Burns - Resuscitation, Referral and Retrieval

Ken HarrisonCareflight

Westmead Hospital NSW

Welcome

Disclosed Interests

Financial - nil

Disclosed Interests

Financial - nil

Emotional - plenty

Burns and EBM

There is no MetaanalysisThere is one Randomised trial (it showed more deaths in the trial group)There are precious few case controlled trials (all from >25 years ago)There are lots of case reports/audits/ideas/suggestions

Types of Burn Injury

Thermal–Scalds –Flame– Contact– Cold

Electrical

Chemical

Radiation

‘Medical’ Skin loss e.g. Toxic Epidermal Necrolysis

Incidence of Burn Injuries100 severe burns requiring resuscitation per year – half of these are children20 - 30 deaths/year in Australia50% firstly admitted to non-specialist units Incidence falling Prognosis improving

Scald Injury

Burns

Resuscitation– First Aid– Primary Survey– Fluids– Analgesia– Dressings

RetrievalDisasters

History

Time of burn Flame/scald/chemical/electricalEnclosed spaceAssociated trauma

First Aid

Cool Running WaterFor about 20mins ??Time = Tissue

First Aid

Cool Running WaterFor about 20mins ??Time = Tissue

But once the heat has gone, warm them up.

Waiting for EmmaI was sitting in my usual restaurant when my attention was drawn by the hizz and steam as a plate of sizzling oriental steak was paraded aloft with style towards a young couple dining alone. As the waiter reached the table, he tripped or faltered and the entire contents of the plate fell onto the young womans chest.

Waiting for EmmaShe screamed in agony and as my hand flew to cover my mouth in horror, I observed a man sitting 2 tables away from her immediately arise, stride to her table, picking up a bottle of Moet from the table in between

Waiting for Emma

and pulling her blouse away from her chest, he proceeded to empty the champagne onto her ample clevage with immediate relief on her part.

First Aid

Time is Tissue

Burns

Resuscitation– First Aid– Primary Survey– Fluids– Analgesia– Dressings

RetrievalDisasters

Primary Survey A-Airway

Airway BurnsVoice change, stridorSooty sputumFacial burn Singed nasal hair

Upper Airway Injury

Sit upAvoid excessive resuscitation fluidsEarly ophthalmic referral No role for steroidstie/wire/tape/

What is an inhalation injury?

Damage caused by aspiration of superheated gases, steam, hot liquids or noxious products of combustion Damage may be to upper or lower airway or bothIf the event was associated with an explosion, there may also be “blast” injury to the lungs

A- continued

Intubations are not more difficult than normal if done earlyBut may be difficult +++ laterSuxamethonium safe in first 24 hours

Case Report

It was a dark and stormy night45 year old man, had new shiny BBQ on new shiny deck.20+ for dinner and numerous beers“decided” to move the BBQ under cover, due to rain, so disconected from mains gas and connected to bottled.difficult to start - followed by bang.

Case Report

arrived by private car in small hospital 50 km from Sydneyobvious facial, inhalational and upper arm and torso burnsanaesthetist called immediately as he had just walked through to go to maternity

Case Report

He came back to ED and saw the 115kg past front rower man sitting upright in pain as preparations were being made to intubate him.Past GA history “difficult to get the tube down”.Lots of discussion with Burns hospital and Medical retreival

Case Report

Patient given 100mls/hr and analgesiaMedical retrieval drove to the hospitalSat up in ambulance en route to burns centre“interesting fibreoptic intubation ” at burns centre

Primary Survey B - Breathing

Breathing and control of ventilationRemember usual trauma causes of breathing problems, pneumothorax, haemothorax etcThink about Blast vs Burnt lungExclude circumferential burn to chest

Primary Survey C - Circulation

Stop the BleedingAssess Circulation BP, P, peripheral perfusionHypovolaemic shock at early stage will not be due to burn - suspect traumaLarge bore IV access through unburnt skin and not distal to large burnsSecure lines well

Mumford’s Rule of Tape

In a retrieval the amount of tape and ties used to hold in lines and tubes

shall not exceed the distance between the patient and the receiving hospital,

but anything less than that is acceptable

Harrison’s Corollary

In a retrieval no matter how you secure the ETT, when you arrive at the

receiving ICU, it will be wrong

So follow Mumford’s rule

Parkland FormulaParkland (Baxter) formula (1968)Easy, simple, widely used throughout the world4 ml kg-1 TBSA-1 Hartmann’s over 24hrs from the time of the burnFirst half given over first 8 hours Second half over next 16 hoursNo Colloid in first 24hrsEndpoint UO 0.5-1 ml-1 kg-1 hr-1

Hypertonic Saline (HTS)

Restoration of intravascular volume by reabsorption of fluid from interstitial space?Immunomodulatory action (IL 1,IL10, TNF)Ovine models of burn trauma associated with improved organ perfusion and less oedema if given early

213 burns patients (65 HTS)HTS received significantly less fluid Fourfold increase in renal failure in the HTS gp (40.0 vs. 10. 1%) Doubling of mortality in HTS patients (53.8 vs. 26.6%)

Primary Survey - D

If altered is this– trauma– hypoxia • hypoxic environment• chest pathology• CO poisoning

Primary Survey - E

Exposure and Estimation of Depth and SizeRemove clothing and jewellery on burned limbsLose heat rapidly- KEEP WARM and DRYEstimate BSA burned- Rule of 9’s, Lund and Browder Chart, Palmar surface (1%)

Analgesia

No good evidence MorphineMorphineMorphine or maybe Fentanyl – N and V– give centrally

Ketamine– beware secretions

Escharotomy vs Fasciotomy

urgencydegree of difficultysometimes need both

Wrapping

GladwrapKeep warm

Wrapping

GladwrapKeep warmApparently Viagra has a place

Electrical

Energy proportional to square of voltage Tissue damage proportional to heat generationPath of least resistanceDivision low/high tension/arc injuryECG monitoring only if Hx LOC or Abnm ECG

Retrieval and Referral

Burns CentresState Retrieval Coordination centresIphonesNot urgent retrievalsBFCD

Disasters/Major Incidents

Burns over-represented as causeSmall number of Burns bedsCoordination needed and is doneThinks about BATS teams

Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia. Med J Aust. 2009 Jul 6;191(1):11-6.

Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, Niggemeyer L, Truesdale M, Holman P, Mehra R, Wasiak J, Cleland H.

Abstract

There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state's burns referral centres, of whom 18 were adults. There were a further 390 bushfire-related ED presentations. Most patients with serious burns were triaged to and managed at burns referral centres.

CONCLUSIONS:

Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system

Ashmore Reef

43 patients ??taken from boat to rig to Truscott AirfieldTriage and resuscitation thereDispersed to Perth, Adelaide, Darwin

Ashmore Reef

Great work by RAN team at seaGreat coordination between civil and militaryGreat Coordination to from TruscottMASBURNSPLAN, BAT’s,