Trauma

Question 1

Burns assessment?

Answer 1

Depth, Extent, Location.
Depth in degrees-
1st degree: superficial, epidermis only; characterised by pain + erythema + NO blisters. Not life threatening; do not require fluids
2nd degree: i.e. partial thickness involving epidermis,and dermis; characterized by severe pain&hypersensitivity + red&mottled appearance + swelling + blisters +/- wet appearance
3rd degree: i.e. full thickness involving epidermis,dermis,subQ; characterized by painless + pale/charred + leathery + dry appearance, and does not blanch
4th degree:Skin, fat, muscle, bone – LIFE THREATENING!
Extent -
Based on Wallace’s rules of nine (per cent) in adults, and Lund-Browder chart for children.

Question 2

Which burns require admission to burns centre?

Answer 2

-Major burns:
Full thickness burns, mixed partial and full thickness burns that is >10% BSA in >50yo or 20% BSA in 10-50 yo, burns involving delicate areas (eyes, ears, face, hands, buttocks, perineum), circumferential burns in limbs and trunk, inhalational injury, electrical and chemical burn, burns coexisting with chronic medical problem.

Question 3

Risk factors for upper airway obstruction?

Answer 3

Hoarseness of voice
Inspiratory stridor
Soot in nostrils or burnt nasal hairs
Burns around nose, mouth, tongue
Swelling of buccal mucosa
Laryngeal edema on laryngoscopy

Question 4

Initial Mx of Major burn

Answer 4

ATLS protocol - primary survey must include assessment of need for intubation based in RF (if intubated, in th presence of senior staff, start with awake intubation technique before RSI, surgical airway equipment ready), O2 supplementation via NBM at 15L/min, IV access, crystalloid infusion

Question 5

Initial investigations?

Answer 5

GXM, FBC, U/E/Cr, ABG, Coagulation studies, CBG, COHb levels, ECG, CXR, Urinary cath for I/O assessment, Prevent hypothermia!

Question 6

Further management?

Answer 6

Fluid replacement:

• fluid replacement needed if >20% BSA affected.
• to calculate replacement -> Parkland’s formula and Wallace’s rule of nine/Lund-browder chart to calculate BSA.
• set large bore IV in peripheral vein (iv placement event through burnt skin)
• parkland’s formula: requirement in 1st 24hr = 2-4ml/kg/% BSA Hartmann’s solution or NS, use first half of volume within first 8 hrs and next half within last 16hrs.

Pain relief:
IV fentanyl, morphine, tramadol or entonox inhalation.
NB- opioids can cause hypotension in already fluid depleted burns pt

Burn wounds Management:
Cooled with clean water, covered with sterile dressing. Never cold water for burns > 10% BSA.
Escharotomy- indicated in full thickness circumferential burns of trunk and limbs. Done w/ or w/o analgesia, using sterile knife, following anatomical lines, cutting through full length of eschars, reaching fat layer.

Question 7

caveats for burns

Answer 7

• Burns can be managed outpatient if they r not full-thickness, >10% Bsa in children and >15% in adults, do not involve areas like eyes, ears,face, hands, buttocks, perineum, circumferential burns, inhalational injuries, electrical injuries, chemical injuries
• cooling is an important measure to limit damage caused by heat trapped in tissues and, to reduce pain.
• Alkali burns are more sinister than acid burns because penetrate deeper through liquefactive necrosis.

Question 8

initial Mx of minor burns

Answer 8

• ABC, vital
• remove burning objects
• remove potentially constricting objects(rings, bangles, watches)
• cooling burns using ‘10-15’ rule - cool within 10-15min, cold water of 10-15degC, cool/immerse for 10-15min
• wound dressing of 3 layers: inner non-adherent, middle absorbent (cotton wool), outer protective (bandage)
• analgesia initially opioids, subsequently NSAIDs and paracet suffice.
• if blisters large and tense, they are aspirated
• minor FACIAL burns do not require dressing. Wash with cold saline, antiseptic solution, cover with bland ointment/cream e.g liquid paraffin, avoidance of sun exposure for 14 days to prevent hyper pigmentation, possibility of swelling in first 3 days
• Abx cream without oral prophylaxis. Use 1% silver sulfadiazine before dressing wound.
• tetanus immunisation status checked. updated with boosters if necessary

Question 9

f/u Mx of burns

Answer 9

outpatient burns pt shld be f/u within 24-48hr. Check for:
1) signs of exudate seepage through dressing layers - if so, add another layer of dressing
2) signs of infection - serosanguinous, pus-like,foul-smelling d/c, inflamed wound margins, wound tenderness, fever chills
3)Dressing change within 48hr, and subsequently at 3-5 days, avoid changing too frequently- disrupts granulation and epithelial formation. Only change outer and middle layer.
Partial thickness wound heals within 10-15 days and inner dressing layer separates when new epithelium formed.