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

Stuart Watson Pic.jpg

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

  1. 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

  2. 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

  3. 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

  1. Children:

    • >2% burns of any depth

      • vulnerable to infection more than adults

    • any suspicion of NAI

  2. 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

  1. 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

  2. Commonest problem that could be improved: Avoid Hypothermia

    1. clean wound with warm saline

    2. wrap in cling film (not too tight)

    3. cover with big sterile towels

    4. use a warming blanket and actively warm

    5. Prehospital cooling for larger burns - brief cooling, cling-film then emergency transfer

      • deeper burns = damage often done and cooling has less impact

  3. Airway management in major burns

    1. overall airway management is excellent

    2. possibly slightly-overintubate but still safest method for transfer

    3. superficial facial burns may not require intubation - maybe wait 30minutes and thoughtfully consider need with an anaesthetist

  4. Inhalational Burns

    1. no evidence base for any specific treatment for airway burns

    2. popular to do early broncho-pulmonary lavage with buffered solution to remove acrnoaceous material which is damaging for alveoli

    3. persistent acidosis could receive hydroxycobalamin for potential cyanide poisoning (synthetic furniture)

    4. modern ventilation techniques (high-frequency ventilation and proning) have improved outcomes

  5. Fluid resuscitation

    1. Give an appropriate amount quickly (a good starting point for patient)

      1. 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

      2. 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

      3. Add maintenance fluids for children but not for adults (use NG feeding instead)

      4. ongoing fluid requirements:

        • Adults 0.5-1ml/kg/hr

        • Children 1-1.5ml/kg/hr

  6. Milk - VERY KEEN ON IT

    1. Major burn patient with delayed transfer - makes a material difference to outcome if commence early feeding

    2. After the 'dust has settled' - safe analgesia, IV access, cleaning and dressing

      • within 1-2 hours from presentation

      • milk from the fridge is fine

  7. Mortality prediction = use the baux score

  8. Major Burns Patients - 'typical journey'

    1. 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)

    2. Over a few weeks they heal up with their own skin

    3. 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)

    4. Takes about 4-8 weeks of ICU and frequent surgery to get better

    5. Non-Survivors:

      • typically older patients, this with addiction issues or comorbidities

      • sometimes younger patients due to overwhelming sepsis (open wounds)

    6. 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)

  9. ESCHAROTOMY - probably not a necessary skill for ED folk

    1. if in a remoter community (and unable to transfer) could talk a surgeon throughout it (6-12 hours)

    2. can be significant problems with bleeding and creates significant open wounds so best done in theatre

 

EXTRAS

  1. When to take to theatre:

    1. Electrical burns - as soon as possible to remove dead muscle and revascularise if needed

    2. Full thickness (life-threatening) - 24-48 hours to remove as much dead skin as possinle

      • after they are reasonably stable

    3. Full thickness (skin-grafting for function or healing) - within 5 days

    4. 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)


Links

 

 

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