burns%20-%20initial%20management
BURNS - INITIAL MANAGEMENT
Thermal burns are burns due to external heat sources that raises skin and tissue temperature causing tissue cell death or charring. Flame is the most common type of burn. Inhalation injury is found in 30% of victims of major flame burns.
Chemical burns are due to strong acids, alkalis, detergents or solvents coming into contact with the skin. Tissues are damaged by protein coagulation or liquefaction rather than hyperthermic activity.
Electrical burns are due to electrical current or lightning coming in contact with the body.
First degree burns or superficial burns appears similar to sunburn that is painful, dry, swollen, erythematous without blisters and involves only the epidermis.
Second degree burns or partial-thickness burns has appearance of moist blebs, formation of vesicle and blister; underlying tissue is mottled pink and white with good capillary refill; this involves the entire epidermis and a variable portion of the dermal layer.
Third degree burns or full-thickness burns appears dry, leathery eschar, mixed white waxy, khaki, mahogany and soot stained. It involves the entire epidermis and dermis, leaving no residual epidermis cells, may include fat, subcutaneous tissue, fascia, muscle and bone.

Indications For Referral To A Burn Unit

  • Extremes of age (<5 or >60 years)
  • Site of injury
    • Face, hands or perineum
    • Feet (dermal or full thickness loss)
    • Any flexure, particularly the neck or axilla
    • Circumferential dermal or full thickness burn of limb, torso or neck
  • Inhalational injury – any substantial injury, including carbon dioxide poisoning
  •  Mechanism of injury
    •  Chemical injury >5% of the total body surface area (BSA)
    •  Exposure to ionising radiation
    •  High pressure steam injury
    •  High tension electrical injury
    •  Hydrofluoric acid burn >1% of total body surface area
    •  Suspicion of non-accidental injury
    •  Electrical burns (including lightning injury)
  •  Partial-thickness burns of  >10% total BSA
  •  Large size (dermal or full thickness loss)
    •  <16 year - >5% of total BSA
    •  >16 year - >10% of total BSA
  •  Coexisting conditions
    • Any serious medical condition
    • Any associated injuries
  •  Patients requiring social, emotional or rehabilitation intervention
  •  Refer all significant burn injuries to surgery for proper wound debridement
  •  Patients with worsening wounds within the past 72 hours, with wounds starting to produce scarring, & presence of any degree of contracture
  •  Burns with or without trauma at high risk for morbidity & mortality

Primary Survey & Management

  • Assess the airway, breathing, circulation, disability, exposure (ABCDE) of resuscitation

Airway

  • Assess whether airway is compromised or is at risk of compromise
    • Inhalation of hot gases will result in a burn above the vocal cords & the burn will become edematous over the next few hours, especially after fluid resuscitation has begun
    • In small children, the small airway diameter is vulnerable to any narrowing
  • Direct inspection of the oropharynx should be done by anesthesiologist
  • Intubate if there is concern about the patency of the airway, symptomatic inhalation injury, or any thermal injury to the face, mouth or oropharynx

Indication for Intubation

  • Erythema or swelling of the oropharynx on direct visualization
  • Change in voice, with hoarseness or harsh cough
  • Stridor, tachypnea or dyspnea
  • Burns >20-25% body surface area (BSA)
  • Pulmonary toilet

Breathing

  • Assess lung status by bilateral auscultation & respiratory rate & depth determination 
  • Breathing problems are those that affect the respiratory system below the vocal cords
  • The effect of circulating inflammatory mediators can reduce lung compliance in the absence of overt inhalational injury
  • All burn patients should receive 100% oxygen (O2) through a humidified non-rebreathing mask

Causes of Compromised Breathing

  • Mechanical restriction to breathing
    • Deep second-degree & third-degree circumferential burns of the chest can limit chest expansion & ventilation
    • May require escharotomy, refer for surgical consult
  • Blast injury
    • Penetrating blast injury may cause pneumothorax
    • The blast itself may cause lung contusions & alveolar trauma that may lead to acute respiratory distress syndrome (ARDS)
  • Smoke inhalation
    • The products of combustion act as irritants to the lungs which may cause bronchospasms, inflammation & increased sputum formation
    • The ciliary action of pneumocytes is impaired in inhalation injury, & atelectasis &/or pneumonia may follow
    • Non-invasive managements, such as nebulization & positive pressure ventilation with positive end-expiratory pressure, may be attempted
  • Carboxyhemoglobin
    • All patients with large burns &/or closed space burns should be assumed to have carbon monoxide (CO) poisoning until otherwise proven
    • Blood gas analysis may reveal metabolic acidosis & decreased partial pressure of oxygen in arterial blood (PaO2)
    • Delivery of 100% oxygen counteracts the effects of CO & enhances its clearance
    • Oxygen therapy should be continued until the metabolic acidosis is resolved

