Severe Burns - Initial Assessment and Management
These diagrams and illustrations have been designed to help you learn, memorise and recall key information.
Patients should be managed in accordance with EMSB principles.
It is important to Stop the burning process
- extinguish flames / interrupt electricity / dilute chemicals.
COOL THE BURN (but warm patient)
- running water (~15˚C) (not ice water - causes vasospasm & damages tissues).
- wet gauze or hydrogels can be used also (most useful in first 30mins but still useful up to 2hrs).
- reduces direct thermal injury & the release of histamine & inflammatory mediators & stabilises mast cells.
CONSIDER OCCULT INJURIES
Always remember the burnt patient may have other significant occult injuries!
“I would assess the airway with cervical spine control.”
Ensure manual inline stabilisation and then a correctly fitted hard collar, sand bags and adhesive strapping.
“I would call an anaesthetist to intubate the patient if I was concerned about impending airway compromise.”
eg Circumoral or neck burns, hoarseness, stridor, singed nasal hairs or inhalational burns.
“I ensure that intubation is with a reinforced tube (as a normal tube may kink).”
A high volume low pressure cuff is best.
“I ensure the tube is not cut short (it may disappear if swelling occurs).”
The endotracheal tube may be in for a long time!
- therefore it can be helpful to wire the tube in place (eg with dental wire around the teeth - canine is best).
- When doing this place the tube where the anaesthetist says he/she wants it!
- Rigorous oral hygiene is needed in this setting.
“I would assess for any chest or lung injury & administer 100% oxygen.”
“I consider the need for escharotomy for circumferential chest burns.”
Inhalation injury is a common cause of death in burns victims. ARDS leads to hypoxia.
It is rare however for this process to occur whilst the patient is still in the accident department.
“I assess for any other chest injury eg Tension pneumothorax.”
(Treatment: - large-bore cannula, 2nd intercostal space, midclavicular line.)
If the burn is >15% TBSA in an adult or >10% TBSA in a child then iv resus is indicated.
For burns >30% TBSA fluid resuscitation is essential and urgent!
Consider occult sources of haemorrhage
(eg abdomen, retroperitoneum, pelvis, long bones).
2 short, wide-bore IV cannulae are needed.
Placement should ideally be in the antecubital fossa through unburnt skin.
Alternative access could be via a cut-down or a central line.
Cannulae must be secured firmly.
Blood tests:- FBC, UEs, G&S, Glu (esp children/edlerly) CarboxyHb ?Amylase (abdo traum) ?Drug & alcohol screen.
“I would resuscitate with Hartmanns solution, allowing the drip to run steadily while calculating requirements.”
“I assess %TBSA using Wallace’s rule of nines initially (and a lund & browder chart at a later stage).”
Exclude erythema from this calculation.
Fluid requirements are maximal in the first 8 hours after the burn.
Parkland Formula 2-4mls x kg x %TBSA (half in first 8hrs half subsequent 16hrs).
AVPU / GCS
The patient should be catheterised (with an hourly urometry bag) and a urine sample taken.
Pay particular attention to the volume produced and the colour.
Arterial Blood Gas.
Essential X-rays as indicated (chest, pelvis and c-spine).
Entanox 50%nitrous oxide + 50%O2 or
Morhpine iv 0.1-0.2mg/kg titrated to the pain (10mg diluted with 10mls water = 1mg/ml) (monitoring RR). Note morphine must not be given subcutaneously (it remains unabsorbed till the circulation improves!)
Eg “AMPLE” history (in reverse) Events, Last ate, PMH, Meds, Allergies.
Always go back and re-assess ABC.
Ask the nursing staff to monitor observations every 15mins.
Some situations warrant additional fluids:
- paediatric burns
- inhalation injury 25% increase
- pre-existing dehydration (alcohol related or fire-fighters)
- electrical burns
- delay in resus.
BLOOD TRANSFUSION (When is this indicated?)
(Muir proposed ~1unit for each additional 10% TBSA over & above the first 10% TBSA)
Some propose that in general it is better to give blood in the 2nd 24hr period when the extent of the need is clearer.
… the need for escharotomy.
… the burn with a LUND & BROWDER Chart.
Reassess the depth and extent of the burns and would apply appropriate dressings.
The ideal dressing is non-adherent & absorbent.
Burnt hands and feet must be elevated.
Antibacterial dressings are not required in the 1st 24hrs (and may make the assessment of burn depth difficult).
Consider non-accidental injury (are additional x-rays required?).
“The management of burns requires a multi-disciplinary approach”
Communicate clearly with staff and family members.
Ensure transfer to an appropriate burns service and consider the need for early surgery.
Always ensure that events are documented carefully including PHOTOGRAPHY if appropriate.
ON THE WARDS
Plan nutritional requirements early.
Consider the need for an NG tube and dietician input.
A naso-jejunal (NJ) tube may be better for a big burn.
AN NJ tube facilitates multiple trips to theatre while continuing with nutrition cycles.
COMPLICATIONS and SEQUELAE OF SIGNIFICANT BURNS
Hypovolaemia (U/O <0.5mls/kg/hr)
- consider increasing the infusion by 50% (assess response over next hr).
Hypovolaemia + clinically hypovolaemic
- consider increasing the infusion by 50% + give a fluid bolus 10-15mls/kg.
Hypervolaemia (U/O >2mls/kg/hr) … beware of pulmonary oedema developing!
- consider reducing infusion
- consider frusemide (0.5mg/kg)
- probably secondary to hyponatraemia which is more common in children.
Impaired renal function.