BurnsKaty Talbot

What is a Burn Injury? A disruption of the normal tissue architecture of the

skin/other organic structure. The most damaging feature is the interruption of blood supply to the skin.

A burn has multiple aetiologies:

Thermal (hot or cold)

Electrical

Chemical (acids)

Radiation (sunburn)

Friction

Pathophysiology of a BurnCoagulation-Irreversible tissue necrosis.

Stasis-Ischaemia which may be reversible, depending on management

Hyperaemia-Reversible erythema

Emergency Management of Burns

1. Stop the burn process & Cool the burn.

2. ATLS & Assessment of burn wound.

3. Resuscitation.

4. Reassess burn.

5. Definitive Treatment.

First Aid to a Burns Patient

STOP THE BURN PROCESS Remove the source of the burn e.g fire,

radiation etc.

Remove all burnt clothing unless adhered to the skin.

Acid burns can be irrigated with a sodium bicarbonate solution (baking powder & water)

First Aid to a Burns Patient

COOL THE BURN WITH WATER Irrigate the wound with running water.

It reduces pain and slows the necrotic process – reduces burn depth and improves outcome.

Warm the Patient, Cool The Burn.

Those at the extremes of age, and those with extensive burns are at particularly at risk of hypothermia after a burn injury.

Try and keep the patient covered up and warm while cooling the burn.

It is recommended to limit the cooling time to 20 minutes due to the risk of hypothermia.

First Aid to a Burns Patient

COVER THE BURN If you have no dressings available cover

the wound with cling film while being transferred to hospital.

Important not to wrap circumferentially – can exert pressure and have a tourniquet effect if oedema starts to develop.

ATLS For Burns Patients

AIRWAY WITH C-SPINE PROTECTION The airway can become obstructed due to swelling of

neck tissues secondary to a burn, or due to a primary inhalation injury.

Indications for Intubation: Stridor Prophylactic GCS <9 Agitation

A

Inhalation Injury Inhalation injury is a burn of the respiratory tract

due to breathing in toxic gases.

Causes airway obstruction due to swelling of the soft tissue structures.

Suspect inhalation injury when: Burn in a confined space Facial burn/singed facial hair Soot/Charring Mucosal inflammation in mouth or nose Carbonaceous sputum Stridor/Hoarse Voice.

ATLS For Burns Patients

BREATHING WITH VENTILATION Give high flow 100% humidified oxygen.

Assess the chest for ventilation and movement defects

Deep circumferential burns to the chest can restrict chest wall movements, reducing compliance leading to breathing difficulty.

May need to release skin with escharotomies.

B

Chest Escharotomy

ATLS for Burns Patients CIRCULATION WITH HAEMORRHAGE CONTROL Assess Circulation – non-burnt skin colour, temp, cap

refill, pulse, BP, JVP.

Insert 2 large bore cannulas, preferable in non- burnt skin.

Fluid resuscitation o Adults with >15% TBSA o Children with >10% TBSA

C

Resuscitation for Burns Patients

Burns patients have a large risk of hypovolaemic shock

In a burn wound there are microvasculature changes which increase capillary permeability and damage the lymphatic system. The oncotic pressure of the plasma is reduced and of the tissue is increased.

Therefore widespread burns can lead to a systemic loss of volume from the vasculature.

Parklands Formula

3-4mls/kg/TBSA% = mls in 24hours post injury.

½ in the first 8 hours.

½ in the next 16 hours.

Ringers Lactate/Hartmann’s are the preferred fluids.

Also essential to monitor urine output (>0.5ml/kg/hr)

ATLS for Burns Patients

DISABILITY Assess neurological status

Reduced GCS could be due to inhalation of toxic products of combustion (CO) causing hypoxia.

D

ATLS for Burns Patients

EXPOSURE Expose and assess the extent of injury

Remove any clothing or jewellery which may become constrictive with swelling.

E

Assessing the Size of a Burn Uses Total Body Surface Area

(TBSA)

Wallace Rule of 9s for adults.

Lund-Browder Chart for paediatric cases – the head of a child typically takes up more of their TBSA.

A handprint is about 1% TBSA. This can be useful for estimating very small or large burn size.

Lund-Browder Chart

Assessing Burn Depth

Superficial Burn Involves the epidermis only

Appearance: Dry and red, blanches to pressure, moderately painful, no blisters at the time of injury.

Will heal within 7 days with no scarring.

Not included in TBSA assessment.

Assessing Burn Depth Superficial Dermal Partial Thickness Involves the epidermis and the papillary

(superficial dermis)

It is extremely painful due to the exposure of sensory nerves.

Appearance – pale pink, fine blisters are characteristic. Blanches to pressure, with a rapid cap refill.

Will heal in 14 days, and may have a pigment defect scar.

Assessing Burn Dept Mid Dermal Partial Thickness Involves epidermis and part of the dermis.

Skin adnexal organs are also affected.

Less painful than superficial dermal burns as some of the pain nerve endings will be damaged.

Appearance – Dark pink/red, large blisters, sluggish cap refill.

Heals in 14-21 days, and may cause hypertrophic scarring

Assessing Burn Depth Deep Dermal Partial

Thickness Involves epidermis, and most of the

dermis. Only the very deep adnexal organs intact.

Decreased sensation

Appearance – Red and White blotches, extensive blisters which rupture soon after injury, no cap refill, no blanching.

Takes >21 days to heal and most often needs surgery. 81% chance of scarring.

Assessing Burn Depth Full Thickness Burn All epidermis, dermis, and adnexal

structures destroyed. No blood supply = infarction of the skin.

NO SENSATION TO PINPRICK

Appearance – White, charred leathery skin, no blisters, no cap refill, no blanching.

Will not heal without surgery, and will scar.

Escharotomy Full thickness burns may require escharotomy surgery.

This is a full thickness incision of the burned skin down to SC fat.

It is done to relieve the constricting effect of the leathery tight skin. This can restrict ventilation in the chest or cause limb ischaemia.

Early Management Nasogastric Tube – Early feeding is essential in

burns patients as they go into a state of hypermetabolism. Indicated in adults >20% TBSA and children >15% TBSA.

Tetanus Prophylaxis

Hypothermia Prevention – Insulate the patient, warm room, warm IV fluids.

Infection control

Definitive Burn Surgery Debride devitalised skin and blisters

Skin grafts – Autograft is preferred. In patients with extensive injury skin substitutes can be used until they grow some more skin to graft.

Meshed grafts are good for extensive injuries as can cover a larger area, and allows the damaged skin to drain.

Sheet grafts have a better cosmetic and functional outcome.

Use compression to reduce hypertrophic scarring, and splints to prevent contractures.

References http://www.vicburns.org.au/about.html

http://www.acidviolence.org/index.php/acid-violence/first-aid-information/

http://reference.medscape.com/article/934173-treatment#a1135

http://membership.uhms.org/?page=ATBI

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC478230/

http://www.who.int/mediacentre/factsheets/fs365/en/index.html