Burns

Define burn, its types, and how it differs from a scald

• A burn is an injury caused by exposure to energy in the form of

  • Thermal (heat)

    • Scalds, flame injuries, contact burns

  • Electrical

    • Entry and exit point, touching energised source, lightning

  • Chemical

    • Corrosive agents (acids and alkali) and organic products (bitumen)

  • Radiation

    • Sunburn (UV), nuclear, ionised

• A scald is a burn caused by contact with a hot liquid or steam

How are burns classified?

• Erythema/superficial/first degree

  • Involves epidermis only

  • Local pain and redness

  • No blistering

  • Should heal within scar formation

• Partial thickness/second degree

  • Involves epidermis and dermis

  • Blistering

  • Very painful

  • Moist appearance

• Full thickness/third degree

  • Through all layers of dermis

  • White, waxen or charred

  • Will not heal without intervention

  • Destruction of tissue and blood supply

  • Damage to deeper structures (nerves, muscles, tendons)

  • No pain in full thickness wound itself (nerves completely destroyed)

  • Non blanching

Why are circumferential burns dangerous?

• Burns all around a limb or body part will constrict blood flow/tissue movement with no where to go (e.g. chest, neck - can restrict breathing)

What are burn red flags?

• Significant facial burns

• ABCD issues

• Airway burns/soot/oedema

• >15% adults and >10% children burns

• Hot gas inhalation

What are some key factors for assessing burns?

• Identify immediate complications

  • Infection

  • Hypotension (fluid moving to heal burns)

  • Inhalation injuries

  • Other significant injuries

• Assess burn severity

  • Location and size

  • Extent of the burn

  • Depth of the burn

• Consider possibility of non-accidental injury and child/adult safeguarding

What are some methods for assessing total burned surface area (TBSA)

• Wallace rule of 9s

  • Each area of patient’s body can be divided into multiples of 9

    • Head and neck 9%

    • Each lower limb 18%

    • Each upper limb 9%

    • Anterior torso 18%

    • Posterior torso 18%

    • Genitals 1%

• Mersey burns chart (via an app)

  • Shade over injured areas, can differential partial and full thickness, calculates an estimate %

• Using the patient’s palm (approx 1% of body surface area)

  • Useful for irregular/patchy burns

What are some challenges you could encounter with assessing burns and TBSA?

• In white skin, full thickness burns may be mistaken for unburnt skin

• In pigmented skin, superficial or dermal burns may not appear red

Using the medical model, what are specific considerations for burns in primary survey?

• D - do we need LFB/MPS? Windscreen report?

• R - AVPU and monitor continually for deterioration

• C - Don’t overlook distracting injuries (cat haem)

• A - any indication of → Airway burns, sooty marks, inhalation injury, strider, black sputum

• B - increased RR, wheezing, hoarseness, check JRCALC for O2

• C - Assess rate, CRT, signs of shock, distal pulses

• D - AVPU, pupils, glucose

• E - expedite removal, check trauma tool, expose to assess

Using the medical model, what are specific considerations for burns in Secondary Survey?

History:

• Time of burn, - any cooling/tx provided? Duration of burn?

• Mechanism/source- flame, object, contact time, chemical, oil, electrical

• Environment - Enclosed, outdoors, associate injuries

• SAMPLE

• Severity and character, exacerbating (relevant parts of SOCRATES)

• Co-morbidities - respiratory illness, CV disease, mobility, disease

• Social context - safe guarding? Vulnerabilities?

Examination:

• Head - asses for injuries

• Neck - TWELVE

• Chest - inspect (injuries/palpate), auscultate both sides (?equal ?wheezing?)

• Abdominal - inspect

• Neuro - reassess AVPU/gcs, MSCx4, pupils

• Limbs SLPIDUCT

• Expose and assess wounds and burns (caution for chemical burns not to spread when taking clothes off, or if stuck to skin)

Observations:

• AVPU/GCS for change

• Airway and breathing for degeneration

• RR, Auscultate, response to O2

• SpO2 and ETCO2

• Pulse and ECG

• BGL

• Pain managed effectively?

• Complete set to form baseline

Describe thermal burns management

• Manage ABCD issues first

• Signpost wheezing to senior clinician

• Cool burn for up to 20 minutes

  • Use running water (local stores, LFB, house), saline if water not available, burns dressing if not available

  • Don’t use ice cold water, aim for tepid/lukewarm

  • Cool the burn, not the patient

• Cling film (kept in dressings)

  • Discard first length (IPC)

  • Place sheets of cling film in a patchwork, do NOT wrap circumferential

  • Don’t use ointments/creams

  • Elevate if possible

• Provide analgesia

  • Entonox if indicated and no contras

  • Pain score and description befroe and after

  • Consider parts medic for further analgesia

• Cut off burned/smouldering material

• Remove constrictive items/jewellery

• Address any other injuries

How do we manage chemical burns differently to thermal burns?

• Do not investigate containers, spillages

• Remove clothing - cut it away rather than dragging off

• Irrigate for 20 mins but priorities hands, eyes, face, and be aware of runoff

• No cling film

• HART team notification

How do we manage taser injuries?

• Successful taser deployment is both a:

  • Electrical injury

  • Penetrating injury if skin broken

• Consider:

  • Do NOT remove barbs. Can cut wires but not barbs.

  • ICDs can be sensitive to low voltages

  • 12 lead monitoring is essential

  • Arrhythmias may develop after the incident

What are complications of burns?

• Shock

• Infection

• Respiratory tract damage

• Psychological/scarring

• Associate injuries

• Co-morbidities

• Pain

• Healing inhalation of hot gases

• Hypotension

• End-Organ hypo-perfusion

• Bronchoconstriction

• Acute Respiratory Distress Syndrome: even in non-inhalation injury

What are some advanced clinical interventions we may need for burns?

Using SBAR to handover when asking for advanced clinical backup:

• Early ET tubing

• BVM

• Early opiate analgesia

• Easily fluid resuscitation

+ extra hands to assist with extrication