I’m just back from an Emergency Management of Severe Burns course.
Great little course. Concise manual. A day of very brief lectures, then skills stations, then scenarios then a written and practical exam. It runs in 16 countries including Australia, NZ, UK and South Africa.
Not everyone will be able to go on the course tomorrow so I’m going to cram the key points into 20 minutes for you.
A big focus of the course is to ensure the ABCs are assessed and reassessed, and a reminder that a lot of severe burns are potentially multitrauma.
They have adapted the standard trauma primary and secondary survey by putting First Aid between the primary and secondary survey. First aid includes 20 minutes of cooling which can be effective up to 3 hours post burn (which was new to me). And they used the mnemonic FATT for the first aid component: fluid, analgesia, tests and tubes. I’ll go into this in more detail soon.
An approach to the Severely Burned Patient
For a moderate/severe burn:
A: includes C-spine control if there is a chance of trauma. The airway assessment particularly looks for signs of potential airway burn: singed nasal hairs, soot in the mouth, change in voice, stridor, sooty sputum. If there are any of these signs get a senior to consider urgent intubation.
B: Looks for signs of trauma eg pneumothorax, signs of inhalational injury eg increased work of breathing, hypoxia, creps. If there is any chance of significant exposure to cyanide or carbon monoxide ->high flow oxygen – and this is one situation where we don’t wont to taper the oxygen quickly. Oxygen sats may be normal in significant carbon monoxide poisoning. Inhalation injury (lung damage) may develop quickly – keep reassessing the patient’s lungs. If there decreased chest movement because of tight burned skin an escharotomy will be required.
C: HR, BP, capillary refill (they were keen for an unburned digit – i think a central CRT is generally accepted as a better measure of circulatory status). Look for other sources of shock if signs of shock eg external haemorrhage, EFAST. Big IV lines (through unburned skin if possible). Use an IO if necessary. Bloods including carboxyhaemoglobin, lactate, and G+H, FBC, U+E, BHCG, BSL.
D: AVPU and pupils
E: Remove all jewelry and piercings as they may be hot and keep burning, or may cause problems as the patient swells. Remove all clothing. Log roll now to check the back and see the extent of burns. Cover the patient and prevent hypothermia.
Cooling: Cooling for 20 minutes, if not already done, can be effective up to 3 hours post burn. For a big burn you might be able to put the patient in your decontamination shower and cool them with water at about about 37˚- cool enough to cool wounds, but hopefully won’t cause hypothermia
Fluids: 3-4ml x kg x % BSA burned (excluding epidermal burns (erythema without blistering ie looks like unblistered sunburn) over 24 hours with the first half within 8 hours of the time of burn (not ED arrival). They are keen on Hartmann’s/lactated Ringer’s for this resuscitation fluid. With kids give standard maintenance fluid (eg 1/2 normal saline with 5% dextrose) at standard rates through a separate cannula (could be piggy backed if necessary). More discussion re fluids later.
Tests – blood tests if not already taken, and what ever trauma imaging is required if not already done
Tubes – NG tube if the patient is being transferred by air or if over 10% BSA in kids or 20% BSA in adults – to decompress the stomach early, and then to start NG feeding within 6 hours.
Then their description of a secondary survey is:
AMPLE history (I always stick a T at the end of this to remind me about tetanus, I know AMPLET doesn’t roll off the tongue but some times the sillier the mnemonic the better I remember it). In the Events we particularly want to know the details of the burn: when, duration of the burn, type of burn (eg what chemicals), clothing worn / burned, temperature of the fluid (eg water at max 100˚C or canola oil at max 800˚C), first aid before ED.
Head to toe examination looking for extent of burns and complications of burns eg decreased peripheral circulation or sensation due to eschar (burned skin) or compartment syndrome. Also looking for associated trauma.
Documentation: eg use a referral form from your local burn unit eg http://www.nationalburnservice.co.nz/pdf/referralform.pdf
Arrange transfer to a burns unit for definitive therapy.
