Burns

 

Bat call:

Mechanism

·      Chemical

·      Electrical

·      Flame

·      Hot liquid

Location

·      Airway?

·      Lungs?

·      Chest wall?

·      Limbs?

Extent

·      Surface area

·      Thickness

Other injuries

·      Head

·      C-spine

·      Chest

·      Abdomen

 

Zero point survey:

 

Get people ready:

Briefing

·      Situation

·      Priorities

Role allocation

·      Team leader

·      Surgery

·      Airway

·      Vascular access

·      Blood products

Heads up

·      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: general

Airway

·      Is it injured? (look)

·      Is it patent? (stridor, signs of obstruction)

·      Is it protected? (conscious state)

Breathing

·      Is oxygenation ok? (colour, sats)

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

Circulation

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

 

Primary survey: burns

Location

·      Airway?

·      Lungs?

·      Chest wall?

·      Limbs? (esp circumferential)

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

·      Observe

·      Intubate early if airway burn

·      RSI without sux

·      Teeth tie or trachie tie

·      Consider lung-protective ventilation

3.Circulation

3a. Access:

·      2 x big PIVC wherever possible

·      Urinary catheter

3b. Fluid:

·      Parkland resus: 2-4mL/kg/%BSA, ½ first 8 hours, ½ next 16 hours

·      Titrate against urine output + lactate

4.Surgery

·      Assessment

·      Dressings

·      Debridement (A&E vs OR)

 

Anaesthesia issues:

Multi-organ dysfunction

·      CVS: ↑cardiac output, ↓SVR (except very beginning)

·      Resp: early APO, later restrictive

·      Metab: severe catabolic state, elec derangement, risk of rhabdo

·      Haem: risk of DIC

·      Immune: risk of sepsis

Difficult monitoring

·      Sats probe

·      BP cuff vs arterial line

·      ECG dots

Difficult procedures

·      Airway

·      Vascular access

Difficult homeostasis

·      Feeding

·      Hydration

·      Normothermia

·      Analgesia

Traumatic event

·      Patient suffering +++

·      Parental guilt +++

 

Anaesthesia management:

Goals

·      Facilitate surgery

·      Attend to ABC

·      Minimise suffering

Airway

·      Intubate

·      RSI without sux

·      Secure ETT to teeth or with trachie tie

Breathing

·      Consider lung-protective ventilation

Circulation

Access:

·      Peripheral IV

·      +/- Central IV

·      +/- Arterial line

·      Burns-specific dressings

Fluids:

·      Observe Parkland formula

·      Titrate against urine output, lactate

Drugs

Analgesics:

·      Titrate to effect, often large dose

·      Consider transfer to ICU anaesthetized and intubated

·      Paracetamol

·      Ketamine infusion

·      Opioid infusion

·      Acute pain service

Other:

·      Avoid sux except on day 1

Exposure

·      Warmed theatre

·      Warmed table

·      Warmed fluid

 

 

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