Emergency Medicine

BURNS

252 Surgical Emergencies

7 Determine the depth of the burn.

(i) Full-thickness: the skin is white or brown, dry, leathery, and

anaesthetic with no capillary refill. This will require skin grafting.

(ii) Partial-thickness

(a) deep dermal – the skin is pink or white, feels thickened, does

not blanch, and has reduced sensation. This should heal over

in about 3 weeks, but some areas may require grafting to

avoid leaving a scar

(b) superficial – the skin is red and blistered, blanches and is

painful. This should heal spontaneously in 10–14 days.

(iii) Superficial: erythema, blanching and pain occur, followed by

peeling as in sunburn. This should heal rapidly in 5–7 days.

8 Insert two large-bore i.v. cannulae and send blood for FBC, U&Es, CK, blood

sugar, G&S and a drug screen if there is suspected alcohol or drug abuse.

(i) The cannula may be placed through burned skin if absolutely

necessary, or use a cut-down technique if no vein is found.

(ii) Avoid central line insertion because there is a high risk of sepsis

from this procedure.

9 Check ABGs. An elevated carboxyhaemoglobin level will confirm exposure

to carbon monoxide (see p. 184).

10 Monitor the ECG and attach a pulse oximeter to the patient.

11 Request a CXR.

MANAGEMENT

1 Confirm the adequacy of the airway and give 100% oxygen by tight-fitting

mask with reservoir bag.

2 Give salbutamol 5 mg nebulized for wheeze.

3 Organize for an airway-skilled person to perform urgent endotracheal

intubation using an RSI technique with an uncut endotracheal tube in

patients with:

(i) Significant burns involving the face, tongue and pharynx.

(ii) Stridor, hoarseness, respiratory distress or a deteriorating level of

consciousness.

(iii) Evidence of cyanide toxicity from smoke and fume inhalation.

4 Commence i.v. f luids in any burn >10% BSA in a child or 15% BSA in an

adult, or for associated injuries causing hypovolaemia.

5 Determine the rate of f luid administration using the Parkland formula:

(i) Give fluid at 4 mL/kg per percentage of BSA burned

(a) administer the first 50% in the initial 8 h, and the remaining

50% in the subsequent 16 h.

(ii) More rapid fluid replacement may be required to catch up if

there has been a delay in reaching hospital.