1. Burn Management Kathryn Clark

2. Burn Management Burn injuries in NZ ~1 million people per year in the US seek medical care for burns ~ 1/3 of these in ED. 1311 adults/children admitted to hospital with burn injuries in 2002-2003 33% from fire, flame, smoke 77% from scalds and contact with hot objects 26% Maori, 10.5 % PI 66% Male NZGG, Management of Burns and Scald in Primary Care 2007

3. Burn Management Most burn injuries occur at home Children <5 years at greatest risk of burn related hospitalization and death 50% scalds- hot drinks, fat, cooking oil, water. >90% at home in developed countries Burn injuries in NZ NZGG, Management of Burns and Scald in Primary Care 2007

4. Burn Management Mr F 53 year old candle maker on Waiheke Flown in by Westpac Candle making equipment in covered car port caught fire in the night Mr F went out into the car port to move the car Sustained burns to face, torso, arms, hands

5. Burn Management Types of Burns Thermal: Heat/flame/contact - scald burns most common children - flame more common in adults Cold exposure (frostbite) Chemical: Acid/alkali Electrical Current Inhalation Radiation: Sunburn, radiation therapy

6. Burn Management Other History Time of injury First aid/pre-hospital treatment? Other trauma Inhalation injury Non-accidental injury

7. Burn Management Initial Assessment Airway at risk secondary to: –Direct injury/trauma –Fluid resuscitation –Oedema from inflammatory response Airway –Clear airway –Maintain cervical spine protection –Consider early intubation if airway compromised –ICU/anaesthetic/ENT r/v as required

8. Burn Management Breathing –Apply supplemental oxygen –Consider early mechanical ventilation

9. Burn Management Inhalation Injury Upper airway injury –Direct visualisation of posterior pharynx –Scope cords Lower airway injury –Consider bronchoscopy if uncertain –ARDS Carbonmonoxide poisoning –COHb level –100% O 2 –Hyperbaric

10. Burn Management To intubate or not to intubate… Signs of significant smoke inhalation and potential need for intubation: –Cough, stridor, wheeze, hoarseness –Deep facial or circumferential neck burns –Nares with inflammation or singed hair –Carbonaceous sputum/burnt matter in the mouth/nose –Blistering, sloughing, edema of the oropharynx –Depressed mental status (inc. drug/EtOH) –Respiratory distress –Hypoxia/hypercapnia –Elevated CO and/or CN-

11. Burn Management Circulation –Establish IV access - 2 wide bore cannulae –Through unburnt tissue –IV Fluid bolus –Control any site of haemorrhage –Trauma - internal bleeding? Severe inflammatory reaction –Capillary leak –Intravascular fluid loss –High fevers –Organ Malperfusion –ESOF Initial bloods –FBC, Haematocrit, – U&Es, COHb

12. Burn Management Wound Assessment Burn depth Body surface area estimation Burn distribution

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14. Burn Classification Epidermal: –Dry, red, no blisters, epidermis only –Very superficial –May be painful –Heal within 7 days –No scarring

15. Burn Management Superficial dermal : – Pale pink, with fine blisters, blanches with pressure – Usually extremely painful – Heals within 2 weeks –Can have colour match defect Mid dermal: – Dark pink, large blisters, sluggish cap refill – Less painful – Heals 14-21 days, moderate risk hypertrophic scarring

16. Burn Management Deep dermal : –Blotchy red/white, may blister, no cap refill –No sensation –Heals very slowly >21 days –Usually needs grafting –High risk of hypertrophic scarring Full thickness : –White, waxy, charred, no blisters, no cap refill –Insensate –Grafting needed if <1 cm 2, will scar

17. Burn Management Burn Surface Area Orgill D. N Engl J Med 2009;360:893-901 The Rule of Nines and Lund–Browder Charts

18. Burn Management Fluid Resuscitation Required for: –All adult burns >15% TBSA –All paediatric burns >10% TBSA Modified Parkland Formula –3-4 x Wt(kg) x %TBSA = mL/24 hours –1/2 volume over 1 st 8hrs –1/2 over next 16 hours from time of injury

19. Burn Management Type of Fluid Lactated Ringers Hartmans Plasmalyte Avoid normal saline as large volumes will result in a hypercholoraemic metabolic acidosis. Bunn, et al. Cochrane systematic Review, 2004 Huang, et al. Ann Surg. 1995

20. Burn Management Monitor UO –0.5 mL/kg/hr adults –1.0 mL/kg/hr children –IDC if IV resus required If haemochromagens present in urine increase goal of UO to 1-2 mL/kg/hr

21. Burn Management Wound Management Appropriate first aid –Prevent further tissue damage –Minimise wound complications –Manage pain –Prevent hypothermia

22. Burn Management 20 mins cool running water –8-25 deg C (aim for 15 deg) –Immediately or within 3 hours of injury –Continuous running water Cooling decreases incidence of needing surgery, scarring and decreases costs –Skinner, Peat, NZMJ 2002 Avoid hypothermia –Check patient’s temperature –Ensure room is heated, doors closed –Remove wet clothing

23. Burn Management Remove all non-adherent clothing and jewelry, debris Apply cling film –Longitudinal strips, do not wrap around –Sterile guards may be placed over cling film for comfort and security

24. Burn Management Manage swelling –Elevation –Elevate head of bed if facial/head burns –Q1hly monitoring of circumferential burns Colour Warmth CRT Pulse –Deep circumferential burns may require early escharotomy

25. Burn Management Escharotomy Indications Circumferential burns Compartment syndrome - abdominal or extremity Difficulty with ventilation in chest burns

