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National guide-lines criteria for referral to a specialised burns unit were issued in Health Circulars 83/339 and 86/102.
This means that if a patient fits any of these criteria, you must consult a burns unit Hospitals are instructed to ensure that consultation takes place on all such patients, although not all patients in these categories would benefit from transfer to a specialised burns unit / service. Because of our limited facilities at Liverpool we encourage burns units to accept our patients at an early stage
ASSESSMENT A major burn can be defined as covering more than 15% of the body surface area in adults and 10% in children. The burns assessment chart must be used to assess the extent of the burn. Evaluate the patency of the airway: Inhalation injury usually appears within 2~48 hours post burn and is secondary to inhalation of combustion products. Symptoms include rales, rhonchi, stridor, hacking cough and laboured or rapid breathing. All patients should have high flow humidified oxygen to prevent drying and sloughing of mucosa and hypoxia whilst the airway is being assessed. Airway Assessment for inhalation injury includes: 1. Respiratory distress or upper airway obstruction 2. Burns around face or neck 3. Oedema of face or lips 4. Oropharyngeal carbon or carbonaceous sputum 5. Singed nasal hairs, eyebrows, eyelashes 6. Inflammation or oedema of oropharynx 7. Impaired Consciousness These signs, especially 1, 2, 3 and 4 indicate the need to intubate N.B. burn patients are among the most difficult intubations an anaesthetists will ever face. It is better to intubate early, possibly unnecessarily, than not at all at the appropriate time.
TREATMENT Stop the burning process by removing clothing, rings and other jewellery. ~nmerse or cover the affected area in cool water Treat Hypovolemia. An intravenous cannula (16G or 14G) should be inserted through unburnt skin. Resuscitation should be commenced with Hartmans solution. Potassium should not be added. The Parkland formula is only a guide, and replacement should be reassessed on a regular basis.. Parkland formula for first 24 hours post burn (Half to be administered in first 8 hours post burn): 4 mls x % of body surface area burnt x body weight (kg) as Hartmans solution. + normal fluid requirements + blood from traumatic loss. This should be reassessed hourly. A urine catheter must be inserted to assess urine output. Urine output should be no less than 0.7ml/kg/hr. If urine output is inadequate, increase infusion by 200ml next hour. Treat cardiovascular instability: Cardiac rhythm should be continually monitored for arrhythmias. Monitor vital signs. Acidosis, hypovolemia and hypothermia contribute to decreased cardiac output. Electrolyte disturbances are thought to be secondary to a defective sodium pump. Potassium is usually elevated 24-36 hours following the burn due to lysis of cells. After 72 - 96 hours, hypokalaemia may develop as cell membranes regain their integrity. Burns may be covered with cool water (not icy) if this brings relief. Unburnt areas should be covered to maintain normothermia. Burns 20% or greater carry a high incidence of paralytic ileus and Curling Ulcer. A naso-gastric tube should be inserted and Sucralfate administered. Assess for concomitant injuries. Elevate limbs to decrease oedema. Flame burns to the neck and chest may contribute to respiratory difficulties as the inelastic eschar of the anterior and posterior thorax inhibits respiratory efforts. Escharotomies may be necessary Do not administer antibiotics. (Additional information: Escharotomy section in Trauma Procedures)
INVESTIGATIONS Arterial blood gases Arterial Carboxyhaemoglobin levels Full blood count Group and Hold Electrolytes Blood Cultures Chest X Ray
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