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COMMONWEALTH OF AUSTRALIA
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Burn Management
Dr David Milliss
FANZCA FJCICM
10% Hospital
EMSB
Burn Admissions (%)
Adult Children
EMSB
Place of Burn
Home 61%
Work 17%
Roadway 10%
Outdoors 8%
Institution 4%
Elsewhere 2%
EMSB
Childrens Burns
Kitchen
Bathroom
EMSB
Pathophysiology
Jackson Burn Wound Model
Zone of Survival
Slide
Zone of Damage
Zone of Necrosis
Coagulation
Stasis
Hyperaemia
EMSB
Pathophysiology
ZONE OF STASIS
Compromised but viable cells;
Impaired blood flow:
Platelet aggregation; stiff heat-injured rbcs;
white cells adhere to vessel walls; fibrin
deposition
Hypovolaemic shock
EMSB
General Response
Early Care
First aid
Stop the burning
Avoid hypothermia
Immediate Management
Airway & C-spine
Breathing & O2
Disability (neurological)
Fluids
Eg. Sunburn
Red
Painful
No blisters
Healing in less than
one week
No scarring
Superficial
Dermal
Red
Painful
Blisters
Capillary refill
present
Healing slower,
over a few weeks
May be some
scarring
Deep
Dermal
Dark red
Not Painful
Blisters may be
seen
No capillary refill
Minimal or no
healing
Scarring will
occur
Full Thickness
White, waxy, charred
No sensation
No blisters
No capillary refill
No healing
Initial Assessment - Depth
Classic progression
Erythema
Blistering
Pink, blanching
Red, non-blanching
Leathery or charred.
Mixed
Dynamic
Progression in a Burn Wound
4 hours after injury 4 days later
Note early rigidity of deep All areas have become
burn around waist deep.
Fluid Resuscitation
Which type?
Na containing, Hartmanns solution, albumin
How much
Size and depth: not epidermal
Parkland formula: 3-4 ml/kg/%TBSA burnt
Administration: in first 8 hrs; in next 16 hrs
Inhalation injury
Electrical burns
Associated trauma
Other factors
Dehydration
Drugs
Dressings
Dry clean linen
Glad wrap
I=V/R
Basic Principles
Resistance of body tissues (least greatest)
nerves
blood
mucus membranes
muscle
dry skin
tendon
fat
bone
Cardiac injury
P (heat) = I2 x R x t
Basic Principles: pathophysiology
Damage to the tissues
in the body:
Strength of the current
Voltage difference
High voltage:
>1000
Power lines, utilities, industry (AC)
Typically: 11,000 / 33,000 volts, may be more
Lightning:
>1 million volts
DC
Low voltage injuries
Commonly seen in
children
Produce local
contact wounds
Usually mouth
(80%) or hands
May produce
cardiac problems
Low voltage injuries
Documented rate of arrhythmia following
electrical injury is about 8-15%
most occur within the first few hours
sudden cardiac death can occur
asystole (DC)
ventricular fibrillation (AC)
other arrhythmias include sinus tach,
transient ST elevation, reversible QT
prolongation, PVCs, AF, BBB
Low voltage injuries
Indications for cardiac monitoring
cardiac arrest
Reduced LOC
abnormal ECG
documented dysrhythmia
history of cardiac disease or risk factors
concomitant severe injury
suspicion of conductive injury through thorax
chest pain
hypoxia
Low voltage injuries
Asymptomatic patients who have suffered
a 110 V or 240 V electrical injury and have
a normal initial ECG, do not need
admission for cardiac monitoring
Muscle
Vascular
Renal, Neural
Other injuries
Trauma
High voltage injuries
High voltage injuries
Mostly work related
Some due to risk taking behaviour
Usually male, adults, some adolescents
More operations
More complications
Muscle damage: fasciotomy, amputations
Associated injury: brain, orthopaedic
Increased length of stay, higher mortality
High voltage injuries
Cardiac:
Not common
Arrhythmias
Cardiac arrest: asystole, VF
Early dysfunction, cardiomyopathy
Vascular:
Thrombosis, vessel rupture, spasm
Compartment syndromes
High voltage injuries
Neural:
Peripheral:
direct, myelin sheath vascular supply,
compartment syndrome
Spinal cord:
Immediate evidence of damage
Delayed presentation, prolonged recovery
Brain:
Transient loss of consciousness
Prolonged coma with eventual recovery, cataracts
Head trauma
High voltage injuries
Muscle and other tissue damage
Direct coagulation necrosis, vessel
damage, compartment syndrome
Damage is erratic
Damage can be deep
High voltage injuries
Muscle damage:
Direct coagulation necrosis, vessel
damage, compartment syndrome
Myoglobin released; Renal impairment
Fasciotomy
Amputations
High voltage injuries
Management:
Usual
Remove patient from danger
Protect self
ABC
Knowledge of the event
Burns
Deep tissue damage
Other injuries
High voltage injuries
Fluid resuscitation:
Formula: plus more than calculated from
cutaneous injury due to deep injuries
Myoglobinuria
Skin
less than 5% have deep burns (exit wound)
superficial burns
Linear
Punctate
Feathering
Thermal
Mechanisms of injury
Direct strike, orifices
Contact
Side flash, splash
Blunt trauma
Management:
Usual
Remove patient from danger
Protect self
ABC
Burns