IN CASUALTY
Remove all patient’s clothes.
Flush chemical burns with copious amount of water at least for 30 minutes.
Examine for associated injuries.
Estimate extent of the burn injuries (rule of nine’s, Lund-Browder chart or consider the area of
patient’s palm as 1% of total surface area).
Check criteria for admission.
Prescribe tetanus prophylaxis: Tetanus Toxoid - 0.5 mL IMI.
Unknown status of immunization:Tetanus Immune Globulin – 250 to 500 Units IMI + Tetanus Toxoid - 0.5 mL IMI
If patient requires admission:
Put up an IV line with a large bore needle (one or two peripheral IV lines) for an adult patient with more than 15% TBSA or a CVP for an adult patient with more than 25% of TBSA. Put up an IV line for a child < 2 years old with more than 5% of burned area and > 2 years old with more than 8- 10% of burned area.
Start the fluid replacement for the initial 24 hours according to Parkland
Adults: 4 mL of Ringer Lactate x % of TBSA x Weight of the patient (Kg). Half of the calculated amount must be given in the first 8 hours from the burn injury time; the other half must be given over the next 16 hours according to the hourly urine output, blood pressure and pulse rate.
Children: 2 – 4 mL of Ringer Lactate x % of TBSA x Weight of the patient (Kg). Half of the calculated amount must be given in the first 8 hours from the burn injury time; the other half must be given over the next 16 hours according to the hourly urine output, blood pressure and pulse rate; add maintenance fluids (see EMSB manual)
For electrical burns:
Calculate +- 6 mL RL x TBSA x Kg (adults) and 4mL RL x TBSA x Kg (children) to keep
urine output higher.
ON ADMISSION AND 1ST 24 HOURS
Below we have listed important data to guide young doctors when writing a burned patient’s history and physical examination. A guide for the management and treatment chart during the admission is also provided. The 1st 24 hours are very important for the resuscitation of the patient (patients may have hypovolemic shock). A close follow-up of the vital signals is very important, as well as the balance between intake and output, especially the hourly urine output. Correction of the fluid deficit must be done to prevent renal failure.
INFORMATION TO BE COLLECTED FOR STATS/ DATABASE
Ask the date and time of the burn injury.
Describe where did it happen (specify exact place where it happened-if at home, at work, in a public building, on the street, if a road accident). Describe if it happened in an enclosed or opened space (burning shack or motor vehicle).
Document the date and time of admission to hospital.
Describe the type of injury (etiological agent: hot/ boiling water, contact with hot source like heater, flame/open fire, contact with electricity or chemical agent, candle wax, paraffin or petrol, friction)
The nature (domestic accident, assault, domestic violence, self-inflicted) and circumstances (child pulled kettle from the stove; explosion of paraffin stove; assaulted by boy/ girlfriend; building caught fire; MVA with fire).
If possible, describe the duration of exposure (if the patient was kept with burning/chemical clothes, if he/she was inside a car/building in fire for several minutes).
Ask for predisposing factors (e.g. use of alcohol/ drug abuse close to flame, epileptic fit close to flame, psychotic disorder/ hearing voices to put fire on him/her, child was left alone).
Ask for risk or co-morbid factors (pre-existing high blood pressure, diabetes, COPD, seizure disorders, smoking habits, mental disorders, alcoholism/ drug abuse and any other medical condition).
Ask patient’s occupation, grade of instruction (or the parents, in case of small children).
Write down patient’s race.
PAST MEDICAL HISTORY, MEDS, ALERGIES, SOCIAL HISTORY OF INTEREST
Any allergy (specifically to sulphur, penicillin, and iodine).
All illnesses and medications currently in use (anti-hypertensive, anti-epileptic).
Use of alcohol and any illicit drug.
TB exposure and treatment.
HIV status and medication in use (check if the patient is registered on the program for HIV).
Women of childbearing age: ask for menstrual period and possibility of pregnancy. If needed,request pregnancy test.
Tetanus immunization status (usually doctors in Casualty give tetanus toxoid).
Any treatment received before admission (if referred from other hospitals).
PHYSICAL ASSESSMENT AND EMERGENCY MEASURES
Burn size: % of Total Body Surface Area burned (use the rule of nines or, preferentially, the Lund-Browder chart)
Burn depth: specify according to the location in the body (e.g. 2nd degree superficial on the face, 2nd degree deep on the chest wall, 3rd degree on the right forearm).
Breathing: In the case of suspected inhalational injury (enclosed space burns, changes in mentation, singeing of the face and facial/nasal hair, soot around the face or mouth, carbonaceous sputum, conjunctivitis) the patient must be put in facemask (humidified oxygen- 12 to 15 L/min).
