emergency quality, education, and safety teleconference · teleconference burns cases dr louisa ng...

Emergency

Quality, Education, and Safety

Teleconference

Burns Cases

Dr Louisa Ng | Advanced Trainee | Emergency Care Institute

Dr Paris Ramrakha| Advanced Trainee | Emergency Care Institute

August 2019

Thanks for joining

House Rules

Confidentiality

Respect

AGENDA

• Case reviews

• Underlying causes

• NSW Health guidance

Participation encouraged throughout

(But please turn off camera & mute mic when not talking)

Case 1: 32yo Electrician

Special thanks to Dr Hana Imamura for supplying case, and to the patient, who kindly

provided consent for the case to be used for educational purposes.

Case 1 – Mr. LO, 32yo

• Walk in presentation to Level 1 Emergency Department in far Western NSW

• Base Hospital is 1hr 15 mins away by road

• Touched a live wire on a solar farm: 660V DC

• Burns to hands

• Walking and talking with normal vital signs

• Triage category?

• Is this presentation consistent with a 660V electrocution?

• What else would you worry about?

Case 1 – Mr. LO, 32yo

• Triage Category 3: ECG, continuous monitoring

• History:

• Electrician working on a solar farm, right hand dominant

• Electrical current entered right hand and exited left hand

• Brief loss of consciousness

• Normally fit and well, no regular medications

• ADT status unknown

• Smoker

Case 1 – Mr. LO, 32yo

no critical bleeding

own, patent

RR 14/min

O2 sats 97%

HR 82/min, BP 120/75

ECG next slide

GCS 15

T 36.9

no long bone injuries

clinically euvolaemic

BGL 5.3

Case 1 – Mr. LO, 32yo – ECG

Case 1 – Mr. LO, 32yo

Case 1 – Mr. LO, 32yo – Secondary survey

• Face and scalp: Upper lip laceration, no further intra-oral injury

• Neck and C-spine: nil injury

• Thorax: nil injury

• Upper limbs: third degree burns to right hand fingertips, some electrical burns

in left hand fingertips.

• Pelvis and lower limbs: nil injury

• Back and spine: nil injury

More detail about the burns

Right hand

3rd/4th/5th finger palmar aspect

blisters with appropriate pain

sensation, fingertips have a small

area of blackening with pain

sensation. Blister also to palm

near fingers.

Left hand

2nd/3rd/4th/5th finger palmar aspect blisters

with appropriate pain sensation. Fingertips

spared. Palm near fingers also blistered.

No other areas of burns identified.

Photos sent to burns team @Concord by

treating team at the base hospital.

Management plan:

• ADT

• IV access

• IV fluids

• Transfer to base hospital for electrical trauma workup and discussion with

plastics

• Keep in cardiac monitor for now

Which of these are a time critical retrieval for a burns?

A.Uncontrolled pain

B.Mid dermal, deep dermal or full thickness burns

>5% of total body surface area in children

C.Burns with significant comorbidities

D.Mid dermal circumferential burn to limb

C. Burns with significant comorbidities

Studies have shown significant cardiac and

respiratory comorbidities eg ACS, significant

cardiac arrhythmias and severe COPD and also

old age/frailty and significant pre-existing

disabilities

These are conditions that could adversely affect

patient care and outcomes

2. Which of these patients can be considered for non

time critical referral and local (if resources allow)

management?

A.Burns with concomitant trauma

B.Intubated patients

C.Burns at extremes of age

D.Pregnancy with cutaneous burns

2. Which of these patients can be considered for non

time critical referral and (if resources allow) local

management?

A.Burns with concomitant trauma

B.Intubated patients

C.Burns at extremes of age

D.Pregnancy with cutaneous burns

3. How long should I wait for the road/air ambulance?

A.Should be now!

B.Up to 2 hours

C.Up to 4 hours

D.Up to 8 hours

3. How long should I wait for the road/air ambulance?

C. Up to 4 hours

If possible….

If an intensive care bed is required for time critical

transfer the ACC will organise transfer for adults

and NETS will do so for children

Cardiac Dysrhythmia

CNS, Spinal Cord and PNS Injury

Cutaneous Burns

Orthopaedic, Vascular, and Muscular Injury

Ocular and Auditory Canal injuries

Tintinalli’s Emergency Medicine

Fatalities due to asystole or ventricular fibrillation usually occur prior to arrival in the

ED. Asymptomatic patients with normal ECGs on arrival to the hospital do not

develop later dysrhythmias after low-voltage (<1000 V) injuries.

Low-voltage (< 1000V) AC can produce ventricular fibrillation by direct stimulation of

the heart, or it can occur after several minutes of respiratory arrest resulting from

paralysis of respiratory muscles

High-voltage (>1000V) AC and DC are more likely to produce transient ventricular

asystole.

Tintinalli’s Emergency Medicine

Apnea with pulses sometimes occurs in linemen working above the ground

near high-voltage lines.

Maintain vigorous resuscitation efforts for cardiac arrest from electric shock,

because there may be insignificant tissue damage despite the potentially lethal

dysrhythmia.

