see also: [[Airway#Burns airway|Burns airway]] > [!references]- > - [RCH - Burns](https://www.rch.org.au/clinicalguide/guideline_index/Burns/), [Rosen - Thermal injuries](x-devonthink-item://339B27F6-6499-4988-8A86-614A6ACC7CF9?page=0), [Tintinalli - thermal burns](x-devonthink-item://FEDB96F9-3A4C-48E0-94CF-9ECFCE5D8E93?page=51) > - [victoria Burns Unit](https://www.vicburns.org.au/burn-assessment/burn-depth/) > - [Alfred Burns Management Guidelines](https://www.alfredhealth.org.au/services/statewide-services/victorian-adult-burns-service/victorian-state-burns-clinical-practice-guidelines) see also: [[Weapons of Mass destruction|terrorism]] # Burn size estimate > - rule of 9 inaccurate in age < 10. use Lund Browder chart or consider Hand method (palmer surface equivalent to 1% TBSA) > - erythema (superficial burns) not included in calculation ## Adults rule of 9s ![[Pasted image 20241101142909.png]] ## infants ![[Pasted image 20241101142547.png]] # Pathophysiolgy ![[Pasted image 20241015232056.png]] three zones of burn injury to the skin: 1. central zone of ==coagulation== or *irreversible necrosis* 2. intermediate and *potentially reversible* ==zone of stasis== or ischemia 3. peripheral *reversible zone* of hyperemia or ==inflammation== ![[Pasted image 20241015231610.png]] # depth assessment 1. **Epidermal:** Only the outer layer of the skin (epidermis) is affected. These burns typically heal without scarring. 2. **Superficial Dermal Partial Thickness:** Damage extends into the superficial layer of the dermis. These burns are painful and usually heal within 7-14 days with minimal scarring. 3. **Mid Dermal Partial Thickness:** Damage penetrates deeper into the dermis. These burns often require longer healing times and may result in scarring. 4. **Deep Dermal Partial Thickness:** More extensive damage to the dermis, with potential involvement of hair follicles and sweat glands. Healing may require weeks to months and scarring is common. 5. **Full Thickness:** Damage extends through the entire thickness of the skin, often involving underlying tissue, muscles, or bones. These burns typically require surgical intervention and may result in significant scarring and functional impairment. ![[Pasted image 20241015231533.png]] ![[Pasted image 20241015232545.png]] # management **Parkland Fluid formula:** 2-4mL/kg X TBSA % over 24 hours with *half of this given in first 8 hours* (more if deeper wounds, less if superficial burns)  - weight (kg) x TBSA burn = mL fluid to give in 2 hours (good for in the field) Aim for urine output 0.5-1mL/kg/hour in adults (30-50mL/h) ## cool affected area - <3 hours following injury - decreases depth, provides analgesia, reduced subsequent fluid requirements - cool saline pack 15 deg C - 'burn aid' helpful, but not recommended for burns >20% TBSA due to risks of hypothermia - apply cooling method for max of 20 min - following cooling, cover pt with sterile dressings to prevent heat loss - plastic cling wrap if pt able to be transfered to a burns centre within 8 hrs of injury - *apply longitudinally* over limbs, rather than circumferentially - paraffin gauze or silver dressings if > 8 hours ![[Pasted image 20240516192511.png]] # Escharotomy ![[Pasted image 20240516192648.png]] ![[Pasted image 20240516192934.png|escharotomy of hand Tintinalli]] # possible ventilation issues high pressures - trauma causes: pneumothorax 2/2 blast injury, primary pulm contusion, haemothorax  - burns-related: thoracic burns requiring escharotomy, pulm oedema 2/2 fluid resus or third-spacing, ARDS - ETT obstruction from burn secretions or blood - patient-ventilator dyssynchrony - obstructive lung disease # OSCE burns - [RMH 2019 station 6](x-devonthink-item://B3ABF2E8-4F7B-44E3-BC90-8ADF6621645C) - consider eg SCBD for *paeds burn*, teach a resident - first aid - assessment ***initial approach:*** - primary survey → special care to sensitive areas eg neck , mouth/face, genitals, circumferential burns - assessment of burn size (eg hand or Lund Browder) - AMPLE history - home safety - [[carbon monoxide|CO]]/[[Cyanide]] risks - consider other traumatic injuries - Ix: trauma imaging, bloods esp VBG look at K and lactate, BSL, coags, creatine kinase, ECG ***Mgmt:*** - first aid cool with water up to 30 hours post; burn shield to areas that cannot be irrigated, more likely to use hydrogel/wet towels - **avoid hypothermia** - absorptive dressing ie: bactigras or acitcoat applied - cling wrap should not be used for a patient > 6 hours! - Airway - O2 - opiate analgesia - parkland: 3-4 ml/kg/% burn/24 hours. 50% first 8 hours, next over 16 hours - assess fluid status and urine output - add to [[Paediatric fluids#Maintenance (mL/H)|paeds IV maintenance fluid rate]] - Tetanus ***Potential causes of high [[Lactic acidosis|lactate]] in a burns patient?*** - cyanide - CO poisioning - hypovolaemic shock - severe hypoxia - seizure - underlying sepsis ***desaturation in paeds burn patient? eg 8 years old*** - likely inhalation injury / pneumonitis - assess for stridor if upper airway burn - ddx: lung contusion from trauma, pneumothorax - see: [[#possible ventilation issues high pressures]] **Assess:** - CXR, POCUS for PTx , any wheeze? **Mgmt**: see [[Airway#Burns airway|Burns airway]] - preoxygenation HFNC and NRB - ventilator: *Lung protective ventilation* - PEEP 8-10 - TV 5-6 mL/kg - RR 25 - FiO2 1.0 then titrate down # Related Questions ## blast injury - [x] 1Q: [Explosion injury](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=34) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=23) ## burn - [ ] 2Q: [Facial burn](x-devonthink-item://80040649-2DDB-4266-9A7C-4DE4E6DD4AE6?page=11) -- [Answer](x-devonthink-item://C96EDD2F-137A-43E5-80EE-5F42C5971D55?page=15) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=12) ## burns - [ ] 3Q: [Burns](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=1) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=2) - [ ] 4Q: [Burns](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=34) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=36) - [ ] 5Q: [Burns](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=8) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=3) - [ ] 6Q: [Burns](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=23) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=16) - [ ] 7Q: [Burns](x-devonthink-item://7E9EF652-F67B-42C5-A536-2EE85BA1954F?page=36) -- [Answer](x-devonthink-item://2DE5FACA-6D8F-41A2-8EAA-8DFE1E76FA61?page=22) - [ ] 8Q: [Burns](x-devonthink-item://EB2A381E-D8D3-4236-B51F-2DF81CE08885?page=11) -- [Answer](x-devonthink-item://8455B512-D9BD-4314-927B-D3208619EE2A?page=10) - [ ] 9Q: [Burns](x-devonthink-item://8993893C-07A9-47B0-A68B-F8ED4C37C83D?page=2) -- [Answer](x-devonthink-item://C6A8980F-CAE5-458C-AC1E-FEBE553FDDE2?page=1) ## explosion - [x] DUPLICATE Q: [Burns](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=34) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=36)