Burns

 

Burns and Scalds kill>800people per year in the U.K.

Those under 3 years and the elderly most at risk e.g. dip burns, tip over scalds

 

Types of burns

Thermal, electrical, chemicals, radiation, cold

Factors - temperature, exposure time, conduction of heat into tissues

Scalds - hot water, steam,

 

Prevention††

Fire guards††††††††††††††††††††††††††††††††††††††††††††††††††† Flame proof clothes (especially children)

Supervision of children††††††††††††††††††††††††††††† Care with hot fluids

Avoid trailing flex - use coiled flexes††††††† Cold water into bath first

Smoke detectors

 

Assessment

 

Criteria for in-patient care

> 5%†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Full thickness >10-15 cm2

Deep burns over joints/flexor surfaces††††††††††††††† Facial involvement

Suspicion of inhalation smoke/vapours††††††††††††† Electrical or chemical burns

Social context, e.g. elderly living alone, NAI†††††† Small burns can be serious if not properly managed

 

History

Degree of inhalation

Effects may be delayed by several hours

 

Electrical burns

Check ECG†††††††††††††† Check for an exit wound††††††††††††††† Deeper tissues may be involved

 

Chemical burns

Necrotising agents may be absorbed into tissues†††††††† Identify agent and effects

Identify any specific antidotes

†††††††††††††††††††††††††††††††††††

Airway burns

Suggested by; hoarseness, stridor, dysphagia, facial and mouth burns, singeing of nasal hair, soot in mouth or nose

 

Associated injuries

Bony and spinal injuries may occur as a result of blasts or jumps to escape from a fire

 

Surface area involved - Rule of 9 for adults

front torso††††† =††††††††† back torso†††† =††††††††† arm†††††††††††††††† =††††††††† leg †††††††††††††††† =

head†††††††††††††† =††††††††† groin†††††††††††††† =††††††††† palm of hand††††††††††† =

 

Record patients weight

 

Factors effecting mortality

Prior disease and pre-existing condition†††††††††††† Inhalation burn increase mortality

% of body surface burnt

 

Local effects

In order of increasing severity

 

1. ††††††† Capillary dilation - redness - fluid loss from capillaries - rise in interstitial pressure - stimulation of pain receptors

2. ††††††† Fluid loss - blistering - death of epidermis involved

††††††††††† Regeneration from adjacent epithelium

3.†††††††† Destruction of epidermis and upper part of dermis

Regeneration takes place from epidermal elements in hair follicles and glands

††††††††††† healing usually takes 10 - 14 days

4.†††††††† Destruction of the dermis only leaving epithelial elements in some deep glands and ††††† follicles in the adipose layer

††††††††††† Re-epithelialise slowly leaving poor thin skin

5.†††††††† Destruction of all skin elements and underlying tissue

††††††††††† Will not heal without surgical intervention

 

Classification

From sensation tests and history

Describe the % involvement for the different classifications

 

Superficial (1st degree)

Relatively minor erythema ††††††††††††††††††††††† Loss of part of epidermis only

May be extremely painful due to damaged or exposed nociceptors

Healing is spontaneous

 

Partial thickness (2nd degree)

Loss of part of the dermis†††††††††††††† Deeper skin structures remain

Healing may be slowish†††††††††††††††† May heal with or without a scar

 

Full thickness (3rd degree)

Loss of full dermal thickness†††††††† Possible loss of deeper structures

Not painful††††††††††††††††††††††††††††††††††††††† Do not blister

Heal only by grafting

 

Systemic effects

 

Shock

Fluid loss ----- hypovolaemia ----- shock ----- complications of shock

 

Hypovolaemia ----- constriction of peripheral vessels

†††††††††††††††††††††††††††††††††††

Pulse- compensatory tachycardia, fast weak thready

BP†††††† - starts to fall as tachycardia fails to compensate

 

