This document discusses the management of burn patients. It notes that in Australia from 1997-2005, the rate of burn-related deaths was 0.5 per 100,000 people and hospitalization rates for fire, burn, and scald injuries was 31.9 per 100,000 per year. During 2001-02, burns and scalds accounted for over 6,000 hospitalizations costing $132 million. The document then covers classifications of burns, first aid, fluid resuscitation protocols, monitoring burn patients, determining burn depth and wound management, as well as scar management. It emphasizes the importance of a multidisciplinary team approach in treating burn patients.

1. Management of the
burn patient
NATHAN STEWART
ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS

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. Progress in Burn Care
Fluid resuscitation
Dedicated burns units
Antimicrobials
Intensive care
Nutrition
Early excision
Skin cover
Specialisation
3

4. Classification of burns
Thermal

hot

cold
4

5. Classification of burns
Thermal

immersion

cascade scalds
5

6. Classification of burns
Thermal

contact

flame

flash
6

7. Classification of burns
Chemical

acid

alkali

organic chemicals
7

8. Classification of burns
Electrical

low voltage

high tension

lightning
8

9. Classification of burns
Friction
Radiation
9

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. 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
Minor
burns

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. Dressings for Burns

15. 15
Major
burns

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. 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. 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. Burns Resuscitation:
Monitoring

Physiology:
URINE OUTPUT
Haematocrit
Blood Gases
Urine Osmolality
Electrolytes & Urea
Nutritional Status
Cardiovascular Function

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. 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. Lower airway/pulmonary
problems
Primary burn damage
Pulmonary oedema
ARDS
22

23. Burn Resuscitation:
Airway
INVESTIGATIONS

Blood Gases

Carboxyhaemaglobin

Chest X-ray

24. Burn Resuscitation:
Airway
TREATMENT

FiO2
40 - 60%

Nebulisers
-
-
? 100%
Saline
Salbutamol / Terbutaline

Oro/Nasal Intubation

Tracheostomy

25. Burn Resuscitation:
Breathing

COAD -
Hypoxic Drive

MECHANICAL:

Upper Airway Swelling

Chest Wall Constriction

26. Burn Shock
Likely if burned area more than

15% body surface in adults

10% body surface in children (and elderly)
26

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. 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. Burn Resuscitation:
Burn Depth

Erythema
-
ignore

Superficial Partial Thickness

Deep Partial Thickness

Full Thickness

30. Rule of nine
30

31. Management of the
burned patient
Full “primary and secondary” surveys
Check for other injuries
31

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. Depths of burn
33

34. Assessment of burn depth
Clinical examination: 50-75% accurate
Pinprick test
Repeated examination
34

35. Assessment of burn depth
35
Easy when very superficial
or full-thickness
Harder when intermediate
or mixed

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. Timing of surgery
“Ultraconservative”
Conservative
Early
Acute
37

38. Urgent surgery
High-tension electrical injury
Deep encircling burns - escharotomy

limbs

trunk
38

39. For small burns
Excision and grafting
as soon as clearly non-healing
39

40. Early excision of burns
Tangential excision to viable tissue on day 3-5
Janzekovic (1970)
Jackson & Stone (1972)
40

41. Tangential burn excision
and split skin grafting
41

42. Excision to fascia
42

43. Early burn surgery
Superior outcomes where suitably equipped

mortality

length of hospital stay

morbidity during acute burn

scar quality
43

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. 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. Scar management
The potential problem
46

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. Scar management
Splintage
48

49. Pressure garments
Almost universally used
Apparently effective
Many published observations
49

50. Pressure garments
Aids to compliance
50

51. Conformers and splints
51

52. Silicone gel
Mechanism not fully known - not pressure
52