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

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

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

4. 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 = seconds
Children’s skin burns with 4 times the speed

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

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

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

8. 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

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

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

11. Lund & Browder

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

13. 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

14. 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

15. 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

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

17. 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

18. Dressings?

19. 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

20. 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

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

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

23. 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

24. 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”

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

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

27. Questions?

28. Summary Treat first, question later ABC Analgesia & fluids
Special considerations
Tetanus
Safeguarding