Poor tissue perfusion -----renal hypoperfusion ------- failure

Acidosis, changes in acid base balance

 

Protein loss in exudate------- osmotic changes in plasma

 

Thirst

 

Hypoxia

COHb†††††††††††† ABGs††††††††††††† Constriction from chest burns ††††† Airway swelling

Give high concentrations of oxygen

 

Infection

Further local tissue loss and pain††††††††††††††††††††††† Spread of infection to healthy tissues

Bacteraemia --- septicaemia --- shock †††† Scarring

†††††††††††

Pain

May require iv. opiates and antiemetics

 

Gastrointestinal changes

Increased sympathetic activity ------ reduced peristalsis ------ possible ileus

Gastric mucosal ischaemic ------ peptic ulceration------occult blood

haemorrhageand haematemesis

 

Metabolic changes

Cellular breakdown ††††††††††† ----- increased K+

 

Inhalation problems

Carbon Monoxide poisoning - Carboxyhaemoglobin

Small volumes of soot particles are filtered larger amounts may enter lungs

Superheating may burn nasal mucosa and lower tissues in the respiratory tract

Pulmonary oedema

Upper airway obstruction may occur up to 48 hours after the burn, due to pharyngeal and laryngeal oedema.

Neck oedema may cause tracheal compression.

Tourniquet effect on breathing from chest burns.

Burning Plastic - toxic fumes eg. Hydrogen cyanide, Hydrochloric acid, Sulphuric acid

 

First aid

 

ABC

Remove the heat from the hot tissue to prevent ongoing necrosis

 

Cold water

Removes heat so limits tissue damage†††††††††††††† Eases pain

Removes caustic agents††††††††††††††††††††††††††††††††††††††† Usually 20 minutes in more extensive burns

 

Flame burn

Put out flame††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Remove from smoke

Do not remove adherent burnt clothes††††††††††††††† Dousing with cold water

 

 

Chemical burn

Eyes††††† †††††††† ††††††††††† - irrigate with water

Cement and lime†† -use large volumes of water

Use specific antidotes if known, indicated and available

 

Scalds††††††††††

Remove clothing wet with hot water or steam

Apply cold water for 10 - 15 minutes to prevent tissue necrosis and limit pain

 

Electrical burns

Remove patient from current, without electrocuting yourself.

Check for cardiac and respiratory function - CPR if indicated

Ensure power is off before application of water

Wrap in towel or sheet which has been soaked in cold water.

Irrigate for a long time

 

First aid dressings

Water††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Wet compresses for transportation

Wet towels (Sterile if possible)††††††††††††††††† Non-adherent dressings

Do not use antiseptics or antibiotics††††††† Do not apply, butter, honey, flour, etc.

Cling film or polythene bags as a temporary first aid dressings after use of water, may also be used to may be used to retain a compress

 

Systemic management

 

Fluid replacement

Oral replacements; in adults for > 10%††††††††††††††† in children for > 15%

 

If greater areas involved IVT is essential

 

Parkland Formula - Fluid replacement in first 24 hours = 4mls x weight (in Kg) x % burn area

 

Half of the volume should be given in the first 8 hours and the rest over the following 16 hours. To this add 3 litres per day for other losses.

Start from time of injury

Ringerís lactate (Hartmannís) is the crystalloid of choice for the first 24 hours. They cause less pulmonary oedema than colloids.

