Episode 22: Burns Part 2
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Stuart Watson
19/09/18
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Guest Bios
Stuart Watson
Mr Stuart Watson is a Consultant Burns and Plastic Surgeon at the Canniesburn Unit in Glasgow Royal Infirmary, as well as a Director of ReSurge Africa. He is also one of the european representatives on the Executive Committee of the International Society for Burn Injuries (ISBI) and a member of the steering group of the ISBI developing international guidelines for care of burn injuries.
Show Notes
Eoghan and Stuart discuss the management of burn injuries including pre-hospital care, emergency management and follow-up. In this episode they cover some special circumstances as well as the management of major burns - airway management, temperature control, fluids, milk, surgery and a whole lot more...
Take Home Points
SPECIAL CIRCUMSTANCES
Electrical burns
high voltage burns (>1000volts)
follow ATLS principles and look for other injuries (cervical, limb, chest, abdominal, pelvis etc)
cardiac arrhythmia from direct cardiac injury
monitor
risk of muscle damage from direct injury or secondarily via compartment syndrome
this releases myoglobin that can poison the kidneys
to prevent = fluid load with sodium chloride (avoid k+ which is released from muscle cells)
aim for a high urine output
otherwise use hartmann's for all other scenarios
monitor for signs of compartment syndrome and decompress if required
Chemical burns
irrigate for an hour or so then refer
hydrofluoric acid requires specialist advice
can case hypokalaemia and hypomagnasaemia
a beneficial treatment is topical calcium gluconate
Alkali burns are often underrated in terms of severity
cause a liquefactive necrosis allowing the burning agent to penetrate deeper
more prolonged irriagtion may be required (for hours)
WHEN TO REFER
Children:
>2% burns of any depth
vulnerable to infection more than adults
any suspicion of NAI
Adults:
all full thickness burns
burns that compromise:
life
e.g. airway involvement, electrical burns
aesthetic outcome
large/deeper burns, face
function
hands, circumferential, overlying joints, eyes
or a higher risk of infection
buttocks, perineum, feet
MAJOR BURNS
Get a sense of whether it is more complex than the skin injury is telling you
talk to them and paramedics
were they conscious when it happened?
was it an enclosed space with flames?
risk of inhalation injury/hypoxia/other physical injury
Commonest problem that could be improved: Avoid Hypothermia
clean wound with warm saline
wrap in cling film (not too tight)
cover with big sterile towels
use a warming blanket and actively warm
Prehospital cooling for larger burns - brief cooling, cling-film then emergency transfer
deeper burns = damage often done and cooling has less impact
Airway management in major burns
overall airway management is excellent
possibly slightly-overintubate but still safest method for transfer
superficial facial burns may not require intubation - maybe wait 30minutes and thoughtfully consider need with an anaesthetist
Inhalational Burns
no evidence base for any specific treatment for airway burns
popular to do early broncho-pulmonary lavage with buffered solution to remove acrnoaceous material which is damaging for alveoli
persistent acidosis could receive hydroxycobalamin for potential cyanide poisoning (synthetic furniture)
modern ventilation techniques (high-frequency ventilation and proning) have improved outcomes
Fluid resuscitation
Give an appropriate amount quickly (a good starting point for patient)
you could ignore the parkland formula initially and give a decent volume
1-2Litres of fluid in an adult (hartman's)
20% blood volume as hartmans
Then calculate the parkland formulas around this
use parkland formulas carefully
too much fluid can lead to problems (pulmonary oedema, abdominal compartment syndrome) - over-resuscitation can be as deleterious as under-resusctitating with fluids
Add maintenance fluids for children but not for adults (use NG feeding instead)
ongoing fluid requirements:
Adults 0.5-1ml/kg/hr
Children 1-1.5ml/kg/hr
Milk - VERY KEEN ON IT
Major burn patient with delayed transfer - makes a material difference to outcome if commence early feeding
After the 'dust has settled' - safe analgesia, IV access, cleaning and dressing
within 1-2 hours from presentation
milk from the fridge is fine
Mortality prediction = use the baux score
Major Burns Patients - 'typical journey'
Take to theatre within 24-36 hours to remove as much dead skin as possible
replace with donated skin or synthetic dermis (bovine collagen product)
Over a few weeks they heal up with their own skin
common ICU problems in this time:
Often multiple episodes of infection, high levels of inotropes, respiratory distress
problems with guts (XS fluid affecting gut function)
Takes about 4-8 weeks of ICU and frequent surgery to get better
Non-Survivors:
typically older patients, this with addiction issues or comorbidities
sometimes younger patients due to overwhelming sepsis (open wounds)
After 2 months they can often go home with close contact and treatment for scars
often off work for 6-24 months (sometimes forever)
often require psychological support
after 1-2 years they may need further surgery for scars (some need every year for 20+years)
ESCHAROTOMY - probably not a necessary skill for ED folk
if in a remoter community (and unable to transfer) could talk a surgeon throughout it (6-12 hours)
can be significant problems with bleeding and creates significant open wounds so best done in theatre
EXTRAS
When to take to theatre:
Electrical burns - as soon as possible to remove dead muscle and revascularise if needed
Full thickness (life-threatening) - 24-48 hours to remove as much dead skin as possinle
after they are reasonably stable
Full thickness (skin-grafting for function or healing) - within 5 days
Children with deep partial scalds - around 10 days
still time to heal before 3 weeks (and avoid thick scarring)
not earlier if doubtful about the depth
CAREER ADVICE
Learn from the people in the multidisciplinary team including the nurses
the more junior you are often the less tolerant you are of other health professionals
be more thoughtful learning from them and others (they have a lot of experience)
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