Circulation

  • Patients requiring intravenous (IV) resuscitation
    • Children with burns >10% BSA, those with 30% BSA burns or greater needs a central venous access
    • All inhalational injury for control of fluid intake
    • All high-tension & electrical injuries to ensure forced alkaline diuresis to prevent myoglobinuric renal failure
  • IV assessment should be established using large bore needles preferably on unburnt area
    •  Consider giving 20 mL/kg boluses of lactated Ringer’s solution or normal saline if there is inadequate pulse or child is hemodynamically compromised
  •  Parkland formula is used to compute for the total fluid to be given in the first 24 hours post burn
    •  4 mL lactated Ringer’s solution/kg/% BSA burn
  •  Administer ½ of calculated volume over the first 8 hour, the other ½ of calculated volume over the next 16 hours
  •  Urine output must be monitored in all patients requiring IV fluids
    •  Adequate urine output is 1 mL/kg/hour
  •  Total target urine output is increased to 1-2 mL/kg/hour for electrical burns due to risk of high myoglobin levels
  •  Titrate infused IV fluid based on the child’s response to therapy:
    •  Adequate urine output
    •  Normal pulses
    •  Normal blood pressure (BP)
  •  Extremities must be assessed for any deep or full thickness circumferential burn as these may occlude perfusion to distal extremities
    •  Peripheral circulation must be checked with Doppler
    •  There is an increased risk for compartment syndrome to develop during fluid resuscitation as burned tissue loses the ability to stretch
    •  A decreased perfusion due to circumferential burn warrants referral to surgery for early escharotomy & debridement
  •  Neurologic status must be briefly assessed by evaluating level of consciousness using the Glasgow coma scale
    •  A Glasgow coma score of 8 or less warrants intubation
  •  Cerebral injury may be caused by hypoxia from smoke inhalation or hypovolemia from fluid loss
  •  Signs of increased intracranial pressure (ICP) & progressive neurologic deterioration must be treated immediately
    •  Hyperventilate patient using bag-valve mask to lower partial pressure of carbon dioxide in arterial blood (PaCO2) to promote cerebral vasoconstriction
    •  Use mannitol cautiously because it promotes osmotic diuresis, which may exacerbate hypovolemia
  •  Consult w/ neurosurgery for co-management if there is persistent increase in intracranial pressure

Exposure/Environmental Control

  • All smoldering clothing or clothing saturated with hot liquid should be cut away to facilitate exam
  • Children easily become hypothermic, so they should be warmed with radiant warmers or heated blankets & IV fluid as soon as possible
  • Cover the burned area with clean, dry sheet & apply cold wet compresses to small injuries
    • Do not use cold compress dressings on large burn surface area (>15-20% BSA) as this will decrease body temperature
  • In chemical injury, brush off any remaining chemical if powdered or solid, then use copious irrigation or wash the affected area with water
    •  Call poison control for the neutralizing agent to treat a chemical ingestion
  •  If burn is caused by hot tar, use mineral oil to remove the tar
  •  Cleanse area with warm saline or mild soap & water
  •  Debride open wounds & necrotic tissue
    •  Unruptured blisters should be left intact & dressed

Secondary Survey & Emergency Care

  • Secondary survey includes a head-to-toe exam of the patient to determine any concomitant injuries
  • Evaluate for associated injuries, common if the child fell from a height during the burn incident & injuries to spine, bones & thoracic or intra-abdominal organs may occur
  • Child should be placed on cervical spine precaution until this injury is ruled out
  • Ventricular tachycardia & fibrillations are common when burn results from high electric voltage injury
  • Children with burns >15% body surface area (BSA) should not be given anything per orem (PO) & requires insertion of nasogastric tube to prevent aspiration
  • Insertion of a Foley catheter is mandatory to monitor urine output in patients requiring intravenous (IV) resuscitation
  • Pain control can be managed initially with intramuscular (IM)/IV analgesics
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