Burns

Sept 2015East of England CT3 Days

Burns - aims

♦ Skin♦ Types of burns♦ Management

♦ Burns♦ Associated bits

♦ Tips for children

What difference does skin make?

♦ Function of skin♦ Thermoregulation♦ Fluid conservation♦ Protection

♦ Immune♦Physical

♦ Flexibility / movement

Skin thickness

Superficial

Partial Thickness

Full...

What is a burn?

♦ Burn ♦ Scald♦ Chemical♦ Electrical♦ Inhalation

♦ Other injuries

♦ Tetanus

Superficial –

erythema (sunburn)

Partial thickness –

Pink

Blistered

White - sensate

Full thickness –

Charred

Waxy white

Insensate

Treatment (First Aid)

A Airway

B Ventilation

C Fluid replacement

DE

Special considerations

Airway & BreathingLoss of hair & eyebrows

Singed nasal hairs

Soot stained nose / lips

Confinement with fire

Blistered lips

Circumferential neck burns

Mucosal erythema

Hoarse voice / stridor

COHb

Carbon Monoxide♦ Unexplained obtundation♦ “Cherry Red Lips”♦ Toxicity

♦ Varies♦ >10% indicates toxicity♦ Chronis vs Acute

♦ ?HBO

♦ Cyanide?

C - Fluid loss

♦ Replace fluid loss from time of injury♦ Adults and children♦ Hartman’s solution

♦ Equation...♦ BSA♦ Parkland formula…

♦ Maintenance fluids

♦ Shock♦>15% (Adult)♦>10% (Child)

♦ Resuscitation

♦ Maintenance

Parkland formula4ml / kg / %burn over 24hrs…

=

2 ml x kg x %burn over 8hrs+

2ml x kg x %burn over 16hrs

Add in maintenance fluids4ml / kg / hr for first 10kg

2 ml / kg / hr for next 10 kg1 ml / kg / hr for rest of weight

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

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

Analgesia♦ Assessment and reassessment♦ Pain ladder…

♦ Opiates♦ Intra-nasal diamorphine♦ Intravenous morphine

♦ Oramorph?

♦ Oral analgesia♦ Non-drug methods

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

Dressings?

Special Considerations

♦ Joints♦ Circumferential burns♦ Hands / Feet / Perineum / Face

♦ Other Injuries♦ Inhalation of CO / CN

♦ Cyanokit♦ HBO?

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

Referral criteria

Referral criteria – unwell patients

Fluid management

Sepsis / TSS

Useful telephone numbers

Tetanus

♦ Tet Tox♦ Basic course ♦ Boosters♦ Exceptions

♦ Tetanus prone wounds

♦ Immunoglobulin

Immunisation status

Clean Wound Tetanus Prone Wound (see definition below)

Vaccine Vaccine Human tetanus immunoglobulin (TIG) Alternative normal immunoglobulin product if TIGis unavailable

Fully immunised i.e. has received a total of 5 doses of tetanus vaccine at appropriate intervals

None required 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 immunoglobulinSubgam ® 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)

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 ImmunoglobulinSubgam ® 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)

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 or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns

Normal immunoglobulinSubgam ® brand only 750mg IMorNormal ImmunoglobulinSubgam ® 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

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 or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns

Normal immunoglobulinSubgam ® brand 750mg IMorNormal immunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites

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”

Safeguarding♦ Red flags

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

Safeguarding

♦ Patterns of injury♦ Clear imprints♦ Cig burns♦ Dunking♦ Depth inconsistent with history

♦ Who do you inform?

Questions?

Summary

Treat first, question laterABCAnalgesia & fluidsSpecial considerationsTetanusSafeguarding

http://www.lsebn.nhs.uk/