1. Burns
Katy Talbot

2. What 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)
Electrical
Chemical (acids)
Radiation (sunburn)
Friction

3. Pathophysiology of a Burn
Coagulation
-Irreversible tissue necrosis.
Stasis
-Ischaemia which may be reversible, depending on management
Hyperaemia
-Reversible erythema

4. Emergency Management of Burns
Stop the burn process & Cool the burn.
ATLS & Assessment of burn wound.
Resuscitation.
Reassess burn.
Definitive Treatment.

5. First Aid to a Burns Patient
STOP THE BURN PROCESS
Remove 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)

6. First Aid to a Burns Patient
COOL THE BURN WITH WATER
Irrigate the wound with running water.
It reduces pain and slows the necrotic process – reduces burn depth and improves outcome.

7. Warm 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.

8. First Aid to a Burns Patient
COVER THE BURN
If 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.

9. ATLS For Burns Patients
AIRWAY WITH C-SPINE PROTECTION
The airway can become obstructed due to swelling of neck tissues secondary to a burn, or due to a primary inhalation injury.
Indications for Intubation:
Stridor
Prophylactic
GCS <9
Agitation

10. Inhalation Injury
Inhalation 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 space
Facial burn/singed facial hair
Soot/Charring
Mucosal inflammation in mouth or nose
Carbonaceous sputum
Stridor/Hoarse Voice.

11. ATLS For Burns Patients
BREATHING WITH VENTILATION
Give high flow 100% humidified oxygen.
Assess the chest for ventilation and movement defects
Deep circumferential burns to the chest can restrict chest wall movements, reducing compliance leading to breathing difficulty.
May need to release skin with escharotomies.

12. Chest Escharotomy

13. ATLS for Burns PatientsC
CIRCULATION WITH HAEMORRHAGE CONTROL
Assess Circulation – non-burnt skin colour, temp, cap refill, pulse, BP, JVP.
Insert 2 large bore cannulas, preferable in non- burnt skin.
Fluid resuscitation
Adults with >15% TBSA
Children with >10% TBSA

14. Resuscitation for Burns Patients
Burns patients have a large risk of hypovolaemic shock
In 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.

15. Parklands 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)

16. ATLS for Burns PatientsD
DISABILITY
Assess neurological status
Reduced GCS could be due to inhalation of toxic products of combustion (CO) causing hypoxia.

17. ATLS for Burns Patients
EXPOSURE
Expose and assess the extent of injury
Remove any clothing or jewellery which may become constrictive with swelling.

18. Assessing 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.

19. Lund-Browder Chart

20. Assessing 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.

21. Assessing 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.

22. Assessing 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

23. Assessing Burn Depth Deep Dermal Partial Thickness
Involves epidermis, and most of the dermis. Only the very deep adnexal organs intact.
Decreased sensation
Appearance – 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.

24. Assessing Burn Depth Full Thickness Burn
All epidermis, dermis, and adnexal structures destroyed. No blood supply = infarction of the skin.
NO SENSATION TO PINPRICK
Appearance – White, charred leathery skin, no blisters, no cap refill, no blanching.
Will not heal without surgery, and will scar.

25. Escharotomy 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.

26. Early Management
Nasogastric 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 Prophylaxis
Hypothermia Prevention – Insulate the patient, warm room, warm IV fluids.
Infection control

27. Definitive Burn Surgery
Debride devitalised skin and blisters
Skin 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.

29. References http://www.vicburns.org.au/about.html
violence/first-aid-information/
treatment#a1135
ndex.html