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Airway and breathing
Inhalation injury is important as it could potentially stop breathing and damage the lungs. There can also be carboxyhaemaglobin (COHb) where oxygen can no longer bind to haemoglobin, and can kill. Inhalation injury is made more likely by:
- Hx: fire in enclosed space
- Examination: burnt oropharynx or nasal hair; soot in upper airway or sputum; or burns evident on bronchoscopy.
- Carboxyhaemoglobin, ABG
- High-flow 100% O2 - reduces COHb half-life from 250 to 40 minutes.
- Call anaesthetist - intubate if in doubt
Insert 2 wide-bore IV cannulae. The aim of fluid resuscitation is to anticipate and prevent shock. As such, it is important to have a good idea of how extensive burns are as that gives an idea of how much fluid has been lost.
Burn Surface Area (BSA)
You can use a burn chart; the rule of serial halves (>1/2, <1/2, 1/4-1/2, <1/4); or the Wallace rule of nines:
- Arm (all over) 9%
- Leg (all over) 18%
- Front 18%
- Back 18%
- Head (all over) 9%
- Genitals/perineum 1%
- Palm and fingers (one side of the hand) 1%
After you've figured out how much of somebody is on fire, you have to figure out how much fluid to give them. There a variety of formulae but the main one is Parklands.
You give 1/2 in 1st 8h, 1/2 in next 16h.
The Burn Itself
Now you've dealt with the airway and breathing, next is the burn itself.
- Remove burnt clothing
- Irrigate burns with cool saline for 10-20 minutes
- Warm patient
- Use clingfilm longitudinally
For chemical burns, continually irrigate.
Assessment of burns
After figuring out how much of the body is burnt, you need to figure out how deep the burns are. Remember a scald is a burn caused by hot liquid or gas.
- Full thickness burns are white/grey/black, thick and insensate
- Superficial burns are painful, red and have blisters.
It can be difficult when talking about intermediate burns but that gives a basic idea.
This is where a circumferential band of full-thickness burn acts as a torniquet. Full-thickness burns are stiff and inflexible and can constrict blood drainage from and supply to an arm. Escharotomy, cutting through the band of burn to "release the torniquet" is the best treatment.
Transfer and dressing
Clean the wound with 0.9% saline, leaving blisters unless they're causing pain. Cool wet dressings for pain relief; Clingfilm and then blankets for warmth; hands and feet elevated in plastic bags; analgesia; and tetanus prophylaxis.
All the stuff about assessing fluid management and BSA doesn't apply to children. They need to be treated earlier, essentially.