Trauma

Question 1

initial management of burns?

Answer 1

• if multiply injured pt complicated by burns, ensure A to E approach and initial stabilisation, with consideration to other injuries, before t/f to specialist burns unit
• cool the burns-irrigation or immersion in tepid water-don’t want cold as induces vasoconstriction so will reduce heat loss from the skin, be careful of causing hypothermia in children.
• remove loose skin and dress wound following estimation of total burnt surface area (TBSA) and depth.
• analgesia-opiate?
• assess need for tetanus immunization.

Question 2

how are burns classified according to depth?

Answer 2

• superficial (epidermal)
• partial thickness (dermal)- subdivided into superficial partial thickness and deep partial thickness, the 1st extends into upper dermis layers and causes blistering, the 2nd extends into deeper dermis layers
• full thickness-burn extends through all skin layers into SC tissue.

Question 3

features of burns that help decide their depth?

Answer 3

bleeding on needle prick-no bleeding suggests full thickness burn
sensation-full thickness are insensate, diminished pain perception with needle prick suggests deep dermal injury
blanching-obvious blanching which then rapidly refills=superficial, a pale dry burn which slowly refills with colour is superficial dermal, deep dermal=do not blanch, mottled cherry red colour, full thickness=dry, leathery, waxy, do not blanch.

Question 4

r/f criteria to burns centre?

Answer 4

• full thickness burns at any age
• partial thickness burns with more than 10% TBSA in adult, more than 5% in child
• burns involving face, hands, feet, genitalia, perineum or major joints
• circumferential burns to chest-*risk of airway compromise-inflammation, torso or limb
• electrical burns including lightning injury
• chemical burns more than 5% TBSA, hydrofluoric acid burn more than 1%.

Question 5

when and why is fluid resuscitation required in burns patients?

Answer 5

when total burnt surface area (TBSA) more than 15% in adults or more than 10% in children, as excessive fluid volumes can be lost from burns, causing hypotension and shock.

Question 6

what does TBSA (total burnt surface area) include?

Answer 6

this is an area where burn is at least partial thickness, areas of simple erythema are not included.

Question 7

how can the fluid requirements for a burns patient needing fluid resuscitation be calculated?

Answer 7

parkland formula:
for 1st 24hrs use crystalloid e.g. 0.9% sodium chloride
total fluid requirement in 24hrs is 4ml X (TBSA as %) X (body weight in kg)
50% given in 1st 8 hours, 50% in next 16 hours (from time of BURN)
this volume is additional to maintenance fluid

if muscle damage, aim for higher urine output (1.5-2ml/kg/hr) to help prevent rhabdomyolysis.

Question 8

how can burns be dressed?

Answer 8

• initially can use clingfilm, but don’t make circumferential as risk of ischaemia
• if pt not being transferred, use simple paraffin gauze (jelonet) with dressing gauze, adding a layer of absorbent gauze or wool and firm crepe bandage
• can use silver sulfadiazine cream (flamazine)-effective against gram -ve bacteria
• avoid topical ointments initially as can make estimating burn depth difficult
• r/v in 24hrs-then continue with dressings if wound likely to heal by secondary intention within 3 wks, if likely to take longer than r/f to plastic surgeon or burn service.
• change dressing every 2-5 days depending on how healing.

in children, use non-adhesive silicone dressing as less wound adherent.

Question 9

indications for allowing a wound to heal by secondary intention?

Answer 9

contaminated or infected wound as high infection risk if these are sutured
excessive swelling placing tension on wound
dead or empty space below wound if was sutured

Question 10

how can total burn SA be calculated?

Answer 10

• Lund-Browder chart-most accurate
• rule of nines (wallace rule)
• palmar SA-roughly 0.8%

Question 11

important components to the assessment of burns?

Answer 11

type of burn
depth (dependent on contact temp and duration of contact) and extent (TBSA)
risk of inhalation injury-singed nasal hair, black carbon in sputum, carbon in oropharynx
coexisting medical conditions
predisposing factors
NAI
social circumstances
need for r/f

Question 12

what treatment may be necessary for full thickness circumferential burns?

Answer 12

escharotomy

Question 13

why are alkali burns with longer duration of contact worse than acid burns?

Answer 13

alkali more permeable so causes avascular necrosis