Burns Trauma & Acute Deterioration – Week 10

Session Overview

• Week 10 focuses on two intertwined themes:

  • Management of burns trauma (≈ ¾ of session).

  • Recognition & response to any acute deterioration (burns or otherwise) in the pre-hospital setting.

• Inclusion of deterioration content driven by ambulance “ramping” (patients remaining on stretchers for long periods) and longer inter-facility transfers.

• Adult early-warning tool: NEWS. Paediatric tool: PARROT.

Epidemiology & Context of Burns

• Burns remain common: daily media examples (house fires in QLD & WA highlighted in lecture).

• Sources: scalds in children, house/industrial fires, aviation accidents, chemicals, electricity, bitumen, etc.

• Demographics: higher incidence in males; decreasing in developed countries, rising in developing nations.

• Children & elderly sustain deeper injuries for the same insult due to higher surface-area-to-mass ratio and comorbidities.

Skin Anatomy & Physiology Relevant to Burns

• Skin layers:

  • Epidermis (outer, avascular).

  • Dermis (papillary + reticular layers; vessels, nerves, appendages).

  • Sub-cutaneous/hypodermis (fat, fascia).

• Key functions compromised by burns:

  • Thermoregulation.

  • Fluid & electrolyte homeostasis.

  • Immunological barrier (infection risk).

  • Sensation & pain.

Burn Pathophysiology – Jackson’s Three Zones

• Zone of Coagulation

  • Direct contact with heat; irreversible necrosis.

• Zone of Stasis

  • Ischaemic; salvageable if perfusion restored (fluid resuscitation + oxygen).

• Zone of Hyperaemia

  • Vasodilation; invariably recovers unless profound sepsis/hypoperfusion.

Burn Depth Classification (modern terms)

• Superficial (formerly 1°)

  • Epidermis only; red, painful, moist, blanches.

• Partial-Thickness

  • Superficial PT: epidermis + upper dermis; blisters; very painful; heals with minimal scarring.

  • Deep PT: deeper dermis; mottled, wetter; may scar.

• Full-Thickness (formerly 3°)

  • Entire dermis destroyed ± sub-cutaneous tissues; dry/leathery, white/charred, non-blanching, often painless centrally.

Systemic Effects of Major Burns

• Massive capillary leak → intravascular ➜ interstitial fluid shift ➜ hypovolaemic shock.

• Inflammatory cytokine surge; risk of SIRS/sepsis.

• Immune suppression & infection.

• Renal hypoperfusion → AKI.

• Altered thermoregulation (marked heat loss; hypothermia can worsen shock).

Estimating Burn Size – Adult Rule of Nines

• Head & neck = 9\%.

• Anterior trunk = 18\% (≈ 9\% chest + 9\% abdomen).

• Posterior trunk = 18\%.

• Each arm (entire) = 9\%.

• Each leg (entire) = 18\% (front 9\%, back 9\%).

• Perineum/genitalia = 1\%.

• Include ONLY areas where skin integrity is breached (blistering or worse), not simple erythema.

Pre-hospital Burn Management

DR + ABCDE Emphasis

• Danger (ongoing fire, chemicals, electricity, structural collapse).

• Catastrophic haemorrhage rare but consider.

• C-Spine: mechanism (e.g. aircraft crash) may preclude clearing with NEXUS; use head blocks/lanyard over semi-rigid collar.

Airway

• Look for HISSS mnemonic: Hoarse voice, Inspiratory stridor, Singed facial/nasal hair, Soot in saliva/sputum.

• Anticipate rapid oedema → early RSI by CCP/HEMS; if resources absent and obstruction imminent, front-of-neck access (cricothyrotomy).

Breathing

• High-flow \text{O}2 via non-rebreather regardless of SpO2 (pulse-oximetry unreliable with carboxy-Hb).

• Nebulised salbutamol (e.g. 5\,mg continuous) for lower-airway irritation/bronchospasm.

