Burns result from damage to skin & deeper tissues caused by external sources or substances.
Burns are a major cause of injury and death worldwide. They can have devastating physical and psychological effects on an individual, that can lead to chronic disability. They may be caused by thermal, chemical, frictional or electrical injury.
Mortality is increased with large burns, with increasing age and with associated inhalational injury. Effective management necessitates a multi-disciplinary approach.
Most burns are thermal injures due to scalds, contact & flame burns.
Burns may be thermal, chemical, frictional or electrical. Thermal injuries are the most common and include scalds, contact and flame burns.
A common form of trauma, in both adults & children, the likeliest place to be burnt is the home.
In the UK, approximately 250,000 burns occur each year. Of these, roughly 10% (25,000) require hospitalisation and around 1% (2,500) are life-threatening, with roughly 300 deaths. The UK incidence is fairly representative of the developed world.
Burns are common in both children and adults, although different types of burn are prevalent in each group. The likeliest place to be burnt is in the home.
Burns are also a substantial problem in the developing world. Sadly, mortality in these countries is typically much higher.
Jackson's burn wound model is a model for understanding the local response of burns wounds.
Three zones of a burn wound were described by Jackson in 1947:
In a burn that covers >25-30% of total body surface area (TBSA), widespread release of inflammatory mediators results systemic effects.
In large burns, cytokines and inflammatory mediators result in a number of systemic effects:
TBSA and depth of injury are vital in the initial assessment of a burn wound.
Three common methods of estimating burn surface area
Wallace 'Rule of Nines' for adults and children
Estimation of burn depth is difficult. Furthermore, the depth of a burn may transition over the first 3-5 days.
The depth is relative to the energy of the burn and the thickness of the skin. Burns are graded according to increasing depth (epidermal, superficial dermal, mid-dermal, deep-dermal, and full-thickness).
Burn wounds are assessed clinically using the following:
In clinical practice, most burns are a mixture of different depths. Burn wounds are also dynamic and reassessment should be performed following resuscitation.
Acute severe burns are managed using a modified advanced trauma and life support (ATLS) algorithm.
This consists of three elements:
Priority is to ensure the airway is patent and cervical-spine protected.
Although the airway may be patent on arrival, this may change, especially with the initiation of fluid resuscitation.
Inhalational injury may occur from the inhalation of hot gases or products of combustion resulting in oedema above the level of the vocal cords or direct injury to the respiratory tract. It is particularly associated with burns to the head and neck or burns sustained in an enclosed space (e.g. house fire).
Indications for intubation include:
Essentially, if in doubt intubate.
Expose chest and assess breathing.
100% humidified oxygen should be administered via a non-rebreathe mask.
Breathing may be compromised by:
An escharotomy is an emergency procedure to incise burnt tissue in circumferential or near-circumferential deep-dermal or full-thickness burns in order to improve respiration and / or circulation to a limb.
Check pulses and obtain intravenous (IV) access.
Bloods should be taken and IV fluid resuscitation initiated.
Limbs should be assessed to ensure they are adequately perfused. Circumferential or near-circumferential burns can severely restrict blood supply; with devitalised tissue acting as a tourniquet. Again, If this is suspected, immediate escharotomy is indicated.
Assess patient’s consciousness with either AVPU or GCS, examine pupils and check blood glucose level.
Assess patient’s consciousness with either AVPU (alert, responsive to voice, pain or unresponsive) or using the Glasgow Coma Scale (GCS). Ensure pupils are equal and reactive, and check blood glucose level.
Beware that hypoxaemia and shock can cause restlessness and reduced GCS.
Fully expose the patient and examine head-to-toe.
Remove all jewellery, piercings and watches. Log roll the patient to examine the posterior surfaces. Assess burns and look for other injuries. Remember - patients with large burns lose heat rapidly, so cover and warm the patient as soon as the assessment is completed.
IV fluid resuscitation should be started in adult burns > 15% TBSA.
Patient’s should be resuscitated according to Parkland’s formula. Parkland’s formula takes into account the patients weight (Kg) and TBSA (%). Half of the total fluid calculated should be given in the first eight hours following the burn. The second half should be given in the subsequent 16 hours.
Remember - fluids should be calculated starting from the time the burn occurred and should take into account any fluid given enroute to hospital. For example, if presentation is delayed by three hours post burn, half the total amount is given over the remaining five hours.
The recommended fluid is Hartmann’s Solution.
IV fluid resuscitation should be started in paediatric burns > 10% TBSA.
For children <30Kg, maintenance fluids need to be added. The recommended maintenance fluid is 5% glucose in 0.45% sodium chloride. Although some NHS trusts, particularly in Scotland, use human albumin solution (HAS). Maintenance fluid is given at a constant rate over 24 hours.
There are no level I or II publications to guide the choice of resuscitation fluid in either adults or children.
Burns can be extremely painful. Appropriate analgaesia is paramount.
IV morphine (at a weight adjusted dose) should be administered to all patients with large burns and titrated against pain and respiratory depression. In children, intra-nasal diamorphine is also commonly used.
Investigations can be organised into bedside, bloods, imaging and special tests.
An NG tube & urinary catheter should be placed in large burns (>20% TBSA in adults; >15% TBSA in children).
NG / NJ tube
Large burns have systemic effects, including immunosuppression and loss of normal gut barrier function. Gastric ileus is a potential complication and the stomach should be decompressed with the insertion of a nasogastric (NG) or nasojejunal (NJ) tube. Patients should be kept nil by mouth (NBM).
A Foley catheter should be placed to measure urine output.
Look for other injuries that may have been missed on the primary survey.
Burn sites are specifically susceptible to tetanus infection. Tetanus prophylaxis should be administered.
Documentation should be meticulous and clinical photography should be performed. Photographs provide an objective description of the burn injuries at the time of admission.
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