Dr Luke Phillips Emergency Physician
Peer review: Dr David McCreary
WELCOME TO FAST FRIDAYS – A CASE-BASED, RAPID REVIEW OF A TOPIC. THE CASES HAVE BEEN ADAPTED FROM REAL PATIENTS BUT HAVE BEEN CHANGED FOR ANONYMITY AND TO EMPHASISE KEY LEARNING POINTS.
THE CASE
A 18-year-old male has been brought to your rural Emergency Department suffering a mixture of mid-deep dermal burns to his face, left arm and thorax and full thickness burns to his right arm. He was lighting a campfire and poured petrol onto the fire which resulted in his burns. The paramedics report initial first aid was given at the scene. You estimate the extent of the burns to be around 35% Total Body Surface Area (TBSA). This was an isolated injury, and no other trauma was reported. There were no circumferential burns.
His initial vital signs are Glasgow Coma Scale 15, Blood Pressure 150/80, Heart Rate 130, Oxygen Saturations 98% (Room Air). His estimated weight is 80kg
The Alfred is a major burns centre, we receive all the adult major burns in the state; how the patient is initially assessed, resuscitated and then packaged for transfer is important in their ongoing care. This post highlights some of the key concepts that apply both at our centre but also in a non-burns centre. With the upcoming Easter Holidays (think camping trips and campfires 🏕), I thought it would be timely to remind ourselves of the key aspects of managing this patient group.
☝️ Practice Pearl: Get an APP to help you estimate TBSA. A great examples can be found on the Trauma VIC app (iPhone/Android)
WHAT ARE THE KEY PRINCIPLES IN MANAGING THIS PATIENT WITH SEVERE BURNS?
1. RESUSCITATION
On reception of a burns patient a systematic assessment using an A-E approach should be used with interventions as necessary.
Look specifically for signs of airway burns such as hoarse voice, stridor, harsh cough, facial burns (especially mouth/lips/nose) + singed hairs, inflamed oropharynx, coughing up carbonaceous sputum and soot in mouth/oropharynx. You should also exclude associated trauma as required and if all is ok then move on to managing the burns.
2. ANALGESIA
Burns are bloody painful, particularly if they are mid-deep dermal where all those nociceptors are located. Give your patient some form of intravenous opioid medication (Morphine 5-10mg q5min or Fentanyl 50-100mcg q5min). He is 18-years-old so please don’t mess about with paediatric doses and give a decent dose.
You could also consider Ketamine (10-20mg IV boluses) as an adjunct and potentially commence an infusion if there are high opioid requirements. Don’t forget your multi-modal analgesia, so load them up on paracetamol 1g QID and ibuprofen 400mg TDS.
3. FLUID MANAGEMENT
A large TBSA burn (>20% in adults) means you have lost the skin barrier; these patients loose fluids via third spacing caused by capillary leak. Commence fluid resuscitation early using the modified Parkland formula:
3-4ml x TBSA% x Wt (kg)
In this case, we calculated 8.4 – 11.2L. My preference is to use Hartmann’s Solution, giving 50% (4.2-5.6L) in the first 8 hours and the remainder over the next 16 hours. Physiological targets are important to monitor and in this case I would aim for normotension or a MAP >60-65mmHg, urine output > 0.5ml-1ml/kg/hr, monitor the lactate and base excess and examine the patient for signs of worsening perfusion.
☝️Practice Pearl: A rising lactate or persistent lactate > 10 along with a metabolic acidosis can be a sign of cyanide toxicity a common byproduct of burning all the plastic crap we have in our houses. If in doubt treat for this.
4. TEMPERATURE MANAGEMENT
That pesky skin again – apparently losing your skin leads to problems controlling temperature. Remember to keep your patient warm and aim for normothermia. Monitor temperature centrally (IDUC catheters are ideal for this) and use warmed fluids, blankets or Bair Huggers to prevent heat loss. Don’t forget to change all those soaked sheets from the leaky capillaries too.
5. WOUND MANAGEMENT We don’t need anything fancy here. Once the patient arrives at a burns centre, we can sort this out. If contaminated, please do your best to clean the burns then after your assessment cover them in either cling film or impregnated gauze/crepe bandages. Application of dressings can help with decreasing fluid losses and pain and improving thermoregulation. You should also administer ADT (if required) and if grossly contaminated burns, then consider IV antibiotics (Antibiotics should not be given routinely).
☝️Practice Pearl: Don’t apply your cling film circumferentially or too tight as you can cause an iatrogenic compartment syndrome. Apply loosely and if able longitudinally.
6. TRANSFER
Early referral to your nearest trauma centre is important for both operative management of the burns and ICU supports for large TBSA burns. Contact your local retrieval service to help coordinate this.
THE OUTCOME The key principles of management were applied to this patient, and they were retrieved to a major burns centre where, after their initial reception in ED, they were transferred to ICU for ongoing supportive care. The patient underwent extensive skin grafting before being discharged to a community rehabilitation centre.
REFERENCES AND FURTHER READING:
Trauma Victoria – Burns Guidelines
VicBurns Website – Burns Management Guidelines
ALFRED EMERGENCY EDUCATION - THE PROCEDURES COURSE
The Procedures Course from Alfred Emergency Education is a cadaver based practical course where you can learn how to perform several emergent procedures including how to perform a burns escharotomy.
This excellent podcast from Dr Mike Noonan discusses key principles of Escharotomy.
LUKE PHILLIPS
Emergency Physician
Dr Luke Phillips is an Emergency Physician at Alfred Health in Melbourne and currently the Co-Director of Emergency Medicine Training. He is a passionate educator and has been fortunate enough to be able to combine this with his love of emergency ultrasound. Luke has a special interest in the use of focused ultrasound for critically unwell patients, in trauma management and in the use of ultrasound to guide procedures and improve patient safety in the ED. He is currently the Co-Chair of the Emergency Medicine Ultrasound Group (EMUGS.org) Board of Directors and holds a number of CCPU units through ASUM. Luke is also involved in the department’s international education program and has developed a Certificate of Emergency Medicine which is currently being run in both Germany and India. He also has interests in human factors, debriefing (particularly after clinical events), and simulation. His Twitter handle is @lukemphillips.
