Burns

Background

Burns may be from flame, electricity, hot fluid, etc.,
Classified as superficial, deep dermal or full thickness
Classified as complex or simple
Area estimated = rule of 9s in adult, burns charts in children
1% = area of the palm (excluding wrist but including fingers) in any agegroup
Areas of erythema alone or soot covered unharmed skin are not included
Major burns = > 15% in an adult or > 10% in a child/elderly

Complex burns

Age

under 5yrs or over 60yrs

Site

Face or hands or perineum or feet (with dermal or full thickness loss)
any flexure (esp neck or axilla)
circumferential dermal
full thickness burn of the limbs/torso/neck

Inhalation injury

Any significant such injury (excluding pure CO poisoning)

Mechanism of Injury

Chemical injury, > 5% TBSA, exposure to ionizing radiation injury, high pressure steam injury
High tension electrical injury, hydroflouric acid injury (> 1% TBSA)
Suspicion of NAI

Age

< 16 >5% TBSA (dermal or full thickness loss)
Adult >10% TBSA

Basic principles of resuscitation and airway management. If you are worried about a burn, discuss it with the one of the EM consultants. They will see any burn you are concerned about. If it is a major burn, discuss with EM consultant before discussing with local burns unit. The majority of burns we see can be treated here in the ED.

Discuss all complex burns wiith the duty EM SpR or Consultant.

A burn may also be complex if it occurs with:

Cardiac limitation and/or MI within 5yrs
Respiratory limitation of exercise
Diabetes, either IDDM or NIDDM
Pregnancy
Immuno-suppression for any reason
Hepatic impairment; cirrhosis
Associated injuries:
- Crush injuries
- Fractures
- Head injurie
- Penetrating injuries

Management Major burns

If possible smoke/thermal injury to respiratory tract or burns to head / neck - manage airway.

Treatment

Seek help
Clear and maintain airway - with C-spine cautions
Give oxygen (high concentration)
Check PEFR and give nebulizer if bronchospasm
Consider RSI and intubation(sore throat, hoarse, carbaceous sputum)
Check pulse, blood pressure and respirations
Cannulate away from burn if possible
Give IV crystalloid
Do not insert a central line
Administer analgesia
Chart area involved Lund & Browder)
Catheterise (accurate urine output)

Investigations

ABG including COHb
CXR
FBC (PCV, Hb)
X-match
U&E, COHb
Forensic serum sample

Obtain brief history

Mechanism of injury (exclude co-existing trauma)
Type of thermal injury
AMPLE history
Note time of burn

Examination notes

Area: rule of 9's for adults, Lund & Browder chart for children
Area of hand = 1%
Depth of burn:
- History - electricity, epilepsy, ethanol and burnt clothing imply full thickness
- Record exact timings if possible
- Appearance - white discolouration / eschar suggest full thickness by pin-prick test
- General examination particularly for other signs of trauma
- Circumferential burns of a limb may cause severe compression with the risk of ischaemia; therefore always consider whether any escharotomy needs to be performed. If in doubt - ask!
Apply sterile dry dressings, e.g. paraffin gauze or cling film
Check tetanus cover
Do not apply ointment
Discuss with your ED senior before you contact a burns unit

Fluid management in major burns (Parkland formula)

Hartmans 2ml/kg x weight x %burn in adults
Hartmans 3 ml/kg x weight x %burn in children
Fluid management should be guided by urinary output - Aim for a urine output of 1 ml / kg / hour
Remember - these are in addition to normal fluid requirements

Burns in children

Use the same ABC approach as above
Remember children can decompensate very quickly
Airway compromise is more common in children
Use the paediatric burns body charts to estimate surface area of the burn
Check for complex burn criteria
Give analgesia early - intravenous morphine 0.1 mg / kg
Lund & Browder chart

Transfer arrangements

Before transfer

Ensure airway is safe
Ensure IV lines are reliable, esp if long journey
Keep warm, especially children
Transfer with dry dressing or cling film, not wet towels
Arrange appropriate escort
Documentation
Analgesia

Phone accepting hospital as you are leaving.

Minor burns

Discuss the management of full thickness burns (even if localised) with EM consultant.

