Burn Management: Assessment, Resuscitation, and Rehabilitation

Management of Burns

• Burns can be caused by thermal energy, electrical energy, and chemical energy (acid or alkaline)
• Initial assessment of a major burn involves a modified ATLS primary survey, with emphasis on airway and breathing assessment
• Burn injury must not distract from sequential assessment, as serious associated injuries may be missed

Initial Assessment of a Major Burn

• Primary survey:
  • A: Airway with C Spine Control
    • Assess for compromised or at-risk airway
    • Signs of inhalational injury: history of flame burns, deep dermal or full-thickness burns to face, neck, or upper torso, singed nasal hair, or carbonaceous sputum
  • Indications for intubation: erythema or swelling of oropharynx, change in voice, stridor, tachypnoea, or dyspnoea
• Breathing:
  • All burn patients should receive humidified oxygen via a non-rebreathing mask
  • Compromise can occur via mechanical restriction, blast injury, or smoke inhalation
• Carboxyhaemoglobin:
  • CO binds preferentially to Hb and intracellular proteins, leading to intra- and extracellular hypoxia
  • Signs of CO intoxication vary with COHb levels
  • Rx with 100% oxygen, and ventilate patients with COHb levels > 25-30%

Initial Assessment (Continued)

• Circulation:
  • Establish IV access with 2 large-bore cannulas, preferably through unburnt skin
  • Hypovolaemia is not a normal initial response to a burn
• D - Neurological Disability:
  • Assess GCS
  • Confusion may be due to hypoxia or hypovolaemia
• E - Exposure with Environmental Control:
  • Fully assess burn area and depth
  • Check for concomitant injuries
  • Keep warm to prevent hypothermia
• F - Fluid Resuscitation:
  • Use guidelines
  • Urinary catheter mandatory in burns > 20% TBSA
  • Analgesia: IV morphine titrated against pain and respiratory depression

Assessment of Burn Area

• 3 commonly used methods: palmar surface, Wallace rules of nines, and Lund and Browder chart
• Erythema should not be included in burn area calculation
• Palmar surface: surface area of pt's palm is roughly 1% TBSA, but less accurate for medium-sized burns
• Wallace rules of nines: quick way to estimate large burns in adults, but not accurate in children
• Lund and Browder chart: most accurate method, compensates for variation in body shape with age, and gives accurate assessment in children

Assessment and Resuscitation

• Minor burn: TBSA < 15% in adults and < 10% in children warrant formal resuscitation
• Parkland's formula: pure crystalloid formula, easy to calculate, and rate is titrated against urine output
• Fluid resuscitation regimens: guidelines for probable amount of fluid required, continuously adjust according to urine output, pulse, BP, and RR
• Regular investigations: plasma sodium, base excess, lactate, and packed cell volume

Transfer and Care

• Who to transfer: adults with > 10% FT, > 20% deep partial, flexors, perineum, inhalation, head and neck, and children with > 5% FT, > 10% deep partial
• When is care "futile": > 60% FT with inhalation, > 70% FT without inhalation, > 80% DP
• Transfer wound coverage: Burnshield, Cling-wrap

In-hospital Care

• Prevent sepsis
• Cover with silver-containing cream
• Debride blisters
• Resuscitate
• Early enteral feeding
• Early excision and biological wound coverage

Skin Cover Options

• Autologous split skin grafts
• Living related donors
• Cadaver skin
• Synthetic analogues
• Xenografts (pig and frog)
• 20% BSA per sitting
• Tissue biopsy for MCS

Rehabilitation

• Early chest physio
• Early mobilisation
• Post-graft splinting
• ADL adaptation
• Compression garments and dynamic hand splints
• Social worker, psychologist, dietician, pastor/Imam/rabbi, family, and community involvement
• Reconstructive (plastic) surgeon

Learn about the management of burns, including assessment, resuscitation, and rehabilitation. This quiz covers the causes of burns, initial assessment, and primary survey of a major burn.