Burns

Sept 2015
East of England CT3 Days
 Burns - aims
♦ Skin
♦ Types of burns
♦ Management
♦ Burns
♦ Associated bits
♦ Tips for children
 What difference does skin make?
♦ Function of skin
♦ Thermoregulation
♦ Fluid conservation
♦ Protection
♦ Immune
♦ Physical
♦ Flexibility / movement
Skin thickness

Superficial
Partial
Thickness

Full
.
.
.
 What is a burn?

♦ Burn
♦ Scald
♦ Chemical
♦ Electrical
♦ Inhalation

♦ Other injuries

♦ Tetanus
Superficial –
erythema (sunburn)

Partial thickness –
Pink
Blistered
White - sensate

Full thickness –
Charred
Waxy white
Insensate
 Treatment (First Aid)
A Airway
B Ventilation
C Fluid replacement
D
E

Special considerations
 Airway & Breathing
Confinement with fire Loss of hair &
eyebrows
COHb

Singed nasal hairs

Soot stained nose /

lips
Mucosal erythema
Blistered lips

Circumferential Hoarse voice /

neck burns stridor
 Carbon Monoxide
♦ Unexplained obtundation
♦ “Cherry Red Lips”
♦ Toxicity
♦ Varies
♦ >10% indicates toxicity
♦ Chronis vs Acute
♦ ?HBO

♦ Cyanide?
 C - Fluid loss
♦ Replace fluid loss from time of injury
♦ Adults and children
♦ Hartman’s solution

♦ Equation...
♦ BSA
♦ Parkland formula…
♦ Maintenance fluids
♦ Shock
♦ >15% (Adult)
♦ >10% (Child)

♦ Resuscitation

♦ Maintenance
 Parkland formula
4ml / kg / %burn over 24hrs…
=
2 ml x kg x %burn over 8hrs
+
2ml x kg x %burn over 16hrs

Add in maintenance fluids

4ml / kg / hr for first 10kg
2 ml / kg / hr for next 10 kg
1 ml / kg / hr for rest of weight
 Example
♦ 10kg child with 8% burns

♦ 60ml / hr for 8 hrs

= 20ml / hr plus 40 ml/hr maintenance
♦ 50ml / hr for 16 hrs
= 10ml / hr plus 40 ml/hr maintenance

♦ Clinical parameters
 Treatment (First Aid)
A Airway Simultaneously

B Ventilation ♦ Stop the burn /

C Fluid replacement constriction
♦ Pain management
D Other injuries
♦ Dressings...
E Exposure ♦ Tetanus??

♦ Safeguarding
 Analgesia
♦ Assessment and reassessment
♦ Pain ladder…

♦ Opiates
♦ Intra-nasal diamorphine
♦ Intravenous morphine
♦ Oramorph?
♦ Oral analgesia
♦ Non-drug methods
 Debridement?
♦ Deroofing
♦ Smaller than patient’s little fingernail
♦ Aseptic technique: Forceps & scissors
♦ Clean with dilute chlorhexidine
♦ Dressing

♦ Why
♦ Decreases infection
♦ Analgesia
♦ Fluid lost in a controlled way
Dressings?
 Special Considerations
♦ Joints
♦ Circumferential burns
♦ Hands / Feet / Perineum / Face

♦ Other Injuries
♦ Inhalation of CO / CN
♦ Cyanokit
♦ HBO?
 Follow-Up
♦ “Major Burns” – Referral to 3° centre
♦ “Consider” if >1% partial thickness
♦ Special considerations
♦ Minor Burns
♦ By local arrangement
♦ Less than 10% BSA
♦ Demarcation / Healing
♦ Late referral
♦ Not healing (> 2 weeks)
♦ Depth
♦ Unwell
Referral criteria
Fluid
management
Useful
telephone
numbers

Referral criteria –
unwell patients

Sepsis /
TSS
 Tetanus
♦ Tet Tox
♦ Basic course
♦ Boosters
♦ Exceptions

♦ Tetanus prone wounds

♦ Immunoglobulin
Immunisation Clean Wound
status Tetanus Prone Wound (see definition below)
Vaccine Vaccine Human tetanus immunoglobulin (TIG) Alternative normal
immunoglobulin product if
TIG
is unavailable
Fully immunised i.e. None required None required Only if high risk (heavy contamination with Normal immunoglobulin
has received a total of material likely to contain tetanus spores and/or Subgam ® brand only, 1.5g IM
5 doses of tetanus extensive devitalised tissue) given at a minimum of two
vaccine at appropriate 500 units (2ml) TIG IM separate sites.
intervals
Primary immunisation None required None required Only if high risk Normal Immunoglobulin
complete, boosters (unless next dose (unless next dose (heavy contamination with material likely to Subgam ® brand only, 1.5g IM
incomplete but up to due soon and due soon and contain tetanus spores and/or extensive given at a minimum of two
date convenient to give convenient to give devitalised tissue) separate sites.
now) now) 500 units (2ml) TIG IM
Primary immunisation A reinforcing dose A reinforcing dose Yes: one dose TIG at a different site. Normal immunoglobulin
incomplete or of vaccine and of vaccine and 250 units (1ml) IM if < 24 hours since injury, Subgam ® brand only 750mg
boosters not up to further doses as further doses as not heavy contamination and not following a IM
date required to required to burn or
complete the complete the or Normal Immunoglobulin
recommended recommended 500 units (2ml) IM if >24 hours since injury or Subgam ® brand only, 1.5g IM
schedule (to schedule (to risk of heavy contamination or following burns given at a minimum of two
ensure future ensure future separate sites
immunity) immunity)
Not immunised or An immediate An immediate Yes: one dose of TIG at a different site. Normal immunoglobulin
immunisation status dose of vaccine dose of vaccine 250 units (1ml) IM if < 24 hours since injury, Subgam ® brand 750mg IM
not known or followed, if records followed, if records not heavy contamination and not following a or
uncertain confirm this is confirm this is burn Normal immunoglobulin
needed, by needed, by or Subgam ® brand only, 1.5g IM
completion of a full completion of a full 500 units (2ml) IM if >24 hours since injury or given at a minimum of two
5 dose course to 5 dose course to risk of heavy contamination or following burns separate sites
ensure future ensure future
immunity immunity
 Sepsis
♦ Toxic Shock
♦ Staph aureus or strep pyogenes
♦ Temperature>38°C
♦ Rash
♦ D&V
♦ Unwell

♦ What are the subtle signs?

♦ Poor appetite
♦ Listless
♦ “just not right”
 Safeguarding
♦ Red flags
♦ Multiple ages / delay to presentation
♦ Changing or bizarre history
♦ Child’s history
♦ Multiple presentations
♦ Parental “pathology”
♦ Interaction
♦ Register
 Safeguarding

♦ Patterns of injury
♦ Clear imprints
♦ Cig burns
♦ Dunking
♦ Depth inconsistent with history

♦ Who do you inform?

Questions?
Summary

Treat first, question later

ABC
Analgesia & fluids
Special considerations
Tetanus
Safeguarding

http://www.lsebn.nhs.uk/