Transfer may be indicated according to anatomical site, e.g. face, hand, perineum
Blisters should be left intact whenever possible for pain relief and to reduce infection. If bulk is a problem, aseptic aspiration is second choice. However, if a blister has burst and there is a layer of sloughed epidermis this should be removed and the exposed burn cleaned and dressed
Apply vaseline ointment only to areas treated by exposure (face, perineum) and Bactroban or flamazine for occluded areas (hands)
Alternatively the hands can be placed in a polythene bag containing Bactroban or flamazine
Discuss with senior nursing staff
To other areas apply sterile non-adherent dressing, e.g. Betadine on release with gauze to soak up exudate (and crepe to cover)
Elevate all limb burns
Check tetanus cover
Review patients not requiring admission in the ED clinic (± lavage with 50:50 mix of Betadine and normal saline before similar dressings)
New blisters may need to be managed as above.
Wound depth is often best assessed 2 or 3 days after a burn
Be wary of non-accidental injury
Please discuss any cases needing plastics opinion with the on-call plastics team at CUH prior to completing the soft tissue clinic referral form

Watergel

Watergel should be used if there is concern about ongoing burning
Waterjel dressings are available in the resuscitation room ± store room in the ED
Are water-based, sterile, bacteriostatic, non-toxic, non-adhesive burn dressings
Can be applied over burnt clothing etc
Aim of treatment is to cool the burn and not the patient!
Indications for use include any area where there is a need for heat to be dissipated from body surface area
Contra-indications include any dry ‘powder’ chemical contamination (needs to be brushed from area carefully) or any liquid chemical contaminants (almost all require irrigation for a minimum of 30 minutes)
Waterjel dressings have the cooling capacity of up to 250L of water
Can dissipate temperature up to 1100° C
Vital to obtain a ‘pre-cooling’ history from the E.M.T. or witness
Ensure to get as full a history as possible (both scene and patient history). For example, ascertain whether female patients are menstruating (in case of toxic shock syndrome from tampon use);
Extremely useful in Tar/Bitumen, molten metal/glass/plastic burns,
- Apply dressing as usual, but may require more dressings
- Tar/bitumen etc, should harden and heat is removed from tar etc
Useful in treatment of ‘jellyfish’ stings as dissipate heat
Extra gel in the packs can also be used on area not covered by dressing, i.e. zone of hyperaemia
Dressings may be removed as soon as burn is cooled (discuss with patient)
Normal wash down procedures apply to Waterjel

Non acute referrals to local burns unit

Wound healing any wound unhealed at 14 days post injury
Complications any significant infection, septic episode or suggestion of a Toxic Shock-like illness
Plastic surgery trauma clinic at CUH Referral Form

Rehabilitation

Conmsider early in wound where scarring suggests:

A significant aesthetic impact and/or psychological disturbance
The need to consider skin camouflage
A significant functional limitation
The need to consider pressure therapy or other forms of scar modification
The need to consider surgical reconstruction

Specific types of burns

Burns to the face

May pose upper airway oedema and obstruction
In general, leave burns to the face exposed
Clean twice a day

Supficial burns to the hand

Should be treated with Bactroban in a polythene bag with daily dressings and the hands washed under the tap between dressings
The use of Bactroban should not be too liberal
The patient may need to have the dressing changed twice a day (a soggy, macerated mess, you are probably using too much Bactroban)
Once the Bactroban and bag dressing is stopped the hand will dry and heal very quickly

Chemical

With the rare exception of alkali metals which can explode in the presence of water (sodium, potassium, rubidium and caesium) irrigate copiously with water
Beware of causing hypothermia in children
Avoid neutralisation reactions (exothermic)
Ca⁺⁺ gluconate is indicated for hydrofluoric acid burns (topical gel and/or local injection). Alkali binds to the tissues and exerts its effect deceptively for some hours, so continue irrigation and refer to Burns Unit via your ED senior. Systemic toxicity is produced by hydrofluoric acid, phenols and yellow (white) phosphorus which ignites in air and must be covered by water or wet dressings. Hydrofluoric acid and phosphorus can both depress calcium levels which should be checked in larger burns
Phenol can be removed from burns by swabbing with polyethylene glycol 300

Electrical

More details in Environment - Electrocution page
Perform an ECG
Treat any arrhythmia as appropriate
Admit for observation if loss of consciousness, cardiac arrest, cardiac or respiratory history, arrhythmia or conductive injury

Bactroban

This should be used for routine burn dressings or occlusive bags. Vaseline is adequate for exposure of clean areas such as the face.

Topical application should not be applied to patients being transferred to the burns unit.

Toxic Shock Syndrome ( TSS )

Septicaemia (usually staphylococcal) can occur from surprisingly small burns or scalds in young children. This unusual but potentially lethal complication manifests with high fever, malaise, diarrhoea and vomiting, conjunctival and mucosal injection, a macular rash, and ultimately septic shock. The child should be treated as for septic shock. More on TSS.