Burns

 

Bat call:

Mechanism

·      Chemical

·      Electrical

·      Flame

·      Hot liquid

Surface area

·      Rule of 9s for adults

·      Rule of 7s for babies

·      1% = palm

Thickness

·      Less deep: red, blanching, painful

·      More deep: white, non-blanching, painless

Location

·      Airway?

·      Lungs?

·      Chest wall?

 

Primary survey:

As for trauma, right?

 

Primary response:

1.Team leader

·      Allocate roles

·      Observe

·      Co-ordinate

2.Airway + breathing

·      Observe

·      Intubate early if airway burn

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: by issue

Goals

·      Facilitate surgery

·      Seek homeostasis

·      Minimise suffering

Referrals

·      Burns unit

·      ICU post-op

·      Acute pain service

Airway

·      Modified rapid sequence induction (avoid sux)

·      Video laryngoscope first line

Breathing

·      Consider lung-protective ventilation

Circulation

Access:

·      Peripheral IV

·      +/- Central IV

·      +/- Arterial line

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