Burns

Last Updated on by FRCEM Intermediate

Overview

  • Burns are injuries to tissues caused by heat, friction, electricity (an entry and exit point), radiation, or chemicals (Alkalis penetrate deeper than acids)
  • Burns >15% BSA in Adults and >10% in children can cause profound circulatory shock
  • Non-pharmacological methods include cooling the burn under cold running water and covering with cling film

Burn Assesment

  • Estimating Total Body Surface Area (TBSA) % of Burn
  • Estimating Depth of Burn

Common tools of estimating % burn of BSA

  • Rules of 9’s
  • Palm of patient = 1% TBSA burn
  • Lund-Browder Chart

Assessing the depth of burn

  • Superficial – epidermis only
  • Superficial Partial Thickness burn -(epidermis and upper layer of dermis),
  • Deep Partial Thickness burn- (extends to deeper layer of dermis)
  • Full – all layers of dermis and may involve underlying tissue

 

Fluid Replacement

  • Modified Parklands Formula
    • Adults – 4mL/kg/%
    • Children – 3-4mL/kg/%
  • give 1/2 in first 8h since the time of injury
  • give 1/2 in next 16h
  • + maintenance fluid for children <30 kg aim for urine output of 0.5mL/kg/hr and normal cardiovascular
  • parameters (HR, BP) then albumin after first 24 hours (keep albumin > 20)
  • more fluid is typically required if: inhalational injury, electrical burns or delayed resuscitation

The indication to discuss/refer burn facility 

  • All burns ≥2% TBSA in children or ≥3% in adults
  • All full thickness burns
  • All circumferential burns
  • Any burn not healed in 2 weeks
  • All burns to hands, feet, face, perineum or genitalia
  • Any chemical, electrical or friction burn
  • Any cold injury
  • Any unwell/febrile child with a burn
  • Any concerns regarding burn injuries and co-morbidities that may affect treatment or healing of the burn
  • Burns in a pregnant patient
  • Suspicion of Non-Accidental Injury

Important factors to consider in burn

  • Resuscitation – airway patency, breathing, circulation, LOC
  • Adequacy of resuscitation to date – HR, BP, urine output, fluid received
  • Associated trauma
  • Airway burn or inhalational injury – stridor, burns to face, nose and mouth, carbonaceous sputum
  • Facial and/or corneal burns, perineal burns
  • Circumferential burns – extremities -> compartment syndrome, ventilator inadequacy -> escharotomy
  • Rhabdomyolysis
  • Inhalation of toxic gases – CO
  • Temperature
  • Adequacy of analgesia
  • tetanus cover
  • Problems with vascular access
  • Evidence of drug/alcohol ingestion
  • Co-morbid conditions

Airway

Factors that increase the suspicion of airway obstruction or inhalation injury

  • Hoarse voice
  • Carbonaceous sputum
  • Raised carbon monoxide (CO)
  • Deep facial burns
  • A history of burns in an enclosed space
  • Respiratory distress/ stridor

Management of airway in burn

  • Sit patient upright
  • Any suspected airway injury necessitates senior anaesthetic review to identify and predict deterioration
  • If indicated, early intubation with an uncut tube prevents the tube moving in the event of further swelling
  • maximum wound oedema takes place at 12-36hrs after injury
  • FOB or nasoendoscopy
  • Bronchoscopy – soot, charring, mucosal erythema, necrosis, airway oedema
  • RSI
  • sux ok for 24-48h then none for 2 days -> 2 yrs
  • may need AFOI or surgical airway

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