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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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