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Burn Management
Burn Management
Kathryn Clark
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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
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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
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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
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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
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Other History
• Time of injury• First aid/pre-hospital treatment? • Other trauma• Inhalation injury• Non-accidental injury
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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
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• Breathing– Apply supplemental oxygen– Consider early mechanical ventilation
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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
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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-
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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
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Wound Assessment
• Burn depth• Body surface area estimation• Burn distribution
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Burn Classification• Epidermal:
– Dry, red, no blisters, epidermis only– Very superficial– May be painful– Heal within 7 days– No scarring
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• 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
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• 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
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Burn Surface Area
Orgill D. N Engl J Med 2009;360:893-901
The Rule of Nines and Lund–Browder Charts
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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
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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
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• 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
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Wound Management
• Appropriate first aid– Prevent further tissue damage– Minimise wound complications– Manage pain– Prevent hypothermia
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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
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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
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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
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Escharotomy Indications
• Circumferential burns• Compartment syndrome - abdominal or extremity• Difficulty with ventilation in chest burns
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Burn Management
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• Ensure adequate analgesia– Entonox– Paracetamol + NSAIDs + Codeine or Tramadol– IV opioids– Supervised sedation/Ketamine
• Tetanus toxoid/immunoglobulins• Antibiotics not usually indicated
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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)
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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
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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
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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.
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• Glad Wrap– Transparent– Easy to put on/remove– Non-adherent– Traps moisture/reduce fluid loss– Prevents contamination– Traps heat– Reduces hypersensitivity
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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
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Burn Management
SSD Cream Intrasite Gel
$12.30/50 g
Antimicrobial
Expensive moisturiser if skin intact
$3.14/8 g
Bacteriostatic
~95% water
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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)
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Burn Management
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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
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Burn Management
Electrical Burns
• Low / high voltage < 1000 volts >• Lightning• AC / DC• Pathway
– Look for entry and exit wounds– Low / high resistance tissues
• Duration
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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
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Chemical Burns
• End the exposure• ABCDE• Alkalis generally cause worse damage• Initial treatment Empiric: irrigation with
water• Dry powder should be brushed off
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• 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.
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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
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Ocular Burns
• Often chemical• Steam/heat• Contact lenses need to be removed• Copious irrigation• Sterile dressings• Opthalmology Evaluation ASAP
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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
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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
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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.