Burn Management

Burn Management

Kathryn Clark

Burn Management

Burn injuries in NZ• ~1 million people per year in the US

seek medical care for burns • ~ 1/3 of these in ED. • 1311 adults/children admitted to

hospital with burn injuries in 2002-2003• 33% from fire, flame, smoke• 77% from scalds and contact with hot

objects• 26% Maori, 10.5 % PI• 66% Male

NZGG, Management of Burns and Scald in Primary Care 2007

Burn Management

• Most burn injuries occur at home

• Children <5 years at greatest risk of burn related hospitalization and death

• 50% scalds- hot drinks, fat, cooking oil, water.

• >90% at home in developed countries

Burn injuries in NZ

NZGG, Management of Burns and Scald in Primary Care 2007

Burn Management

• Mr F• 53 year old candle maker on Waiheke• Flown in by Westpac

• Candle making equipment in covered car port caught fire in the night

• Mr F went out into the car port to move the car

• Sustained burns to face, torso, arms, hands

Burn Management

Types of Burns

• Thermal: Heat/flame/contact

- scald burns most common children

- flame more common in adults• Cold exposure (frostbite)• Chemical: Acid/alkali • Electrical Current Inhalation• Radiation: Sunburn, radiation therapy

Burn Management

Other History

• Time of injury• First aid/pre-hospital treatment? • Other trauma• Inhalation injury• Non-accidental injury

Burn Management

Initial Assessment• Airway at risk secondary to:

– Direct injury/trauma– Fluid resuscitation– Oedema from inflammatory response

• Airway– Clear airway– Maintain cervical spine protection– Consider early intubation if airway compromised– ICU/anaesthetic/ENT r/v as required

Burn Management

• Breathing– Apply supplemental oxygen– Consider early mechanical ventilation

Burn Management

Inhalation Injury

• Upper airway injury– Direct visualisation of posterior pharynx– Scope cords

• Lower airway injury– Consider bronchoscopy if uncertain– ARDS

• Carbonmonoxide poisoning– COHb level– 100% O2

– Hyperbaric

Burn Management

To intubate or not to intubate…• Signs of significant smoke inhalation

and potential need for intubation:– Cough, stridor, wheeze, hoarseness– Deep facial or circumferential neck burns– Nares with inflammation or singed hair– Carbonaceous sputum/burnt matter in the

mouth/nose– Blistering, sloughing, edema of the

oropharynx– Depressed mental status (inc. drug/EtOH)– Respiratory distress– Hypoxia/hypercapnia– Elevated CO and/or CN-

Burn Management

• Circulation– Establish IV access - 2 wide bore cannulae– Through unburnt tissue– IV Fluid bolus– Control any site of haemorrhage– Trauma - internal bleeding?

• Severe inflammatory reaction– Capillary leak– Intravascular fluid loss– High fevers– Organ Malperfusion– ESOF

• Initial bloods–FBC, Haematocrit,– U&Es, COHb

Burn Management

Wound Assessment

• Burn depth• Body surface area estimation• Burn distribution

Burn Management

Burn Management

Burn Classification• Epidermal:

– Dry, red, no blisters, epidermis only– Very superficial– May be painful– Heal within 7 days– No scarring

Burn Management

• Superficial dermal :– Pale pink, with fine blisters, blanches with pressure– Usually extremely painful– Heals within 2 weeks–Can have colour match defect

• Mid dermal:

– Dark pink, large blisters, sluggish cap refill– Less painful– Heals 14-21 days, moderate risk hypertrophic scarring

Burn Management

• Deep dermal:– Blotchy red/white, may blister, no cap refill– No sensation– Heals very slowly >21 days– Usually needs grafting– High risk of hypertrophic scarring

• Full thickness:– White, waxy, charred, no blisters, no cap refill– Insensate– Grafting needed if <1 cm2, will scar

Burn Management

Burn Surface Area

Orgill D. N Engl J Med 2009;360:893-901

The Rule of Nines and Lund–Browder Charts

Burn Management

Fluid Resuscitation

• Required for:– All adult burns >15% TBSA– All paediatric burns >10% TBSA

• Modified Parkland Formula– 3-4 x Wt(kg) x %TBSA = mL/24 hours– 1/2 volume over 1st 8hrs – 1/2 over next 16 hours from time of injury

Burn Management

Type of Fluid

• Lactated Ringers• Hartmans• Plasmalyte

• Avoid normal saline as large volumes will result in a hypercholoraemic metabolic acidosis.

