aka Trauma Tribulation 032
It’s 4 am on a steady night shift in your regional Emergency Department when the bat phone rings….
A 24 year old male has been involved in a house fire. He has burns to his anterior chest, face, neck, and right arm. These are his vitals:
P 120 BP 100/62 RR 25 Sats 95% GCS 10.
Are you ready to deal with a major burns patient? You’d better be, the ambulance bay doors are about to open.
Q1. How are you going to approach the preparation, assessment and management of this patient ?
You’ve got some time to prepare before your patient arrives, so check out Trauma Tribulation 013 for what to do before he get’s here.
The approach to the patient with a major burn is the same as the patient who has sustained any other type of major trauma, the ABCDE approach.
- Airway maintenance with cervical spine protection
- Breathing and ventilation
- Circulation with hemorrhage control
- Exposure and environmental control
For a refresher of the initial assessment and management in trauma check out Trauma Tribulation 014.
Q2.What is a major burn?
The definition of a major burn varies between authors.
One definition suggests that those burns requiring fluid resuscitation, or with an inhalational component be considered major burns.
Other definitions are similar to those injuries requiring Burns Centre Referral, see below.
Q3. What are the specific things to consider in the assessment of the major burns patient ?
When dealing with a patient with major burns, there are special considerations that need to be occur during the ABCDE approach.
A – Airway
- Don’t forget C-Spine immobilisation
- Burns are a major distracting injury and patients with burns are at risk of c-spine injuries e.g. jumping from burning building, explosions, and lightning strikes.
- Assess for evidence of airway burns e.g. singed facial hair, soot in the nose or mouth, stridor, voice change
- Assess for evidence of neck burns / swelling that might impede airway
- Consider early intubation if evidence of airway compromise
- All burns patients should have high flow oxygen 15L/min via non-rebreather mask
- Assess for the presence of constrictive chest wall burns
- Assess for presence of toxic gas inhalation particularly carbon monoxide and cyanide toxicity
- Place iv cannulae through unburnt skin where possible
- Assess for circumferential burns to limbs
- Shock due to burns is uncommon in the early phase and if present other courses should be sought e.g. tension pneumothorax, abdominal injury, spinal injury etc.
- Remember hypoxia and toxic gas inhalation can result in altered mental status
- Caution with risk of hypothermia especially in children
- Remove jewellery and burnt / wet clothes (see first aid below)
The presence of circumferential burns to limbs or the chest may result in mechanical compromise leading to limb ischaemia or difficulty in ventilation. In these scenarios an escharotomy may be indicated, although rarely performed in the ED unless significant delays to definitive burns care is anticipated. Early discussion with regional burns unit is advised if an escharotomy appear indicated.
Read more about escharotomies in Trauma Tribulation 005.
Q4. How do you assess a burn wound?
Burns Wound Assessment is a two-part process consisting of:
- Estimating Total Body Surface Area (TBSA) % of Burn
- Estimating Depth of Burn
Q5. How should burn TBSA % be estimated?
Estimating the area of a burn is difficult, especially in the early phase after injury.
Erythema (epidermal) depth burns are NOT included in the estimation of burns area.
Options for calculating burn area include:
- The patient‘s palmar surface, palm and fingers, is approximately 1% of their TBSA.
- This can be used to estimate the size of smaller burns or used to measure unburnt skin in large burns
Rule of Nines
- Divides the body into 11 areas each of 9% TBSA, and the perineum ~1%.
- Allows quick assessment in the Adult burns patient
- An example of an Adult Rule of Nines chart can be found here
Paediatric Burns Area Assessment
- Children have a larger head TBSA % and a smaller leg TBSA % than adults
- Paediatric Specific Burns chart or a Lund & Browder chart must be used
- Examples can be found here and here
Lund & Browder Chart
- Most accurate measure tool
- Can be difficult and time consuming if not familiar
- Allows for estimation of burn TBSA % in both adults and children
- Examples can be found here
Q6. How is burn depth estimated?
Burn depth can be divided into five groups
- Superficial dermal
- Mid dermal
- Deep dermal
- Full thickness
Description, pictures and poster of the various burn depths can be found here.
- When calculating burn TBSA % epidermal burns should NOT be included.
- Differentiating between an epidermal and superficial dermal burn in the early stage can be very difficult. Nikolsky’s sign may help differentiate epidermal from superfical dermal. Rubbing of the skin results in the superficial layer of skin slipping off the deeper layers and should not occur in epidermal burns.
- Most patients who have sustained burns will have mixed depths across the burn area.
Q7. Does a patient with burns require iv fluid, and if so how much ?
