BURNS INJURIES MANAGEMENT IN EMERGENCY DEPARTMENT

1. THERMAL INJURIES
BY RENIN JUMA AND KESSIO EUNICE

2. introduction
 Thermal injuries are major causes of morbidity and mortality
 Attention to the basic trauma rescucitation and timely application on
simple emergency can help minimize motarlity and morbidity
 These priciples include
1. A high index of suspicion for presence of airway compromise following
smoke inhalation,identification and management of associated
mechanical injuries
2. Manatain hemodynamic normality via fluid rescucitation
3. Treat and prevent potential complication of thermal injuries i.e
rhabdomyolysis,cardiac dysrhythmias as seen in electrical burns

3. introduction
4. Temperature control and removal from injury provoking environment

4. Types of burns
 Chemical burns ; alkali and acid , alkali is more severe causes deep
penetration into the skin by liquifying the skin [liquification necrosis]. Acid
burns penetrate less because they cause coagulation injury [coagulation
necrosis]
 Electrical burns –can be deceiving with small entry and exit wound but
internal organ damage may be extensive
 Thermal injury – are most common most are small and superficial burns
causing local injuries ; they can also be large and deeper

5. Immediate life saving measures of
burn injuries
 What is the priority:
 Airway control
 Stopping the burn process
 Gaining the iv access
AIRWAY CONTROL
 Burns can result to massive edema, upper airway is at risk of obstruction

6.  Signs of obstruction may initially be subtle until patient is in crisis
therefore evaluate early for the need of endotracheal intubation
 Factors that increase risk of upper airway obstruction include :increasing
burn size and depth,burns to the head and face, inhalation injury and
burns inside the mouth
 Burns localized to the face and mouth cause more localized edema and
pose greater risk of airway compromise
 Children are at high risk for airway problems

7. How to identify in halation injury
 Face or neck burns
 Hoarseness
 Explosion with burns to head and dorsal
 Acute inflammatory changes to oropharynx eg erythema
 Singeing of the eye brows and nasal vibrissae
 Carbon deposit in the mouth and nose with carbonaceous sputum

8.  Any of the above indicated inhalation burns and need for intubation
 Transfer to burn center all inhalation burn injuries if transport is
prolonged perform intubation. stridor, circumferential burns to the neck
are indicators of early intubation
2. STOP THE BURNING PROCESS
 Remove all clothing to stop the burning process
 Dont peel of adherent clothing,remove clothes burned by chemicals
 Rinse the involved body part to chemical burn with cupious amount of tap
water

9.  Cover the patients with warm clean and dry linens to prevent hypothermia
3.INTRAVENOUS ACCESS
 Establish venous access using large bore cannula
 Upper extremities are preferred for venous access than lower extremities
due to risk of phlebitis,
 Begin infusion with crystalloids preferably ringers lactate

10. How to assess apatient with burns
Patient history:
 Time of the injury
 Associated factors like loss of consciousness
 Enviroment eg enclosed can lead to inhalation burns
 Age
 Associated injuries eg escape from blast can lead to fructures and injuries
 Pre exisisting disease like epilepsy,psychiatric disorders,htn,dm,ccf; allergies;drug
therapy

11. Evaluation and management
 Type of burn –thermal,electrical,chemical or radiation,blast
 Extent of burns – percentage of TBSA involved
 Depth of burns – 1st ,2nd ,3rd degree burns
 Other factors – age>50,10< ,preexisting illness
 Possible inhalation
 Ass traumatic injuries

12. How to assess apatient with burns
Body surface area:
 Use rule of nines ; children differs from adults @arm 9%,head 9%
@anterior abdomen and chest 18% posterior chest and back 18%,@leg
18%,perineum1% for children head 18% @leg13.5%
 It helps determine extend of injury
 Lund and browder chart – more accurret method especially for children
@ arm 10%,anterior and posterior trunk @13% calculated the head and
legs basing on age

13. How to assess apatient with burns
 Palmar surface including fingers = 1% bsa with no fingers is 0.5%
*When calculating extent of burns only partial and full thickness are
considered superficial burns are excluded
Depth of burn:
 Helps in evaluating the severity of the wound ,wound care
planning,predicting cosmetic and functional results

14. First degree burns [superficial]
 Involves epidermis Includes sunburns –characterized by erythema, pain
and absence of blisters ,warm,soft blunch when touched
 They are not life threatening and do not require fluid therapy because
epidermis is intact