If shortness of breath, hoarse speech and stridor are found, the patient must be intubated and put on a T-tube (if spontaneous breathing and no signs of respiratory distress), or a ventilator (ICU doctors shall be contacted for support). If there is a circumferential burn to the chest wall, an escharotomy must be done in the first 24 hours.
The ideal would be to perform a bronchoscope examination to diagnose smoke inhalation.
A gross examination of the oropharynx with the laryngoscope may show erythema and swelling of the vocal chords, and /or soot in the oropharynx and hypopharynx. These are indirect signs of upper airway injury.
If there is a circumferential burn to the chest wall causing respiratory distress (due to constraint), an escharotomy must be done in the first 24 hours.
Circumferential burn lesions on the upper/lower limbs: assess the blood circulation for the limb (temperature + capillary refill + palpation of pulse + Doppler) and perform an escharotomy at bedside, if indicated (cold limb + decreased pulse + delayed capillary refill or decreased arterial blood flow on Doppler - in comparison with the other limb).
In case of doubt, postpone escharotomy and follow for up to 72 hours. If electrical burns, a fasciotomy must also be performed (in theatre, under general anesthesia).
Associated injuries (fractures, soft tissue laceration / head/ neck / chest/ abdominal trauma): other specialists must be contacted for further management.
LAB TESTS
Adults: Full Blood Count (FBC), Urea, Creatinine and Electrolytes (UEC), Albumin, Random Glucose. If inhalational injury suspected: arterial blood sample for blood gas analysis and carboxyhemoglobin – COHb levels (if carbon monoxide –CO-
If electrical burn: CPK- MM and MB. Liver Function Tests (LFTs) for those with history of alcohol abuse (including cholesterol).
Children: Full Blood Count (FBC), Urea, Creatinine and Electrolytes (UEC), Albumin, Random Glucose. If inhalational injury suspected: arterial blood sample for blood gas analysis and carboxyhemoglobin – COHb levels (not available). If electrical burn: CPK- MM and MB.
OTHER TESTS AND CHARTS
Adults and children:
Chest X-Rays (if inhalation injury suspected: initial and subsequent).
ECG (if electrical burn or any heart condition).
Urine dipstick (to be repeated every second week).
Wound Swab for MCS (to be requested weekly and whenever needed).
Weight (weekly) and Height.
Temperature, BP chart, pulse and respiratory rates (hourly, or hourly and according to needs).
Fluid Chart 24 hours.
Hourly urine output (if necessary, a urine catheter- Foley - must be placed).
Blood glucose ( hrly).
PRESCRIPTION CHART
Fluid replacement:
Review the fluid replacement amount calculated in casualty.
Follow the success of resuscitation with the urine output by catheter and aim for the following:
Adults: 30 –50mL/ hour (75 –100mL/ hour if electrical burn).
Children: 1mL/Kg/hour < age 12.
Other not-so-reliable ways to follow the success of fluid replacement: Minimal level of blood pressure > 60mmhg
Pulse rate < 110.
If the patient doesn’t need fluid IVI, prescribe oral intake of fluids (old burns, minor burns).
Pain Medication:
Adults/ >50Kg:
Morphine Sulphate (10 mg/mL) diluted to 10 mL of solution with N/Saline or water
(1mg/mL): give 2 - 4mg IVI q2-3 hrly PRN. Use only in selected cases. *
OR
Morphine Sulphate (10 mg/mL): give 5 mg to 10mg IMI 4-6 hrly;
Morphine Sulphate 15 mg/mL): give 7.5 to 15mg IMI 4-6 hrly (0.1 – 0.2 mg/kg/dose).
OR
Morphine Sulphate syrup (15mg/10mL –i.e. 1.5 mg/mL): give 5 to 10 mL PO
(0.2 – 0.5 mg/kg/dose).
Caution when 10mg total dose of morphine IVI is reached, specially in patients with respiratory impairment. Use oxygen by mask or nasal prongs and close monitorization for at least 30 min with pulse oximetry. Preference for IVI in moderate to major burns because the IMI absorption is delayed, and oral for patients with minor to moderate burns. Do not give an IVI bolus if patient has hypovolemia (fluid resuscitation must precede the bolus, which should be given in smaller dosage increments). Use the IVI doses for severe/very severe pain and no oral intake.
OR
Pethidine injection (25mg/mL, 50mg/mL or 100mg/2mL): give 50 to 100mg (average 75 mg) IMI hrly (1mg/kg/dose IMI 4 to 6 hrly). *
*Avoid Pethidine in epileptics, psychotics or patients in use of psychotic drugs- it is a neuroexcitatory drug.
+
Paracetamol (Panado ®) (500mg): give ÍÍ tablets (1g) PO
OR
Paracetamol + Codeine (Dolorol Forte ®) (500mg + 8mg): give ÍÍ tablets (1g) PO
Do not prescribe Paracetamol if patient has history of chronic alcohol abuse and possible liver failure; check liver function tests first.
