Sept 2015 East of England CT3 Days Burns Sept 2015 East of England CT3 Days

Burns - aims Skin Types of burns Management Tips for children Burns Associated bits Tips for children

What difference does skin make? Function of skin Thermoregulation Fluid conservation Protection Immune Physical Flexibility / movement

Skin thickness Superficial Partial Thickness Full . Depth is a function of exposure x temp. Average water temp = 60OC; Time for superficial burn = 5-7 seconds Time for full thick burn = 60-90 seconds Children’s skin burns with 4 times the speed

What is a burn? Burn Scald Chemical Electrical Inhalation Other injuries Tetanus 75% scalds. Rest irons, hair straighteners, fireworks etc

Superficial – erythema (sunburn) Partial thickness – Full thickness – Pink Blistered White - sensate Full thickness – Charred Waxy white Insensate

Treatment (First Aid) A Airway B Ventilation C Fluid replacement D E Special considerations

Airway & Breathing Confinement with fire Loss of hair & eyebrows COHb Singed nasal hairs Soot stained nose / lips Mucosal erythema Blistered lips Hoarse voice / stridor Circumferential neck burns

Carbon Monoxide Unexplained obtundation “Cherry Red Lips” Toxicity Varies >10% indicates toxicity Chronis vs Acute ?HBO Cyanide?

C - Fluid loss Replace fluid loss from time of injury Adults and children Hartman’s solution Equation... BSA Parkland formula… Maintenance fluids

Lund & Browder

Shock >15% (Adult) >10% (Child) Resuscitation Maintenance

Add in maintenance fluids Parkland formula 4ml / kg / %burn over 24hrs… = 2 ml x kg x %burn over 8hrs + 2ml x kg x %burn over 16hrs Add in maintenance fluids 4ml / kg / hr for first 10kg 2 ml / kg / hr for next 10 kg 1 ml / kg / hr for rest of weight

Example 10kg child with 8% burns Clinical parameters 60ml / hr for 8 hrs = 20ml / hr plus 40 ml/hr maintenance 50ml / hr for 16 hrs = 10ml / hr plus 40 ml/hr maintenance Clinical parameters

Treatment (First Aid) A Airway B Ventilation C Fluid replacement D Other injuries E Exposure Simultaneously Stop the burn / constriction Pain management Dressings... Tetanus?? Safeguarding

Analgesia Assessment and reassessment Pain ladder… Opiates Intra-nasal diamorphine Intravenous morphine Oramorph? Oral analgesia Non-drug methods Remember two patients in “pain”

Debridement? Deroofing Why Smaller than patient’s little fingernail Aseptic technique: Forceps & scissors Clean with dilute chlorhexidine Dressing Why Decreases infection Analgesia Fluid lost in a controlled way

Dressings?

Special Considerations Joints Circumferential burns Hands / Feet / Perineum / Face Other Injuries Inhalation of CO / CN Cyanokit HBO? HBO – Cardiac / Cerebral toxicity. Pregnancy. Ensure no other injuries. Cyanokit- unexplained acidosis

Follow-Up “Major Burns” – Referral to 3° centre Minor Burns “Consider” if >1% partial thickness Special considerations Minor Burns By local arrangement Less than 10% BSA Demarcation / Healing Late referral Not healing (> 2 weeks) Depth Unwell

Referral criteria Fluid management Useful telephone numbers Referral criteria – unwell patients Sepsis / TSS

Tetanus Tet Tox Tetanus prone wounds Immunoglobulin Basic course Boosters Exceptions Tetanus prone wounds Immunoglobulin Never assume. Cambridge, travellers, immigrants / refugees

Tetanus Prone Wound (see definition below) Immunisation status Clean Wound Tetanus Prone Wound (see definition below) Vaccine Human tetanus immunoglobulin (TIG) Alternative normal immunoglobulin product if TIG is unavailable Fully immunised i.e. has received a total of 5 doses of tetanus vaccine at appropriate intervals None required Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue) 500 units (2ml) TIG IM Normal immunoglobulin Subgam ® brand only, 1.5g IM given at a minimum of two separate sites. Primary immunisation complete, boosters incomplete but up to date None required (unless next dose due soon and convenient to give now) Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue) Normal Immunoglobulin Primary immunisation incomplete or boosters not up to date A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) Yes: one dose TIG at a different site. 250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or 500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns Subgam ® brand only 750mg IM Subgam ® brand only, 1.5g IM given at a minimum of two separate sites Not immunised or immunisation status not known or uncertain An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity Yes: one dose of TIG at a different site. Subgam ® brand 750mg IM 2009 update

Sepsis Toxic Shock What are the subtle signs? Staph aureus or strep pyogenes Temperature>38°C Rash D&V Unwell What are the subtle signs? Poor appetite Listless “just not right”

Safeguarding Red flags Multiple ages / delay to presentation Changing or bizarre history Child’s history Multiple presentations Parental “pathology” Interaction Register

Safeguarding Patterns of injury Who do you inform? Clear imprints Cig burns Dunking Depth inconsistent with history Who do you inform?

Questions?

Summary Treat first, question later ABC Analgesia & fluids Special considerations Tetanus Safeguarding http://www.lsebn.nhs.uk/