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Burns management
- 1. Management of the burn patient NATHAN STEWART ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS
- 2. In 1997-2005 the rate of total Burn Injury related deaths for Australia was 0.5 per 100,000 persons. In 2003-04 the age-adjusted hospitalisation rate of fire, burn and scald related injury in Australia was 31.9 cases per 100,000 population per year. During the period of 2001-02, throughout Australia, burns and scalds were responsible for 6,248 hospitalisations in public hospitals with the average length of stay being 7.1 days incurring an estimated cost of $132 million.
- 3. Progress in Burn Care Fluid resuscitation Dedicated burns units Antimicrobials Intensive care Nutrition Early excision Skin cover Specialisation 3
- 7. Classification of burns Chemical acid alkali organic chemicals 7
- 8. Classification of burns Electrical low voltage high tension lightning 8
- 10. Everybody Every intervention influences the scar worn for life, therefore, everyone who assists in the management of that patient becomes a member of the burn care team
- 11. First Aid for burns Remove from burn source Cold water - except when in contact with electricity This has the most effect on the final outcome! Still some effectiveness up to 4 hours post burn. At least 20 minutes of cold running water. Remove clothes. Need to avoid Hypothermia though! Gels e.g. Burnshield Cling film & dry clean sheet No ointments, creams, powders, butter, etc. etc. 11
- 12. 12 Minor burns
- 13. Minor burns Defined by exclusion of area more than 5% of body surface deep infected problem area - face, hands, perineum, feet inhalation injury other injury or underlying medical problem suspected non-accidental injury 13
- 15. 15 Major burns
- 16. Burns Resuscitation: At the Scene Remove Patient & Self from Injury Source Extinguish actively burning material & Cool burn (Tap Water) ABC: Airway, Breathing, Circulation (ATLS) Brief HISTORY: Time of Injury - For resuscitation Nature of Injury- Flame, Indoors, Chemicals Brief EXAMINATION: Area) Burn Size (% Total Body Surface Burn DEPTH: Erythema (ignore) Superficial Partial Thickness Deep Partaial Thickness Full Thickness
- 17. Burns Resuscitation: In the A&E Department ATLS: ABC & Secondary Survey Brief HISTORY & EXAMINATION Airway/ Breathing Control FLUID RESUSCITATION Baseline Investigations: FBC U&Es Carboxyhaemaglobin Calculate the burn depth - IVI* Chest Xray Blood Gases Toxicology
- 18. Burns Resuscitation: In the Burns Unit ATLS: ABC + Secondary Survey Full HISTORY: Full EXAMINATION: % Burn (TBSA) Body Mass (Kgm) Resuscitation History: Crystalloid Fluids - - Colloid Reveiwed Protocol: Trials, Advances, Units, etc. MONITORING
- 19. Burns Resuscitation: Monitoring Physiology: URINE OUTPUT Haematocrit Blood Gases Urine Osmolality Electrolytes & Urea Nutritional Status Cardiovascular Function
- 20. Burn Resuscitation: A Team Effort Anaesthetist Surgeon Intensivist Microbiologist Paediatrician Haematologist Chemical Pathologist etc Specialist Nurse Physiotherapist Occupational Therapist Theatre Nurse Ward Clerk Secretary Play Therapist etc
- 21. Burn Resuscitation: Airway HISTORY EXAMINATION Confusion / Altered Consciousness Fire in an ENCLOSED SPACE e.g. House fire Burns to Face / Oropharynx Car fire Toxic fumes (Industrial) Hoarseness / Stridor / Exp rhonchi Soot in nostrils or Sputum Dysphagia / Drooling
- 22. Lower airway/pulmonary problems Primary burn damage Pulmonary oedema ARDS 22
- 24. Burn Resuscitation: Airway TREATMENT FiO2 40 - 60% Nebulisers - - ? 100% Saline Salbutamol / Terbutaline Oro/Nasal Intubation Tracheostomy
- 25. Burn Resuscitation: Breathing COAD - Hypoxic Drive MECHANICAL: Upper Airway Swelling Chest Wall Constriction
- 26. Burn Shock Likely if burned area more than 15% body surface in adults 10% body surface in children (and elderly) 26
- 27. Burn Resuscitation: Shock Definition (Dietzman & Lillehei (1968)) The inability of the circulatory system to meet the needs of tissues for oxygen & nutrients and the removal of their metabolites.
- 28. Parkland formula for fluid resuscitation 4ml Hartmann’s solution per 1% burn per kg body weight half in first 8hrs post-burn half in the following 16hrs = 0.25ml/%burn/kg/hr in first 8 hrs from time of burn colloid in second 24hrs 28
- 29. Burn Resuscitation: Burn Depth Erythema - ignore Superficial Partial Thickness Deep Partial Thickness Full Thickness
- 30. Rule of nine 30
- 31. Management of the burned patient Full “primary and secondary” surveys Check for other injuries 31
- 32. Managing the burn wound - considerations Surgery vs. spontaneous healing Mechanisms of healing Pathological zones in the burn Determination of burn depth Influence of dressings 32
- 34. Assessment of burn depth Clinical examination: 50-75% accurate Pinprick test Repeated examination 34
- 35. Assessment of burn depth 35 Easy when very superficial or full-thickness Harder when intermediate or mixed
- 36. Why excise the burn? Burn wound is a focus for sepsis Burn stimulates inflammatory mediators Deep burns cannot heal without grafts Possible effect on future scar quality but Non full-thickness burns may heal spontaneously Superficial burns heal with acceptable scars Excised burn wound must be closed Major burn surgery is hazardous 36
- 38. Urgent surgery High-tension electrical injury Deep encircling burns - escharotomy limbs trunk 38
- 39. For small burns Excision and grafting as soon as clearly non-healing 39
- 40. Early excision of burns Tangential excision to viable tissue on day 3-5 Janzekovic (1970) Jackson & Stone (1972) 40
- 41. Tangential burn excision and split skin grafting 41
- 43. Early burn surgery Superior outcomes where suitably equipped mortality length of hospital stay morbidity during acute burn scar quality 43
- 44. Desirable surgical management Excision of all non-shallow burns as soon as practicable in as few stages as possible Closure of excised wounds with autograft, allograft or artificial material Definitive wound closure 44
- 45. Large area burns - the problem Area / mass of necrotic tissue Shortage of donor sites Infection Systemic effects (SIRS, ARDS) Associated problems of inhalation 45
- 46. Scar management The potential problem 46
- 47. Scar management Pre-emptive measures prompt surgery splintage & physiotherapy Pressure garments and conformers Silicone gel and contact media Medical and surgical treatment 47
- 49. Pressure garments Almost universally used Apparently effective Many published observations 49
- 50. Pressure garments Aids to compliance 50
- 52. Silicone gel Mechanism not fully known - not pressure 52