Burns

 

Bat call:

Patient

·      Vanilla adult

·      Comorbid

·      Psychotic

·      Pregnant

·      Child

Mechanism

·      Chemical

·      Electrical

·      Flame

·      Hot liquid

Location

·      Airway?

·      Lungs?

·      Chest wall?

·      Limbs?

Extent

·      Surface area

·      Thickness

Other injuries

Trauma:

·      Head

·      C-spine

·      Chest

·      Abdomen

Poisoning:

·      Carbon monoxide

 

Zero point survey:

 

Get people ready:

Briefing

·      Situation

·      Priorities

Role allocation

·      Team leader

·      Surgery / burns

·      Airway

·      Vascular access

Heads up

·      Closest burns unit

·      Theatre

·      Blood bank

·      Radiology

·      ICU

·      Acute pain service

 

Get things ready:

Environment

·      Danger

·      Space

·      Light

·      Noise

·      Crowd control

Equipment

·      Surgery: dressings initially

·      A: ETT, ETT fastener

·      B: bag-valve-mask, ventilator

·      C: IVC kit, arterial kit, pumpset, fluid warmer

Monitoring

·      Sat probe

·      NIBP and arterial

·      ECG

·      Capno

 

Primary survey:

Airway

·      Is it burned?

o  Hx: combustion, closed space

o  Ex: swelling, soot

o  Ix: nasendoscopy

·      Is it patent?

o  Distress

o  Dysphonia

o  Stridor

·      Is it protected?

o  Conscious state

Breathing

·      Is it burned? (SpO2, CXR)

·      Is there poisning (CO, HCN)

·      Is oxygenation ok? (colour, sats)

·      Is ventilation ok? (look, listen, capno)

Circulation

·      Is organ perfusion ok? (conscious state, capillary refill)

Disability

·      Is conscious state ok?

·      Is there drug intoxication?

·      Is there carbon monoxide poisoning?

Exposure

·      Expose whole body

·      Assess burns (location, extent, thickness)

·      Assess other life-threatening injuries

·      Beware hypothermia

 

Burns assessment:

Location

·      Airway?

·      Lungs?

·      Chest wall?

·      Limbs?

·      Perineum?

Surface area

·      Rule of 9s adults

·      Rule of 7s infants

·      Patient’s palm = 1%

Thickness

·      Beware: often misdiagnosed if early

·      Superficial: painful, red, fast cap refill

·      Deep: painless, white, slow cap refill

 

Primary response:

1.Team leader

·      Allocate roles

·      Observe

·      Co-ordinate

2.Airway + breathing

Indications:

·      Going to theatre

·      Going to the Alfred

·      A: burn to airway or around the neck

·      B: respiratory failure

·      C: shock

·      D: unconscious

·      E: TBSA >15% full, >30% partial

Method:

·      Consider transfer to theatre

·      If simple: RSI (sux if <24h, roc if >24h)

·      If complex: AFOI

·      If complex and unco-operative: ketamine + AFOI

·      Use small size ETT if swollen

·      Securement: teeth tie or trachie tie

·      Lung-protective ventilation

3.Circulation

Access:

·      2 x big PIVC wherever possible

·      A-line

·      Urinary catheter

Resuscitation:

·      Parkland formula:

o   Hartmann’s 3-4mL/kg/%BSA

o   ½ first 8 hours, ½ next 16 hours

o   Indication: >20% TBSA adult, >10% TBSA paed

·      Adjustment:

o   Go hard for first 8 hours

o   Then titrate against BP, UO, Hct, lactate

o   Too little: shock, death

o   Too much: tissue necrosis, abdo compartment syndrome
(i.e. fluid creep)

4.Burns

·      Dressings

·      ±Escharotomy

·      ±Debridement

·      A&E vs OR vs transfer

5.Transfer

Major burns = transfer

·      High TBSA: (>10% partial, >5% full, >5% paeds)

·      High risk group: very young, very old, pregnant, comorbid ASA3+

·      Important spot: airway, face, hands, feet, joints, perineum

·      Circumferential: chest wall, limbs, neck

·      Dangerous mechanism: chemical, electrical, assault

·      Associated trauma

 

Anaesthesia issues:

Multi-organ dysfunction

·      Airway: swollen

·      Breathing: APO

·      Circulation: “burn shock”

o   Early: “burn shock” (↑SVR, ↓CO, ↓blood volume)

o   Later: SIRS-like (↓SVR, ↑↑CO)

·      Metabolic: catabolic state, electrolytes

·      Haematological: risk of DIC

Homeostasis

·      Protein loss

·      Fluid loss

·      Heat loss

·      Blood loss

Logistics

·      Monitoring

·      Access

·      Positioning

·      Transfers

Suffering

·      Pain

·      Distress

·      Guilt

·      Conflict

 

 

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