• Monitor end-tidal \text{CO}_2 (if available).

Circulation & Fluid Resuscitation

• IV/IO access (large-bore, through unburnt skin if possible).

• Continuous ECG (especially electrical burns).

• Begin fluids when criteria met (see below). Use warmed Hartmann’s/Normal Saline.

Modified Parkland Formula (WA)

\text{24-h Fluid (mL)}
= 2\,mL \times \%TBSA \times \text{Weight (kg)}.

• Deliver \dfrac{1}{2} in first 8 h (from TIME OF BURN) and remaining \dfrac{1}{2} over next 16 h.

• Example (Jandakot case):
  2 \times 28 \times 80 = 4480\,\text{mL};\ \ 2240\,\text{mL} in first 8 h.

When to Initiate Formula

• Adults > 15\% TBSA.

• Children > 8!–!10\% (age-dependent) or any airway/facial/critical-site burn.

Disability

• Serial GCS; analgesia (IV opioids, ketamine, methoxyflurane) early.

Exposure – Cooling & Dressings

• Cool with running water ≈15^{\circ}C for FULL 20 min (within 3 h ideal).

• Avoid ice/iced water.

• Prevent hypothermia: warm ambient temp, space blanket, cover non-burned skin.

• Remove rings, watches, belts, smouldering clothing.

• Gentle debridement of loose devitalised tissue improves cooling & assessment.

• After cooling: apply sterile non-adherent dressing (cling film, Burn Aid®) or continue wet-dressings (giving-set drip) en route.

Transport & Destination Decisions

• Direct to specialist burns unit (e.g. Fiona Stanley Hospital WA) when ANY:

  • Adult > 10\% TBSA (child > 5\%).

  • Airway involvement/ inhalation injury.

  • Burns to face, hands, feet, perineum, genitalia, or circumferential limb/torso.

  • Electrical, chemical, or high-voltage burns.

• Pre-notify hospital with TBSA %, time of burn & fluids given.

Specific Burn Types

Chemical Burns

• Personal protective equipment first.

• Brush off dry powders → copious water irrigation ("solution to pollution is dilution").

• Remove contaminated clothing/ jewellery.

Electrical Burns

• Ensure power isolated (lock-out/ tag-out).

• Consider C-spine (falls/ tetanic injuries).

• Continuous cardiac monitoring (arrhythmias, asystole, VF).

• Entry/exit wounds often small – internal damage may be extensive.

Bitumen/Tar Burns

• Cool with water; allow tar to harden; do NOT forcibly peel.

• Petroleum jellies/vegetable oils later (hospital) to remove residue.

Paediatric & Geriatric Specifics

• Larger surface-area–mass ratio → faster fluid and heat loss.

• Lower physiological reserves; early hypothermia & shock.

• Always consider non-accidental injury in children – pattern, story, delay.

• Elderly: frailty, comorbidities, thinner skin → deeper burns; cautious fluid loading.

Compartment Syndrome & Circumferential Burns

• Full-thickness circumferential limb or chest burns may cause vascular/ventilatory compromise.

• Elevate limbs, monitor pulses, cap-refill; hospital may perform escharotomy.

Case Study – Jandakot Airport Cessna Crash

• 46-yo male, 80\,kg.

• Full-thickness burns: head, neck, both arms → 28\% TBSA.

• Initial V/S: RR 20, SpO_2 94 % (room air), BP 114/76, HR ??, GCS 15, hoarse voice, cough, singed hair.

• Management highlights:

  • Anticipate airway oedema; call CCP for RSI; HISSS positive.

  • High-flow \text{O}_2 + salbutamol.

  • Calculate Parkland: 4480\,mL → 2240\,mL in first 8 h.

  • 20-min cooling, jewellery off, sterile cling wrap.

  • Opioid analgesia; cardiac monitor; head-blocks.

  • Direct transfer to burns unit (airway + >10 %).

