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Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management...

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Burns Sept 2015 East of England CT3 Days
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Page 1: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Burns

Sept 2015East of England CT3 Days

Page 2: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Burns - aims

♦ Skin♦ Types of burns♦ Management

♦ Burns♦ Associated bits

♦ Tips for children

Page 3: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

What difference does skin make?

♦ Function of skin♦ Thermoregulation♦ Fluid conservation♦ Protection

♦ Immune♦Physical

♦ Flexibility / movement

Page 4: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Skin thickness

Superficial

Partial Thickness

Full...

Page 5: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

What is a burn?

♦ Burn ♦ Scald♦ Chemical♦ Electrical♦ Inhalation

♦ Other injuries

♦ Tetanus

Page 6: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Superficial –

erythema (sunburn)

Partial thickness –

Pink

Blistered

White - sensate

Full thickness –

Charred

Waxy white

Insensate

Page 7: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Treatment (First Aid)

A Airway

B Ventilation

C Fluid replacement

DE

Special considerations

Page 8: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Airway & BreathingLoss of hair & eyebrows

Singed nasal hairs

Soot stained nose / lips

Confinement with fire

Blistered lips

Circumferential neck burns

Mucosal erythema

Hoarse voice / stridor

COHb

Page 9: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Carbon Monoxide♦ Unexplained obtundation♦ “Cherry Red Lips”♦ Toxicity

♦ Varies♦ >10% indicates toxicity♦ Chronis vs Acute

♦ ?HBO

♦ Cyanide?

Page 10: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

C - Fluid loss

♦ Replace fluid loss from time of injury♦ Adults and children♦ Hartman’s solution

♦ Equation...♦ BSA♦ Parkland formula…

♦ Maintenance fluids

Page 11: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.
Page 12: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.
Page 13: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

♦ Shock♦>15% (Adult)♦>10% (Child)

♦ Resuscitation

♦ Maintenance

Page 14: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Parkland formula4ml / kg / %burn over 24hrs…

=

2 ml x kg x %burn over 8hrs+

2ml x kg x %burn over 16hrs

Add in maintenance fluids4ml / kg / hr for first 10kg

2 ml / kg / hr for next 10 kg1 ml / kg / hr for rest of weight

Page 15: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Example

♦ 10kg child with 8% burns

♦ 60ml / hr for 8 hrs= 20ml / hr plus 40 ml/hr maintenance

♦ 50ml / hr for 16 hrs = 10ml / hr plus 40 ml/hr maintenance

♦ Clinical parameters

Page 16: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Treatment (First Aid)

A Airway

B Ventilation

C Fluid replacement

D Other injuries

E Exposure

Simultaneously

♦ Stop the burn / constriction

♦ Pain management♦ Dressings... ♦ Tetanus??

♦ Safeguarding

Page 17: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Analgesia♦ Assessment and reassessment♦ Pain ladder…

♦ Opiates♦ Intra-nasal diamorphine♦ Intravenous morphine

♦ Oramorph?

♦ Oral analgesia♦ Non-drug methods

Page 18: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Debridement?♦ Deroofing

♦ Smaller than patient’s little fingernail♦ Aseptic technique: Forceps & scissors♦ Clean with dilute chlorhexidine♦ Dressing

♦ Why♦ Decreases infection♦ Analgesia♦ Fluid lost in a controlled way

Page 19: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Dressings?

Page 20: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Special Considerations

♦ Joints♦ Circumferential burns♦ Hands / Feet / Perineum / Face

♦ Other Injuries♦ Inhalation of CO / CN

♦ Cyanokit♦ HBO?

Page 21: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Follow-Up♦ “Major Burns” – Referral to 3° centre

♦ “Consider” if >1% partial thickness♦ Special considerations

♦ Minor Burns♦ By local arrangement♦ Less than 10% BSA♦ Demarcation / Healing

♦ Late referral♦ Not healing (> 2 weeks)♦ Depth♦ Unwell

Page 22: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Referral criteria

Referral criteria – unwell patients

Fluid management

Sepsis / TSS

Useful telephone numbers

Page 23: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Tetanus

♦ Tet Tox♦ Basic course ♦ Boosters♦ Exceptions

♦ Tetanus prone wounds

♦ Immunoglobulin

Page 24: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Immunisation status

Clean Wound Tetanus Prone Wound (see definition below)

Vaccine Vaccine Human tetanus immunoglobulin (TIG) Alternative normal immunoglobulin product if TIGis unavailable

Fully immunised i.e. has received a total of 5 doses of tetanus vaccine at appropriate intervals

None required None required Only if high risk (heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue)500 units (2ml) TIG IM

Normal immunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites.

Primary immunisation complete, boosters incomplete but up to date

None required (unless next dose due soon and convenient to give now)

None required (unless next dose due soon and convenient to give now)

Only if high risk(heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue)500 units (2ml) TIG IM

Normal ImmunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites.

Primary immunisation incomplete or boosters not up to date

A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)

A reinforcing dose of vaccine and further doses as required to complete the recommended schedule (to ensure future immunity)

Yes: one dose TIG at a different site.250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns

Normal immunoglobulinSubgam ® brand only 750mg IMorNormal ImmunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites

Not immunised or immunisation status not known or uncertain

An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity

An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 5 dose course to ensure future immunity

Yes: one dose of TIG at a different site.250 units (1ml) IM if < 24 hours since injury, not heavy contamination and not following a burn or500 units (2ml) IM if >24 hours since injury or risk of heavy contamination or following burns

Normal immunoglobulinSubgam ® brand 750mg IMorNormal immunoglobulinSubgam ® brand only, 1.5g IM given at a minimum of two separate sites

Page 25: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Sepsis♦ Toxic Shock

♦ Staph aureus or strep pyogenes♦ Temperature>38°C♦ Rash♦ D&V♦ Unwell

♦ What are the subtle signs?♦ Poor appetite♦ Listless♦ “just not right”

Page 26: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Safeguarding♦ Red flags

♦ Multiple ages / delay to presentation♦ Changing or bizarre history♦ Child’s history♦ Multiple presentations♦ Parental “pathology”♦ Interaction♦ Register

Page 27: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Safeguarding

♦ Patterns of injury♦ Clear imprints♦ Cig burns♦ Dunking♦ Depth inconsistent with history

♦ Who do you inform?

Page 28: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Questions?

Page 29: Burns Sept 2015 East of England CT3 Days. Burns - aims ♦ Skin ♦ Types of burns ♦ Management ♦ Burns ♦ Associated bits ♦ Tips for children.

Summary

Treat first, question laterABCAnalgesia & fluidsSpecial considerationsTetanusSafeguarding

http://www.lsebn.nhs.uk/


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