BURNSBURNS

Emergency Department

Warwick Hospital

BackgroundBackground

A common cause of A&E attendanceAlmost all of us have experienced burn

injuryPeak incidence 0-5, 20-29 & >75 yearsSignificant morbidity results while most are

not life threateningHigh risk of death in very young & old Always consider NAI in children under 5

Causes & IncidenceCauses & Incidence

Scald 33.6% Flame 29.2% Hot surfaces 12.2% Chemicals 9.1% Electrical 3.6% Others 12.4%

* Others would include sun, friction and radiation burns.

PathophysiologyPathophysiology

*stopping the burning process is essential to stop an initially superficial burn to progress to a full thickness burn that requires surgery. The larger the BSA, the more the fluid and heat loss. The more the depth, the more the damage to nerve endings and epithelium.

Classification of BurnClassification of Burn

EpidermalSuperficial dermal partial thicknessMid dermal partial thicknessDeep dermal partial thicknessFull thickness

Other ClassificationsOther Classifications

1st Degree – Superficial Epidermal2nd Degree – Superficial Dermal3rd Degree – Deep or full thickness burn

Depth & Clinical Features Depth & Clinical Features

1st Degree - Erythema, no blisters, painful2nd Degree – Pink/Mottled, Blisters, painful3rd Degree – Dry, pale, dark, leathery, and

no pain

* Pain is inversely proportional to the depth of burn injury

First DegreeFirst Degree

Second DegreeSecond Degree

Third DegreeThird Degree

Burn Surface Area (BSA)Burn Surface Area (BSA)

Use Wallace rule of 9 or the Palm of the patient hand

Minor < 10% children or 15% adults Major >10% children & 15% adultsLund & Browder chart is more accurate

Rule of NinesRule of Nines

ManagementManagement

Immediate Life Saving Measures

. Safety

. Remove patient from cause of burn & stop the burning Process

. Check ABC & First Aid

Assessment in ED

. History

. Primary Survey ABCDE

. Check for signs of inhalation stridor is an indication for intubation

. Estimate extent and depth of burn

ABC StrategyABC Strategy

Airway & C-spine controlBreathing & signs of inhalationCirculation & Perfusion/FluidsDisability & Pain controlEnvironment – skin integrity & temperature

Signs of InhalationSigns of Inhalation

Fire in an enclosed/confined space Face and neck burns Singeing of eyebrows & nasal hair Hoarse voice Dyspnea Carbonaceous sputum Brassy cough Carboxyhemoglobin (HbCO) >10%

Fluid ResuscitationFluid Resuscitation

Indicated in Burns >5% in children & >10% in adults

Use Hartmann’s or Normal SalineParkland formula recommended Monitor adequacy by normal urine

outputFollow the Departmental fluid

requirement chart

Burns Transfer – Fluid ChartBurns Transfer – Fluid Chart

Secondary SurveySecondary Survey

Head to toe examination for associated injuries.

Assess peripheral circulation in circumferential burns

Analgesia – Morphine preferredAntibiotics & TetanusWound dressing

Burn Wound DressingBurn Wound Dressing Deroof/decompress blisters if possible Adequate wound cleaning before dressing Flamazine, Mepitel or Urgotul SSD. Face - leave exposed (Polyfax or

Chloramphenicol ointment) Hand - Flamazine hand bag or light Mepitel

dressing. The fingers must move. In transfer use cling film or sterile sheet Review all dresings within 48 hrs

Chemical BurnsChemical Burns

Usually Acids/Alkali but remember Phenols/Petroleum products.

Alkali burns generally worse than acids (due to penetration)

Flush with large amount of waterMeasure the PhNeutralizing agents available?Consult the National poisons centre

Electrical BurnsElectrical Burns

Usually more serious than they appearHistory of fit/thrown overUnconsciousness or depressed GCSEntry and Exit wounds Changes in ECG, myoglobinuria or

abnormal CK/TroponinAdmit if any of the above present

Indication for Transfer Indication for Transfer

Superficial burns – child >5%, Adult >10%Significant burns of special areasSignificant full thickness burnsPresence of inhalation injurySignificant Electrical and Chemical burnsRadiation burnsAssociated major trauma

QuestionsQuestions