Burns management

Burns Management

1. Management of the burn patient Nathan Stewart Adapted from presentation by Dr Alan Phipps

2. In 1997-2005 the rate of total Burn Injury related deaths for Australia was 0.5 per 100,000 persons . In 2003-04 the age-adjusted hospitalisation rate of fire, burn and scald related injury in Australia was 31.9 cases per 100,000 population per year. During the period of 2001-02, throughout Australia, burns and scalds were responsible for 6,248 hospitalisations in public hospitals with the average length of stay being 7.1 days incurring an estimated cost of $132 million.

3. Progress in Burn Care Fluid resuscitation Dedicated burns units Antimicrobials Intensive care Nutrition Early excision Skin cover Specialisation 3

4. Classification of burns Thermal hot cold 4

5. Classification of burns Thermal immersion cascade scalds 5

6. Classification of burns Thermal contact flame flash 6

7. Classification of burns Chemical acid alkali organic chemicals 7

8. Classification of burns Electrical low voltage high tension lightning 8

9. Classification of burns Friction Radiation 9

10. Everybody Every intervention influences the scar worn for life, therefore, everyone who assists in the management of that patient becomes a member of the burn care team

11. First Aid for burns Remove from burn source Cold water - except when in contact with electricity This has the most effect on the final outcome! Still some effectiveness up to 4 hours post burn. At least 20 minutes of cold running water. Remove clothes. Need to avoid Hypothermia though! Gels e.g. Burnshield Cling film & dry clean sheet No ointments, creams, powders, butter, etc. etc. 11

12. Minor burns 12

13. Minor burns Defined by exclusion of area more than 5% of body surface deep infected problem area - face, hands, perineum, feet inhalation injury other injury or underlying medical problem suspected non-accidental injury 13

14. Dressings for Burns

15. Major burns 15

16. Burns Resuscitation: At the Scene Remove Patient & Self from Injury Source Extinguish actively burning material & Cool burn (Tap Water) ABC: Airway, Breathing, Circulation (ATLS) Brief HISTORY: Time of Injury - For resuscitation Nature of Injury- Flame, Indoors, Chemicals Brief EXAMINATION: Burn Size (% Total Body Surface Area) Burn DEPTH: Erythema (ignore) Superficial Partial Thickness Deep Partaial Thickness Full Thickness

17. Burns Resuscitation: In the A&E Department ATLS: ABC & Secondary Survey Brief HISTORY & EXAMINATION Airway/ Breathing Control FLUID RESUSCITATION - IVI* Baseline Investigations: FBC Chest Xray U&Es Blood Gases Carboxyhaemaglobin Toxicology Calculate the burn depth

18. Burns Resuscitation: In the Burns Unit ATLS: ABC + Secondary Survey Full HISTORY: Full EXAMINATION: % Burn (TBSA) Body Mass (Kgm) Resuscitation History: Fluids - Crystalloid - Colloid Reveiwed Protocol: Trials, Advances, Units, etc. MONITORING

19. Burns Resuscitation: Monitoring Physiology: URINE OUTPUT Haematocrit Blood Gases Urine Osmolality Electrolytes & Urea Nutritional Status Cardiovascular Function

20. Burn Resuscitation: A Team Effort Anaesthetist Surgeon Intensivist Microbiologist Paediatrician Haematologist Chemical Pathologist etc Specialist Nurse Physiotherapist Occupational Therapist Theatre Nurse Ward Clerk Secretary Play Therapist etc

21. Burn Resuscitation: Airway HISTORY Fire in an ENCLOSED SPACE e.g. House fire Car fire Toxic fumes (Industrial) EXAMINATION Confusion / Altered Consciousness Burns to Face / Oropharynx Hoarseness / Stridor / Exp rhonchi Soot in nostrils or Sputum Dysphagia / Drooling

22. Lower airway/pulmonary problems Primary burn damage Pulmonary oedema ARDS 22

23. Burn Resuscitation: Airway INVESTIGATIONS Blood Gases Carboxyhaemaglobin Chest X-ray

24. Burn Resuscitation: Airway TREATMENT FiO2 40 - 60% ? 100% Nebulisers - Saline - Salbutamol / Terbutaline Oro/Nasal Intubation Tracheostomy

25. Burn Resuscitation: Breathing COAD - Hypoxic Drive MECHANICAL: Upper Airway Swelling Chest Wall Constriction

26. Burn Shock Likely if burned area more than 15% body surface in adults 10% body surface in children (and elderly) 26

27. Burn Resuscitation: Shock Definition (Dietzman & Lillehei (1968)) The inability of the circulatory system to meet the needs of tissues for oxygen & nutrients and the removal of their metabolites.

28. Parkland formula for fluid resuscitation 4ml Hartmann’s solution per 1% burn per kg body weight half in first 8hrs post-burn half in the following 16hrs = 0.25ml/%burn/kg/hr in first 8 hrs from time of burn  colloid in second 24hrs 28

29. Burn Resuscitation: Burn Depth Erythema - ignore Superficial Partial Thickness Deep Partial Thickness Full Thickness

30. Rule of nine 30

31. Management of the burned patient Full “primary and secondary” surveys Check for other injuries 31

32. Managing the burn wound - considerations Surgery vs. spontaneous healing Mechanisms of healing Pathological zones in the burn Determination of burn depth Influence of dressings 32

33. Depths of burn 33

34. Assessment of burn depth Clinical examination: 50-75% accurate Pinprick test Repeated examination 34

35. Assessment of burn depth Easy when very superficial or full-thickness Harder when intermediate or mixed 35

36. Why excise the burn? Burn wound is a focus for sepsis Burn stimulates inflammatory mediators Deep burns cannot heal without grafts Possible effect on future scar quality but Non full-thickness burns may heal spontaneously Superficial burns heal with acceptable scars Excised burn wound must be closed Major burn surgery is hazardous 36

37. Timing of surgery “Ultraconservative” Conservative Early Acute 37

38. Urgent surgery High-tension electrical injury Deep encircling burns - escharotomy limbs trunk 38

39. For small burns 39 Excision and grafting as soon as clearly non-healing

40. Early excision of burns Tangential excision to viable tissue on day 3-5 Janzekovic (1970) Jackson & Stone (1972) 40

41. Tangential burn excision and split skin grafting 41

42. Excision to fascia 42

43. Early burn surgery Superior outcomes where suitably equipped mortality length of hospital stay morbidity during acute burn scar quality 43

44. Desirable surgical management Excision of all non-shallow burns as soon as practicable in as few stages as possible Closure of excised wounds with autograft, allograft or artificial material Definitive wound closure 44

45. Large area burns - the problem Area / mass of necrotic tissue Shortage of donor sites Infection Systemic effects (SIRS, ARDS) Associated problems of inhalation 45

46. Scar management The potential problem 46

47. Scar management Pre-emptive measures prompt surgery splintage & physiotherapy Pressure garments and conformers Silicone gel and contact media Medical and surgical treatment 47

48. Scar management Splintage 48

49. Pressure garments Almost universally used Apparently effective Many published observations 49

50. Pressure garments Aids to compliance 50

51. Conformers and splints 51

52. Silicone gel Mechanism not fully known - not pressure 52