Colloids usually used after the first 24 hours

Formulas are only a starting point

Further titration based on Urine output, blood tests, patient response and CVP

Full fluid balance recording Ė catheterise if necessary

 

Other systemic management

Analgesia††††††††††††††††††††††††††††††††††††††††††††††††††††† Tetanus toxoide

Possible systemic antibiotics†††††††††††††††††††† Wound dressing

NBM until ileus has been assessed††††††† H2 blockers

 

Ongoing management/rehabilitation

Monitor weight

Diet - burns induce a hypercatabolic state - when able ample protein and carbohydrate with possible supplementation

Aid with alteration in body image

Involve family

 

Physiotherapy

Prevent contractures†††††††††††††††††††††† Complications of immobility

Minimise muscle wasting†††††††††††††† Occupational therapy

 

Local management options

 

Surgery

Contracture release†††††††††††††††††††††††††††††††††††† Scar revision

 

Exposed(open)

For areas difficult to dress eg. face†††††††††† Nurse in a single room

 

Semi-open†††††††††††††††

Covered with a topical agent and gauze

 

Closed

Paraffin gauze or Flamazine very well covered with dressing

Changed24 or 48 hourly

 

Superficial

Hydrocolloids, films, chlorhexidine, aqueous povidine iodine

 

Full thickness

Silver sulphadiazine

 

Hands

Plastic or PTFE bags to allow movement and physiotherapy

 

Prevent infection

Isolation†††††††††††††††††††††††††††††††† Strict asepsis††††††††††††††††††††††††††††††††††† Debridement as required

Culture and sensitivity††††††† Topical antibiotics††††††††††††††† Topical antiseptics †††††††††††††††††††††††††

Skin grafting

 

Other complications

Bronchopneumonia - smoke or heat damage to lungs

Renal failure†††††††††††† DVT and other complications of immobility

Stress diabetes†††††††† Psychological stress effects

 

Management principles

Prevent shock and hypoxia†††††††††††††††††††††††††††††††††† Limit tissue damage

Prevent infection - burns are easily infected †††† Stretch areas over joints, or leave mobile

Promote healing††††††††††††††††††††††††††††††††††††††††††††††††††††† Loss of normal functions of the skin

 

 

 

 

 

 

Questions

 

1.A burn involving all of the left arm in an adult female would represent damage to approximately what percentage of the skin surface?

a.4.5%††††††††††††††††††††† b.9%†††††††††††† c.18%†††††††††† d.22%

 

2. The palm of the hand approximates to what percentage of the skin surface?

a.1%†††††††††††††††††††††††† b.2%†††††††††††† c.3%†††††††††††† d.4%

 

3.The usual mortality rate in the U.K. from burns is in the order of,

a.100†† deaths per year†††††††††††††††† b.400†† deaths per year †††

c.800†† deaths per year††††††††††††††††† d.1000 deaths per year

 

4.A partial thickness burn is one in which,

a.Only part of the epidermis is burnt††††† b.All of the epidermis and part of the dermis is burnt

c.All of the dermis is burnt††††††††††††††††††††††† d.Part of the subcutaneous tissue is burnt

 

5.Which of the following statements are true?

a.A full thickness burn will be more painful than a partial thickness burn

b.A partial thickness burn will be more painful than a superficial burn

c.A superficial burn may be more painful than a full thickness burn

d.Many burns are so painful they require opiates in hospital to control the pain

 

6.A child tips a hot cup of tea over his arm.Which of the following actions would you carry out immediately?

a.      Wrap the arm in damp towels

b.      Apply a thick layer of butter or other fatty material to the arm

c.      Immerse the arm in cold water ††††††††††† d.Immerse the arm in tepid water

 

7.A mechanic splashes some battery acid in his eye.Which of the following should be carried out first?

a.Neutralise the acid with an irrigation of water and baking soda

b.Place a firm pad over the eye and take the mechanic to hospital

c.Encourage tear production by stimulation of the cornea

d.Irrigate the eye under running water

 

 

Why would you want to know the following?

If the patient had been burnt in an explosion

If the fire and patient had been in an enclosed space

The nature of the burning material

 

Why would the following assessments be carried out?

Pulse

BP

Surface area burns

Assessment of burn depth

 

What are the possible causes of shock after burns

 

What factors may contribute to hypoxia after a burn

 

What factors may contribute to the development of renal failure

 

How would you treat blisters

 

What classification of burn causes blisters