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27. Ensure adequate analgesia –Entonox –Paracetamol + NSAIDs + Codeine or Tramadol –IV opioids –Supervised sedation/Ketamine Tetanus toxoid/immunoglobulins Antibiotics not usually indicated

28. Burn Management Debride loose skin Clean wounds with aqueous chlorhexadine Blisters –Leave small blisters intact –Debride blisters over joints if restricting movement –Snip large, tense blisters Australasian Cochrane Centre (2009)

29. Burn Management Apply cling film if will reach local burn unit within 8 hours Apply simple non-adherent dressing if due for transfer within 24 hours If transfer delayed more than 24 hours commence silver dressing after consultation with burns unit NZ National Burn Service Guideline, 2011

30. Burn Management Wound Dressings Prevent infection Promote healing –Function –Aesthetics Comfort -aim for patient to be pain free Ease of care –All require 24 hr reassesment –Easy to remove, cause no further injury Cost

31. Burn Management Immediate Presentation Skin intact/small blistersSkin broken Intrasite gel under cling film Film dressing secured with hypafix or bandage Intrasite filled glove Intrasite gel under cling film Film dressing secured with hypafix or bandage Intrasite filled glove If infection is a concern SSD cream Hypafix directly onto a burn on day 1 is usually a bad idea.

32. Burn Management Glad Wrap –Transparent –Easy to put on/remove –Non-adherent –Traps moisture/reduce fluid loss –Prevents contamination –Traps heat –Reduces hypersensitivity

33. Burn Management Delayed Presentation Skin intact/small blistersSkin broken Hypafix vs film dressing vs simple moisturising cream GP Review Increased risk of infection and delayed healing/scarring SSD Cream or other silver based products Antibiotics generally not needed Specialist nursing review Consider NAI in at risk populations

34. Burn Management SSD CreamIntrasite Gel $12.30/50 g Antimicrobial Expensive moisturiser if skin intact $3.14/8 g Bacteriostatic ~95% water

35. Burn Management Silver SSD –Broad spectrum –Does not penetrate eschar very well –Avoid if sulfa allergy –Side effects: neutropenia/thrombocytopenia Silver antimicrobial products –Acticoat Ag –Mepilix Ag –Aquacel Ag Change every 3 (7) days Moisten with water (NOT saline - inactivates the Ag)

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39. Wound Management: Burn Excision & Grafting Autograft Full-thickness skin grafts (FTSG) Split-thickness skin grafts (STSG) – epidermis/pt dermis, more likely to survive Meshed vs. Sheet Allograft- temporary, replaced after 2 weeks Porcine xenograft – Deep partial thickness Dermal substitutes: Integra, expensive

40. Burn Management Electrical Burns Low / high voltage Lightning AC / DC Pathway – Look for entry and exit wounds – Low / high resistance tissues Duration

41. Burn Management Electrical Burns Cardiac arrhythmias CNS injury Muscle injury / Myoglobinemia Renal injury / direct electrical / myoglobin Local and Occult injury - requires trauma evaluation Risk of rhabdomyolysis, compartment syndrome Peripheral nerve injury Late complications - cataracts, progressive demyelinating neurologic loss

42. Burn Management Chemical Burns End the exposure ABCDE Alkalis generally cause worse damage Initial treatment Empiric: irrigation with water Dry powder should be brushed off

43. Burn Management Systemic absorption of some chemicals is life threatening. The clinical signs of severe chemical injury: –altered mental status, –respiratory insufficiency, –cardiovascular instability, –period of unconsciousness or convulsions.

44. Burn Management Chemical Burns Treatment Specific... –Hydrofluoric : Irrigate, Calcium Gluconate –HCL / Sulfuric : Bicarbonate irrigation –Phenol : No irrigation –White Phosphorous : Ignites with irrigation Sample or container to hospital Treatment Kits at Industrial Sites

45. Burn Management Ocular Burns Often chemical Steam/heat Contact lenses need to be removed Copious irrigation Sterile dressings Opthalmology Evaluation ASAP

46. Burn Management When to Refer/Discuss with Regional Burn Unit >10 % TBSA in adult >5% TBSA in child >5% TBSA full thickness Special areas: –Face, hands, feet, perineum Electrical or Chemical burns Inhalation injury Circumferential Extremes of age ( 70 yrs) Associated trauma NAI Complicating co- morbidities Failure to heal with conservative management after 2 weeks

47. Burn Management Take Home Always start with ABCs The airway is at risk in burn patients Assess for trauma Modified Parkland formula Rule of Nines/Lund-Browder Keep burns clean Keep dressings simple Early intervention saves lives

48. Burn Management 1. Management of Burns and Scalds in Primary Care. NZGG/ACC 2007. 2. Singer et. Al. Management of local burns in the ED. AJEM. 2007. 25. 666- 671 3. Tenenhaus. Local treatment of burns: Topical antimicrobial agents and dressings UpTo Date. 2014. 4. Rice, Orgill. Classification of burns. UpToDate. 2014. 5. National Burn Centre Clinical Committee. National Burn Service Initial Assessment Guideline. 2011. 6. New Zealand National Burn Service. Escarotomy guidelines. 7. Rice, Orgill. Emergency care of moderate and severe thermal burns in adults. UpToDate. 2014. 8. Skinner, Peat, NZMJ 2002 9. Bunn, et al. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004; 10. Huang, et al. Hypertonic sodium resuscitation is associated with renal failure and death. Ann Surg. 1995;221(5):543. 11. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944; 79:352. 12. Monafo WW. Initial management of burns. N Engl J Med 1996; 335:1581.