Burns

Question 1

What is the first aproach to managing a patient presenting with burns?

Answer 1

Immediate first aid - ABC, remove person from source

Question 2

What is the immediate management of a patient presenting with burns caused by heat?

Answer 2

• remove person from the source
• within 20 minutes of the injury, irrigate the burn with cool (not iced) water for 10-30 minutes
• cover burn using clin film - layered rather than wrapped around a limb

Question 3

Within what time and for how long should a burn caused by heat be irrigated?

Answer 3

within 20 minutes of the injury

for between 10-30 minutes

Question 4

How should you cover a burn caused by heat?

Answer 4

with cling film, layered rather than wrapped around a limb

Question 5

What is the immediate first aid for an electrical burn?

Answer 5

switch off power supply, remove the person from the source

Question 6

What is the immediate management of chemical burns?

Answer 6

brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended

Question 7

What is a useful rule to initially assess the extent of a burn?

Answer 7

Wallace’s rule of Nines

Question 8

What are 8 aspects to Wallace’s rule of nines to assess the extent of a burn?

Answer 8

1. head + neck = 9%
2. each arm = 9%
3. each anterior part of leg = 9%
4. each posterior part of leg = 9%
5. anterior chest = 9%
6. posterior chest = 9%
7. anterior abdomen = 9%
8. posterior abdomen = 9%

Question 9

What is the most accurate method for assessing the extent of a burn?

Answer 9

Lund and Browder chart

Question 10

What proportion of the total body surface area is the palmar surface?

Answer 10

1%

Question 11

What are the 4 classes of depth of burn? (modern and former terminology)

Answer 11

1. Superficial epidermal (first degree)
2. Partial thickness (superficial dermal) (second degree)
3. Partial thickness (deep dermal) (second degree)
4. Full thickness (third degree)

Question 12

What will the appearance of a superficial epidermal (first degree) burn be?

Answer 12

Red and painful

Question 13

What is the appearance of a partial thickness - superficial dermal (second degree) burn?

Answer 13

pale pink, painful, blistered

Question 14

What is the appearance of a partial thickness - deep dermal (second degree) burn?

Answer 14

typically white, may have patches of non-blanching erythema. Reduced sensation

Question 15

What is the appearance of a full-thickness (third degree) burn?

Answer 15

white/brown/black in colour, no blisters, no pain

Question 16

What are 6 situations when you should refer burns to secondary care?

Answer 16

1. All deep dermal and full-thickness burns
2. Superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children
3. Superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso or neck
4. any inhalation injury
5. any electrical or chemical burn injury
6. suspicion of non-accidental injury

Question 17

What are the 2 situations when you should refer superficial dermal burns to secondary care?

Answer 17

1. >3% TBSA in adults or >2% in children
2. involving face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso or neck

Question 18

What is the management of superficial epidermal burns in primary care?

Answer 18

symptomatic relief - analgesia, emollients

Question 19

What is the initial management of superficial dermal burns in primary care? 5 aspects

Answer 19

1. cleanse wound
2. leave blister intact
3. non-adherent dressing
4. avoid topical creams,
5. review in 24h

Question 20

After what time period should you review a superficial dermal burn in primary care?

Answer 20

24h

Question 21

What is the pathophysiology following severe burns, locally at the site of the burn?

Answer 21

local response with progressive tissue loss and release of inflammatory cytokines

Question 22

What is the systemic response to severe burns pathophysiologically?

Answer 22

• cardiovascular effects from fluid loss and sequestration of fluid into the third space
• marked catabolic response
• immunosuppression common with large burns

Question 23

What effect is a recognised event in the gut following severe burns?

Answer 23

translocation of bacteria from gut lumen

Question 24

What is a common cause of death following major burns?

Answer 24

sepsis

Question 25

What is the initial aim in the management of severe burns?

Answer 25

stop the burning process and resuscitate the patient

Question 26

In what 2 instances are IV fluids required in the management of severe burns?

Answer 26

1. Children with burns \>10% TBSA 2. Adults with burns \>15% TBSA

Question 27

What is the formula used to calculate the IV fluids needed in severe burns management?

Answer 27

Pakland formula volume of fluid = total body surface area % x weight (kg) x 4

Question 28

What are 3 aspects of the initial management of **severe** burns?

Answer 28

1. IV fluids: half of fluid is administered in first 8 hours 2. Insert urinary catheter 3. Analgesia

Question 29

How should fluid, calculated using the Parkland formula, be given in severe burns?

Answer 29

50% of IV fluid administered in first 8 hours 50% given in next 16 hours

Question 30

When should you transfer a patient with severe burns to a burns unit? 3 situations

Answer 30

1. complex burns 2. burns involving hand, perineum and face 3. burns \>10% TBSA in adults and \>5% in children

Question 31

What specific treatment may circumferential burns affecting a limb or severe torso burns impeding respiration require?

