Burn- Emergency Management

HIRA ASHRAF
RESIDENT EMERGENCY MEDICINE
Burns are soft-tissue injuries created by destructive energy transfer via radiation, thermal, or electrical
energy
Skin Anatomy and Function
• Epidermis
Outermost layer

• Dermis
Below epidermis
Vascular and nerves
Thickness
1-4mm (varies)

• Subcutaneous tissue
Hair follicles
Assessing the area of a burn
The patient’s whole hand is 1 per cent TBSA, and is a useful
guide in small burns
• The Lund and Browder chart is useful in larger burns

• The rule of nines is adequate for a first approximation only

Rule of nine
Lund and Browder
Assessing the depth of a burn
Depth of burn
American Burn Association Burn Classification
Immediate management
•Prehospital
Prehospital carecare
• Ensure rescuer safety

• Stop the burning process.

• Check for other injuries.

• Cool the burn wound

• Give oxygen if available

• Elevate.

• Transfer
Immediate management
Hospital care

• A, Airway control

• B, Breathing and ventilation

• C, Circulation

• D, Disability – neurological status

• E, Exposure with environmental control

• F, Fluid resuscitation.
Airway
Hospital care
• Reevaluation of airway
• Early elective intubation for any sign of breathing difficulty, airway burn,
swelling, or suspected inhalation injury
• Delay can make intubation very difficult because of swelling
• Be ready to perform an emergency cricothyroidotomy, if intubation is
delayed
Inhalational injury
• A history of being trapped in the presence of smoke or hot gases
• Burns on the palate or nasal mucosa, or loss of all the hairs in the nose
• Deep burns around the mouth and neck
• Toxic inhalants are divided into three large groups: tissue asphyxiants, pulmonary irritants,
and systemic toxins
• The two major tissue asphyxiants are carbon monoxide and hydrogen cyanide
 Breathing
Inhalational burn Metabolic poisoning Mechanical blocking

• Time is also a factor • History • Examination.

• Clinical features progressive increase in • Blood gases • Carbon dioxide retention

respiratory effort and rate rising pulse,
anxiety and confusion and decreasing
oxygen saturation

• can take 24 hours to 5 days to develop • treatment is oxygen • Treatment is (escharotomy).

• Physiotherapy, nebulizers and warm

humidified oxygen are all useful.
Circulation
• Fluid resuscitation with Establishment of two large-bore peripheral IV lines in unburned skin

• In children with burns over 10 per cent TBSA and adults with burns over 15 per cent TBSA,
consider the need for intravenous fluid resuscitation
• Cardiac monitoring

• Fluids needed can be calculated from a standard formula

• The key is to monitor urine output

Parklands formula
Crystalloid resuscitation
Crystalloids
Ringer’s lactate is the most commonly used crystalloid

In children, maintenance fluid must also be given. This is

normally dextrose–saline given as follows:
• 100 mL/kg for 24 hours for the first 10 kg;
• 50 mL/kg for the next 10 kg;
• 20 mL/kg for 24 hours for each kilogram over 20 kg body
weigh
Hypertonic saline
• Hypertonic saline has been effective in treating burns shock for many years.

• It produces hyperosmolarity and hypernatraemia. This reduces the shift of intracellular

water to the extracellular space.
• Advantages include less tissue edema and a resultant decrease in escharotomies and
intubations
 Colloid resuscitation
Human albumin solution (HAS) is a commonly used colloid
Proteins should be given after the first 12 hours of burn because, before this
time, the massive fluid shifts cause proteins to leak out of the cells
The most common colloid-based formula is the Muir and
Barclay formula:
• 0.5 × percentage body surface area burnt × weight = one
portion;
• periods of 4/4/4, 6/6 and 12 hours, respectively;
• one portion to be given in each period.
Adjuncts
• Placement of Foley catheter
• Insertion of nasogastric tube
• Administration of tetanus booster
• Assessment for other trauma using Advanced Trauma Life Support guidelines
• Pain control
• CBC, BUN, creatinine, electrolytes, glucose level
• ABGS
• Urine analysis
• Chest radiographs
• ECG
TREATING THE BURN WOUND
Initially, wounds are best covered with a clean, dry sheet
small burns can be covered with a moist saline-soaked dressing
For large burns, sterile drapes are preferred, because application of saline-soaked dressings to a
large area can cause hypothermia.
Escharotomy
Circumferential full-thickness burns to the limbs require emergency surgery. The tourniquet
effect of this injury is easily treated by incising the whole length of full-thickness burns. This
should be done in the mid-axial line, avoiding major Nerves
Key features of escharotomy placement.
Upper limb Mid-axial, anterior to the elbow to avoid the ulnar nerve
Hand Midline in the digits. Release muscle compartments if tight. Best done in theatre
and with an experienced surgeon
Lower limb Mid-axial. Posterior to the ankle to avoid the saphenous vein
chest Down the chest lateral to the nipples, across the chest below the clavicle and across
the chest at the level of the xiphisternum
General rules Extend the wound beyond the deep burn
Diathermy any significant bleeding vessels
Apply haemostatic dressing and elevate the limb postoperatively
Escharotomy
ED care of minor burns
NON-THERMAL BURN INJURY
• Electrical burns
• Low-voltage injuries cause small, localised, deep burns
• They can cause cardiac arrest through pacing interruption without significant direct
myocardial damage
• High-voltage injuries damage by flash (external burn) and conduction (internal burn)
• Myocardium may be directly damaged without pacing interruption
• Limbs may need fasciotomies or amputation
• Look for and treat acidosis and myoglobinuria
Chemical injuries
• Damage is from corrosion and poisoning
• Copious lavage with water helps in most cases
• Then identify the chemical and assess the risks of absorption
Ionizing radiation injury
Local burns causing ulceration need excision and vascularized flap cover, usually with free flaps

Systemic overdose needs supportive treatment

Thankyou