2What 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)ElectricalChemical (acids)Radiation (sunburn)Friction
3Pathophysiology of a Burn Coagulation-Irreversible tissue necrosis.Stasis-Ischaemia which may be reversible, depending on managementHyperaemia-Reversible erythema
4Emergency Management of Burns Stop the burn process & Cool the burn.ATLS & Assessment of burn wound.Resuscitation.Reassess burn.Definitive Treatment.
5First Aid to a Burns Patient STOP THE BURN PROCESSRemove 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)
6First Aid to a Burns Patient COOL THE BURN WITH WATERIrrigate the wound with running water.It reduces pain and slows the necrotic process – reduces burn depth and improves outcome.
7Warm 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.
8First Aid to a Burns Patient COVER THE BURNIf 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.
9ATLS For Burns Patients AIRWAY WITH C-SPINE PROTECTIONThe airway can become obstructed due to swelling of neck tissues secondary to a burn, or due to a primary inhalation injury.Indications for Intubation:StridorProphylacticGCS <9Agitation
10Inhalation InjuryInhalation 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 spaceFacial burn/singed facial hairSoot/CharringMucosal inflammation in mouth or noseCarbonaceous sputumStridor/Hoarse Voice.
11ATLS For Burns Patients BREATHING WITH VENTILATIONGive high flow 100% humidified oxygen.Assess the chest for ventilation and movement defectsDeep circumferential burns to the chest can restrict chest wall movements, reducing compliance leading to breathing difficulty.May need to release skin with escharotomies.
13ATLS for Burns Patients CCIRCULATION WITH HAEMORRHAGE CONTROLAssess Circulation – non-burnt skin colour, temp, cap refill, pulse, BP, JVP.Insert 2 large bore cannulas, preferable in non- burnt skin.Fluid resuscitationAdults with >15% TBSAChildren with >10% TBSA
14Resuscitation for Burns Patients Burns patients have a large risk of hypovolaemic shockIn 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.
15Parklands 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)
16ATLS for Burns Patients DDISABILITYAssess neurological statusReduced GCS could be due to inhalation of toxic products of combustion (CO) causing hypoxia.
17ATLS for Burns Patients EXPOSUREExpose and assess the extent of injuryRemove any clothing or jewellery which may become constrictive with swelling.
18Assessing 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.
20Assessing 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.
21Assessing 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.
22Assessing 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 days, and may cause hypertrophic scarring
23Assessing Burn Depth Deep Dermal Partial Thickness Involves epidermis, and most of the dermis. Only the very deep adnexal organs intact.Decreased sensationAppearance – 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.
24Assessing Burn Depth Full Thickness Burn All epidermis, dermis, and adnexal structures destroyed. No blood supply = infarction of the skin.NO SENSATION TO PINPRICKAppearance – White, charred leathery skin, no blisters, no cap refill, no blanching.Will not heal without surgery, and will scar.
25Escharotomy 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.
26Early ManagementNasogastric 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 ProphylaxisHypothermia Prevention – Insulate the patient, warm room, warm IV fluids.Infection control
27Definitive Burn Surgery Debride devitalised skin and blistersSkin 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.