Management of the
burn patient

NATHAN STEWART
ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS


In 1997-2005 the rate of total Burn Injury related
deaths for Australia was 0.5 per 100,000 persons.



In 2003-04 the...
Progress in Burn Care
Fluid resuscitation
Dedicated burns units
Antimicrobials
Intensive care
Nutrition
Early excision
Ski...
Classification of burns
Thermal



hot



cold

4
Classification of burns
Thermal



immersion



cascade scalds

5
Classification of burns
Thermal



contact



flame



flash

6
Classification of burns
Chemical



acid



alkali



organic chemicals

7
Classification of burns
Electrical



low voltage



high tension



lightning

8
Classification of burns
Friction

Radiation

9
Everybody

Every intervention influences the scar worn for life,
therefore, everyone who assists in the management
of that...
First Aid for burns
Remove from burn source
Cold water - except when in contact with electricity

This has the most effect...
12

Minor
burns
Minor burns
Defined by exclusion of


area more than 5% of body surface



deep



infected



problem area - face, ha...
Dressings for Burns
15

Major
burns
Burns Resuscitation:
At the Scene






Remove Patient & Self from Injury Source
Extinguish actively burning material ...
Burns Resuscitation:

In the A&E Department


ATLS:

ABC & Secondary Survey



Brief HISTORY & EXAMINATION



Airway/ B...
Burns Resuscitation:
In the Burns Unit


ATLS:

ABC + Secondary Survey



Full HISTORY:



Full EXAMINATION:

% Burn (T...
Burns Resuscitation:
Monitoring


Physiology:

URINE OUTPUT
Haematocrit
Blood Gases

Urine Osmolality
Electrolytes & Urea...
Burn Resuscitation:
A Team Effort









Anaesthetist
Surgeon
Intensivist
Microbiologist
Paediatrician
Haematolo...
Burn Resuscitation:
Airway


HISTORY



EXAMINATION

Confusion / Altered
Consciousness

Fire in an ENCLOSED SPACE
e.g. H...
Lower airway/pulmonary
problems
Primary burn damage
Pulmonary oedema
ARDS

22
Burn Resuscitation:
Airway

INVESTIGATIONS


Blood Gases



Carboxyhaemaglobin



Chest X-ray
Burn Resuscitation:
Airway

TREATMENT


FiO2

40 - 60%



Nebulisers

-

-

? 100%

Saline

Salbutamol / Terbutaline


...
Burn Resuscitation:
Breathing


COAD -

Hypoxic Drive



MECHANICAL:


Upper Airway Swelling



Chest Wall Constrictio...
Burn Shock
Likely if burned area more than


15% body surface in adults



10% body surface in children (and elderly)

2...
Burn Resuscitation:
Shock

Definition
(Dietzman & Lillehei (1968))
The inability of the circulatory system to meet the
nee...
Parkland formula
for fluid resuscitation

4ml Hartmann’s solution per 1% burn per
kg body weight



half in first 8hrs p...
Burn Resuscitation:
Burn Depth


Erythema

-

ignore



Superficial Partial Thickness



Deep Partial Thickness



Ful...
Rule of nine

30
Management of the
burned patient
Full “primary and secondary” surveys

Check for other injuries

31
Managing the burn wound
- considerations

Surgery vs. spontaneous healing
Mechanisms of healing
Pathological zones in the ...
Depths of burn

33
Assessment of burn depth
Clinical examination: 50-75% accurate

Pinprick test

Repeated examination

34
Assessment of burn depth

35

Easy when very superficial
or full-thickness

Harder when intermediate
or mixed
Why excise the burn?
Burn wound is a focus for sepsis
Burn stimulates inflammatory mediators

Deep burns cannot heal witho...
Timing of surgery
“Ultraconservative”
Conservative
Early

Acute

37
Urgent surgery
High-tension electrical injury
Deep encircling burns - escharotomy


limbs



trunk

38
For small burns
Excision and grafting
as soon as clearly non-healing

39
Early excision of burns
Tangential excision to viable tissue on day 3-5
Janzekovic (1970)
Jackson & Stone (1972)

40
Tangential burn excision
and split skin grafting

41
Excision to fascia

42
Early burn surgery
Superior outcomes where suitably equipped


mortality



length of hospital stay



morbidity during...
Desirable surgical
management
Excision of all non-shallow burns as soon as
practicable in as few stages as possible
Closur...
Large area burns - the
problem
Area / mass of necrotic tissue
Shortage of donor sites
Infection