15. Partial thickness 2nd degree burns
 Extend through epidermis to dermis
 The included burns from hot fluids, surfaces ,flames
 Are characterized with red or mottled appearance, swelling and blister
formation
 The surface can have a weeping ,wet appearance, its very painful
hypersensitive even to air current

16. Full thickness burns
 Extend through epidermis,dermis and subcutaneous fat or even deeper
 Are dark and leathery, skin may appear translucent, waxy white,charred
and feel firm to palpation with no blanching are due to hot
fluids,flames,superheated gasses
 The surface is painless and generally dry, it may be red and does not
blanch with pressure
 There is little swelling neighboring tissue may swell significantly

17. Treatment and management
Recommendation for referral to burn unit as per American burn association
 Partial thickness burns greater than 10% of total bsa in all age
 Full thickness burns in all age
 Patient with burn injury with concomitant traumatic injuries posses
increased rate of morbidity and mortality
 Burns in patients who will require special and emotional or long term
rehabilitative support eg suspected child maltreatment and neglect

18. Treatment and management
 Burns of hands ,face, feet ,genitalia or major joints partial or full thickness
 Electrical burns , lightening strike injuries due to risk of acute kidney injury
and other complication due to significant tissue beneath injury
 Significant inhalation burns
 Burns in patient with preexisting conditions that may prolong recovery or
complicate treatment
 Significant chemical burns
 Children with burn injuries who are seen in hospital with no qualified
personnel or equipment to manage should be transferred to burns unit.

19.  Patient in need of transferer do not need extensive debridement or topical
antibiotics before transfer
 Contact the burn center before referring or transferring the patient
MINOR BURNS A
Treat them with C
 COOLING –use of tap water and saline to prevent progression of burns and
to reduce burns
 CLEANING- use mild soap and water,antibacterial wash, depate continues
over best treatment for blisters

20.  However debride large blisters while small blisters and blister involving
palms and soles are left intact
 COVERING –use topical antibiotics ointments or cream with absorbent
dressing or use specialised burn materials
 COMFORT –offer pain medication when needed, splints can also be used
 For chemical burns both acid and alkali :copious irrigation of affected
external areas is indicated
 Avoid anti emetic for risk of aspiration

21.  Ingested hydrofluoric acid is fatal despite concerns of perforation
consider gastric lavage using calcium chloride 20mmol in 1000ml ns
after securing the air way
 HF acid can be treated with cupious irrigation of and application of paste
calcium gluconate
 Disc batteries ingestion alkali burns consider early removal and will
require endoscopic and radiographic tracking of location if the battery has
passed the pylorus watchful waiting and inspection of stool is
recommended
 No indication for systemic antibiotics steroids,prophylactic heapatorenal
therapies


22. Fluid therapy
 For burns classified as severe >20 percent
 Fluid resuscitation should be initiated to maintain fluid output of
0.5ml/kg/hr
 Parkland formula total amount of fluid to be given in 1st 24 hours =4mls
of ringers lactate *patients weight * TBSA
 A half of the calculated fluid should be given in 1st 8 hours then half in
next 16hrs
 Rememeber fluid rescucitation for burns is only an estimate apatient may
need more or less fluid based on vitals sighns ,urine output,other injuries
or other medical conditions

23. Inhalation burns management
 Its pulmonary exposure to wide range of chemicals in various forms
including smoke,gases,vapours or fumes
 Smoke inhalation is most common
 High index of suspicion is important for all clinicians to have when
evaluating patient with inhalation injury ,its important to identify whether
the patient was exposed to smoke flames or possible chemicals
 History should be complete and thorough , burn patient may have
extensive injuries but smoke inhalation may affect those with no outward
signs

24. Inhalation burns management
 Patient exposed to smoke may have burning sensation to the nose throat
,cough with increased sputum production ,stridor, dypnea,ronchi,other
symptoms may be headache odynophagia,headache delirium and
hallucination ,comatose
 Physical examination may incluse ; looking for facial burns ,carbonaseous
material or soot in mouth or sputum
 Use of accessory muscle muscles ,cynosis
tachpnea,stridor,wheeze,rhonchi,rales

25. Inhalation burns management
 Duration and exposure
 in patients with moderate severe flame burns
 Check caboxyhemoglobin levels and place the patient on high flow
oxygen until carbon monoxide is ruled out

