Post on 05-Jul-2020
Emergency
Quality, Education, and Safety
Teleconference
Burns Cases
Dr Louisa Ng | Advanced Trainee | Emergency Care Institute
Dr Paris Ramrakha| Advanced Trainee | Emergency Care Institute
August 2019
Thanks for joining
House Rules
Confidentiality
Respect
AGENDA
• Case reviews
• Underlying causes
• NSW Health guidance
Participation encouraged throughout
(But please turn off camera & mute mic when not talking)
Case 1: 32yo Electrician
Special thanks to Dr Hana Imamura for supplying case, and to the patient, who kindly
provided consent for the case to be used for educational purposes.
Case 1 – Mr. LO, 32yo
• Walk in presentation to Level 1 Emergency Department in far Western NSW
• Base Hospital is 1hr 15 mins away by road
• Touched a live wire on a solar farm: 660V DC
• Burns to hands
• Walking and talking with normal vital signs
• Triage category?
• Is this presentation consistent with a 660V electrocution?
• What else would you worry about?
Case 1 – Mr. LO, 32yo
• Triage Category 3: ECG, continuous monitoring
• History:
• Electrician working on a solar farm, right hand dominant
• Electrical current entered right hand and exited left hand
• Brief loss of consciousness
• Normally fit and well, no regular medications
• ADT status unknown
• Smoker
Case 1 – Mr. LO, 32yo
no critical bleeding
own, patent
RR 14/min
O2 sats 97%
HR 82/min, BP 120/75
ECG next slide
GCS 15
T 36.9
no long bone injuries
clinically euvolaemic
BGL 5.3
Case 1 – Mr. LO, 32yo – ECG
Case 1 – Mr. LO, 32yo
Case 1 – Mr. LO, 32yo – Secondary survey
• Face and scalp: Upper lip laceration, no further intra-oral injury
• Neck and C-spine: nil injury
• Thorax: nil injury
• Upper limbs: third degree burns to right hand fingertips, some electrical burns
in left hand fingertips.
• Pelvis and lower limbs: nil injury
• Back and spine: nil injury
More detail about the burns
Right hand
3rd/4th/5th finger palmar aspect
blisters with appropriate pain
sensation, fingertips have a small
area of blackening with pain
sensation. Blister also to palm
near fingers.
Left hand
2nd/3rd/4th/5th finger palmar aspect blisters
with appropriate pain sensation. Fingertips
spared. Palm near fingers also blistered.
No other areas of burns identified.
Photos sent to burns team @Concord by
treating team at the base hospital.
Management plan:
• ADT
• IV access
• IV fluids
• Transfer to base hospital for electrical trauma workup and discussion with
plastics
• Keep in cardiac monitor for now
Which of these are a time critical retrieval for a burns?
A.Uncontrolled pain
B.Mid dermal, deep dermal or full thickness burns
>5% of total body surface area in children
C.Burns with significant comorbidities
D.Mid dermal circumferential burn to limb
C. Burns with significant comorbidities
Studies have shown significant cardiac and
respiratory comorbidities eg ACS, significant
cardiac arrhythmias and severe COPD and also
old age/frailty and significant pre-existing
disabilities
These are conditions that could adversely affect
patient care and outcomes
2. Which of these patients can be considered for non
time critical referral and local (if resources allow)
management?
A.Burns with concomitant trauma
B.Intubated patients
C.Burns at extremes of age
D.Pregnancy with cutaneous burns
2. Which of these patients can be considered for non
time critical referral and (if resources allow) local
management?
A.Burns with concomitant trauma
B.Intubated patients
C.Burns at extremes of age
D.Pregnancy with cutaneous burns
3. How long should I wait for the road/air ambulance?
A.Should be now!
B.Up to 2 hours
C.Up to 4 hours
D.Up to 8 hours
3. How long should I wait for the road/air ambulance?
C. Up to 4 hours
If possible….
If an intensive care bed is required for time critical
transfer the ACC will organise transfer for adults
and NETS will do so for children
Cardiac Dysrhythmia
CNS, Spinal Cord and PNS Injury
Cutaneous Burns
Orthopaedic, Vascular, and Muscular Injury
Ocular and Auditory Canal injuries
Tintinalli’s Emergency Medicine
Fatalities due to asystole or ventricular fibrillation usually occur prior to arrival in the
ED. Asymptomatic patients with normal ECGs on arrival to the hospital do not
develop later dysrhythmias after low-voltage (<1000 V) injuries.
Low-voltage (< 1000V) AC can produce ventricular fibrillation by direct stimulation of
the heart, or it can occur after several minutes of respiratory arrest resulting from
paralysis of respiratory muscles
High-voltage (>1000V) AC and DC are more likely to produce transient ventricular
asystole.
Tintinalli’s Emergency Medicine
Apnea with pulses sometimes occurs in linemen working above the ground
near high-voltage lines.
Maintain vigorous resuscitation efforts for cardiac arrest from electric shock,
because there may be insignificant tissue damage despite the potentially lethal
dysrhythmia.
