Editing Burns (section)

=== '''Moderate to severe burns: initial assessment and treatment''' ===

** '''Trauma ABCD assessment'''
*** Can be hard to take BP due to charred extremities - need invasive arterial monitoring in this setting, with peripheral pulses being used as a proxy of perfusion in the meantime
** '''Basics'''
*** Cover burns with clingfilm (can give a rinse if possible)
*** Bloods (?G+H)
*** IV access - prefer peripheral veins in unburned skin, but IVC through burned skin is better than no access at all
*** BSL
*** Pregnancy test
*** Check for compartment syndrome
**** Especially high-voltage electrical injuries, circumferential burns, delayed resus, or high-volume resus
**** Typically evolves over 12-72 hours following burn and resus
**** Hands, feet, legs, forearms, abdomen, eyes
**** Check for acute nerve compression syndromes
**** Serum CK and myoglobin can assist diagnosis
*** Remove jewellery
*** NGT if vomiting or TBSA>20%, according to Sabiston, as high-risk for aspiration
*** Tetanus if >10% TBSA
*** Consider deliberate burns
**** Burns on soles of feet
**** Buttocks
**** Other injuries present
**** Poor nutritional/developmental/psychologic state
** '''Assess for inhalation injury'''
*** Generally occurs above vocal cords
*** Can be catastrophic
*** Tends to worsen over the course of hours, not minutes
*** '''Signs of inhalation injury:''' (all individually non-sensitive, need to use clinical context as a whole, and bronchoscopy)

**** Persistent cough, stridor, wheezing
**** Hoarseness - impending airway obstruction
**** Deep facial or circumferential neck burns
**** Singed nares/inflammation
**** Carbonaceous sputum
**** Obvious blistering/oedema of oropharynx
**** Elevated carbon monoxide or cyanide levels
**** Hypoxia/hypercapnia

*** AIS grading of inhalation injury by bronchoscopy is as follows:

**** 0 (no injury) – Absence of carbonaceous deposits, erythema, edema, bronchorrhea, or obstruction
**** 1 (mild injury) – Minor or patchy areas of erythema or carbonaceous deposits in the proximal or distal bronchi
**** 2 (moderate injury) – Moderate degree of erythema, carbonaceous deposits, bronchorrhea, or bronchial obstruction
**** 3 (severe injury) – Severe inflammation with friability, copious carbonaceous deposits, bronchorrhea, or obstruction
**** 4 (massive injury) – Evidence of mucosal sloughing, necrosis, endoluminal obliteration

*** Cyanide inhalation

**** Cyanide toxicity can occur with burns in enclosed spaces - anaerobic metabolism -> hyperlactataemia or unexplained metabolic acidosis. 
**** Treat with hydroxycobalamin.

*** Carbon monoxide exposure

**** Presume in all suspected inhalation injuries
**** Most commonly causes dizziness, altered mental status, arrhythmias or even MI
**** HbCO levels:
***** <20% asymptomatic
***** 20-30% headache/nausea
***** 30-40% dyspnoea, confusion
***** 40-60% syncope, seizures, obtundation
***** >60% death
***** Also look for cherry-red skin but this is rare
***** If exposure has occurred, give 100% O2 via non-rebreather. Half-life is expected to be 40 mins with this, or 4 hours without O2.

*** '''Intubate if:'''

**** Deep burns to face and neck 
**** Blisters/oedema of oropharyns, burns inside mouth
**** Stridor (late)
**** Use of accessories
**** Resp distress or signs of compromise (fatigue, inability to clear secretions)
**** Sub/suprasternal retractions
**** Hypoventilation 
**** TBSA >40% - often intubated prophylactically for impending oedema
**** Needing emergent transfer
**** Carboxyhaemoglobin >10% is a relative indication
**** May require bronchoscopy later - prefer size 8mm internal diameter tube (4.5mm in child)

*** If not intubated:

**** Aim sats >90% with humidified high-flow
**** Coughing/deep breathing q2h
**** Chest physio
**** Saline nebs
**** Bronchodilator if wheezing
**** Mobilise if possible
**** Prophylactic antibiotics are not needed for inhalation injury