Burn 1

1. HKCEM College Tutorial Burn 1 author Dr. Axel YC Siu Revised by Dr. Chan ming yin July, 2013

2. Case • A 35 year old man was sent to the ED after rescue from a household fire accident

3. What is your first priority of management? • ABC • Assessment of airway to rule out potential airway burn • Secure the airway in case of imminent airway compromise

4. How would you assess the airway?

5. Airway Assessment • History • Duration of exposure? • Closed or entrapped environment? • Any history of loss of consciousness? • Fire involved chemical? • Explosion e.g. LP gas

6. Airway Assessment • Physical assessment • Facial and neck burn • Oro-pharyngeal +/- carbon deposits • Singed nasal hair +/- eyebrows • Carbonaceous sputum • Hoarseness of voice • Stridor

7. Case Progress • Initial assessment showed BP 144/75mmHg, pulse 115/min, RR 28/min and SaO2 92% on 100%O2 • There was singed nasal hair and audible stridor.

8. How would you manage this patient?

9. Management on Compromised Airway • Confirmation of airway burn • 100% O2 by mask • Secure the airway by endotracheal intubation with rapid sequence intubation • Close monitor vital signs

10. Case Progress • After intubation, you noticed thatthe SpO2 was still 93% in 100%O2 and the high pressure alarm was on • What are the possible reasons?

11. Possible Causes for Persistent Hypoxaemia with High Airway Pressure • Displacement of tube • Obstruction • Pneumothorax • Equipment problem • Lower airway burn • Circumferential chest burn

12. Circumferential Full Thickness Burn • Please describe how would you manage a circumferential full thickness chest burn.

13. Escharotomy • No analgesics is required • Drape and sterilize • Incise along the anterior axillary line from supraclavicular region down below the costal margin • Additional horizontal incision may be made along the subclavicular and subcostal region Deep to bleeding tissue!

14. Describe the fluid management for this patient

15. Fluid Management • There are different fluid regimes for burn • Modified Parkland Formula is commonly used: • 2-4mL x TBA 2 degree or above Burn(%) x BW Ringer Lactate Solution • ½ to be given in the first 8 hours from time of injury • The rest to be given in the following 16 hours

16. What factors will affect your management of burn wounds? Age Depth Extent Location Mechanism e.g. chemical, electrical

17. How do you estimate burn depth and burn area?

18. Depth of Burn Estimation • 1st Degree Burn • Involves epidermis • 2nd Degree Burn • Superficial partial thickness = epidermis with superficial dermis • Deep partial thickness = epidermis with deep dermis • 3rd Degree Burn • Full thickness burn with damage to nerve ending • 4th Degree Burn • Full thickness burn involving underlying muscle or bone BMJ 2004;329:158–60Management of burn injuries of various depths

19. First degree • Includes only the outer layer of skin, the epidermis • Skin is usually red and very painful • Typical example: sunburn • Blistering may occur but is not common • Dry in appearance • Healing occurs within one week, injured epithelium peels away from the healthy skin • Hospitalization is for pain control and maybe fluid imbalance

20. Second degree: Can be classified as superficial partial thickness or deep partial thickness • Superficial partial thickness • upper dermis and the epidermis • Blistering is common • Wound will be pink, red in color, painful and wet appearing • Wound will blanch when pressure is applied • Healing is expected within two weeks by regeneration ofepidermis • Deep partial thickness • Can be red or white in appearance, but will appear dry. • Involves the destruction of the entire epidermis and most of the dermis • Sensation can be present, but diminished • Blanching is sluggish or absent • may need excision & skin grafting to heal especially over functional or cosmetically sensitive areas

21. Third degree • All layers of the skin is destroyed • Extend into the subcutaneous tissues • Areas can appear, black or white and will be dry • Can appear leathery in texture • Will not blanch when pressure is applied • No pain

22. Fourth degree • Full thickness that extends into muscle and bone

23. Total Body Surface Burn Estimation • Include 2-4 degree burn only ( not 1 degree) • Standard Burn Chart (e.g. Lund and Browder Chart) • Rule of Nines • Palm size estimation ( own palm size = 1% excluding fingers)

24. Rule of Nines

25. Wound care • Irrigate with copious NS for chemical agent (do not use neutralising agent) • Cold stress should be avoided ( prevent hypothermia) • Protect wound with clean dressing

26. Miscellaneous Management • Foley catheter should be inserted for urine output monitoring in major burn patient • Nasogastric or orogastric tube to relieve gastric distension after intubation • ATT prophylaxis if indicated • Morphine by titration for pain after ABC taken care of.

27. Baseline investigation • Chest X-ray • CBP, electrolytes and ABG • Carboxyhaemoglobin as indicated • Methaemoglobin as indicated • Electrocardiogram for electrical burn • X-match for major burn patients

28. What are the criteria for hospitalisation?

29. Extent of Burn • Second degree and third degree burns of more than 10% TBA in patients under 10 or over 50 years old • Second degree and third degree burns of more than 20% TBA in all other age group • Third degree burns of more than 5% TBA in any age group

30. Type of Burn • Scald • Flame burn • Chemical burn • Electrical burn • Radiation burn • Inhalation injury • Circumferential burns

31. Special Area • Face • Hands • Feet • Perineum

32. Decreased host resistance • Diabetes Mellitus • AIDS • Alcoholism

33. Others • Burn patients with co-existing trauma • Suspected child abuse • Inadequate care at home

34. Back to Case • 30% 2-3degree burn with inhalation injury • Intubated and ventilated, given Parkland formula IVF, wound covered with dressing. • Transfer to Burn unit? • COHb 35% • Troponin I elevated • History of LOC now GCS 15/15. BP/P stable • Hyperbaric oxygen therapy?

35. Thank You