burns

see also:

• Sage burns calculator
• RCH guideline - burns in children
• NSW NETS severe burns transfer guidelines (pdf)
• NSW NETS severe burns service - models of care (pdf)
• Sth Aust. RAH Burns Service - Detailed algorithmic burns Mx document 2009 (pdf) - very nice document indeed!
• Vic. multiple burns casualties guidelines 2015
• Victorian Burns Unit Management Guidelines
• electrocution / electrical injury

• Vic. Major Trauma Transfer Criteria for time critical transfer:
  • burns > 20% BSA
  • inhalational burns
  • electrical burns > 1000V or lightning injury
• patients who should probably have non-time critical transfer to a burns service:
  • Burns greater than 10% TBSA
  • Full thickness burns greater than 5% TBSA
  • Burns to special areas: face, ears, hands, major joints, feet and genitalia
  • Electrical burns >240 volts or arc explosion
  • Chemical burns
  • Circumferential burns to limbs or chest
  • Burns with associated trauma
  • Burns in the very young or older people
  • Burn injury in patients with pre-existing illness or disability that could adversely affect patient care and outcomes
  • Suspected non accidental injury in children or older people
  • Small surface area burns in people with social problems, including children at risk
  • Burns occurring in pregnant women
  • Burn injuries which are slow to heal or about which the referring unit is concerned

• deep burns to face or neck
• stridor
• respiratory distress
• hypoxic
• hypercapnoeic

• the following are derived from the Sth Australian RAH burns service guidelines 2009¹⁾
• 90% of burn oedema will develop by 4 hours post-burn
• patients at risk of airway oedema should be intubated well BEFORE the airway becomes compromised as then intubation may be impossible
• patients with possible inhalational injury in whom it is decided not to intubate should be closely monitored with head elevated to 45deg (if Cx spine cleared), continuous SaO2, 15min airways obs for 1st 4hrs, then 1/24 observations for until 12hrs, then 4/24 obs
• if there is oropharyngeal erythema or hoarseness, an option may be to do laryngoscopy and intubate if upper airway oedema rather than just erythema is present²⁾
• those at high risk for lower airway injury generally need longer term intubation while upper airway injuries generally need only short term intubation.

• history of prolonged confinement in smoke filled environment ie house or car fire including under car hood
• “significant” facial burns
• history of unconsciousness or obtundation
• raised carboxyhaemoglobin
• hypoxia
• respiratory difficulty (dyspnoea, tachypnoea, increased use of accessory muscles and increased work of breathing)
• sooty or productive sputum
• wheezing or added sounds on auscultation
• abnormal finding below the cords on bronchoscopy
• deteriorating condition

• explosive or short contact with thermal agent (eg. petrol)
• no confinement in smoke filled environment
• scalds or contact burns
• normal mentation and speech
• normal appearance below the vocal cords

• steam inhalation
• intraoral burns or blisters
• hoarse voice
• stridor
• deteriorating condition

• history of explosive or short contact with thermal agent such gas/petrol explosion characterized by superficial facial burn or erythema, with some singing of facial hair/nostril hair.
• normal voice at initial examination

• Primary survey
  • airways, breathing, circulation, disability, exposure/environment control
• Secondary survey
  • history
  • head to toe examination
  • burns assessment - depth and extent (see below)
  • check for circumferential burns (even on fingers)
  • investigations - U&E, FBE, etc
• early Mx
  • manage airway - consider intubation if at risk of airway oedema (see above)
  • analgesia
  • IV fluid resuscitation based upon TBSA% (see Parkland formula below)
    • when possible use warm IV fluids
  • wound care - plastic wrap is an excellent initial choice - but not circumferentially
    • if it is a bitumen burn, do not remove any bitumen that is stuck as you are likely to cause more harm
  • check for eschars which may be causing a compartment syndrome and need for early escharotomy
  • monitor urine output
  • prevent heat loss and hypothermia and regular check temperature
    • once burns are dressed, remove any wet dressings or sheets, then cover with warm blankets, space blankets &/or consider Bair Hugger device
  • tetanus prophylaxis
  • keep nil orally
  • nasogastric tube to manage likely gastric ileus if >20% TBSA in adults, > 15% TBSA in children
  • ensure next of kin is notified
  • contact burns service

• epidermal burns
  • erythema, should heal within 1 week without scarring eg. minor sunburn or minor flash burn
  • may develop small blisters over next few days
  • NB. it is NOT an epidermal burn if the epidermis slides separately to the underlying dermis when you use a finger to gently push it
  • Rx hydrogels or moisturisers
• superficial dermal partial thickness
  • very painful, brisk capillary return, large blisters - when they rupture, they expose pink papillary dermis
  • heal by epithelialisation over 2 weeks
• mid dermal partial thickness
  • less severe pain, capillary return is present but delayed, may have blisters, underlying tissue is pale to dark pink
  • require regular review and dressings
  • Rx silver based dressings
• deep dermal partial thickness
  • extensive blisters develop within hours then rupture early exposing generally pale reticular dermis but may be red due to extravasated blood cells
  • very diminished capillary return; reduced sensation; fairly dry wounds with less exudate
  • Rx silver based dressings and refer to a surgeon
• full thickness
  • dense white or waxy appearance but may look charred; no sensation, no pain, no capillary return
  • the coagulated dead skin forms a leathery eschar which may cause a compartment syndrome and require incision
  • Rx silver based dressings and refer to a surgeon as it may need eshcarotomy and/or skin grafting

• do not include epidermal burns!

• Wallace Rule of Nine – Adults
  • head and each arm are 9% each
  • each leg, front of trunk, rear of trunk are all 18% each
  • genitalia is 1%
  • see https://www.vicburns.org.au/burn-assessment-overview/burn-tbsa/rule-of-nine/

• Lund Browder burns assessment chart using the Paediatric Burns Assessment Ruler
  • see https://www.vicburns.org.au/burn-assessment-overview/burn-tbsa/lund-browder/

• amount of IV fluid for 1st 24hrs: 4mL x TBSA% x weight in kg
  • give half in 1st 8hrs post injury
  • give remainder in the 16hrs post injury
• titrate according to urine output