Recognising & Responding to Acute Deterioration

Rationale

• Ramping/ prolonged stretcher time → crews must detect subtle changes early.

National Early Warning Score (NEWS) – Adults

• Parameters & individual scores (0–3):

  • Respiratory rate.

  • SpO2 (two scales: 1 = normal, 2 = chronic hypoxic pts on home O2).

  • Requirement for supplemental \text{O}_2.

  • Temperature.

  • Systolic BP.

  • Heart rate.

  • Consciousness (AVPU/GCS).

• Total NEWS:

  • 0–4 = routine obs.

  • 5–6 or any individual score 3 = urgent review/ sepsis screen.

  • ≥7 = treat as critical; Priority 1 transport.

• Purple Trigger (any single extreme): unresponsive, HR <30 or >220, BP <70 or >250, RR <5 or >45, SpO2 < 85 % on O2.

  • Manage as emergency → resus/ MET activation.

PARROT Tool – Paediatrics

• Same colour logic; age-banded ranges for RR, HR, SBP, SpO_2.

• Does NOT use temperature in infants.

Practical Use

• Reassess at set intervals; document scores to show trajectory (e.g. 3 → 7).

• Communicate numeric score to triage & operations centre to justify escalation.

• Integrates with sepsis pathway (not examined in trauma unit but mentioned).

Pathophysiology of Burn Shock (summary diagram)

• Burn insult → Cytokine release → ↑ vascular permeability.

• Plasma (water, proteins) leaks into interstitium → ↓ preload.

• Compensatory tachycardia, vasoconstriction; if uncorrected → de-compensated shock, MODS.

Key Formulas & Numbers to Memorise

• Modified Parkland (adult WA): 2\,mL \times \%TBSA \times kg.

• Cool water duration: 20 min at \approx15^{\circ}C (within 3 h ideally).

• Adult Burn Centre referral: > 10\% TBSA OR airway/critical sites.

• NEWS escalation bands: 0–4 / 5–6 / ≥7; purple trigger immediate.

Practical, Ethical & Real-World Implications

• Early appropriate cooling & fluids shrink zone of stasis → better functional & cosmetic outcome.

• Oxygen despite “normal” sats reflects duty to understand technology limits (CO-Hb).

• Ramping creates moral distress; early-warning tools provide objective language for advocacy.

• Paediatric burns raise safeguarding/abuse considerations; mandatory reporting.

Links to Previous & Future Lectures

• Builds on earlier modules: shock physiology, fluid therapy, airway management.

• NEWS/PARROT scoring will recur in next semester’s Diagnostics & Medical Studies.

• Burn wound care, grafting & long-term rehab covered in later surgical/critical-care lectures.

Session Overview

• Week 10 focuses on two intertwined themes:

  • Management of burns trauma (≈ ¾ of session).

  • Recognition & response to any acute deterioration (burns or otherwise) in the pre-hospital setting.

• Inclusion of deterioration content driven by ambulance “ramping,” which refers to patients remaining on stretchers for extended periods in emergency department corridors, leading to delayed care and a need for pre-hospital clinicians to manage patient deterioration over longer durations.

• Adult early-warning tool: National Early Warning Score (NEWS). Paediatric tool: Paediatric Advanced Resuscitation and Response Observation Tool (PARROT), designed to detect subtle physiological changes indicating clinical worsening.

Epidemiology & Context of Burns

• Burns remain common: daily media examples (house fires in QLD & WA highlighted in lecture, industrial accidents, vehicle fires).

• Sources vary widely:

  • Scalds (hot liquids) in children, most common cause in this age group.

  • House/industrial fires (direct flame/smoke inhalation).

  • Aviation accidents (crash and post-crash fires).

  • Chemicals (acids, alkalis, strong oxidizers).

  • Electricity (direct current, alternating current, lightning).

  • Bitumen/tar (high-temperature contact).

