Burns

1. Burns Katy Talbot

2. 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

3. Pathophysiology of a Burn Coagulation -Irreversible tissue necrosis. Stasis -Ischaemia which may be reversible, depending on management Hyperaemia -Reversible erythema

4. Emergency Management of Burns • Stop the burn process & Cool the burn. • ATLS & Assessment of burn wound. • Resuscitation. • Reassess burn. • Definitive Treatment.

5. 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)

6. 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.

7. 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.

8. 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.

9. ATLS For Burns Patients A • 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

10. 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.

11. ATLS For Burns Patients B • 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.

12. Chest Escharotomy

13. ATLS for Burns Patients C • 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 • Adults with >15% TBSA • Children with >10% TBSA

14. 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.

15. 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)

16. ATLS for Burns Patients D • DISABILITY • Assess neurological status • Reduced GCS could be due to inhalation of toxic products of combustion (CO) causing hypoxia.

17. ATLS for Burns Patients E • EXPOSURE • Expose and assess the extent of injury • Remove any clothing or jewellery which may become constrictive with swelling.

18. 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.

19. Lund-Browder Chart

20. 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.

21. 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.

22. 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

23. 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.

24. 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.

25. 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.

26. 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

27. 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.

29. 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