Emergency Department Warwick Hospital BURNS Emergency Department Warwick Hospital

Background A common cause of A&E attendance Almost all of us have experienced burn injury Peak incidence 0-5, 20-29 & >75 years Significant morbidity results while most are not life threatening High risk of death in very young & old Always consider NAI in children under 5

Causes & Incidence Scald 33.6% Flame 29.2% Hot surfaces 12.2% Chemicals 9.1% Electrical 3.6% Others 12.4% * Others would include sun, friction and radiation burns.

Pathophysiology *stopping the burning process is essential to stop an initially superficial burn to progress to a full thickness burn that requires surgery. The larger the BSA, the more the fluid and heat loss. The more the depth, the more the damage to nerve endings and epithelium.

Classification of Burn Epidermal Superficial dermal partial thickness Mid dermal partial thickness Deep dermal partial thickness Full thickness

Other Classifications 1st Degree – Superficial Epidermal 2nd Degree – Superficial Dermal 3rd Degree – Deep or full thickness burn

Depth & Clinical Features 1st Degree - Erythema, no blisters, painful 2nd Degree – Pink/Mottled, Blisters, painful 3rd Degree – Dry, pale, dark, leathery, and no pain * Pain is inversely proportional to the depth of burn injury

First Degree

Second Degree

Third Degree

Burn Surface Area (BSA) Use Wallace rule of 9 or the Palm of the patient hand Minor < 10% children or 15% adults Major >10% children & 15% adults Lund & Browder chart is more accurate

Rule of Nines

Management Immediate Life Saving Measures . Safety . Remove patient from cause of burn & stop the burning Process . Check ABC & First Aid

Assessment in ED . History . Primary Survey ABCDE . Check for signs of inhalation stridor is an indication for intubation . Estimate extent and depth of burn

ABC Strategy Airway & C-spine control Breathing & signs of inhalation Circulation & Perfusion/Fluids Disability & Pain control Environment – skin integrity & temperature

Signs of Inhalation Fire in an enclosed/confined space Face and neck burns Singeing of eyebrows & nasal hair Hoarse voice Dyspnea Carbonaceous sputum Brassy cough Carboxyhemoglobin (HbCO) >10%

Fluid Resuscitation Indicated in Burns >5% in children & >10% in adults Use Hartmann’s or Normal Saline Parkland formula recommended Monitor adequacy by normal urine output Follow the Departmental fluid requirement chart

Burns Transfer – Fluid Chart

Secondary Survey Head to toe examination for associated injuries. Assess peripheral circulation in circumferential burns Analgesia – Morphine preferred Antibiotics & Tetanus Wound dressing

Burn Wound Dressing Deroof/decompress blisters if possible Adequate wound cleaning before dressing Flamazine, Mepitel or Urgotul SSD. Face - leave exposed (Polyfax or Chloramphenicol ointment) Hand - Flamazine hand bag or light Mepitel dressing. The fingers must move. In transfer use cling film or sterile sheet Review all dresings within 48 hrs

Chemical Burns Usually Acids/Alkali but remember Phenols/Petroleum products. Alkali burns generally worse than acids (due to penetration) Flush with large amount of water Measure the Ph Neutralizing agents available? Consult the National poisons centre

Electrical Burns Usually more serious than they appear History of fit/thrown over Unconsciousness or depressed GCS Entry and Exit wounds Changes in ECG, myoglobinuria or abnormal CK/Troponin Admit if any of the above present

Indication for Transfer Superficial burns – child >5%, Adult >10% Significant burns of special areas Significant full thickness burns Presence of inhalation injury Significant Electrical and Chemical burns Radiation burns Associated major trauma

Questions