Tintinalli’s Emergency Medicine
Broad range of CNS dysfunction
• Transient LOC is common and may be followed by seizures
• Confusion or agitation
• Deeply comatose and require airway protection
• May also have focal neurologic deficits eg quadriplegia, hemiplegia, aphasia, or visual disturbances
• Remember!! - Spinal cord injury in 8% due to trauma!
• Peripheral nerve injuries
• Hands after the individual touches a power source
• Paraesthesias may be immediate and transient or delayed in onset, appearing up to 2 years after injury
• Extensive peripheral nerve damage may occur with minimal thermal injury
• Electrical contact with the palm produces median or ulnar neuropathy more often than radial nerve injury.
Tintinalli’s Emergency Medicine
• Entry and exit wounds are classic in DC current,
whereas AC current causes contact wounds.
• Burns are typically painless, grey to yellow,
depressed areas.
• Again do not be distracted by the burn site and
make sure ABCs are in check
Tintinalli’s Emergency Medicine
Fractures may be caused by tetanic muscle
contractions or associated falls.
• May be missed on initial assessment due to
altered GCS and overall severity of
systemic illness
Fractures are more likely to result from high-voltage
injury, [but] fractures of the wrist, forearm, humerus,
femoral necks, shoulders, and scapulae have been
reported from exposure to household voltages
(120 to 220 V AC)
Posterior shoulder dislocations are commonly
seen with electrical injury.
Tintinalli’s Emergency Medicine
Vascular and muscle injuries occur most commonly
in the setting of high-voltage injury, such as power
line contact.
• thrombosis,
• stenosis,
• aneurysm formation.
Because of vascular and muscular
destruction, patients with high-voltage shocks are at
significant risk for development of compartment
syndrome, even if the contact (or arcing) lasted <1
second.
Coagulation disorders such as DIC may occur.
Case 1 – Mr. LO, 32yo – Investigations and Management
Repeat ECG (NSR)
Bloods including CK (155), troponin (4)
Fluids with no added potassium
Urinalysis (no myoglobin)
Telemetry 24 hours (Concord Protocol)
Not for antibiotics
Transfer to Concord when bed available, meantime, admitted to short stay.
Summary and issues raised by LO’s Case:
• Electrical burns to upper limb extremities, < 1% TBSA
• Anything anyone would have done differently?
Summary and issues raised by LO’s Case:
• Anything anyone would have done differently?
Issues
• First Aid for electrical burns
• Analgesia for extremity burns
• Telemetry monitoring
• Two transfers
Case 2: 15yo Girl
Special thanks to Dr Michael Golding for supplying case
Case 2 – 15yo Girl
• History significant for epilepsy, developmental delay, autism, non-verbal
communication
• Standing by a bonfire on a property, fell backwards into fire
• Witnessed grand mal seizure – 2 mins – self-terminated
• Head engulfed, all hair gone
• Initial first aid – wet towel, cooling by paramedics
• Pre-hospital – IN fentanyl, IM ketamine, CSL 200mls
Case 2 – 15yo Girl
• History significant for epilepsy, developmental delay, autism, non-verbal communication
• Standing by bonfire, fell backwards into fire
• Witnessed grand mal seizure - 2 mins – self-terminated
• Head engulfed, all hair gone
• Initial first aid – wet towel, cooling by paramedics
• Pre-hospital – IN fentanyl, IM ketamine, CSL 200mls
• Triage category?
1. Primary survey is for:
A.AMPLE history
B.Obtain pertinent statistics from paramedics and
ambulance handover
C.Determine what consultations need to be made
D.Rapidly identify critical or life threatening diagnosis and
begin treatment at the time of diagnosis
D. Rapidly identify critical or life threatening diagnosis
and begin treatment at the time of diagnosis
A lot of the time this is
more interesting…
Do not get distracted
Case 2 – 15yo Girl – Primary Survey
patent
spontaneous, nil distress
well perfused, BP 111/71, P 88
? Full thickness to scalp, forehead, neck, ears, and patches on back
• TBSA 11% with 3% full thickness *
• Bactigras and gladwrap
35.4
Parkland formula – 181mls/hr
What are your immediate resuscitative priorities?
What else would you worry about?
ABCDE
What is an unreliable marker for patency of the airway and
the need for intubation?
A.Absence of gag reflex
B.Level of consciousness
C.Patient’s change in phonation or inability to phonate
D.Pooling of secretions in the oropharynx
ABCDE
What is an unreliable marker for patency of the airway and
the need for intubation
A. Absence of gag reflex
ABCDE
What is not a sign of tension pneumothorax?
A.Deviation of the trachea away from the side
B.Bruising to the chest wall
C.Hyper-expanded chest that moves little with respiration
D.Increased percussion note
ABCDE
What is not a sign of tension pneumothorax?
B. Bruising to the chest wall
ABCDE
In major deformity and burns patients what are your options
for IV access?
A.Femoral vein
B.Internal jugular vein
C.IO
D.Peripheral IVC large gauge
ABCDE
In major deformity and burns patients what are your options
for IV access?