Due to increased vascular permeability and oedema formation secondary to burns patients with large burns are at risk of hypovolaemia and subsequent shock.
Use of resuscitation fluids is recommended if:
> 15 – 20% Total BSA
> 10% Total BSA
Other scenarios in which fluid resuscitation may be required include:
- electrical burns
- coexistent traumatic injuries
- delayed presentation
- inhalation injury
An estimation of fluid requirement can be made using the Modified Parkland formula. This formula estimates the amount of fluid required for the first 24 hours post burn.
Total Fluid Estimation for first 24 hours post burn = 3 – 4mls x TBSA % Burn x Weight (kg)
1/2 Total Fluid Volume to be given in first 8 hours
1/2 Total Fluid Volume to be given over next 16 hours
- Hartmann’s should be considered first line fluid.
- The timeframe for resuscitation of the initial 8 hour period, and subsequent 16 hour period is taken from the time of the burn, NOT the time of presentation.
- Patients requiring resuscitation fluids should have an urinary catheter placed to allow titration of fluids as the formula provides only an estimate. Aim for 0.5 ml/kg/hr in adults and 1 ml/kg/hr in children.
- In any patient who requires burns resuscitation fluids early discussion with regional burns unit is advised for clarification on local policy and preferences.
Q8. What are the specific things to consider in the history of the major burns patient ?
Taking an ‘AMPLE’ history is just as important in the burns patient as any other trauma patient
- Allergies and ADT status
- Past Medical History
- Last ate and drank; LMP (check for pregnancy in females of child bearing age)
- Events / environment related to injury (i.e. a detailed account of the mechanism of injury)
Take special care regarding the events relating to the burn, particularly:
- The time at which the burn occurred (needed to plan fluid resuscitation)
- Duration of exposure (prognosis of burns depth)
- Where they in an enclosed space ? (risk of Inhalation injury)
Q9. What first aid and dressing should I use ?
First aid opportunities may be limited by the need for other life-saving interventions or investigations in larger burns or in the presence of other injuries.
First aid should include the removal of jewellery, wet clothes (scalds), or hot clothing. If clothing is stuck to the patient leave well alone.
Cooling can be considered using cool running water for 20 minutes, this can be effective up to 3 hours following a burn. In larger burns (>10 TBSA %) and paediatric burns there is a risk of hypothermia from cooling measures and early advice from a burn centre on first aid measures is advised.
Choice of dressings for a large burn will depend on local policy, need for inter-hospital transfer, burn type, contamination, and local resources. Early discussion with regional burns unit is advised for advice on local policy and preferences.
Q10. Which patients should be referred to a Burns Centre ?
Early discussion with your regional burns centre is advised if there is any doubt/concern regarding the management of any burns patient.
As a general guide the following injuries / scenarios require Burns Centre referral
- Burns > 10 % TBSA in an Adult
- Burns > 5 % TBSA in a Child
- Full thickness burns > 5% TBSA
- Burns of face, hands, feet, perineum, genitalia, and major joints
- Circumferential burns
- Chemical or electrical burns
- Burns in the presence of major trauma or significant co-morbidity
- Burns in the very young patient, or the elderly patient
- Burns in a pregnant patient
- Suspicion of Non-Accidental Injury
Specific referral guidelines are published by a number of National Burns Associations, a selection of which can be found below.
References and Links
- Assessment and Management of Minor Burns in the Emergency Department
- Toxicology Conundrum 038 — Smoke inhalation with Carbon Monoxide and Cyanide Toxicity
- Trauma Tribulation 005 — Escharotomy
- Emergency Management of Severe Burns Course Manual. Australian and New Zealand Burns Association. 16th Edition March 2012.
- Fildes J, et al. Advanced Trauma Life Support Student Course Manual (8th edition), American College of Surgeons 2008.
- Dunn R, Dilley S, Brookes J, Leach D, Maclean A, Morland M. The Emergency Medicine Manual (5th Edition), Venom 2010.
- Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK. Tintinalli’s Emergency Medicine (7th Edition), McGraw Hill 2011.
Social Media and Web Resources
- DirtMed — Burn Resuscitation Part 1 and Part 2
- Free Emergency Talks — Burn Wound Evaluation by Amin Jaskille
- Free Emergency Talks — Total Care for the Burn Patient by Dave Bailey
- ICU Rounds Podcast 12 — Burns: Fluid Creep
- ICU Rounds Podcast 28 — Pediatric Burns
- Victoria Burn Management Guidelines (a comprehensive resource covering all aspects of burns assessment and management and a great place to download Burns Surface Area charts and Information Posters for clinical areas)