1. Burns Sept 2015 East of England CT3 Days

2. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children

3. What difference does skin make? ♦ Function of skin ♦ Thermoregulation ♦ Fluid conservation ♦ Protection ♦ Immune ♦ Physical ♦ Flexibility / movement

4. Skin thickness Superficial Partial Thickness Full...

5. What is a burn? ♦ Burn ♦ Scald ♦ Chemical ♦ Electrical ♦ Inhalation ♦ Other injuries ♦ Tetanus

6. Superficial – erythema (sunburn) Partial thickness – Pink Blistered White - sensate Full thickness – Charred Waxy white Insensate

7. Treatment (First Aid) A Airway B Ventilation C Fluid replacement D E Special considerations

8. Airway & Breathing Loss of hair & eyebrows Singed nasal hairs Soot stained nose / lips Confinement with fire Blistered lips Circumferential neck burns Mucosal erythema Hoarse voice / stridor COHb

9. Carbon Monoxide ♦ Unexplained obtundation ♦ “Cherry Red Lips” ♦ Toxicity ♦ Varies ♦ >10% indicates toxicity ♦ Chronis vs Acute ♦ ?HBO ♦ Cyanide?

10. C - Fluid loss ♦ Replace fluid loss from time of injury ♦ Adults and children ♦ Hartman’s solution ♦ Equation... ♦ BSA BSA ♦ Parkland formula…… ♦ Maintenance fluids

12. Superficial Partial thickness Full thickness Total3.5% Or… Size of flat palm = 1%

14. ♦ Shock ♦ >15% (Adult) ♦ >10% (Child) ♦ Resuscitation ♦ Maintenance

15. Parkland formula 4ml / kg / %burn over 24hrs… = 2 ml x kg x %burn over 8hrs + 2ml x kg x %burn over 16hrs Add in maintenance fluids 4ml / kg / hr for first 10kg 2 ml / kg / hr for next 10 kg 1 ml / kg / hr for rest of weight

16. Example ♦ 10kg child with 8% burns ♦ 60ml / hr for 8 hrs = 20ml / hr plus 40 ml/hr maintenance ♦ 50ml / hr for 16 hrs = 10ml / hr plus 40 ml/hr maintenance ♦ Clinical parameters

17. Treatment (First Aid) A Airway B Ventilation C Fluid replacement D Other injuries E Exposure Simultaneously ♦ Stop the burn / constriction ♦ Pain management ♦ Dressings... ♦ Tetanus?? ♦ Safeguarding

18. Analgesia ♦ Assessment and reassessment ♦ Pain ladder… ♦ Opiates ♦ Intra-nasal diamorphine ♦ Intravenous morphine ♦ Oramorph? ♦ Oral analgesia ♦ Non-drug methods

19. Debridement? ♦ Deroofing ♦ Smaller than patient’s little fingernail ♦ Aseptic technique: Forceps & scissors ♦ Clean with dilute chlorhexidine ♦ Dressing ♦ Why ♦ Decreases infection ♦ Analgesia ♦ Fluid lost in a controlled way

20. Dressings?

21. Special Considerations ♦ Joints ♦ Circumferential burns ♦ Hands / Feet / Perineum / Face ♦ Other Injuries ♦ Inhalation of CO / CN ♦ Cyanokit ♦ HBO?

22. Follow-Up ♦ “Major Burns” – Referral to 3° centre ♦ “Consider” if >1% partial thickness ♦ Special considerations ♦ Minor Burns ♦ By local arrangement ♦ Less than 10% BSA ♦ Demarcation / Healing ♦ Late referral ♦ Not healing (> 2 weeks) ♦ Depth ♦ Unwell

23. Referral criteria Referral criteria – unwell patients Fluid management Sepsis / TSS Useful telephone numbers

24. Tetanus ♦ Tet Tox ♦ Basic course ♦ Boosters ♦ Exceptions ♦ Tetanus prone wounds ♦ Immunoglobulin

25. Immunisation status Clean Wound Tetanus Prone Wound (see definition below) Vaccine Human tetanus immunoglobulin (TIG)Alternative normal immunoglobulin product if TIG is unavailable Fully immunised i.e. has received a total of 5 doses of tetanus vaccine at appropriate intervals None required Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue) 500 units (2ml) TIG IM Normal immunoglobulin Subgam ® brand only, 1.5g IM given at a minimum of two separate sites. Primary immunisation complete, boosters incomplete but up to date None required (unless next dose due soon and convenient to give now) Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue) 500 units (2ml) TIG IM Normal Immunoglobulin Subgam ® brand only, 1.5g IM given at a minimum of two separate sites. Primary immunisation incomplete or boosters not up to date A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) Yes: one dose TIG at a different site. 250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or 500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns Normal immunoglobulin Subgam ® brand only 750mg IM or Normal Immunoglobulin Subgam ® brand only, 1.5g IM given at a minimum of two separate sites Not immunised or immunisation status not known or uncertain An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity Yes: one dose of TIG at a different site. 250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or 500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns Normal immunoglobulin Subgam ® brand 750mg IM or Normal immunoglobulin Subgam ® brand only, 1.5g IM given at a minimum of two separate sites

26. Sepsis ♦ Toxic Shock ♦ Staph aureus or strep pyogenes ♦ Temperature>38°C ♦ Rash ♦ D&V ♦ Unwell ♦ What are the subtle signs? ♦ Poor appetite ♦ Listless ♦ “just not right”

27. Safeguarding ♦ Red flags ♦ Multiple ages / delay to presentation ♦ Changing or bizarre history ♦ Child’s history ♦ Multiple presentations ♦ Parental “pathology” ♦ Interaction ♦ Register

28. Safeguarding ♦ Patterns of injury ♦ Clear imprints ♦ Cig burns ♦ Dunking ♦ Depth inconsistent with history ♦ Who do you inform?

29. Questions?

30. Summary Treat first, question later ABC Analgesia & fluids Special considerations Tetanus Safeguarding http://www.lsebn.nhs.uk/