Do not exceed 4 g/24hrs.
Children:
Tilidine (Valoron® drops – 1 drop = 2.5mg): give 1 drop/2.5 kg sublingually 6 hrly (1mg/kg/dose).
+
Paracetamol syrup (Panado® syrup) (25mg/mL or 120mg/5mL): give 2.5 or 5 or 10 mL PO
OR
Paracetamol tablets (Panado®) (500mg) – 20-45 Kg: give 500mg 6 hrly;
45 kg: give 1 g 6hrly.
Do not exceed 90 – 100mg/kg/24 hrs for children <45 kg .
Ulcer Prophylaxis:
Cimetidine/ Tagamet (for moderate to major burns to prevent ulceration of the upper gastrointestinal tract- Curling Ulcer)
Adults: give 200mg PO
Children: give 20 – 40mg/kg/day in 4 divided doses PO
Inhalation therapy (adults):
Ventalin + N/Saline in nebulisation 4 hrly in the ratio of 1: 4
Dressings:
Blisters and wounds are washed with warm water (temperature of water is tested on the patient’s skin). A wound swab is collected on this occasion. Wounds are covered accordingly:
Adults: Jelonet® or Chemspunge® or Flamazine® (Silver Sulphadiazine 1% cream)
Children: <1 year – Jelonet ®.
>1 year - Chemspunge or Flamazine®.
Bed rest with head elevated 45°.
Maintain elevation of burned extremities.
Do not start prophylactic antibiotics.
DAY 2 OF ADMISSION
The clinical condition of the patient must be strictly monitored. Some important considerations for the follow-up management of the burned patient are pointed below.
CLINICAL FOLLOW-UP
Breathing: refer to admission.
Circumferential burn lesions on the upper/lower limbs: refer to admission.
Check Lab results requested on admission/1st 24 hours to correct any abnormality (check particularly electrolytes). There is an expected increase in all blood cells and platelet count.
Check the fluid balance chart (fluid chart assessment) and correct any abnormality (intake vs output).
LAB TESTS
Request any other test needed (blood level of antiepileptic drugs and chemical drugs, pregnancy test), and repeat UCE, and arterial blood gas if necessary. Check results and correct any imbalance.
OTHER TESTS AND MONITORING
Chest X-Rays (if inhalation injury suspected, and also if was not done on admission).
ECG (follow-up of electrical burn).
Enzymes (follow-up of electrical burn).Temperature, BP chart, pulse and respiratory rates (keep hourly, and according to need).
Fluid Chart 24 hours.
Hourly urine output
Blood Glucose ( hrly)
PRESCRIPTION CHART
Fluid replacement:
As a general guide:
Adults: give half of the total amount of volume evaluated for the 1st 24 hours formula in Ringer Lactate, according to the hourly urine output, blood pressure and pulse rate.
Children: give half of the total amount of volume evaluated for the 1st 24 hours formula in Ringer Lactate, according to the hourly urine output, blood pressure and pulse rate.
If the patient doesn’t need fluid IVI, prescribe oral intake.
Pain medication:
Adjust doses prescribed previously if necessary.
Cimetidine: refer to admission.
Correction of hyperkalaemia (choose drugs according to K levels)
Adults:
Request ECG
Kexelate® (sodium polystyrene sulfonate): give 15-30g PO
by retention enema. Repeat 6 hrly as needed.
+
Calcium gluconate 10%: give 10 mL IVI over 10 minutes.
+
Dextrose 50%: give 50 mL with 5 units of short-acting Actrapid, Humulin IV
The ion exchange resin (Kexelate) has a slow onset of action; if a rapid
r reduction in serum potassium is necessary, add the other drugs (blood glucose levels must be monitored and a continuous infusion of glucose should be considered.
or
Salbutamol: 5 – 10 ml nebulized over 10min
+
Infusion 10-20% dextrose: give the amount necessary to maintain a high fluid output (500ml 4-6 hrly).
Children: consult the Pediatric Department for assistance.
Correction of hypokalemia:
Add 40mmol KCL (2 amp) in 200ml saline and run it at 40ml/hr
Oral slow-K may be used for less severe cases
Correction of hyponatremia
Sodium requirement (mmol): TBW (desired Na- serum Na) = (Weight x 0.6) (desired Na-serum Na)
Change fluids to 0.9% Sodium Chloride infusion (N/Saline).
If severe: replace using hypertonic saline
Volume of hypertonic saline required = Na requirement x 1000
Infusate Na concentration
Correction of hypernatremia:
Change fluids to 5% dextrose rehydration solution
Correction of hyperglycemia
Check update
Correction of hypoglycemia
Check update
Prevention of DVT (adults)
Enoxaparin sodium (Clexane ®) (40mg/0.4mL): give 20 mg SC injection daily. Use especially for obese patients, deep burn on the lower limbs, and patients bed- restricted.