• Demographics: higher incidence in males; decreasing in developed countries due to prevention efforts, but rising in developing nations due to socioeconomic factors and lack of safety standards.

• Children & elderly sustain deeper injuries for the same thermal insult due to thinner skin, a higher surface-area-to-mass ratio (in children leading to rapid heat and fluid loss), and comorbidities (in the elderly, impacting healing and physiological reserve).

Skin Anatomy & Physiology Relevant to Burns

• Skin layers:

  • Epidermis (outermost, avascular layer; provides primary barrier function).

  • Dermis (composed of papillary and reticular layers; contains blood vessels, nerves, hair follicles, sweat glands, and sebaceous glands – crucial for skin function and regeneration).

  • Sub-cutaneous/hypodermis (innermost layer; primarily fat and fascia; provides insulation, energy storage, and shock absorption).

• Key functions compromised by burns, leading to systemic effects:

  • Thermoregulation: Damage to sweat glands and blood vessels results in significant heat loss, making patients prone to hypothermia.

  • Fluid & electrolyte homeostasis: Impaired barrier allows massive fluid and protein shifts from the intravascular space into the interstitial space, leading to hypovolemic shock.

  • Immunological barrier: Disruption of the skin's physical and immune defenses increases the risk of local and systemic infections (sepsis).

  • Sensation & pain: Nerve endings are destroyed or damaged, leading to intense pain in superficial and partial-thickness burns, while full-thickness burns may be painless centrally due to complete nerve destruction.

Burn Pathophysiology – Jackson’s Three Zones

• Zone of Coagulation:

  • Direct contact with the heat source; immediately irreversible cellular necrosis occurs due to protein denaturation and cell death.

  • This zone is the most severe and represents the area of primary damage.

• Zone of Stasis:

  • Surrounds the zone of coagulation; characterized by decreased tissue perfusion and ischemia.

  • Cells in this zone are injured but potentially salvageable if timely and adequate perfusion is restored through fluid resuscitation and oxygenation. Without intervention, this zone can progress to full necrosis within 24-48 hours.

• Zone of Hyperaemia:

  • Outermost zone; characterized by vasodilation and increased blood flow to the area.

  • This zone is least severe and invariably recovers completely unless profound systemic compromise such as sepsis or prolonged hypoperfusion supervenes.

Burn Depth Classification (modern terms)

• Superficial (formerly 1°):

  • Involves only the epidermis.

  • Appearance: Red, dry, painful to touch, moist, and blanches readily with pressure.

  • Healing: Typically heals spontaneously within 3-6 days without scarring as the epidermis regenerates.

• Partial-Thickness:

  • Superficial Partial-Thickness (fml. 2°): Involves the epidermis and upper part of the dermis.

    • Appearance: Blisters, intensely painful, red, weeping, and blanches rapidly.

    • Healing: Usually heals in 7-21 days with minimal scarring, as epidermal appendages (hair follicles, sweat glands) in the dermis provide cells for re-epithelialization.

  • Deep Partial-Thickness (fml. deep 2°): Extends deeper into the dermis.

    • Appearance: Mottled (red and white patches), less painful than superficial PT due to more extensive nerve damage, wetter or waxy appearance, slower to blanch or non-blanching.

    • Healing: Takes 3-9 weeks or longer to heal, often with significant scarring and contracture formation, and may require skin grafting for optimal outcome.

• Full-Thickness (formerly 3°):

  • Involves destruction of the entire dermis, potentially extending into sub-cutaneous tissues, muscle, or bone.

  • Appearance: Dry, leathery, white, black/charred, or brown; non-blanching; often centrally painless due to complete nerve destruction (though pain may be felt in surrounding partial-thickness areas).

  • Healing: Does not heal spontaneously and requires surgical excision and skin grafting to close the wound.

Systemic Effects of Major Burns

• Massive capillary leak:

  • Due to direct heat damage and the release of inflammatory mediators (e.g., histamine, bradykinin, prostaglandins) that increase vascular permeability.