Glad wrap / plastic film is a great dressing for patients being transferred.
Explanation and psychological support for patient and family.
So that’s the general approach.
Now some more detail.
Fluid resuscitation: I took the opportunity to ask the burns gurus where we are out with fluid resuscitation for burns. I know after the Bali Bombings and the Ashmore Reef disaster the Darwin legends were keen on less generous fluid resuscitation as they believed they got into less problems with airway swelling and other problems with oedema. The current thinking is that the fluid replacement needs to be reassessed, individualised and fine tuned. The formulae just give a starting point. If the urine output is significantly greater than the targets of 1ml/kg in a child or 0.5ml/kg in an adult, the fluids should be slowed thus reducing the risk of oedema. Reassess hourly.
Burn depth estimation. Burn depth estimation is inaccurate and apparent burn depth can change over the first few days. For initial resuscitation we only really care about burns deeper than epidermal, but we need to be able to describe burns to our colleagues.
We need to describe colour, blistering, capillary refill, pain, exudate, surrounding inflammation, size and distribution.
In a nutshell there are epidermal burns (erythema only), dermal and full thickness burns. Dermal burns are broken down into superficial, mid and deep dermal. Superficial dermal is usually associated with blisters (but blisters may have burst and the epidermis may have gone) the base will be uniformly red, and will blanch, it will be painful and have sensation. Mid dermal will be similar but with darker pink base, may or may not have sensation and will have sluggish capillary refill. Deep dermal burns are blotchy red, with no capillary refill and no sensation. Full thickness burns are charred or white with no capillary refill and no sensation.
As burn depth can change over the first few days we shouldn’t attempt to prognosticate.
Beware of circumferential burns – may need a escharotomy.
Elevate any limb with significant burns especially if impaired circulation or marked swelling.
If the patient is oedematous in both arms get an arterial line in early to assess BP.
Haemo or myoglobinuria (usually from high voltage electricity) requires increased IV fluids aiming for urine output of 2ml/kg/hour.
Burn Centre referral criteria
· Burns greater than 10% total body surface area (TBSA) or 5% in kids
· Burns of special areas, e.g. the face, hands, feet, genitalia, perineum, and major joints.
· Full thickness burns greater than 5% TBSA.
· Electrical burns (including lightning injury).
· Chemical burns.
· Burn injury with inhalation injury.
· Circumferential burns of the limbs or chest.
· Burns at the extremes of age, i.e. young children and the elderly.
· Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality.
All electrical burns should have an ECG on arrival. High voltage should have 24 hours of telemetry.
Patients with electrical injuries can recover well after prolonged CPR – so don’t stop!
There is a new chelating agent called diphoterine which can bind many toxins including acids and alkalis. Very good for eyes. I’m tracking some down for our ED.
Some specific chemicals we need to know about:
Hydrofluoric acid: a 2% BSA exposure can kill. Good antidotes.
Cement: Can cause severe burns hours after exposure -> prolonged irrigation.
Bitumen: Irrigate till well cooled but don’t panic, it’s not toxic.
Petrol: Can cause renal and hepatic toxicty
Alkalis: Required longed irrigation
Blisters. No firm opinions but generally leave small ones alone. Deroof larger ones – partly to allow assessment of the underlying burn depth, partly to avoid the patient panicking when the blister bursts.
Wash all burns.
Use silver impregnated dressing if burn was contaminated. eg acticoat (TM) soak in water, apply silver/blue side to skin, put a damp gauze over top, then adhesive dressing over top. Otherwise use silicone dressings eg mepilex, hydrocolloid eg duoderm, films eg opsite or tegaerm.
SSD (Silver sulphadiazine) is out of fashion for moderate/severe burns as it needs to be applied twice a day to keep silver levels therapeutic and it discolours tissues making burn depth assessment difficult.
Follow up burns at 2-3 days.
Surrounding inflammation suggests infection – discuss with burn unit as infection can worsen burn severity
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