BURNS

Question 1

RED FLAGS

Question 2

DIFFERENTIALS

Answer 2

• Thermal burn
• Radiation (ultraviolet/x-ray) burn
• Chemical (acid/alkali) burn: deep tissue necrosis progresses over hours despite chemical removed.
• Electrical burn: heat generation & electroporation of cell membranes. Can have extensive deep tissue injury in electric conductive tissue (muscle tissue & nerves) find entry/exit wounds (charred black area) –> compartment syndrome.

Question 3

PATHOPHYSIOLOGY

Answer 3

Classification
- Superficial: erythema, painful- sunburn, contact by cooking, flash injury.
- Superficial dermal: progress into dermal area –> blister formation  heal by epithelialisation
- Deep dermal/partial thickness: damage sweat glands & hair follicles– sluggish cap refill, pale/mottled or cherry red. Wks/mnts to heal. Rhabdomyolysis –> myoglobinuria –> acute kidney injury. Compilation: eschar (stiff dead tissue around deep burns) –> compromise vascular supply to limbs due to restriction of oedemal expansion –> localised ischemia. In limbs = “circumferential “eschar”. In thorax or neck –> ventilation compromise.
- Full thickness: painless (nerve damage), to subcutaneous layer, charred or pale, leathery texture.

Zones of burnt area
- Zone of coagulation: maximal damage, proteins become denatured & cell death, irreversible necrosis.
- Zone of stasis/ischaemia: salvageable if managed correctly but somewhat compromised perfusion –> progresses to zone of coagulation if not treated.
- Zone of hyperaemia: not damaged by heat but are affected by inflammatory mediators –> increase blood supply (erythema).

Question 4

COMPLICATIONS

Answer 4

• Burns over joints are a serious as they affect mobility & quality of life.
• Burns rarely happen in isolation –> other trauma, airway burns, CO poisoning.
• Airway burns –> hoarse voice, bronchospasm, reduced SpO2, swollen lips/tongue, difficulty breathing/swallowing –> hypoxia –> confusion, lethargy, coma. Management: intubation/surgical airway intervention, Salbutamol for bronchospasm.
• Inflammatory mediators can cause an increase in vascular permeability, causing proteins & fluids to shift –> generalised oedema, resp. distress, hypovolemia shock.
• DIC
• fluid loss, hypothermia, dehydration

Question 5

TREATMENT

Answer 5

Primary survey
- D: remove from heat source.
- R:
- A: assure patency.
- B: O2.
- C: IV access + fluids (continue fluid resus due to constant fluid shift causing hypovolemia).
- D: analgesia.
- E: maintain normothermia (cool burn, warm Pt), 20-60min under running water, glad wrap (pain, infection control, fluid loss, heat loss). Tx to burns centre.
Secondary Survey: Thorough RSA, CVA, NSA + reassessments.

Question 6

ROLE OF PARAMEDICS

Question 7

DEFINITIVE CARE

Answer 7

• Monitoring/tests: ECG monitoring (electric shock, electrolyte abnormalities). WBCs count (for infection). Urinalysis (myoglobinuria & electrolyte loss). Lung radiography for airway burns, Bronchoscopy (camera view of lungs), intubation.
• Treatment: Escharotomy + manage compartment syndrome from electrical burn. Wound care– water, antimicrobial pads, silver dressings, biosynthetic wound dressing, Surgery/skin grafting/meshed graft. Tetanus shot. Manage hypothermia (warmed fluid). Any burn to neck/torso/face will need feeding tube/ventilatory support. Antibiotics for Staph/Strep infections. Outpatient management– dressings changed, debridement (removal of debris), monitoring for infection.