OR
Heparin sodium: give 5000 IU SC 8-12 hrly. Monitor platelet counts and coagulation test.
Alkalinize urine with Sodium Bicarbonate (NaHCo3,) in electrical burns:
to raise urine pH to 7, and keeping blood pH below 7.5.AdultsCitro-Soda®: give 5 to 10mL or 1-2 tablets in half a glassful of cold water daily (on a empty stomach, followed by additional water).
Children (6-12 years)
Citro-Soda®: give 5mL or 1 tablet 8-12 hrly daily (on a empty stomach followed by additional water).
Use mannitol if heavily protein load in the urine, in electrical burns
Adults
Mannitol® 25% (12.5g/50 mL): give 50 to 100g IVI over 24 hrs- 25g initially, and 12.5g
2 hrly until urine clears the myoglobin pigment. Adjust the rate to maintain a urinary
output of at least 30-50 mL per hour.
Children
Consult the Pediatric Department for assistance.
Nasogastric tube if patient is vomiting, distended (ileum) and for early enteral feeding (if not feeding properly per os).
If adult patient has nausea and vomiting:
Metoclopramide (Maxolon®) (tablets 10mg, syrup 5 mg/5 mL, inject 10mg/2 ML): give
10mg 8 hrly daily (> 60 Kg ) or 5mg 8 hrly (< 60kg), maximum 0.5 mg/kg/24 hrs.
Dressing:
Changes according to specification:
Jelonet ®: changed every second day.
Flamazine ®: daily change.Chemspunge ®: daily change.Early ambulation – must be stimulated. Physiotherapy for active and passive joint mobilisation
the rapy for
Splinting of burned joints according to OTs prescription.
Diet requirements according to dietician’s prescription.
If the patient is not eating well, a NG tube must be inserted for enteral feeding.
Correct low albumin levels (< 17)
Albumin (Albusol®20%) (20g/100mL): give 100mL IVI daily, in infusion.
- Infant: 120- 150mL/Kg /24 hr.
- 2-5 yrs: 100mL/Kg/ 24hr.
- 5-8 yrs: 80mL/ Kg/ 24 hr.
8-12 yrs: 50mL/ Kg/24 hr.
If the patient doesn’t need fluid IVI, prescribe oral intake
Pain medication
Adjust doses prescribed previously, if necessary.
Cimetidine: refer to admission.
Vitamins
AdultsVit C (100mg): give İ tablet +
Vit B Co: give İİ tablets PO
+
Vit B1 (Thiamine) (100mg): give İ tablet PO
OR
Multivitamin syrup: give 5 to 10 mL daily.
Children
Vit C (100mg): give I/2 to İ tablet PO
+
Vit B Co: give I/2 to İ tablet PO daily, or 2.5 to 5 mL PO
OR
Multivitamin syrup: give 2.5 to 5 mL daily.
Add any other medication needed – for hypertension, epilepsy.
Prescribe blood transfusion if needed: draw blood for cross-match together with the prescription.
Adults: Give packed red cells according to formal Hb, in IVI infusion over 4 hours. Remember to give authorization to the sisters in the prescription chart.Children: Give pediatric packed red cells according to formal Hb, 10mL/kg in IVI infusion over 4 hours. Remember to give authorization to the sisters in the prescription chart.
Dressing
Adults: Flamazine ® or Chemspunge®.
Children: <1 year – Jelonet® or Chemspunge®.
AFTER SECOND WEEKFOLLOW-UP
>1 year – Flamazine ® or Chemspunge®.
Temperature chart: refer to 1st week.Check weekly ward Hb, wound swab results, urine dipsticks. Change antibiotic prescription according to wound swab results.Check for any symptoms or signs of stress ulcer of the GI system. If positive, request an endoscopic examination (specially if the patient has complaints of abdominal pain, dizziness, and he/she is pale, the BP is low, and stools are darker).Check for any symptoms or signs of candidiasis of the GI system (check the mouth for thrush). If positive, request an endoscopic examination.Assessment of the wounds: refer to 1st week.
PRESCRIPTION CHART
Fluid replacement: refer to 1st week.
Pain medication Adjust doses prescribed previously if necessary.
Cimetidine: refer to admission.
Add these Vitamins
Adults
Folic acid (5mg): give İ tablet PO
+
Ferrous Sulphate (FeSo4) (200mg): give İ tablet PO
Children
Folic acid (5mg) –1 to 2mg/day: give I/2 to İ tablet PO daily or 2.5 to 5 mL PO
+
Ferrous Sulphate (FeSo4)- 5-10 mg/kg 3 times a day (syrup 300mg/10mL): give 2.5-5 mL three times a day PO
Oral candidiasis:
Mycostatin solution: give 10mL for mouth wash, tds.
