S2E6: Burns - Trauma
We're back with a fiery trauma special, guaranteed to take your breath away!
Mohammed is joined by Marike and Marcus to explore our case, with our Adult in the Room Dr Robyn Powell on hand to check their work.
Orla then sits down with Mr Fergal Hickey to talk training for trauma as we look forward to ATLS courses coming back this year.
Right, let's get to it!
Burns - the non-”traumatic” trauma
Our case opens with our patient having been found unconscious in her apartment after a blanket caught fire – there are extensive burns to her upper limbs, chest and face.
In the wise words of the WHO, a burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.
Trauma Victoria defines a burn as a complex trauma that requires multidisciplinary care and ongoing therapy. Burn injuries can have a devastating impact on both the patient and family, resulting in both physical and psychological scarring.
Why do many people not see burns as a form of trauma?
Well, a major burn is by definition considered a complex trauma case as it requires multidisciplinary care and ongoing therapy.
When we think of burns, we often don’t think of them as a “trauma”. Why is this the case? Is it because we commonly see minor burns and scalds? Or does it just not have that “trauma” factor to it? No fall from a height, no broken bones, no getting hit by a bull or a truck…
What triggers our worry in a case like this?
Low GCS
Extensive burns to the face
When it comes to burns in an enclosed space, the airway should always take priority. Once the primary assessment confirms facial burns, singed facial hair, soot in mouth, hoarse voice or stridor, we should be thinking “we don't have much time with this airway”, and that this patient needs a definitive airway ASAP.
So, we’re worried… What are our first steps?
Zero-point survey
1. Prep Resus
2. Assemble a team — allocate roles consisting of:
An airway team comprising of an airway doctor and a nurse
Doctor in charge of assessing that feeds back to the team leader
Procedure doctor
Circulation team for IV access, drugs, bloods and fluids
3. Assemble equipment
Important here is the difficult airway trolley and FONA set, including a 6mm cuffed tube and a 10 blade, an ultrasound and the EZ-IO gun just in case all else fails
4. Next, the checklist and drugs for RSI should be prepared immediately
5. And finally, while everybody scrambles to get the equipment in place, the team leader will go through the airway strategy with the airway team
Plan A — the bougie + Video laryngoscope, with a maximum of 2 tries
Plan B — front of neck access should be performed in the event of CICO. This would be a good time to confirm if the team are happy with the plan and with performing this procedure
ABCs… With an emphasis on Airway
In a burns case like this, we’re especially worried about the patient’s airway.
Smoke containing superheated steam when inhaled can cause pulmonary damage, but usually this insult also causes glottic swelling, erythema, ulceration, and oedema. When this swelling is sufficient enough, it can obstruct the airways.
Planning for intubation
Premed: fentanyl 100mcg; may reduce bronchospasm
Sedation of choice: Propofol 1-2mg/kg
Muscle relaxant- Sux or Roc? Rocuronium 1-1.2mg/kg
Roc and Roll— I mean, suxamethonium
Ahh. the age-old roc vs sux debate.
Sux has a quicker onset of action, but it has the risk of causing hyperkalemia and malignant hyperthermia among other things, especially in burns. However, it is safe to use sux in burns less than 24 hours according to recent studies.
Can’t Intubate, Can’t Oxygenate? Time for Front of Neck Access
So, what if we end up in a CICO scenario? What’s our next course of action? First, declare CICO and transition to FONA. At this point, the resus room should be quiet.
In terms of equipment, what you’re going to need is a size 10 scalpel, a bougie (preferably with an angled tip), a size 6 tube, and a 10 ml syringe. Position the patient supine, and proceed to the neck.
Perform a laryngeal handshake and confirm position of the cricothyroid membrane, stretch the skin and fix the trachea at that point.
Next, make a transverse incision, then twist it 90 degrees (sharp side down).
Then insert the bougie along the far side of the blade to about 10 cm.
Next, rail road the tube using the bougie through the incision. Inflate the cuff and check for CO2.
Once successful, secure with a tie, ventilate and auscultate for bilateral equal air entry.
Remember, an unsuccessful airway attempt needs to be touched on in debrief!
It’s not the fault of the airway doctor. Don’t think of it as a “failed” airway — some airways just aren't “tubable”
Physiologically difficult airway (oedematous)
Anatomically difficult (immobilisation)
Further compounds difficulty with FONA
Total Body Surface Area of burns
Calculate Percentage of burns – Rule of 9’s, palm of patient, Lund and Browder Chart can be used. Mersey burns app is handy.