A.Femoral vein
B.Internal jugular vein
C.IO
D.Peripheral IVC large gauge
ABCDE
In major deformity and burns patients what are your options
for IV access?
All of these are great ways to access (with the right skill set
and equipment) but…
Peripheral IVC and IO would be choice in trauma setting
and fastest
ABCDE
Which of these is not part of the disability assessment in the
primary survey?
A.Assess GCS
B.Pupil size and responsiveness
C.Dermatomal assessment
D.Gross motor function and BSL
ABCDE
C. Dermatomal assessment
This is part of your secondary survey once you have
managed all other life threatening conditions
ABCDE
The burns patient is at high risk for hypothermia. Which of
the following can you do to minimise the risk to your
patient?
A.Remove wet packs and soaks
B.Clean off any residual cream/dressing product
C.Cover the patient with plastic cling wrap or clean sheet
D.Warm cup of tea and blanket
ABCDE
A.Remove wet packs and soaks
B.Clean off any residual cream/dressing product
C.Cover the patient with plastic cling wrap or clean
sheet
Case 2 – 15yo Girl – Immediate Priorities
Clinical Priority Action
Airway management Assessment and early intubation
Anticipate difficult airway
Burns management Complete first aid
Estimate TBSA *
Photographs
Dressings
ADT if not up to date
Fluid management Parkland’s formula
Analgesia (if not intubated/sedated) Multimodal
Seizure management Anticonvulsant loading
Parkland’s Formula
• Applies to adults with > 20% TBSA Burns
• Applies to children with > 10% TBSA Burns
• Do not include simple erythema (superficial partial thickness)
Case 2 – 15yo Girl – Patient stabilised, what is next?
• Adequacy of airway and ventilation
• Sedation and analgesia
• Secondary Survey
• Supportive Care
• Care of the Family
• Consider NAI (not present in this case)
• Retrieval to tertiary paediatric burns service
Who should I call for retrieval or referral or help?
A.Call a friend
B.Statewide Burns service
C.ACC/NETS
D.Trauma call
Who should I call for retrieval or referral or help?
A.Call a friend
B.Statewide Burns service
C.ACC/NETS
D.Trauma call
Who should I call for retrieval or referral or help?
Should be calling early at the time of MIST and
handover from the CDA/First responders or place
of transfer
Part of your MIST you are looking for the indicators
for time critical factors for transfer
Who should I call for retrieval or referral or help?
Activate your trauma team
Arrange your staff and your roles (and equipment) ie call
your friends!
Consider talking to retrieval early especially if you know that
this patient has indication to have transfer to a larger centre
Talk to the burns registrar early post initial stabilisation to
determine disposition
What if they are being treated at their primary referring site?
ACI statewide burn injury service can support and assist primary
health sites to liaise in ongoing burn management.
This is usually the burns registrar on call for either RNSH or
Concord (Westmead for children) and they are there to also
support your decision making.
If there is need for clinic review, each hospital has outpatient
clinics which can be contacted during business hours.
Case 2 – 15yo Girl – Progress
CCAS – Retrieval to Westmead Children’s Hospital by helicopter
Ventilated 3 weeks
25% burns to multiple sites, full thickness to scalp *
Developed pressure areas to buttocks in ICU
Extubated and ultimately discharged home, with local community health service
for dressings.
CLINICAL TOOLS AND GUIDELINES
Escharotomy
3 C’s:
Circumferential
Circulation – threatened
Compromised - respiration
Escharotomy
https://www.aci.health.nsw.gov.au/__
data/assets/pdf_file/0003/162633/Esc
harotomy-for-Burn-Patients.pdf
Published on the 19th of July
2019
Tips and tricks for
performing escharotomy
•Easier to do with 2 operators
•Make sure you have a plan for haemostasis –
the patient will bleed!
•It is into the subcutaneous fat and no further
•Your scalpel will blunt quickly so have a few
back up
•To cut do one initial cut in the skin and draw
down the line you need – can always go back
and deepen it afterwards
•Make sure you give local into the skin that is not
burnt that you incise into
E-QuESTs so far
•Dangerous Back Pains
•Opthalmological emergencies
•Pulmonary Embolus
•Paediatric Increased WOB
•Burns
•Atypical Chest Pain - ACS
•Sepsis in the elderly
•Abdominal pain in the elderly - AAA
& Ischaemic gut
•Scrotal emergencies
•Deadly headaches
•Paediatric deterioration
•Head injuries
Level 4, 67 Albert Avenue
Chatswood NSW 2067
PO Box 699
Chatswood NSW 2057
T + 61 2 9464 4666
F + 61 2 9464 4728
aci-info@health.nsw.gov.au
www.aci.health.nsw.gov.au
Many thanks!
Next E-QuEST
24 September 2:30pm
we welcome any cases that have piqued your
interest, and any suggestions for future topics
Appendix 1:
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/162635/Minor-
Burns-Mngt-Guidelines.pdf
• These have a good guideline as to assessing depths of burns and for
ongoing wound care