Bunn, et al. Cochrane systematic Review, 2004Huang, et al. Ann Surg. 1995

Burn Management

• Monitor UO – 0.5 mL/kg/hr adults– 1.0 mL/kg/hr children– IDC if IV resus required

• If haemochromagens present in urine increase goal of UO to 1-2 mL/kg/hr

Burn Management

Wound Management

• Appropriate first aid– Prevent further tissue damage– Minimise wound complications– Manage pain– Prevent hypothermia

Burn Management

• 20 mins cool running water– 8-25 deg C (aim for 15 deg)– Immediately or within 3 hours of injury– Continuous running water

• Cooling decreases incidence of needing surgery, scarring and decreases costs– Skinner, Peat, NZMJ 2002

• Avoid hypothermia– Check patient’s temperature– Ensure room is heated, doors closed– Remove wet clothing

Burn Management

• Remove all non-adherent clothing and jewelry, debris

• Apply cling film – Longitudinal strips, do not wrap around– Sterile guards may be placed over cling film for

comfort and security

Burn Management

• Manage swelling– Elevation– Elevate head of bed if facial/head burns– Q1hly monitoring of circumferential burns

• Colour• Warmth• CRT• Pulse

– Deep circumferential burns may require early escharotomy

Burn Management

Escharotomy Indications

• Circumferential burns• Compartment syndrome - abdominal or extremity• Difficulty with ventilation in chest burns

Burn Management

Burn Management

• Ensure adequate analgesia– Entonox– Paracetamol + NSAIDs + Codeine or Tramadol– IV opioids– Supervised sedation/Ketamine

• Tetanus toxoid/immunoglobulins• Antibiotics not usually indicated

Burn Management

• Debride loose skin• Clean wounds with aqueous

chlorhexadine• Blisters

– Leave small blisters intact– Debride blisters over joints if restricting

movement– Snip large, tense blisters

Australasian Cochrane Centre (2009)

Burn Management

• Apply cling film if will reach local burn unit within 8 hours

• Apply simple non-adherent dressing if due for transfer within 24 hours

• If transfer delayed more than 24 hours commence silver dressing after consultation with burns unit

NZ National Burn Service Guideline, 2011

Burn Management

Wound Dressings

• Prevent infection• Promote healing

– Function– Aesthetics

• Comfort -aim for patient to be pain free• Ease of care

– All require 24 hr reassesment– Easy to remove, cause no further injury

• Cost

Burn Management

Immediate Presentation

Skin intact/small blisters Skin broken

Intrasite gel under cling filmFilm dressing secured with hypafix or bandage

Intrasite filled glove

Intrasite gel under cling filmFilm dressing secured with hypafix or bandage

Intrasite filled glove

If infection is a concern SSD cream

Hypafix directly onto a burn on day 1 is usually a bad idea.

Burn Management

• Glad Wrap– Transparent– Easy to put on/remove– Non-adherent– Traps moisture/reduce fluid loss– Prevents contamination– Traps heat– Reduces hypersensitivity

Burn Management

Delayed Presentation

Skin intact/small blisters Skin broken

Hypafix vs film dressing vs simple moisturising cream GP Review

Increased risk of infection and delayed healing/scarring

SSD Cream or other silver based products

Antibiotics generally not needed

Specialist nursing review

Consider NAI in at risk populations

Burn Management

SSD Cream Intrasite Gel

$12.30/50 g

Antimicrobial

Expensive moisturiser if skin intact

$3.14/8 g

Bacteriostatic

~95% water

Burn Management

Silver• SSD

– Broad spectrum– Does not penetrate eschar very well– Avoid if sulfa allergy– Side effects: neutropenia/thrombocytopenia