Systemic effects (SIRS, A...
Scar management
The potential problem

46
Scar management
Pre-emptive measures


prompt surgery



splintage & physiotherapy

Pressure garments and conformers
Sil...
Scar management
Splintage

48
Pressure garments
Almost universally used
Apparently effective

Many published observations

49
Pressure garments
Aids to compliance

50
Conformers and splints

51
Silicone gel
Mechanism not fully known - not pressure

52
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Burns management

  1. 1. Management of the burn patient NATHAN STEWART ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS
  2. 2.  In 1997-2005 the rate of total Burn Injury related deaths for Australia was 0.5 per 100,000 persons.  In 2003-04 the age-adjusted hospitalisation rate of fire, burn and scald related injury in Australia was 31.9 cases per 100,000 population per year.  During the period of 2001-02, throughout Australia, burns and scalds were responsible for 6,248 hospitalisations in public hospitals with the average length of stay being 7.1 days incurring an estimated cost of $132 million.
  3. 3. Progress in Burn Care Fluid resuscitation Dedicated burns units Antimicrobials Intensive care Nutrition Early excision Skin cover Specialisation 3
  4. 4. Classification of burns Thermal  hot  cold 4
  5. 5. Classification of burns Thermal  immersion  cascade scalds 5
  6. 6. Classification of burns Thermal  contact  flame  flash 6
  7. 7. Classification of burns Chemical  acid  alkali  organic chemicals 7
  8. 8. Classification of burns Electrical  low voltage  high tension  lightning 8
  9. 9. Classification of burns Friction Radiation 9
  10. 10. Everybody Every intervention influences the scar worn for life, therefore, everyone who assists in the management of that patient becomes a member of the burn care team
  11. 11. First Aid for burns Remove from burn source Cold water - except when in contact with electricity This has the most effect on the final outcome! Still some effectiveness up to 4 hours post burn. At least 20 minutes of cold running water. Remove clothes. Need to avoid Hypothermia though! Gels e.g. Burnshield Cling film & dry clean sheet No ointments, creams, powders, butter, etc. etc. 11
  12. 12. 12 Minor burns
  13. 13. Minor burns Defined by exclusion of  area more than 5% of body surface  deep  infected  problem area - face, hands, perineum, feet  inhalation injury  other injury or underlying medical problem  suspected non-accidental injury 13
  14. 14. Dressings for Burns
  15. 15. 15 Major burns
  16. 16. Burns Resuscitation: At the Scene     Remove Patient & Self from Injury Source Extinguish actively burning material & Cool burn (Tap Water) ABC: Airway, Breathing, Circulation (ATLS) Brief HISTORY: Time of Injury - For resuscitation Nature of Injury- Flame, Indoors, Chemicals  Brief EXAMINATION: Area) Burn Size (% Total Body Surface Burn DEPTH: Erythema (ignore) Superficial Partial Thickness Deep Partaial Thickness Full Thickness
  17. 17. Burns Resuscitation: In the A&E Department  ATLS: ABC & Secondary Survey  Brief HISTORY & EXAMINATION  Airway/ Breathing Control  FLUID RESUSCITATION  Baseline Investigations:  FBC  U&Es  Carboxyhaemaglobin  Calculate the burn depth - IVI* Chest Xray Blood Gases Toxicology
  18. 18. Burns Resuscitation: In the Burns Unit  ATLS: ABC + Secondary Survey  Full HISTORY:  Full EXAMINATION: % Burn (TBSA) Body Mass (Kgm)  Resuscitation History: Crystalloid Fluids - - Colloid  Reveiwed Protocol: Trials, Advances, Units, etc.  MONITORING
  19. 19. Burns Resuscitation: Monitoring  Physiology: URINE OUTPUT Haematocrit Blood Gases Urine Osmolality Electrolytes & Urea Nutritional Status Cardiovascular Function
  20. 20. Burn Resuscitation: A Team Effort         Anaesthetist Surgeon Intensivist Microbiologist Paediatrician Haematologist Chemical Pathologist etc  Specialist Nurse  Physiotherapist  Occupational Therapist  Theatre Nurse  Ward Clerk  Secretary  Play Therapist  etc
