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Case Presentation: Burns
Transcript of Case Presentation: Burns
A Case Presentation CASE 10/08/10
Industrial estate, Telford
52 M construction worker
Drilled through electric cable
?Electrical flash burn
?Electrical conduction burn Treatment (on scene)
A: Airway intact. ?imminent compromise
B: Shallow and rapid. No additional noises. 15L O2 via Hudson mask
C: Tachycardic, normotensive
D: GCS 15/15
E: Burns – paramedic began dressing with clingfilm and hydrogel dressings to the face
Pt wrapped in blanket
Morphine 10mg IV
Metoclopramide 10mg IV
Ketamine 40 + 30 IV
Midazolam 2mg IV FOLLOW UP
Initial treatment at QE
A&E: Venflon x 3, Arterial line
A: tight, B: RR 26, C: fluctuating but stable BP, still tachy
Appearance: singed eyebrows, hair, nasal hair and lips. Tongue OK
RSI: intubated and ventilated in ICU
> Pre-oxygenation, cricoid P, thiopentone 500mg
> Congestion of supraglottic tissues noted
Fluids, ECG, Catheter
Burn wounds – 10.5% TBSA, Partial-Full thickness Discussion
Until recently, no standardised approach to pre-hospital care of burns patients
Patients arriving to A+E still cold and in pain
‘Allison K. (2001) The UK pre-hospital management of burns patients: current practice and the need for a standard approach’ Burns. 28: 135-142
58% - no treatment policy for burns
12 types of dressing used
74% give oxygen to all patients PLASTIC SURGEONS
Oxygen need not be given to all patients
Analgesia: Etonox +/or IV Morphine PROPOSED REASONS
Most of the texts available for immediate care of burns give an in-depth description of thermal injury and classification systems.
. > Texts also encourage size estimation
. > Too much complexity around burns physiology
. > Not enough emphasis on what to do when first
. presented with a patient. CONCLUSION
Wide variation in basic approach to the first-aid and pre-hospital care of burns patients
Burns in UK responsible for 175,000 attendances to A+E departments; affect 0.5% population/year
New guidelines formulating a national standard approach across all ambulance services could significantly improve patient care Recommendation:
NEED FOR A SIMPLE STANDARDISED APPROACH INITIAL MANAGEMENT OF BURNS PATIENTS
Consensus guidelines: 9 Step Approach:
1) SAFE approach
2) Stop the burning process
3) Cooling (“cool the wound, warm the patient”)
5) Assessment of AcBC
6) Assessment of burn severity
7) Cannulation (and fluids)
9) Transport DRESSINGS Assessment of burn severity
There have been problems deciding an optimal protocol for pre-hospital management of burns patients
Pre-hospital care teams are advised to follow 9 steps according to the consensus guidelines
However, there are ongoing debates regarding the efficacy of pre-hospital management of burns patients
Burns management can be stressful for the pre-hospital carer, especially if multiple injuries present. REFERENCES
Immediate Care of the Burned Patient, SM Jones, PM Gilbert
http://www.bmj.com/content/338/bmj.b1037.full (BMJ 2009; 338:b1037 doi: 10.1136/bmj.b1037 (Published 8 April 2009) Cite this as: BMJ 2009; 338:b1037 )
http://emj.bmj.com/content/21/1/112.full (Emerg Med J 2004;21:112-114 doi:10.1136/emj.2003.008789 Prehospital careConsensus on the prehospital approach to burns patient managementK Allison, K Porter ANY QUESTIONS?? Smith J.J et al. (2004) A comparison of serial halving and the rule of nines as a pre-hospital assessment tool in burns. International Journal of Surgical Reconstruction. 58(7):957-967
125 member of emergency services shown videos with instructions of two methods, and then these techniques were used to assess 10 simulated casualties
No statistical difference between 2 methods
Muehlberger T. (2010). Emergency pre-hospital care of burn patients. The Surgeon. 8(2):101-104
Intensive care and the surgical therapy of burn injuries have made significant advancements.
The immediate care on the scene of the accident, however, is not uniform.
The acute estimate of the percentage of the extent of the burns is of little relevance and does not facilitate the admission to a burn unit.
The emergency calculation of the volume of intravenous infusion is not advisable.
The choice of transport has no discernible impact on the prognosis of the patient.
Avoiding hypothermia and perceiving associated trauma can be of crucial prognostic importance in the pre-hospital care of burn patients.
Detailed knowledge about the circumstances of the injury is of exceeding importance Bethany Fitzmaurice