26. Evaluation of inhalation burns
 Chest xray
 Full hemogram,pulse oximetry,Arterial blood gas,cobocyhemoglobin
level,cynide level,pulmonary function testing,bronchoscopy
TREATMENT /management
 Limit exposure by removing the patient from exposure area secure the
airway,
 Airway protection by early intubation of patients with inhalation
burns,airway edema may occur suddenly and worsen to obstruction
 Management is basically supportive

27.  Maintain and secure the airway via intobation and tracheostomy if
necessary
 Pulmory hygiene can help manage secretion eg hemrrhage,mucosal
sloughing as aresult of edema,N-acetylcysreine is often used as amucolytic
 Obstruction may occur due to airway hyper reactivity for which
broncodilators like salbutamol.ipropium,albuterol may be used
 Early and prophylactic antibiotic usage is not recommended ,Start
antibiotic promptly when empiric diagnosis of pneumonia is made
 Usage of both inhaled and intravenous steroid have not been proven
beneficial in clinical studies

28.  Anticoagulation eg inhaled heparine has shown some promise especially
for smoke inhalation help reduce inflammatory response and fibrine cast
formation helping reduce airway obstruction , dose 5000 to 10 000iu
nebularise 4 hourly alternating with broncho dilator
 Carbon monoxide give high flow oxygen
 Hydrogen Cynide poisoning –give hydroxocobalamine in patients with
high index of suspicion
 Accurate treatment involves checking for possible compounds
inhaled,duration,relative concerntration of exposure ,water solubility of
toxic agent inhaled

29. DDX
 Asthma,copd,ARDS,CCF,PE,interstitial lung disease,pneumonia
Inhalation injury have high risk for complication ,majority fatal burns is
caused by respiratory failure or pneumonia

30. Electrical burns
 Are when high energy current travels through the body due to contact
with electrical source
 Can be due to flow of current,arc flash or clothing that catches fire
 The body converts electricity to heat leading to thermal injury
 Outward appearance of electric burn do not accurately predict the true
extent of injury as internal tissues and organs may be much more burned
than the skin
 Contributing factor to severity and pattern of injury include body
position compared to direction of the current entering the body and
duration of exposure

31.  Ohms law states that current is directly proportional to voltage and
inversely proportional to resistance
 Low frequency AC causes more extensive injury to tissues that high
frequency AC or DC, this is because AC cause local muscle contraction
flexor muscles greater than extensor muscles at side of contact with
electrical source rendering victim unable to go off the offending object
 AC injuries are common as AC powers house hold and buildings
 Dc cause single muscle contraction often throwing avictim away from the
energy source

32.  examples of DC include : lightening ,contact with car battery
 Risk of death .severity from lightening depends on : if the exposure was
adirect lightening strike,lightening hit something else nearby[tree,structure
or ground],then travelled to individuals body
 High voltage burns can cause deeper burns and extensive tissue damage
500-1000 volts, low voltage exposure result to lesser injury
 Electricity follows path of list resistance eg tissues . Skin has more
resistance followed by bones , nerves and blood vessels have lesser
resistance

33.  Higher skin resistance result to more diffuse burns to the skin , skin with
lesser resistance results to deeper burns that are most like to cause severe
internal tissue damage
 Skin burn may appear mild but internal organs are severely damaged

34. History and physical exam
 This patient should be examined and treated following trauma protocols
priority to ABCSEs with primary and secondary survey
 Establish source of electric injury,voltage,current type ac/dc,duration of
exposure, how the injury was incurred, obtain the patient cardiac history
including history of prior arrythmias , do head to toe examination paying
attention to the skin and scalp
 When documenting wounds always refer to areas of burns as contact
points rather than entrance or exit wounds

35. evaluation
 EKG,cardiac enzymes,CBC,uecs urinalysis[check for myoglobin and
rhabdomyolysis]
 Consider ct head in patient with altered mental status ,associated head
trauma,blast injuries
TREATMENT /MANAGEMENT
 Remove the patient from the source of electricity shut off the electric
source
 Remove the patient clothings
 ACLS in patient with no pulse

36.  In aconcious patient pain control and fluid management preferably
ringers lactate would be priorities
 Large bore iv access and large volume rescucitation is important with
anything more than a very low voltage injury
 Avoid hypothermia
 Patient with cardiac disease put on cardiac monitor observe for 6-12hours
, pregnant mothers of 20 weeks gestation put on fetal monitor
 Tetanus vaccination ,clean and treat the wound,