely remove pt clothing
Prevent overexposure / hypothermia
Recognise wound contamination
Brush dry chemical powders from wound and then rinse
Indications for early intubation in thermal injuries
Signs of airway obstruction
Total body surface area burn >40-50%
Extensive / deep facial burns
Burns inside mouth
Significant or risk of oedema
Difficulty swallowing
Respiratory compromise
Reduced GCS
Full thickness circumferential neck burns
High risk factors for airway compromise in thermal injuries
Children
Inhalation injury
Causes of Breathing problems with thermal injuries
Hypoxia
Carbon monoxide poisoning
Smoke inhalation
Causes of hypoxia in thermal injuries
Inhalation injury
Circumferential chest burns
Thoracic trauma unrelated to thermal injury
Diagnosis of CO poisoning
History of burns in enclosed areas
Carboxyhaemoglobin measurement
Management of CO poisoning
100% oxygen via NRB mask
American Burn Association diagnosis of inhalation injury
Exposure to combustible agent
+
Signs of exposure in lower airway below vocal cords seen on bronchoscopy
Management of smoke inhalation injury
Supportive
Intubate
Elevate head + chest 30 degrees to reduce oedema when appropriate
When to provide burn resuscitation fluids
Deep partial or full thickness burns > 20% TBS area
How to calculate initial fluid rate for burn resuscitation fluids
Parkland formula
First half of the volume in first 8 hours
Second half of the volume over next 16 hours
Adjust fluids based on urine output
Fluid of choice for burn resuscitation fluids
Warmed Hartmann’s
Parkland formula for flame burns in Adults and children > 14 yrs
2 (ml) x patient body weight (kg) x TBS area (%)
Target UO for adults and children > 14 yrs with flame burns
0.5 ml/kg/hr
Parkland formula for flame burns in children < 14 yrs and > 30kg
3 (ml) x patient body weight (kg) x TBS area (%)
Target UO in children < 14 yrs and > 30kg with flame burns
1 ml/kg/hr
Parkland formula for flame burns in infants and young children < 30kg
3 (ml) x patient body weight (kg) x TBS area (%)
AND
Sugar containing solution (5% Dextrose) at maintenance rate
Target UO for infants and young children < 30kg with flame burns
1 ml/kg/hr
Parkland formula for electrical burns in all age groups
4 (ml) x patient body weight (kg) x TBS area (%)
Target UO in adults with electrical burns
100 ml/hr
Target UO in all age groups children < 30kg with electrical burns
1-1.5 ml/kg/hr
Why to avoid fluid boluses in thermal injuries (unless pt hypotensive)
Can increase oedema and additional complications
(inc airway compromise and compartment syndrome)
How to assess TBS area percentage
Patient’s palmar surface = 1%
Rule of 9s
Adult burns rule of 9s
Each of the following represent TBS area 9%:
- Head and neck
- Each upper limb
- Anterior chest
- Posterior chest
- Anterior abdomen / pelvis
- Posterior abdomen / pelvis
- Each anterior lower limb
- Each posterior lower limb
Genitalia = the last 1%
Paediatric burns rule of 9s
Differs from adults as head and neck is splint into 2x 9%, and each lower limb section reduced to 7%
Following areas represent TBS area 9%:
- Anterior head and neck
- Posterior head and neck
- Anterior chest
- Posterior chest
- Anterior abdomen / pelvis
- Posterior abdomen / pelvis
- Each upper limb
Each of following are 7%:
- Each anterior lower limb
- Each posterior lower limb
Superficial burn
(Epidermal burn)
Pink
Painful
No blisters
Superficial partial thickness burn
(Superficial dermal burn)
Moist
Pink
Painful
Blisters
Blanches to touch
Deep partial thickness burn
(Deep dermal burn)
Dry
Non blanching
Not painful
Red / mottled
Possible blisters
Full thickness burn
(Third degree burn)
Leathery
Translucent / waxy skin
Painless
Dry
Adjuncts to burns management in secondary survey
Bloods
Assessment for compartment syndrome
NG tube
Tetanus immunisation
Bloods for burns patients
FBC