  21. 21. Burn Resuscitation: Airway  HISTORY  EXAMINATION Confusion / Altered Consciousness Fire in an ENCLOSED SPACE e.g. House fire Burns to Face / Oropharynx Car fire Toxic fumes (Industrial) Hoarseness / Stridor / Exp rhonchi Soot in nostrils or Sputum Dysphagia / Drooling
  22. 22. Lower airway/pulmonary problems Primary burn damage Pulmonary oedema ARDS 22
  23. 23. Burn Resuscitation: Airway INVESTIGATIONS  Blood Gases  Carboxyhaemaglobin  Chest X-ray
  24. 24. Burn Resuscitation: Airway TREATMENT  FiO2 40 - 60%  Nebulisers - - ? 100% Saline Salbutamol / Terbutaline  Oro/Nasal Intubation  Tracheostomy
  25. 25. Burn Resuscitation: Breathing  COAD - Hypoxic Drive  MECHANICAL:  Upper Airway Swelling  Chest Wall Constriction
  26. 26. Burn Shock Likely if burned area more than  15% body surface in adults  10% body surface in children (and elderly) 26
  27. 27. Burn Resuscitation: Shock Definition (Dietzman & Lillehei (1968)) The inability of the circulatory system to meet the needs of tissues for oxygen & nutrients and the removal of their metabolites.
  28. 28. Parkland formula for fluid resuscitation 4ml Hartmann’s solution per 1% burn per kg body weight   half in first 8hrs post-burn half in the following 16hrs = 0.25ml/%burn/kg/hr in first 8 hrs from time of burn colloid in second 24hrs 28
  29. 29. Burn Resuscitation: Burn Depth  Erythema - ignore  Superficial Partial Thickness  Deep Partial Thickness  Full Thickness
  30. 30. Rule of nine 30
  31. 31. Management of the burned patient Full “primary and secondary” surveys Check for other injuries 31
  32. 32. Managing the burn wound - considerations Surgery vs. spontaneous healing Mechanisms of healing Pathological zones in the burn Determination of burn depth Influence of dressings 32
  33. 33. Depths of burn 33
  34. 34. Assessment of burn depth Clinical examination: 50-75% accurate Pinprick test Repeated examination 34
  35. 35. Assessment of burn depth 35 Easy when very superficial or full-thickness Harder when intermediate or mixed
  36. 36. Why excise the burn? Burn wound is a focus for sepsis Burn stimulates inflammatory mediators Deep burns cannot heal without grafts Possible effect on future scar quality but Non full-thickness burns may heal spontaneously Superficial burns heal with acceptable scars Excised burn wound must be closed Major burn surgery is hazardous 36
  37. 37. Timing of surgery “Ultraconservative” Conservative Early Acute 37
  38. 38. Urgent surgery High-tension electrical injury Deep encircling burns - escharotomy  limbs  trunk 38
  39. 39. For small burns Excision and grafting as soon as clearly non-healing 39
  40. 40. Early excision of burns Tangential excision to viable tissue on day 3-5 Janzekovic (1970) Jackson & Stone (1972) 40
  41. 41. Tangential burn excision and split skin grafting 41
  42. 42. Excision to fascia 42
  43. 43. Early burn surgery Superior outcomes where suitably equipped  mortality  length of hospital stay  morbidity during acute burn  scar quality 43
  44. 44. Desirable surgical management Excision of all non-shallow burns as soon as practicable in as few stages as possible Closure of excised wounds with autograft, allograft or artificial material Definitive wound closure 44
  45. 45. Large area burns - the problem Area / mass of necrotic tissue Shortage of donor sites Infection Systemic effects (SIRS, ARDS) Associated problems of inhalation 45
  46. 46. Scar management The potential problem 46
  47. 47. Scar management Pre-emptive measures  prompt surgery  splintage & physiotherapy Pressure garments and conformers Silicone gel and contact media Medical and surgical treatment 47
  48. 48. Scar management Splintage 48
  49. 49. Pressure garments Almost universally used Apparently effective Many published observations 49
  50. 50. Pressure garments Aids to compliance 50
  51. 51. Conformers and splints 51
  52. 52. Silicone gel Mechanism not fully known - not pressure 52
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