Answer 31

escharotomies: surgical procedure performed to allow greater circulation to that part of body

Question 32

What is an escharotomy?

Answer 32

eschar is stiff, dead skin tissue caused by deep 2nd or 3rd degree burns. escharatomy is surgical incision through the eschar to release the constriction, restoring distal circulation and allowing for adequate ventilation

Question 33

What are the 2 key situations when escharotomy is performed?

Answer 33

1. circumferential burn around limb 2. torso burn affecting respiration

Question 34

When is conservative management of severe burns indicated?

Answer 34

superficial burns and mixed superficial burns that will heal in 2 weeks

Question 35

What may the management of more complex, severe burns require?

Answer 35

excision and skin grafting

Question 36

Is excision and primary closure of burns performed? Why/why not?

Answer 36

not generally practised as there is a high risk of infection

Question 37

Is antibiotic prophylaxis/ topical antibiotic treatment given in burn patients?

Answer 37

no evidence to support their use

Question 38

What is the benefit of escharotomy in a burn involving the torso?

Answer 38

careful division of encasing band of burn tissue will potential improve ventilation

Question 39

What is the benefit of escharotomy in a circumferential burn involving a limb?

Answer 39

will relieve compartment syndrome and oedema

Question 40

What happens blood in extensive burns and why?

Answer 40

haemolysis, due to damage of erythrocytes by heat and microangiopathy

Question 41

What are 2 ways that dehydration/hypovolaemia follows burns?

Answer 41

1. **Loss of capillary membrane** **integrity** causing plasma leakage into interstitial space 2. **Extravasation of fluids from the burn sit**e causing hypovolaemic shock (up to 48h after injury) - decreased blood volume and increased haematocrit

Question 42

Up to what time period following extensive burns can hypovolaemic shock occur due to extravasation of fluids from the burn site?

Answer 42

up to 48 hours after injury

Question 43

What can happen to serum protein levels with burns?

Answer 43

protein less - levels decline

Question 44

What type of infections are you particularly prone to following severe burns?

Answer 44

secondary infection e.g. Staphylococcus aureus

Question 45

What are 4 problems secondary to extensive burns that patients are at risk of?

Answer 45

1. Secondary infections e.g. Staph aureus 2. ARDS 3. Risk of Curlings ulcer (acute peptic stress ulcers) 4. Danger of full thickness circumferential burns in an extremity as may develop compartment syndrome

Question 46

How does healing occur in superficial burns?

Answer 46

keratinocytes migrate to form a new layer over the burn site

Question 47

How does healing occur following full thickness burns?

Answer 47

dermal scarring usually need keratinocytes from skin grafts to provide optimal coverage

Question 48

What is the main aim of fluid resuscitation following burns?

Answer 48

to prevent the burn deepening

Question 49

At what point following a burns injury is most fluid lost?

Answer 49

24 hours after the injury

Question 50

What happens to fluid in the first 8-12 hours after a burns injury?

Answer 50

fluid shifts from intravascular to interstitial fluid compartments, therefore circulatory volume can be compromised

Question 51

Why should colloids be avoided for fluid resuscitation following burns?

Answer 51

fluid resuscitation can result in more fluid moving into the interstitial compartment (rather than intravascular), especially colloid, so avoid in first 8-24h

Question 52

What type of fluid should be given IV in burns injuries?

Answer 52

Crystalloid only e.g. Hartman's solution/Ringers' lactate

Question 53

What does the Parkland formula calculated?

Answer 53

total fluid requirement in 24 hours; fluid requirement = 4ml x total burn surface area (%) x body weight (kg)

Question 54

What is considered the resuscitation endpoint following severe burns?

Answer 54

urine output of 0.5-1.0 ml/kg/hr in adults (increase rate of fluid to achieve this)

Question 55

What is the starting point of fluid resuscitation following a burns injury?

Answer 55

the time of injury

Question 56

What should you deduct when calculating IV fluids to give following a burns injury?

Answer 56

fluids already given

Question 57

24hours after a burns injury, what is done next regarding IV fluid replacement? 2 aspects

Answer 57

* colloid infusion is begun at rate of 0.5ml x TBSA (%) x body weight (kg) * maintenance crystalloid (usually dextrose-saline) continued at rate of 1.5ml x (TBSA) x body weight (kg)

Question 58

What are 2 examples of colloids that can be given after 24hrs following a burns injury?

Answer 58

albumin FFP (fresh frozen plasma)

Question 59

What type of burns require more fluid that based on the traditional formulae?

Answer 59

high tension electrical injuries and inhalational injuries

Question 60

In addition to fluids, what else can be supplemented in the treatment of burns?

Answer 60

antioxidants such as vitamin C - to minimise oxidant-mediated contributions to the inflammatory cascade in burns

Question 61

What are 4 things to monitor whilst giving treatment for burns?

Answer 61

1. Packed cell volume 2. Plasma sodium 3. Base excess 4. Lactate