• Silver antimicrobial products– Acticoat Ag– Mepilix Ag– Aquacel AgChange every 3 (7) daysMoisten with water (NOT saline - inactivates the Ag)

Burn Management

Burn Management

Burn Management

Burn Management

Wound Management: Burn Excision & Grafting

• Autograft • Full-thickness skin grafts (FTSG)• Split-thickness skin grafts (STSG) – epidermis/pt dermis,

more likely to survive• Meshed vs. Sheet

• Allograft- temporary, replaced after 2 weeks

• Porcine xenograft – Deep partial thickness

• Dermal substitutes: Integra, expensive

Burn Management

Electrical Burns

• Low / high voltage < 1000 volts >• Lightning• AC / DC• Pathway

– Look for entry and exit wounds– Low / high resistance tissues

• Duration

Burn Management

Electrical Burns• Cardiac arrhythmias • CNS injury• Muscle injury / Myoglobinemia• Renal injury / direct electrical / myoglobin• Local and Occult injury - requires trauma

evaluation• Risk of rhabdomyolysis, compartment

syndrome• Peripheral nerve injury• Late complications - cataracts, progressive

demyelinating neurologic loss

Burn Management

Chemical Burns

• End the exposure• ABCDE• Alkalis generally cause worse damage• Initial treatment Empiric: irrigation with

water• Dry powder should be brushed off

Burn Management

• Systemic absorption of some chemicals is life threatening.

• The clinical signs of severe chemical injury:– altered mental status, – respiratory insufficiency, – cardiovascular instability, – period of unconsciousness or convulsions.

Burn Management

Chemical Burns

• Treatment Specific . . . – Hydrofluoric : Irrigate , Calcium Gluconate– HCL / Sulfuric : Bicarbonate irrigation– Phenol : No irrigation– White Phosphorous : Ignites with irrigation

• Sample or container to hospital • Treatment Kits at Industrial Sites

Burn Management

Ocular Burns

• Often chemical• Steam/heat• Contact lenses need to be removed• Copious irrigation• Sterile dressings• Opthalmology Evaluation ASAP

Burn Management

When to Refer/Discuss with Regional Burn Unit

• >10 % TBSA in adult• >5% TBSA in child• >5% TBSA full thickness• Special areas:

– Face, hands, feet, perineum• Electrical or Chemical burns• Inhalation injury• Circumferential

• Extremes of age (<2 yrs, >70 yrs)• Associated trauma• NAI• Complicating co-morbidities• Failure to heal with conservative management after 2

weeks

Burn Management

Take Home

• Always start with ABCs• The airway is at risk in burn patients• Assess for trauma• Modified Parkland formula• Rule of Nines/Lund-Browder• Keep burns clean • Keep dressings simple• Early intervention saves lives

Burn Management

1. Management of Burns and Scalds in Primary Care. NZGG/ACC 2007.2. Singer et. Al. Management of local burns in the ED. AJEM. 2007. 25. 666-6713. Tenenhaus. Local treatment of burns: Topical antimicrobial agents and dressings UpTo Date. 2014.4. Rice, Orgill. Classification of burns. UpToDate. 2014.5. National Burn Centre Clinical Committee. National Burn Service Initial Assessment Guideline. 2011.6. New Zealand National Burn Service. Escarotomy guidelines.7. Rice, Orgill. Emergency care of moderate and severe thermal burns in adults. UpToDate. 2014.8. Skinner, Peat, NZMJ 20029. Bunn, et al. Hypertonic versus near isotonic crystalloid for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev. 2004;

10. Huang, et al. Hypertonic sodium resuscitation is associated with renal failure and death. Ann Surg. 1995;221(5):543.

11. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet 1944; 79:352.

12. Monafo WW. Initial management of burns. N Engl J Med 1996; 335:1581.