  • Leads to large fluid shifts from the intravascular space into the interstitial space (burn oedema) and subsequently results in hypovolaemic shock.

• Inflammatory cytokine surge: A systemic inflammatory response (SIRS) mediated by pro-inflammatory cytokines (e.g., TNF-α, IL-1, IL-6), leading to a hypermetabolic state and increased risk of sepsis and multi-organ dysfunction syndrome (MODS).

• Immune suppression & infection: Compromised skin barrier, along with systemic immunosuppression, makes burn patients highly susceptible to local wound infections and systemic sepsis, which is a leading cause of death in major burns.

• Renal hypoperfusion: Reduced circulating blood volume due to fluid shifts leads to decreased renal blood flow, predisposing the patient to Acute Kidney Injury (AKI), especially if resuscitation is inadequate.

• Altered thermoregulation: Extensive skin damage results in marked heat loss through evaporation and convection, leading to hypothermia, which can further depress cardiac function, worsen metabolic acidosis, and exacerbate shock.

Estimating Burn Size – Adult Rule of Nines

• This rule provides a quick estimate of total body surface area (TBSA) affected by second-degree (partial-thickness) or third-degree (full-thickness) burns.

• Head & neck = 9\%

• Anterior trunk = 18\% (approximately 9\% chest + 9\% abdomen)

• Posterior trunk = 18\%

• Each arm (entire) = 9\%

• Each leg (entire) = 18\% (front 9\%, back 9\%$)

• Perineum/genitalia = 1\%

• Crucially, include ONLY areas where skin integrity is breached (blistering or worse). Simple erythema (redness without blistering, like a sunburn) is considered superficial and is excluded from TBSA calculations for fluid resuscitation purposes, as it does not cause significant fluid shifts.

Pre-hospital Burn Management

DR + ABCDE Emphasis

• Danger: Ensure scene safety first. Remove the patient and responders from ongoing risks such as active fire, hazardous chemicals, live electricity, collapsing structures, or explosive atmospheres.

• Catastrophic haemorrhage: While rare in burns, assess for and control any significant external bleeding immediately (e.g., from associated trauma).

• C-Spine: Mechanism of injury (e.g., falls from height, explosions, aircraft crash) may suggest spinal injury. In such cases, the NEXUS criteria may not safely clear the C-spine; therefore, maintain spinal immobilization using head blocks and a lanyard over a semi-rigid collar until full assessment can be performed.

Airway

• Look for HISSS mnemonic, signs suggestive of inhalation injury and impending airway compromise:

  • Hoarse voice

  • Inspiratory stridor (a high-pitched breath sound indicating upper airway obstruction)

  • Singed facial/nasal hair

  • Soot in saliva/sputum

• Anticipate rapid oedema: Airway swelling can worsen quickly over hours, leading to complete obstruction. Early intubation (Rapid Sequence Induction - RSI) by a Critical Care Paramedic (CCP)/Helicopter Emergency Medical Service (HEMS) is crucial.

• If resources are absent and obstruction is imminent with failed intubation, emergency front-of-neck access (cricothyrotomy) may be a life-saving procedure.

Breathing

• High-flow ext{O}2 via non-rebreather mask at 12-15 ext{ L/min} is mandatory, regardless of SpO2 readings. Pulse oximetry is unreliable in carbon monoxide (CO) poisoning as carboxyhaemoglobin (carboxy-Hb) falsely elevates SpO_2 readings.

• Nebulised salbutamol (e.g., 5 ext{ mg} continuous) for lower-airway irritation, bronchospasm, or wheezing caused by smoke inhalation.

• Monitor end-tidal ext{CO}_2 (capnography) if available to assess ventilatory status and identify any trends in respiratory compromise.

Circulation & Fluid Resuscitation

• Establish intravenous (IV) or intraosseous (IO) access, using large-bore catheters (14-16 ext{ gauge}) preferably through unburnt skin if possible to facilitate rapid fluid administration.

