Burn Management: Assessment, Resuscitation, and Rehabilitation

Initial Assessment of a Major Burn

• Primary survey is similar to any trauma patient, with emphasis on airway and breathing assessment
• Modified ATLS primary survey is performed to avoid missing associated injuries
• Airway assessment includes 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 visualization
  • Change in voice, hoarseness, or harsh cough
  • Stridor, tachypnoea, or dyspnoea
• Breathing assessment:
  • All burn patients receive humidified oxygen via a non-rebreathing mask
  • Mechanical restriction of breathing can occur due to deep dermal or full thickness circumferential burns of the chest
  • Blast injury can cause lung contusions and alveolar trauma, leading to ARDS
  • Smoke inhalation can cause bronchospasm, inflammation, bronchorrhoea, and impaired ciliary action

Initial Assessment (continued)

• Circulation assessment:
  • Establish IV access with 2 large bore cannulas, preferably through unburnt skin
  • Profound hypovolaemia is not a normal initial response to a burn
  • Hypotension may be due to delayed presentation, cardiogenic dysfunction, or occult blood loss
• Disability assessment:
  • Assess GCS
  • Confusion may be due to hypoxia or hypovolaemia
• Exposure and environmental control:
  • Fully assess burn area and depth
  • Check for concomitant injuries
  • Keep the patient warm to prevent hypothermia
• Fluid resuscitation:
  • Use guidelines, with adjustments based on urine output, pulse, BP, and RR
  • Monitor resuscitation status with regular investigations (plasma sodium, base excess, lactate, and packed cell volume)

Assessment of Burn Area

• Three common methods of estimating burn area:
  • Palmar surface (1% TBSA, less accurate for medium-sized burns)
  • Wallace rules of nines (quick estimate, not accurate in children)
  • Lund and Browder chart (most accurate, compensates for variation in body shape with age)
• Important to expose and assess all of the burn area, remove loose epidermal layers, and calculate burn size

Fluid Resuscitation Regimens

• Formulas estimate fluid requirements, but adjust according to urine output, pulse, BP, and RR
• Certain patient groups require extra fluid: children, inhalational injury, electrical injury, delayed resuscitation, and dehydration

In-Hospital Care

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

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 support
• Reconstructive (plastic) surgeon

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