Major Burn

You are the Plastic Surgery CT1 and are asked to see a 34 year old patient in A+E resus who has sustained a burn – you are not given any further information regarding the type and severity of the burn. 

Example answer introduction

In this scenario I would be most worried about a potential major burn with potential airway compromise.  I would assess this patient using an A-E approach, take a focused history and examine and extent the nature of the burn. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate the plastic surgery registrar.

Initial assessment + simultaneous resuscitation:

 

On arrival, manage the patient using an A to E approach according to the Advance Trauma Life Support Algorithm.

  • Airway with C-spine control

    • In particular look for potential airway compromise / inhalation injury e.g. Burns to face, neck or upper torso; Singed nasal hair; Carbonaceous sputum or soot particles in oropharynx; Change in voice with hoarseness or harsh cough; Dyspnoea; stridor; Erythema or swelling of oropharynx on direct visualisation 

    • If concerns: call anaesthetics as the airway may need securing

  • Breathing

    • oxygen saturations, examine chest, examine work of breathing, breathing depth

    • if concerns give high flow oxygen through a non-rebreathe mask

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output 

    • IV access - large bore and bloods including CRP

    • IV fluid resuscitation: Parkland formula for burns resuscitation 

      • Total fluid requirement in 24 hours = 4ml x BSA (%) x body weight (kg) 

      • 50% given in first 8 hours 

      • 50% given in next 16 hours 

    • Catheterise patient to assess urine output

  • Disability - GCS, pupils, blood sugar, temperature

  • Exposure-  systemic signs of shock, other injuries

Provide constant reassessment during this acute phase.

Focused history​

  • Allergies

  • Medications 

  • Past medical history

  • Last meal

  • Events leading up to this point - HAS THERE BEEN OTHER ASSOCIATED TRAUMA?

  • type of burn sustained e.g. scald, chemical, caustic, flame. 

  • Mechanism of injury

  • Contact time

  • First aid applied e.g. cold water – how long

  • IS THIS DOMESTIC ABUSE?

Burns examination

Assess Burn 

  • Body Surface Area e.g. Lund and Browder, Rule of 9s

  • Type of Burn e.g. flame, scald, chemical, caustic, electrical

  • Depth

  • Superficial: Epidermal - epidermis is affected, but the dermis is intact.  Skin is erythematous and painful but no blisters 

  • Partial thickness: superficial dermal – involves epidermis and upper layers of dermis. skin is pale pink and painful with blistering. 

  • Partial thickness: deep dermal - epidermis, upper and deeper layers of dermis are involved. skin appears dry or moist, blotchy and red, and may be painful or painless. There may be blisters 

  • Full thickness - burn extends through all the layers of skin to subcutaneous tissues . Skin is dry and white, brown, or black in colour, with no blisters. It may be described as leathery or waxy. It is painless. 

 

If any of the following will need referral to burns unit/centre:

  • Child with any burn greater than 2% TBSA 

  • Adult with any burn greater than 3% TBSA 

  • Full thickness burn 

  • Circumferential burn

  • Inhalational injury 

  • Special areas – face, hand or foot, perineum or genitals, flexures, over a joint

  • Chemical / electrical burns 

  • High pressure steam injury

  • Hydrofluoric acid burn 

  • Potentially complex burn e.g. 2° to ionising radiation; suspicion of non accidental injury; coexisting diseases; pregnancy; extremes of age; associated major trauma 

Initial investigations and management

Investigations

  • Bloods – FBC, U+E, CRP

  • Check pH of burn if chemical burn

Management

  • First aid – irrigate the burn with cold water for at least 15 minutes. If chemical burn, check pH of the burn, continue until pH is neutral

  • Analgesia

  • Tetanus

  • Antibiotics

  • Cover burn in cling film

  • Inform plastic surgery registrar

  • Refer to Burns centre/unit for further management

  • Keep patient and any relatives informed

  • Document, document, document!!!

Escalation

Consider discussion with:

  • Plastic Surgery registrar

  • Anaesthetics +/- ICU

  • Other surgical teams if associated trauma

  • Safeguarding if physical abuse is suspected

Useful Resources

Initial management of a major burn: II—assessment and resuscitation (Contains diagrams for assessing Burn Surface Area)

Lund and Browder Chart 

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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