Makindo Medical Notes

Anyone with burns should also be presumed to have smoke inhalation injury—consider the ABCs and watch for signs like stridor, hoarseness, or drooling. These patients are at risk for ARDS and airway compromise, which may require early intubation. Refer to a burns unit if >5% of body surface area is affected in children or elderly patients, or >20% in other age groups. Seek specialist advice if there is any doubt.

Initial Management of Severe Burns: Look for Secondary/Other Injuries

Airway: If suspected inhalational/airway burns or injury: respiratory distress, stridor, wheeze, voice change, deep facial burns, or sooty sputum. If patient has been in an enclosed space or had LOC at the scene, get senior help for early intubation—call 2222 for anaesthetic support. Avoid cutting the endotracheal tube (ETT) in this setting; place an NG tube early. Breathing: Suspect carbon monoxide and cyanide inhalation. Check baseline arterial gases, COHb levels, and oxygen saturations. Administer 100% FiO₂ using a non-rebreather mask. Circulation: Establish bilateral large-bore IV access away from burnt tissue if possible. Send bloods: FBC, U&E, LFT, CRP, Amylase, CK, X-match, Drug/Toxicology as needed. Fluid Resuscitation: Use the Parkland formula: 4 mL x Weight (kg) x % burn. Administer half of the fluid over the first 8 hours, and the remainder over the next 16 hours. Start timing from the onset of the burn. Use warmed Hartmann’s solution to prevent hypothermia. Insert a urinary catheter and monitor fluid balance. Example: A 70 kg patient with 50% burns needs 4 x 70 x 50 = 14,000 mL or 14 L. Give 7 L in the first 8 hours and 7 L over the next 16 hours. Disability: Administer IV opiate analgesia, titrated to pain. Monitor GCS and manage pain adequately. Exposure: Remove non-adherent clothing and use hydrogel. Cool burns with wet compresses for 20 minutes total, avoiding hypothermia. Assess burn area using the Lund and Browder chart and determine depth. Cover wounds with loose cling film (avoid the face). Other Considerations: Insert an NG tube for those at risk of gastric ileus or with significant burns. Escharotomy may be required for circumferential burns of the chest or neck to prevent compartment syndrome. Ensure tetanus prophylaxis is up to date. Keep patients Nil By Mouth (NBM) if considering surgical intervention. Address any safeguarding concerns, especially in children or vulnerable adults.

Types of Burns

• First Degree/Superficial: Involves only the epidermis, characterized by redness and pain without blistering (e.g., sunburn). Generally, no IV fluid therapy is needed, and these burns heal without scarring.
• Second Degree/Partial Thickness: Involves the epidermis and part of the dermis. These burns are red, blistered, and extremely painful. The surface is often moist and weeping. They typically heal with minimal scarring through epithelial growth.
• Third Degree/Full Thickness: Involves all layers of the skin down to subcutaneous tissue. The skin may appear white, charred, or leathery and is often painless due to nerve destruction. Healing requires grafting and results in significant scarring.

Signs of Inhalational Burn Injury

• Burns to the face, neck, or upper torso.
• Singed nasal hair or eyebrows.
• Carbonaceous sputum or soot particles visible in the oropharynx.
• Voice changes, such as hoarseness or a harsh cough.
• Dyspnoea, stridor, erythema, or swelling of the oropharynx on examination.

Assessing Burn Depth and Cause

• Flash Burns: Usually superficial epidermal burns.
• Scalds: Commonly cause superficial or superficial dermal burns.
• Flame Burns: More likely to cause deep dermal or full-thickness burns.
• Contact Burns: Often result in deep dermal or full-thickness injuries.
• Chemical and Electrical Burns: Typically involve full-thickness damage and may require specialized treatment.

Complications of Burns

• Compartment syndrome due to swelling within muscle compartments.
• Hypovolaemia from fluid loss and electrolyte disturbances.
• Infection and sepsis, especially with deep burns or delayed presentation.
• Hypothermia due to loss of skin barrier and heat regulation.
• Chronic pain, neuropathic pain, and itching.
• Hypertrophic scarring and contractures, especially in burns that take longer than 2-3 weeks to heal.
• Psychological impact, including depression, anxiety, PTSD, and social challenges due to scarring.

Special Areas of Concern

• Burns involving critical areas: face, hands, perineum, genitalia, feet, or flexures (e.g., neck, axilla).
• Burns over joints may affect mobility and require specialized care to preserve function.

Signs of Circulatory Deficit in Burn Patients

• Tachycardia and tachypnoea.
• Reduced level of consciousness.
• Prolonged central capillary refill time and cool peripheries.

Non-Accidental Injury (NAI) Considerations

• Unrelated adult presence, unexplained delays in presentation, or inconsistent history.
• Multiple presentations for burns or injuries.
• Suspicious patterns: immersion burns, cigarette burns, scalds to genitalia or buttocks, mirror-image injuries.
• Consider child safeguarding or elder abuse in vulnerable individuals.

Investigations

• Blood Tests: FBC, U&E, glucose, group and save, clotting profile, and CK levels.
• Arterial Blood Gas (ABG): Check for lactate levels and HbCO if carbon monoxide poisoning is suspected.
• CXR: To assess for inhalational injury, especially in cases with respiratory symptoms.

Management Overview

• ABCDE Approach: Assess airway, breathing, and circulation. Provide high-flow oxygen, especially in cases of suspected inhalational injury or burns >15% TBSA.
• Fluid Replacement: Follow the Parkland formula for fluid resuscitation using warmed crystalloid solution. Monitor urine output to guide adequacy of resuscitation (0.5-1.0 ml/kg/hour in adults, 1.0-1.5 ml/kg/hour in children).
• Early Intubation: Consider early intubation for signs of airway compromise or inhalational injury.
• Wound Care: Apply sterile, non-adherent dressings. Use cling film for transfer, avoiding tight wrapping around the affected area.
• Analgesia: Titrate IV morphine for pain control and reassess regularly.
• Nutritional Support: Insert NG tube if needed, as burns patients are hypermetabolic and require increased caloric intake.
• Escharotomy: May be required for circumferential burns of limbs or chest to relieve pressure and restore circulation.
• Specialist Referral: Transfer patients with >20% TBSA burns in adults or >10% in children to a regional burns centre.
• Tetanus Prophylaxis: Administer as needed based on immunization status.

References

• ABC of Burns: Pathophysiology and Types of Burns
• Clinical Guideline: Burns Injury
• Management of Major Burns: A Review