G+S
ABG - carboxyhaemaglobin
Glucose
Electrolytes
Pregnancy test
Indication for CXR in thermal injuries
Intubated patient
Suspected smoke inhalation injury
Thermal injuries with risk of compartment syndrome
Circumferential burns of:
- Extremities
- Chest
- Abdomen
Cause of compartment syndrome in thermal injuries
Reduced skin elasticity
Increased soft tissue oedema
Management of compartment syndrome in thermal injuries
Escharotomy
Allows oedematous soft tissue to expand freely
Escharotomy definition
(Es-car-otomy)
Emergency incision of burnt skin to release the eschar and its restrictive effects
Escharotomy vs Fasciotomy
Escharotomy involves burnt tissue and does not extend to fascial layer
Indication for gastric tube insertion
Vomiting / Abdo distention
Burns > 20% TBS area
Managing agitation in burn patients
Treat hypoxia
Treat hypovolaemia
Analgesia and sedatives if above unsuccessful
Pain management in burns patients
Cover wounds
Analgesia
Wound care for burns
Gently cover with clean sheets
Clean with sterile saline
Things to avoid with burns wound care
Do NOT break blisters
Do NOT apply cold compresses or cold water
Use of prophylactic abx for burns
Avoid in early post burn period
Abx to treat infection only
Management of chemical burns
Brush away any dry powder chemicals FIRST
Irrigate liquid chemicals with copious warm water
Immediate wound care
Attempt to identify the chemical
Electrical burns mechanism of damage
Current travels inside blood vessels / nerves
Cause local thrombosis and nerve injury
Frequently more damaging than appear on body surface
Areas at particular risk from electrical burns
Extremities / Digits
Risk from electrical burns
Muscle injury causing myoglobinuria and renal failure
Treatment of myoglobinuria
Fluid resus with UO target 100 ml/hr in adults
Can consider mannitol
Role of mannitol in treatment of myoglobinuria
Free radical scavenger
Osmotic diuretic to flush out myoglobin along with IV fluids
Test for myoglobinuria
Urine test for hemochromogen
Management of electrical burns
Control airway
IV access
Continuous ECG monitoring
Treatment of rhabdomyolysis / myoglobinuria
Management of tar / asphalt burns
Rapid cooling of tar
Mineral oil used to dissolve tar
Signs of Non Accidental Injury burns
Circular burns
Burns with clear edges
Burn to soles of feet
Burn to buttocks
Old burns with new traumatic injury
Indication for transfer to burns centre
Partial thickness burn > 10% TBSA
Burns involving certain areas
Third degree burn
Electrical burn
Chemical burn
Inhalation injury
Burn with concomitant trauma (eg. fracture
Burns involving which certain areas are indication for transfer to Burns centre?
Face
Hands
Feet
Genitalia
Perineum
Major joints
Types of cold injury
Frostbite
Non-freezing injury
Causes of damage in frostbite
Freezing of tissue
Cell membrane injury secondary to ice crystals
Microvascular occlusion
Tissue anoxia
Reperfusion injury on rewarming
Cause of non-freezing injury
Long term exposure to wet conditions and temperatures just above freezing
Characteristics of non-freezing injury
Microvascular endothelial damage, stasis and vascular occlusion
Signs of non-freezing injury
Black appearance
Alternating arterial vasospasm and vasodilation
Blisters
Oedema
Ecchymosis
Ulcers
Affected tissue progression in non-freezing injury
1) Cold
2) Numb
3) Hyperaemia
4) Painful burning
5) Dysaesthesia
Management of cold injuries
Stop freezing tissue
Remove constricting / damp clothing
Warm blankets
Oral warm fluids
Place injured area in circulating water at constant 40 degrees
Avoid excessive dry heat
Avoid vasoconstrictive agents
Hypothermia definition
Core temperature < 36 degrees
Severe hypothermia definition
Core temperature < 32 degrees
Management of mild hypothermia
Passive warming
Eg blankets
Management of severe hypothermia
Active warming
Eg warmed IV fluids
