Emergency medicine & Surgery integration : BURNS

Managements of Burns, classification, types, along with identification of inhalation injuries

1. BURNS Harita Prakash Reddy Final year MBBS AIMS, Mandya

2. Definition It is an injury caused by heat or by a chemical or physical agent having an effect similar to heat. Types of burns based on causative agent Contact burns : body + hot object Flame burns: body + flame ( flash burn —> sudden ignition from flash fires caused due to gases or petrochemicals) Scalds: body + hot liquid Radiant heat burns : heat waves {electromagnetic waves} + no body contact Ionising radiation burns : exposure may be localised or whole due to X RAY, RADIUM, UV RAYS chemical burns : acids, alkali, vesicants ( blister forming) + body Electric / LIGHTNING BURNS : Filigree burns Microwave burns : heat wave ( thru agitation of water molecules ) Sun burns : UV exposure + body

3. CLASSIFICATION - Burns Severity Classification (ABA) CRITERIA MILD MODERATE MAJOR/ SEVERE TBSA Partial thickness 15% in adults/ 10% in children Full thickness <2% 2nd degree < 15 - 25% / 10- 20 % in children 3rd degree 2- 10 % Doesn’t involve eyes, ears,face,hand,feet, perenium 2nd degree burns >25% in adults / > 20% in children 3rd degree burns >= 10 % Burns involving eyes, ears, feet, hands, perenium all inhalational + electrical burns Burns with # or major mechanical trauma

4. 1st degree 2nd degree 3rd degree 4th degree Red painful, no blisters, shows capillary filling, blanches, outer epidermis involved Mottled, red, painful, blisters ( capillary leak) Superficial - causes pigmentation, upper 1/3rd involved Deep second causes scarring, sensitive, no blanching, few epithelial cells spared, blisters can’t be unroofed Charred, parchment like, painless, insensitive, ( if contracted —> ESCHAR) thrombosis of superficial vessels, no viable epidermal cells, Scalding —> myoglobin to be released so dark red appearance Involves muscles + bones 5 - 7 days 14- 21 days Heals by re-epithelialization from edge. Needs graft UV RAYS / Flame exposure Scalds, flame exposure, Scalding or exposure to high temp for short time

5. Depending on depth of skin involved :

6. ASSESSMENT OF BURNS Lund & Browder chart > Wallace rule of 9 Patient’s hand is 1% —> burn is dynamic wound so regularly assessment should be repeated.

7. CLINICAL FEATURES Pain, burning, anxious state, tachycardia, tachypnoea, fluid loss, Severe —> shock ( tolerable temp for skin is - 40 degree Celsius)

8. INVESTIGATION Clinical Assessment: History and Physical Examination: Determine the cause, extent, and depth of burns. Assess associated injuries and comorbidities, Laboratory Tests: Complete Blood Count (CBC) : Monitor for anemia, infection, and changes in white blood cell counts. Electrolyte Levels : Check for imbalances due to fluid shifts and loss during burns. Blood Gas Analysis : Assess acid-base balance and oxygenation status. GRBS : assess blood sugar levels Imaging Studies : Chest X-ray : Evaluate for inhalation injury, especially in cases of suspected smoke inhalation. CT Scan : Useful for assessing deeper tissue involvement and associated injuries.

9. Wound Culture(Culture and Sensitivity) Collect samples from burn wounds to identify and treat potential infections. Urinalysis (Monitor Kidney Function): Assess for myoglobinuria and potential renal complications. Coagulation Profile : PT/INR, PTT : Evaluate coagulation status, especially in extensive burns. RFT : Serum Creatinine and Blood Urea Nitrogen (BUN) : Assess kidney function and the potential impact of burns on the renal system. Cardiac Enzymes : Troponin, CK-MB : Evaluate cardiac involvement in electrical burns or extensive injuries. Pulmonary function test: Assess respiratory function, especially in cases of inhalation injury. Immunization Status : Tetanus Prophylaxis : Ensure up-to-date tetanus vaccination.

10. MANAGEMENT ABCDEF A : airway control B : breathing & ventilation C : circulation D : disability—> neurological status E : exposure with environmental control F : fluid resuscitation

11. PRE- HOSPITAL CARE : Ensure rescuer safety : important in electrical/ chemical burns Stop burning process : STOP, DROP,ROLL Check for other injuries : standard ABC check followed by head/spine injury assessment Remove & neutralize source/ Clothing should be removed : remove clothing if not amalgamated, remove agent in chemical burns urgently and irrigate area for 30 - 60 mins Maintenance of vitals : Give oxygen : h/o fire in enclosed space with altered level of consciousness Cooling burn wound : aim to neutralise heat source, decrease edema by cooling, NEVER APPLY ICE, cool with water for 30 min Elevation: useful in burned airway, decreases swelling & discomfort in burned limbs Assessment of severity of burns

12. MANAGEMENT Indications for admission: Any moderate/ severe burns Airway burns Burns in extremes of age All electric/ chemical burns Admit patient, maintain ABC( intubate early if required), assess % degree, type of burn, shift patient to clean environment/ BURNS UNIT, Sedation & proper analgesic - Tramadol

13. LOCAL MANAGEMENT Cleaning burns to remove dust, mud Chemoprophylaxis - tetanus toxoid + anti tetanus globulin (ATG - 500 units, IM) Covering dressing - povidine iodine solution and silver sulfadiazine ointment (1%) It’s antiseptic, soothening, causes neutropenia, hydration with softening of eschar — wound coverage after area granulates in 3 weeks ( split skin graft or MESH split skin graft) Comforting with sedation & painkillers

14. REFERENCES : SRB Manual of Surgery - 6th Edition Inhalational injury - theplasticsfella.com International Trauma Life Support for Emergency Care Providers- 7th Edition