Fluid resuscitation: RCEM recommends modified Parkland’s Formula:0.5 in first 8 hrs. Adults @ 3mL/kg/ % TBSA (usually 3ml/kg/% is used)
?cyanide toxicity - hydroxocobalamin
Pressors - have nurses prepare norad infusion; give push doses of metaraminol/adrenalione in the meantime
So, how would you manage burns primarily?
Non adhering dressings like Mepitel and Cling Film. After airway, our primary focus is on insensible fluid losses
We also need to think about escharotomy — even if the circumferential burns are just at the fingers
Debridement of blisters is more for the treatments of minor burns and can be done in theatre at a later time
Consider rhabdo as an early consideration
Keep the patient warm & watch for hypothermia
Tetanus is always indicated. Antibiotics, however are not always indicated for acute burns
Disposition: ICU, plastics involvement, referral, and transfer to a dedicated burns unit.
Tetanus Risk Assessment
Don’t forget carbon monoxide and cyanide!
Physiologically, CO binds with haemoglobin reducing O2 delivery, causing impairment of cellular respiratory mechanisms, and a whole myriad of other cellular processes. But clinically, the symptoms of carbon monoxide are very non-specific. They can range from a simple headache or dizziness to unconsciousness and death.
Often in cases involving burns in an enclosed fire, cyanide then acts synergistically with Carbon monoxide to effectively lower their lethal doses causing the patient to deteriorate much quicker thus worsening the prognosis.
Diagnosis is best made in the presence of high lactate levels, carboxyhemoglobin concentrations greater than 10%, injury history of smoke inhalation from an enclosed fire, and alterations in consciousness. While treatment with hydroxocobalamin for cyanide poisoning is the standard of care it may also reduce concomitant CO toxicity.
Let’s summarise
1. Do your ABC’s, Primary and Secondary surveys
2. Look for oedema and secure an airway early. If necessary, go prepare for front of neck access
3. Ensure adequate access, give analgesia
4. % Burns area
5. Fluid resuscitation
6. Dressings and tetanus
7. Keep patient warm
8. Urinary catheter, pregnancy test and check for a tampon as it can cause toxic shock from being left in
9. Good communication with team and have a quick update of : what we’ve done and what’s our next priority
Resources & References
Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166036/
Burn Resuscitation And Management https://www.ncbi.nlm.nih.gov/books/NBK430795/
Fluid management in major burn injuries https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038406/
Fluid resuscitation management in patients with burns: update https://www.bjanaesthesia.org/article/S0007-0912(17)33788-1/fulltext
Megahed MA, Ghareeb F, Kishk T, et al. Blood gases as an indicator of inhalation injury and prognosis in burn patients. Ann Burns Fire Disasters. 2008;21(4):192-198. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188198/
Miller, RD et al. Miller’s Anesthesia, 7th edition, Churchill Livingstone: p 2490-1. 2009
Sargent RL. Management of blisters in the partial thickness burn: An integrative research review. J Burn Care Res 2006;27(1):66–81. Search PubMed
https://www.racgp.org.au/afp/2017/march/burns-dressings#ref-2
Royal Children’s Hospital Melbourne Burn Protocol: https://www.rch.org.au/burns/clinical_information/
Douglas HE, Wood F. Burns dressings. Aust Fam Physician. 2017 Mar;46(3):94-97. PMID: 28260266.
Henrik Lynge Hovgaard, Peter Juhl-Olsen, "Suxamethonium-Induced Hyperkalemia: A Short Review of Causes and Recommendations for Clinical Applications", Critical Care Research and Practice, vol. 2021, Article ID 6613118, 6 pages, 2021. https://doi.org/10.1155/2021/6613118
Nickson C. (March 17, 2019.) Does Roc rock? Does Sux suck? Life in the Fast Lane. Retrieved May 13, 2019, from www.litfl.com/does-roc-rock-does-sux-suck/.
Tran DTT, Newton EK, Mount VAH, et al. Rocuronium vs. succinylcholine for rapid sequence intubation: A Cochrane systematic review. Anaesthesia. 2014;72(6):765—777.
Lopez DM, Weingarten-Arams JS, Singer LP, Conway EE Jr. Relationship between arterial, mixed venous, and internal jugular carboxyhemoglobin concentrations at low, medium, and high concentrations in a piglet model of carbon monoxide toxicity. Crit Care Med. 2000;28(6):1998-2001. doi:10.1097/00003246-200006000-00053
Eichhorn L, Thudium M, Jüttner B. The Diagnosis and Treatment of Carbon Monoxide Poisoning. Dtsch Arztebl Int. 2018;115(51-52):863-870. doi:10.3238/arztebl.2018.0863
Tetanus Risk Assessment: https://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/chapter21.pdf