Tintinalli’s Emergency Medicine

Broad range of CNS dysfunction

• Transient LOC is common and may be followed by seizures

• Confusion or agitation

• Deeply comatose and require airway protection

• May also have focal neurologic deficits eg quadriplegia, hemiplegia, aphasia, or visual disturbances

• Remember!! - Spinal cord injury in 8% due to trauma!

• Peripheral nerve injuries

• Hands after the individual touches a power source

• Paraesthesias may be immediate and transient or delayed in onset, appearing up to 2 years after injury

• Extensive peripheral nerve damage may occur with minimal thermal injury

• Electrical contact with the palm produces median or ulnar neuropathy more often than radial nerve injury.

Tintinalli’s Emergency Medicine

• Entry and exit wounds are classic in DC current,

whereas AC current causes contact wounds.

• Burns are typically painless, grey to yellow,

depressed areas.

• Again do not be distracted by the burn site and

make sure ABCs are in check

Tintinalli’s Emergency Medicine

Fractures may be caused by tetanic muscle

contractions or associated falls.

• May be missed on initial assessment due to

altered GCS and overall severity of

systemic illness

Fractures are more likely to result from high-voltage

injury, [but] fractures of the wrist, forearm, humerus,

femoral necks, shoulders, and scapulae have been

reported from exposure to household voltages

(120 to 220 V AC)

Posterior shoulder dislocations are commonly

seen with electrical injury.

Tintinalli’s Emergency Medicine

Vascular and muscle injuries occur most commonly

in the setting of high-voltage injury, such as power

line contact.

• thrombosis,

• stenosis,

• aneurysm formation.

Because of vascular and muscular

destruction, patients with high-voltage shocks are at

significant risk for development of compartment

syndrome, even if the contact (or arcing) lasted <1

second.

Coagulation disorders such as DIC may occur.

Case 1 – Mr. LO, 32yo – Investigations and Management

Repeat ECG (NSR)

Bloods including CK (155), troponin (4)

Fluids with no added potassium

Urinalysis (no myoglobin)

Telemetry 24 hours (Concord Protocol)

Not for antibiotics

Transfer to Concord when bed available, meantime, admitted to short stay.

Summary and issues raised by LO’s Case:

• Electrical burns to upper limb extremities, < 1% TBSA

• Anything anyone would have done differently?

Summary and issues raised by LO’s Case:

• Anything anyone would have done differently?

Issues

• First Aid for electrical burns

• Analgesia for extremity burns

• Telemetry monitoring

• Two transfers

Case 2: 15yo Girl

Special thanks to Dr Michael Golding for supplying case

Case 2 – 15yo Girl

• History significant for epilepsy, developmental delay, autism, non-verbal

communication

• Standing by a bonfire on a property, fell backwards into fire

• Witnessed grand mal seizure – 2 mins – self-terminated

• Head engulfed, all hair gone

• Initial first aid – wet towel, cooling by paramedics

• Pre-hospital – IN fentanyl, IM ketamine, CSL 200mls

Case 2 – 15yo Girl

• History significant for epilepsy, developmental delay, autism, non-verbal communication

• Standing by bonfire, fell backwards into fire

• Witnessed grand mal seizure - 2 mins – self-terminated

• Head engulfed, all hair gone

• Initial first aid – wet towel, cooling by paramedics

• Pre-hospital – IN fentanyl, IM ketamine, CSL 200mls

• Triage category?

1. Primary survey is for:

A.AMPLE history

B.Obtain pertinent statistics from paramedics and

ambulance handover

C.Determine what consultations need to be made

D.Rapidly identify critical or life threatening diagnosis and

begin treatment at the time of diagnosis

D. Rapidly identify critical or life threatening diagnosis

and begin treatment at the time of diagnosis

A lot of the time this is

more interesting…

Do not get distracted

Case 2 – 15yo Girl – Primary Survey

patent

spontaneous, nil distress

well perfused, BP 111/71, P 88

? Full thickness to scalp, forehead, neck, ears, and patches on back

• TBSA 11% with 3% full thickness *

• Bactigras and gladwrap

35.4

Parkland formula – 181mls/hr

What are your immediate resuscitative priorities?

What else would you worry about?

ABCDE

What is an unreliable marker for patency of the airway and

the need for intubation?

A.Absence of gag reflex

B.Level of consciousness

C.Patient’s change in phonation or inability to phonate

D.Pooling of secretions in the oropharynx

ABCDE

What is an unreliable marker for patency of the airway and

the need for intubation

A. Absence of gag reflex

ABCDE

What is not a sign of tension pneumothorax?

A.Deviation of the trachea away from the side

B.Bruising to the chest wall

C.Hyper-expanded chest that moves little with respiration

D.Increased percussion note

ABCDE

What is not a sign of tension pneumothorax?

B. Bruising to the chest wall

ABCDE

In major deformity and burns patients what are your options

for IV access?

A.Femoral vein

B.Internal jugular vein

C.IO

D.Peripheral IVC large gauge

ABCDE

In major deformity and burns patients what are your options

for IV access?

