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Version 2.1 Burns 15/03/
Epidemiology:
- In Aus/NZ - 220,000 cases/yr, 10% of these hospitalised, 0.02% fatal.
- Children<4y usually scalds
- Highest rates were young children & elderly.
- ~50% of burns and scalds occur in the kitchen.
Types:
- Thermal 95% - Scalds 60%, flame 40%
- Electrical
Systemic effects
- Cytokine release if burn SA>30%
- Release of TNFα
- ↑Capillary permeability
- ↓Myocardial contractility
- Peripheral & splanchnic vasoconstriction
- Bronchoconstriction
- ARDS if severe
- ↑Basal metabolic rate & basal body temperature (~0.03ºC per % BSA)
- ↓Humeral & cell mediated immunity
Assessment
History: AMPLE, When, what, how long, how hot (or concentrated for chemical), enclosed/open
space, explosion, other trauma. What first aid given.
Examination: Where burnt (esp airway – upper/lower signs, face, hands, genitals), how
extensive, approx depth.
Consider: NAI, EtOH/Drug use.
Burn Surface Area Estimation
Rule of Nines Or Lund & Browder Chart
Age 0 1 5 10 15 Adult A 9.5 8.5 6.5 5.5 4.5 3. B 2.75 3.25 4 4.5 4.5 4. C 2.5 2.5 2.75 3 3.25 3.
Or Hand Method
Child: For every year of age >1yr decrease head by 1% and increase each leg by 0.5%
Burn Depth Assessment Depth Colour Blisters Capillary Refill Sensation Healing Scarring Epidermal (Superficial)
Red No Brisk 1-2s Painful Within 7d None
Superficial Dermal (Superficial Partial)
Red/Pale Pink Small Brisk 1-2s Painful Within 14d None, sl. colour mismatch Mid-Dermal (Partial)
Dark Pink Present Sluggish >2s Painful 2-3 weeks ± Grafting
Yes (if healing
3wk) Deep Dermal (Deep Partial)
Blotchy Red/ White
+/- Sluggish >2s or absent
Variable Grafting required
Yes
Full Thickness White/Brown/ Black/Deep Red
No Absent Absent Grafting required
Yes
Burn Severity TBSA, depth & site (airway, face, hands/feet, genitals), skin thickness (thinner in old/young)
Complications
- Tissue hypoxia – low O 2 , CO, CN-, H 2 S
- Infection esp Pseudomonas spp.
- ARF (hypovolaemia, myoglobinuria, sepsis)
- ARDS
- Hypothermia
- SIADH
- Scarring
- Psychological effects
Investigations Urine: ?haemoglobin/myoglobin, output Bloods: ABG, COHb (±CN/H 2 S), FBC, UEC, Anion gap, LFT, CK, CMP (esp chemical burns e.g. HF) ECG: ?myocardial injury Imaging: CXR if ?inhalation injury, bronchoscopy if airway injury, IV Xenon lung scan
Management
First Aid:
- Stop, drop, cover face & roll if on fire
- 20min+ cold (15ºC) running water(not ice) if <3hrs of burn. BurnAid. Cover with Glad wrap.
- Keep rest of body warm to prevent hypothermia
- Remove clothing and jewellery
- Apply C-spine collar if appropriate
Resuscitation
- Airway: May intubate with suxamethonium if burn <5d old else rocuronium. o Intubate immed if impending airway obs, hypoxia on 100% O 2 , hypoventilation o Intubate urgently if ↓SaO 2 on 60-100% O, voice change, oral erythema/blistering o Early ETT if ?inhalation burn: orofacial burn, carbonaceous sputum, nasal hair/eyebrow singing.
- Breathing: Humidified O 2.
- Circulation: 2 x IVC if major burn. Try to avoid burnt tissue if possible. Aim for urine output of 0.5-1ml/kg/hr in adults, 1-2ml/kg/hr in children. o Fluids: No evidence for colloid over crystalloid. If TBSA>15% (Child: 10%) use Hartmann’s init rate (Parklands): Total 2º/3º BSA (%) x Wt (kg) x 3-4mL. Give 1/ in 1st^ 8h, rest over 16h. Add maintenance fluids for child<30kg. o If low urine output, & not responsive to ↑fluids, can use mannitol + frusemide.
Analgesia: Cooling, wrapping to air currents. PO paracetamol/codeine if minor, opioids e.g.
morphine 0.1mg/kg IV (not IM – variable absorption) if larger.
Prognosis: Mortality RF: Age>60, TBSA>40%, inhalation injury. Mortality related to no. RF: 0 (0.3%), 1 (3%), 2 (33%), 3 (90%)
Fires
Components of injury: Flame burns, hypoxia (O2 depleted by combustion), hyperpyrexia, toxic
gases (CO, CN-, H 2 S), inhalational injury – smoke particles <0.5μm → inflame alveoli.
Chemical Burns
- Can result from exposure to acids, alkalis, or petroleum products.
- Alkali burns (liquefaction) tend to be deeper than acid burns (coagulative necrosis).
- Remove clothing with care and if dry powder still present on skin, brush it away.
- Flush away the chemical with large amounts of water for at least 20-30min. Alkali burns to the eye require longer continuous irrigation until pH normalised.
Cement Burns: Calcium oxide→hydroxide (alkali) on exposure to sweat/water. Mx: irrigation.
Tar Burns: Bitumen laid at 200°C. Adheres to tissue→prolonged contact. Mx: soak in cold water
then olive oil & remove tar carefully. Split tar in circumferential burn (as contracts on cooling).
Hydrofluoric Acid: See Toxicology Article & Antidote article.
Electrical burns See Electrical Injury article
- Are often more serious than they appear on the surface.
- Rhabdomyolysis → myoglobin release, which may → ARF. o Rx: Fluids (so urine output>1.5ml/kg/hr), bicarbonate / mannitol / frusemide.
Sunburn Common from UV radiation.
Risk factors: Duration & timing of sun exposure, UV-B >UV -A, but less prevalent in sunlight,
lack of sunscreens, lighter or lack of skin pigmentation, moist skin, less atmospheric filtration with height/ozone depletion, snow/sand/water glare (cf Arc Eye).
Presentation: Usually superficial burns, occ partial thickness with blistering. Systemic
symptoms can accompany severe burns with headache, chills, malaise +/- nausea & vomiting.
Management
- Mild: Cool soaks and PO/topical NSAIDs may be helpful.
- Moderate: Lack of good evidence for PO NSAIDs, antihistamines and TOP steroids, antioxidants, or emollients.
- Severe: As for any other severe burn.
Complications
- Premature aging, solar keratoses, BCC, SCC and malignant melanoma
- Maybe associated with heatstroke or other heat-related illnesses
- Photosensitivity reactions or exacerbation of dermatological conditions
Prevention: Education, sun block/sunscreen with high SPF, limiting sun exposure. Slip, slap, slop.
Ionising Radiation Iatrogenic, terrorist attack, nuclear accident. LD50=4 Gray.
Tissue sensitivity: Gonads > marrow, lung & GIT > breast, liver, thyroid, bladder > bone & skin.
Features: Early N&V (↑sev), burns after 48h, ↓↓marrow (>2Gy), colitis (>10Gy), pneumonitis, RF,
liver failure. High doses (>15Gy): fatal vascular & cerebral syndromes. Decontam. Specialist Mx.