• Continuous ECG monitoring is essential, especially for electrical burns, to detect arrhythmias (e.g., ventricular fibrillation, asystole) that may develop hours after the initial insult.

• Begin fluid resuscitation only when specific criteria are met (see below). Use warmed Hartmann’s solution (Lactated Ringer's) or Normal Saline to prevent hypothermia and promote adequate perfusion.

Modified Parkland Formula (WA)

\text{24-h Fluid (mL)} \quad = 2\,mL \times \%TBSA \times \text{Weight (kg)}.

• Deliver \dfrac{1}{2} of the calculated total fluid in the first 8 hours (calculated from the TIME OF BURN, not time of arrival at hospital or paramedic contact) and the remaining \dfrac{1}{2} over the next 16 hours.

• Example (Jandakot case):
  \quad 2 \times 28 \times 80 = 4480\,\text{mL};\ \ 2240\,\text{mL} in first 8 hours.

When to Initiate Formula

• Adults with burns > 15\% TBSA.

• Children with burns > 8-10\% TBSA (age-dependent thresholds are crucial, lower for younger children) or any airway/facial/critical-site burn (hands, feet, perineum/genitalia, major joints).

Disability

• Perform serial GCS assessments to monitor neurological status and detect any deterioration.

• Administer adequate analgesia early to manage severe pain: IV opioids (e.g., fentanyl, morphine), ketamine, or inhaled methoxyflurane. Pain control helps reduce metabolic demand and patient distress.

Exposure – Cooling & Dressings

• Cool the burn with clean, running water at approximately 15^{\circ}C for a FULL 20 minutes for optimal effect. This should ideally be initiated within 3 hours of the burn occurrence to reduce burn depth and pain.

• Avoid using ice or iced water, as this can cause vasoconstriction, deepen the burn, and precipitate hypothermia, especially in children and the elderly.

• Prevent hypothermia: After cooling, ensure the patient is kept warm by maintaining a warm ambient temperature, applying a space blanket, and covering non-burned skin.

• Remove all rings, watches, belts, and any smouldering clothing as soon as safely possible to prevent tourniquet effects from swelling and ongoing thermal injury.

• Gentle debridement of loose devitalised tissue improves cooling efficacy, aids in initial assessment, and reduces the bacterial load.

• After adequate cooling, apply a sterile, non-adherent dressing (e.g., clean cling film/plastic wrap, Burn Aid® dressings specific for burns). Alternatively, maintain wet-dressings using a giving-set drip en route for prolonged cooling if necessary.

Transport & Destination Decisions

• Direct transfer to a specialist burns unit (e.g., Fiona Stanley Hospital in WA) is mandated when ANY of the following criteria are met, as these indicate a major burn requiring specialized care:

  • Adult with > 10\% TBSA partial or full-thickness burn (child > 5\%).

  • Any suspected airway involvement or inhalation injury due to risk of rapid airway compromise.

  • Burns to the face, hands, feet, perineum, genitalia, or over major joints (due to high risk of functional impairment, scarring, and long-term disability).

  • Circumferential limb or torso burns (risk of compartment syndrome).

  • Electrical, chemical, or high-voltage burns (often have hidden extensive internal damage).

  • Referrals also apply to burns in specific populations like children, the elderly, or those with significant comorbidities.

• Pre-notify the receiving hospital with critical information: estimated TBSA %, exact time of burn, and total fluids given to allow for preparation and continued resuscitation upon arrival.

Specific Burn Types

Chemical Burns

• Personal protective equipment (PPE) for rescuers is paramount to prevent secondary contamination.

• For dry powders (e.g., lime), brush off as much as possible before irrigation, as water can activate some chemicals.

• Follow with copious water irrigation for prolonged periods (at least 20-30$$ minutes, often much longer for alkalis) – the principle is