Burn Management: Assessment, Resuscitation, and Rehabilitation

Management of a Burn – Assessment, Resuscitation & Rehabilitation

Causes of Burns

• Thermal energy
• Electrical energy
• Chemical (acid or alkaline)

Initial Assessment of a Major Burn

Primary Survey

• Modified ATLS primary survey
• Emphasis on airway and breathing assessment
• Serious associated injuries may be missed if not followed sequentially

Airway with C Spine Control

• Compromised or at risk of compromise
• Signs of inhalational injury:
• History of flame burns or burns in an enclosed space
• Deep dermal or full thickness burns to face, neck, or upper torso
• Singed nasal hair
• Carbonaceous sputum or carbon particles in oropharynx

Indications for Intubation

• Erythema or swelling of oropharynx on direct visualisation
• Change in voice, with hoarseness or harsh cough
• Stridor, tachypnoea, or dyspnoea

Breathing

• All burn patients should receive humidified oxygen via a non-rebreathing mask
• Compromise can occur via:
• Mechanical restriction of breathing (deep dermal or full thickness circumferential burns of the chest)
• Blast injury (blast lung, lung contusions, alveolar trauma, and pneumothoraces)
• Smoke inhalation (products of combustion act as direct irritants, leading to bronchospasm, inflammation, bronchorrhoea, and impaired ciliary action)

Circulation

• Establish IV access with 2 large bore cannulas, preferably through unburnt skin
• Profound hypovolaemia is not the normal initial response to a burn

Neurological Disability

• Assess GCS
• Confusion ?Hypoxia or hypovolaemia

Exposure with Environmental Control

• Fully assess burn area and depth
• Check for concomitant injuries
• Keep warm – burn patients easily become hypothermic, leading to hypoperfusion and deepening of burn wounds

Fluid Resuscitation

• Using guidelines
• Urinary catheter mandatory in burns >20% TBSA

Analgesia

• All patients with large burns should receive IV morphine, titrated against pain and respiratory depression

Assessment of Burn Area

Methods of Estimating Burn Area

• Palmar surface (roughly 1% TBSA)
• Wallace's rule of nines (quick way of estimating large burns in adults)
• Lund and Browder chart (most accurate method, compensates for variation in body shape with age)

Important Considerations

• Erythema should not be included when calculating burn area
• Use a warm environment and sequentially expose small segments of skin to reduce heat loss
• Pigmented skin can be difficult to assess; may need to remove loose epidermal layers to calculate burn size

Resuscitation

Fluid Resuscitation Regimens

• The Parkland formula is commonly used
• The starting point is the time of injury, not time of admission
• Certain patient groups require extra fluid requirements (children, inhalational injury, electrical injury, delayed resuscitation, and dehydration or intoxicated patients)

Transfer and Care

Who to Transfer

• Adults: >10% full thickness, >20% deep partial, flexors, perineum, inhalation, head and neck
• Children: >5% full thickness, >10% deep partial (Red Cross Hospital)

When Care is "Futile"

• >60% full thickness with inhalation
• >70% full thickness without inhalation
• >80% deep partial
• What to do:
• Secure airway (don't ventilate)
• Adequate analgesia (IV)
• Catheter
• Counsel family and call spiritual leader

In-Hospital Care

Prevention of 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 (expensive)
• Xenografts (pig and frog)
• 20% BSA per sitting
• Tissue biopsy for MCS

Rehabilitation: A Team Effort

Early Phase

• Chest physio
• Early mobilisation
• Post-graft splinting
• ADL adaptation
• Compression garments and dynamic hand splints (OT later phase)

Multidisciplinary Team

• Social Worker
• Psychologist
• Dietician
• Pastor / Imam / Rabbi
• Family and community
• Reconstructive (plastic) surgeon