A.Femoral vein

B.Internal jugular vein

C.IO

D.Peripheral IVC large gauge

ABCDE

In major deformity and burns patients what are your options

for IV access?

All of these are great ways to access (with the right skill set

and equipment) but…

Peripheral IVC and IO would be choice in trauma setting

and fastest

ABCDE

Which of these is not part of the disability assessment in the

primary survey?

A.Assess GCS

B.Pupil size and responsiveness

C.Dermatomal assessment

D.Gross motor function and BSL

ABCDE

C. Dermatomal assessment

This is part of your secondary survey once you have

managed all other life threatening conditions

ABCDE

The burns patient is at high risk for hypothermia. Which of

the following can you do to minimise the risk to your

patient?

A.Remove wet packs and soaks

B.Clean off any residual cream/dressing product

C.Cover the patient with plastic cling wrap or clean sheet

D.Warm cup of tea and blanket

ABCDE

A.Remove wet packs and soaks

B.Clean off any residual cream/dressing product

C.Cover the patient with plastic cling wrap or clean

sheet

Case 2 – 15yo Girl – Immediate Priorities

Clinical Priority Action

Airway management Assessment and early intubation

Anticipate difficult airway

Burns management Complete first aid

Estimate TBSA *

Photographs

Dressings

ADT if not up to date

Fluid management Parkland’s formula

Analgesia (if not intubated/sedated) Multimodal

Seizure management Anticonvulsant loading

Parkland’s Formula

• Applies to adults with > 20% TBSA Burns

• Applies to children with > 10% TBSA Burns

• Do not include simple erythema (superficial partial thickness)

Case 2 – 15yo Girl – Patient stabilised, what is next?

• Adequacy of airway and ventilation

• Sedation and analgesia

• Secondary Survey

• Supportive Care

• Care of the Family

• Consider NAI (not present in this case)

• Retrieval to tertiary paediatric burns service

Who should I call for retrieval or referral or help?

A.Call a friend

B.Statewide Burns service

C.ACC/NETS

D.Trauma call

Who should I call for retrieval or referral or help?

A.Call a friend

B.Statewide Burns service

C.ACC/NETS

D.Trauma call

Who should I call for retrieval or referral or help?

Should be calling early at the time of MIST and

handover from the CDA/First responders or place

of transfer

Part of your MIST you are looking for the indicators

for time critical factors for transfer

Who should I call for retrieval or referral or help?

Activate your trauma team

Arrange your staff and your roles (and equipment) ie call

your friends!

Consider talking to retrieval early especially if you know that

this patient has indication to have transfer to a larger centre

Talk to the burns registrar early post initial stabilisation to

determine disposition

What if they are being treated at their primary referring site?

ACI statewide burn injury service can support and assist primary

health sites to liaise in ongoing burn management.

This is usually the burns registrar on call for either RNSH or

Concord (Westmead for children) and they are there to also

support your decision making.

If there is need for clinic review, each hospital has outpatient

clinics which can be contacted during business hours.

Case 2 – 15yo Girl – Progress

CCAS – Retrieval to Westmead Children’s Hospital by helicopter

Ventilated 3 weeks

25% burns to multiple sites, full thickness to scalp *

Developed pressure areas to buttocks in ICU

Extubated and ultimately discharged home, with local community health service

for dressings.

CLINICAL TOOLS AND GUIDELINES

Escharotomy

3 C’s:

Circumferential

Circulation – threatened

Compromised - respiration

Escharotomy

https://www.aci.health.nsw.gov.au/__

data/assets/pdf_file/0003/162633/Esc

harotomy-for-Burn-Patients.pdf

Published on the 19th of July

2019

Tips and tricks for

performing escharotomy

•Easier to do with 2 operators

•Make sure you have a plan for haemostasis –

the patient will bleed!

•It is into the subcutaneous fat and no further

•Your scalpel will blunt quickly so have a few

back up

•To cut do one initial cut in the skin and draw

down the line you need – can always go back

and deepen it afterwards

•Make sure you give local into the skin that is not

burnt that you incise into

E-QuESTs so far

•Dangerous Back Pains

•Opthalmological emergencies

•Pulmonary Embolus

•Paediatric Increased WOB

•Burns

•Atypical Chest Pain - ACS

•Sepsis in the elderly

•Abdominal pain in the elderly - AAA

& Ischaemic gut

•Scrotal emergencies

•Deadly headaches

•Paediatric deterioration

•Head injuries

Level 4, 67 Albert Avenue

Chatswood NSW 2067

PO Box 699

Chatswood NSW 2057

T + 61 2 9464 4666

F + 61 2 9464 4728

aci-info@health.nsw.gov.au

www.aci.health.nsw.gov.au

Many thanks!

Next E-QuEST

24 September 2:30pm

we welcome any cases that have piqued your

interest, and any suggestions for future topics

Appendix 1:

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/162635/Minor-

Burns-Mngt-Guidelines.pdf

• These have a good guideline as to assessing depths of burns and for

ongoing wound care