Burns

Reviewed and revised 2 September 2014

OVERVIEW

Burns are injuries to tissues caused by heat, friction, electricity, radiation, or chemicals

  • Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects
  • extent of burns and fluid resuscitation is often over-estimated in the ED

EPIDEMIOLOGY

  • In adults the usual mechanism is exposure to fire, in child scalding is most common
  • maybe associated with alcohol, abuse, epilepsy or psychiatric problem
  • mortality is related to age (>50yrs), TBSA (40%) burnt and burn depth
  • increased mortality if post-burn resuscitation is delayed >2h

CLASSIFICATION OF BURNS

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

ASSESSING EXTENT OF BURNS

Methods

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

OTHER IMPORTANT ASPECTS

  • 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
  • Problems with vascular access
  • Evidence of drug/alcohol ingestion
  • Co-morbid conditions

MANAGEMENT

Key points

  • EMST/ATLS protocol – primary and secondary survey
  • Burn assessment and management – debridement by 48 hours
  • Transfer to definitive care facility

PRIMARY SURVEY

Airway with C-spine control

  • may need ETT urgently (use an uncut tube + wire to maxilla)
  • warning signs include = singed nasal hairs, horse voice, productive brassy cough, soot in sputum, stridor, facial burns, breathed fire, voice change
  • 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

Breathing with O2

  • 15L/min + reservior bag
  • may require ETT + IPPV because of other injuries, major resusication, sedation, ARDS & analgesia, decreased pulmonary compliance
  • protective lung injury
  • NAC & heparin nebulisers used in some centers
  • suction

Circulation with haemorrhage control

  • >25% -> SIRS with oedema
  • IV access through intact skin where possible
  • IVF for >15% in adults & >10% in children
  • Hartmans is preferred
  • x-match units
  • may have to stop surgery to catch up
  • aim for PCV 0.3

Disability with assessment of neurological function

  • CHI
  • CO poisoning
  • ETOH poisoning
  • analgesia

Exposure with temperature control

  • remove all clothes
  • if stuck to patient, cut around adherent areas
  • keep warm
  • assess %TBSA and depth
  • warm theatre (32 C)
  • humidify (70-80%)

SECONDARY SURVEY

  • cool with running cold water (20min)
  • bronchoscopy for evidence of an inhalational injury (nebulized heparin and NAC)
  • watch for hypothermia
  • cover with clingfilm (limits evaporation, heats loss & pain)
  • IV morphine
  • escharotomy – limbs & chest wall
  • have lots of blood ready
  • watch for COHb -> will need 100% O2 or hyperbaric O2

ICU MANAGEMENT

Fluid replacement

  • required in adult > 15%, children >10%
  • Modified Parklands Formula (original Parkland’s formula included colloids)

-> 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
  • permissive hypovolaemia with non-invasive haemodynamic monitoring is a promising approach
  • test for myoglobinuria -> if +ve then rhabdomyolysis is present:

(1) aim 2-3mL/kg/hr
(2) consider: alkalinise urine with 25mmol of HCO3- for each litre of Hartmans
(3) consider: promote diuresis with 12.5g mannitol to each litre of Hartmans

Dressings

  • biobrane: superficial
  • acticoat: partial
  • subcut infusions: hypertonic saline + acetic acid (anti-pseudomonal)

Other issues

  • NJ tube -> feed
  • strict asepsis
  • vigilance for nosocomial infections: line changes every 7 days
  • tetanus
  • antibiotics in initial period if dirty (frequently cooled at scene with dirty water)
  • family discussion
  • prognosis: age + TBSA burn should be less than 100.
  • monitor for post burn leukopenia (cease silver sulfadiazine and use mafenide acetate, stop cimetidine, consider G-CSF if doesn’t improve in 3 days)

Chemical Burns

  • protect self with gloves, apron & facemask
  • remove contaminated clothing
  • neutralize or dilute with H2O (1hr)
  • Hydrofluoric acid – topical calcium gluconate burn gel + Biers block with 10-15mL of 10% calcium gluconate + 5000U of heparin in 40mL 5 % dextrose
  • Phosphorus – copper sulphate solution
  • Bitumen – cool with H2O, remove with vegetable or paraffin oil

Electrical Burns

  • low voltage (<1000V) -> local contact burn
  • high voltage (>1000V) -> entrance & exit wound -> may require fasciotomy
    -> side flash = nearby lightening strike -> superficial burns, entry & exit burns +/- respiratory arrest
  • direct lightning strike -> often fatal

INDICATIONS FOR REFERRAL TO BURNS CENTRE

Early discussion with your regional burns centre is advised if there is any doubt/concern regarding the management of any burns patient.

  • Burns > 10 % TBSA in an Adult
  • Burns > 5 % TBSA in a Child
  • Full thickness burns > 5% TBSA
  • Burns of face, hands, feet, perineum, genitalia, and major joints
  • Circumferential burns
  • Chemical or electrical burns
  • Burns in the presence of major trauma or significant co-morbidity
  • Burns in the very young patient, or the elderly patient
  • Burns in a pregnant patient
  • Suspicion of Non-Accidental Injury

FLUID CREEP

  • excess fluid loading is also termed ‘fluid creep’
  • fluid creep is common in burns patients
  • possible reasons for fluid creep:
    • inaccurate fluid requirement calculations
    • lack of vigilance in reducing unnecessary fluid infusions
    • increased use of sedation and analgesic agents
    • excess crystalloid over colloid replacement
    • inappropriate use of parameters for monitoring adequacy of fluid replacement

References and links

LITFL

Journals and Textbooks

  • Benson A, Dickson WA, Boyce DE. Burns. BMJ. 2006 Mar 18;332(7542):649-52. Review. Erratum in: BMJ. 2006 Apr 1;332(7544):755. PMID: 16543335; PMCID: PMC1403274.
  • Coban YK. Infection control in severely burned patients. World J Crit Care Med. 2012 Aug 4;1(4):94-101. PMC3953869.
  • Hall KL, Shahrokhi S, Jeschke MG. Enteral nutrition support in burn care: a review of current recommendations as instituted in the Ross Tilley Burn Centre. Nutrients. 2012 Oct 29;4(11):1554-65. PMC3509506.
  • Hettiaratchy S, Dziewulski P. ABC of burns: pathophysiology and types of burns. BMJ. 2004 Jun 12;328(7453):1427-9. Review. Erratum in: BMJ. 2004 Jul 17;329(7458):148. PMC421790.
  • Norman AT, Judkins KC. Pain in the patient with burns. Contin Educ Anaesth Crit Care Pain 2004;4(2):57-61 [Free Full Text]
  • Peck M. Respiratory burn injuries: An overview. Indian J Burns [serial online] 2013 [cited 2014 Sep 2];21:17-23. Available from: http://www.ijburns.com/text.asp?2013/21/1/17/121876
  • Snell JA, Loh NH, Mahambrey T, Shokrollahi K. Clinical review: the critical care management of the burn patient. Crit Care. 2013 Oct 7;17(5):241. PMC4057496.
  • Williams FN, Branski LK, Jeschke MG, Herndon DN. What, how, and how much should patients with burns be fed? Surg Clin North Am. 2011 Jun;91(3):609-29. PMC3255093.

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.