Anyone with burns should also be presumed to have smoke inhalation - ABC's and watch for stridor, hoarseness, drooling of saliva. Can develop ARDS and compromised airway which may require intubation. Refer to Burns unit if > 5% of body surface area affected in a child or elderly or greater than 20% in other age groups. If any doubt seek specialist advice
Initial management of severe burns
- Suspect inhalational injury: Respiratory Distress, Stridor, Wheeze, Voice Change, Deep Facial Burns, Sooty Sputum, Patient has been in an enclosed space, LOC at the scene
- Seek senior anaesthetic assessment for consideration of early intubation – 2222 and request anaesthetic support fast bleep – ETT must not be cut in this setting and NG to be placed early
- Breathing – Suspect carbon monoxide and cyanide inhalation: check baseline arterial gases, COHb and saturations, administer 100% FiO2
- Bilateral large bore IV access away from burnt tissue (if possible)
- Send Bloods (FBC, U&E, LFT, CRP, Amylase, CK, X-match, Drug/Tox as needed)
- Start Fluids: 4mls x Weight in kg x % burn.
- Half over 8 hours, Rest over 16 hours
- Give Warmed Hartmann’s
- Catheterise and Fluid balance chart
- Example: 70 kg and 50% burns is 4 x 70 x 50 = 14,000 mls or 14 L which is 7L in first 8 h and 7L in next 16 h
- Disability – IV opiate analgesia titrated to pain
- Exposure: Remove non adherent clothing and hydrogel. Cool wounds with wet compress– 20 minutes total Assess % with Lund and Browder chart and depth. Cover with loose cling film (not face)
- Others: Have you considered?
- NG Tube
- Escharotomy to chest/neck for circumferential burns
- Tetanus Booster
- Safeguarding concerns
Burns can be divided into
- First degree/Superficial: These are red, painful and usually have no blistering - eg. Sunburn. Involves epidermis. The dermis is intact. They are not life-threatening and generally do not require any intravenous fluid therapy. They are usually mildly painful.
- Second Degree/Partial: These are red or mottled, with blistering and swelling. Epidermis and upper dermis. The surface is usually moist and weeping and they are extremely painful and hypersensitive. Repair by epithelial growth
- Third degree/Full thickness: These are leathery with a dry surface. Epidermis and Dermis down to subcutaneous tissue. They can be white or red in colour and are painless, as the nerves will have been destroyed. Heal by granulation and scarring
Physical signs that may indicate an inhalational burn injury include
- Burns to face, neck or upper torso
- Singed nasal hair
- Carbonaceous sputum or soot particles in oropharynx
- Change in voice with hoarseness or harsh cough
- Dyspnoea, stridor, Erythema or swelling of oropharynx on direct visualisation
The cause of the burn may help to give an indication of its depth
- Flash burns are usually superficial epidermal
- Scalds are usually superficial or superficial dermal
- Flame burns are usually the deep dermal or full-thickness
- Contact burns are likely to be deep dermal or full-thickness
- Chemical and electrical injuries are often full thickness
- Compartment syndrome, Hypovolaemia. Electrolyte disturbance
- Hypothermia. Infection and sepsis, Chronic neuropathic pain and itch.
- Scarring - burns that take more than 2-3 weeks to heal are more likely to result in hypertrophic scarring.
- Psychosocial impact - such as depression, anxiety, post-traumatic stress disorder; changes in body image, stigma, and social isolation following scarring.
- Face, Hand, Perineum or genitals, Feet, Flexures (particularly neck or axilla)
- Burn over joint which may
affect mobility or function
Look for clinical evidence of a circulatory deficit. This may be indicated by
- Tachycardia, Tachypnoea, Reduced level of consciousness
- Prolonged central capillary refill time, Cool peripheries
Remember to consider NAI in any child or elder abuse in any who presents with a burn.
- Unrelated adult, Unexplained delay in presentation, Inconsistent history
- Multiple presentations, Prior abuse or high risk environment
- Immersion type burn pattern, Cigarette burns
- Scalds to genitalia or buttocks, Mirror image injury, Other signs of abuse
- FBC, U&E , Glucose, Group and save, Clotting, CK
- Arterial blood gas and lactate where needed
Management of Patients with burns
- ABCDE and Oxygen with attention to oral mucosa and airway as well as stridor or noisy breathing that would suggest the need for early intubation. Get an early ABG and look for HbCO. Awareness of smoke inhalation and Carbon monoxide poisoning and risk of ARDS/SIRS/AKI. Measure core temp. and maintain >36 C. Strict aseptic precautions. Antibiotics may be indicated
- All patients with an inhalational injury or other major burns must receive high-flow oxygen
via a Hudson mask with a reservoir bag. Regular monitoring of respiratory rate, blood
pressure, ECG and SaO2 must be initiated. In addition, CXR, ABG analysis and COHb
levels are mandatory in any patient with an inhalational injury or major burn.
- Early IV access and fluid replacement fundamental see Parkland formula: 3-4 mL body weight (kg) the percentage of body surface area burned. Crystalloid fluid is typically used. Half should be given in the first 8 hours, and the remainder over the next 16 hours; the 24 hours starts from the onset of the injury.
- Circumferential limb burns may cause distal vascular compromise. The absence of
peripheral pulses or a cool, pale limb warrants urgent discussion with the surgical team
on-call and the Regional Burns Centre.
- The presence of elevated lactate, cardiac arrhythmias, reduced GCS and reduced
arterial-venous oxygen saturation difference may indicate cyanide poisoning
- Analgesia: ensure good analgesia is given. Titrate IV morphine as necessary
- Nutrition: may need NG tube
- An indwelling urinary catheter can help measure output for fluid balance chart with the following targets
- Urine output: 0.5-1.0 ml/kg/hour in adults
- Urine output: 1.0-1.5 ml/kg/hour in children (2-4 ml/kg/hr in infants)
- Consider tetanus prophylaxis
- Apply suitable dressing (clingfilm if for transfer)
- Extend and depth of 2nd and 3rd degree Burns
- Estimate burn size determines fluid and protein loss and vasodilation and fluid shifts
- Estimate burn depth - Partial thickness (Pain, red, blistering) or Full-thickness (painless, grey/white)
- Transfer all burns with Partial > 25% in adults and > 20% in children to regional centre
- Patients are at high risks of scarring and compartment syndrome and may need escharotomy
- Escharotomy may be necessary in patients with circumferential chest burns.
- Discuss with the surgical team on-call and Regional Burns Centre (RBC).