MedSimu Surgery

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(upbeat music)
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Welcome to MedSimu Surgery Podcast.
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- Great to be here.
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- Today we're diving deep into something
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really fundamental for surgeons,
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especially if you're prepping for exams like the MRCS.
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We're talking about the initial management of burn injuries,
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getting those first steps right.
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- Absolutely crucial.
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We'll be pulling together the key information,
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sort of a framework for approaching these patients
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right from the moment they arrive.
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- Sounds good.
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What ground are we covering?
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- We'll look at that initial assessment,
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the underlying pathophysiology,
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what's actually happening in the body,
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then diagnosis, and critically,
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those immediate management strategies.
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Think fluids, wound care, the essentials.
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- Perfect, let's jump straight in then.
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Initial assessment, where do we start?
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- First thing to remember,
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a significant burn isn't just skin deep,
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it's a systemic hit.
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- Right, it affects everything.
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Exactly. Airway, breathing, circulation, your standard trauma priorities, and then obviously
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dealing with the burn itself.
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And a big part of that initial assessment is figuring out how much of the body is burned.
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Precisely. The total body surface area, or TBSA, it guides so much of the early management.
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How do we estimate that quickly? I remember the rule of nines.
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That's the one. For adults, it's a really practical tool. You divide the body into areas
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that are roughly 9% or multiples of 9%.
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So like an entire arm is 9%, a whole leg is 18%.
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- You got it.
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The head, neck together are 9%,
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front of the trunk 18%, back of the trunk 18%,
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makes 11 areas of 9%.
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- And the last 1%.
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- That's allocated to the perineum.
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Just important to note,
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it can sometimes underestimate TBSA in obese patients.
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Something to keep in mind.
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- Good point.
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And these injuries are common, aren't they?
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- Sadly, yes.
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In the UK, we're talking around a quarter
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of a million burn injuries each year.
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- Wow.
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And about 13,000 of those need hospital admission.
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- And eating fluids.
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- Roughly 10% of those admitted
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will need formal fluid resuscitation
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because the burn is significant enough.
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- And tragically, people still die from burns.
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- Yes, despite all our advances,
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around 300 deaths annually in the UK,
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it really highlights why getting
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that initial management right is so vital.
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- Absolutely.
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And what causes these burns typically?
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- It varies.
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Thermal burns are probably the most frequent.
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You see scalds a lot, especially in kids.
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- Right.
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- And flame or fire injuries are more common in adults.
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But there are others too.
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- Oh yes, chemical burns, electrical injuries,
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which can be deceptive, the skin injury might look small,
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but there can be deep damage.
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- Following the current's path.
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- Exactly.
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And then radiation burns from sunburn
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right through to more significant exposures.
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- Okay, so we've got the assessment basics and the causes.
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What's actually happening physiologically
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when someone sustains a major burn?
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- It triggers this massive inflammatory cascade.
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The body just floods with mediators, histamine,
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prostaglandins, bradycanins, leukotrines, serotonin,
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the whole lot.
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- And what do they do?
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- They cause widespread vasodilation blood vessels
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opening up and increased capillary permeability.
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- So the vessels get leaky.
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- Precisely.
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Fluid pours out of the bloodstream
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into the surrounding tissues.
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That causes edema, swelling, and critically,
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it reduces the amount of fluid circulating.
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- Leading to poor oxygen delivery.
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Exactly. It impairs tissue perfusion.
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It's like all the pipes suddenly springing leaks,
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pressure drops, flow is compromised.
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And locally, at the burn site itself?
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We often use the Jackson model to think about that.
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Imagine three zones.
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Innermost is the zone of coagulative necrosis.
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That tissue is dead, directly killed by the heat.
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I'm so saving that now.
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Then surrounding that is the zone of stasis.
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Here, the microcirculation is damaged,
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blood flow is sluggish.
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This tissue is injured, but potentially salvageable.
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- So resuscitation is key for this zone?
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- Absolutely.
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Good fluid management can potentially save
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some of this tissue.
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And the outermost zone is the zone of hyperamia.
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- That's just red and inflamed?
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- Essentially, yes.
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Lots of vasodilation due to those inflammatory mediators.
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This contributes to the swelling too.
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And if the burn is big enough, say over 20% TBSA,
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this local reaction becomes systemic.
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- Right, the whole body gets involved.
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And there's a longer term metabolic thing too, isn't there?
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Yes, the hypometabolic response.
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The stress of the injury triggers a massive release
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of stress hormones, catecholamines, glucagon, cortisol.
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- Putting the body into overdraft.
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- Exactly.
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And at the same time, the body becomes less responsive
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to anabolic hormones like insulin and growth hormone.
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This state can last a long time
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and leads to increased energy needs, muscle breakdown.
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- Makes sense.
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So how does all this manifest when the patient arrives?
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What are the key signs we look for?
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- Well, the most immediate concern is often hypovolemia
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from that fluid loss.
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If it's not treated fast, it can lead to shock,
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organ damage like acute kidney injury.
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The heart struggles too.
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Cardiac output can drop because there's less fluid
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returning to the heart decreased preload.
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Plus there might be some direct myocardial depression
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and increased afterload as the body tries to compensate.
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- What about the lungs?
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- You can see ARDS, acute respiratory distress syndrome,
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especially with large burns or inhalation injury.
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And immunosuppression is a huge issue.
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making infection a major risk.
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- A massive risk.
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These patients are incredibly vulnerable.
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Then you saw the signs of that hypermetabolic state,
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tachycardia, maybe a raised temperature,
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muscle wasting over time.
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- And gut problems.
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- Yes, gut dysfunction, like an alias is common too.
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- It really is a whole body assault.
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So patient arrives, potentially with all this going on.
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How do we approach diagnosis and initial investigations?
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- Stick to the script.
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- A-T-L-S principles, airway first, always.
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- Looking for signs of inhalation injury.
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- Absolutely, history of being in a closed space fire,
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facial burns, sit around the nose or mouth,
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singed nasal hairs, horse voice.
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Any of those should make you very suspicious.
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- And if you are suspicious.
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- Low threshold for early intubation.
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That airway swelling can be insidious
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and peaks around 12 to 36 hours later.
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You don't wanna be caught out.
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- You got it, secure the airway early.
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in high flow oxygen right away.
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Then breathing, circulation, IV access,
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large bore cannulas,
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ideally through unburnt skin if possible.
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- And assessment means getting a proper look.
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- Yes, you have to remove all clothing and jewelry.
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You can't assess the burn properly otherwise.
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It might feel counterintuitive with heat loss,
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but you need to see the full extent.
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Keep them warm afterwards, of course.
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- Standard trauma workup too.
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- Definitely.
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Trauma series, x-rays, chest, pelvis, lateral C-spine,
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just like any major trauma patient,
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Burns often happen alongside other injuries.
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And specific things for certain burns?
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Yes, for electrical burns or if there's any history
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suggesting loss of consciousness
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or an abnormal ECG on arrival,
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get them on continuous cardiac monitoring.
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Risk of arrhythmias is real.
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Okay, primary survey done, immediate threats managed,
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then we focus more on the burn wound itself.
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Exactly, secondary survey time.
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Get a detailed history.
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Mechanism of injury, duration of contact,
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What first aid was given, did they run it under cool water?
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- And assessing the burn depth becomes crucial now.
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- Absolutely critical.
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It dictates fluid management, surgical need, everything.
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It's not just about the percentage TVSA.
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- Is it easy to judge depth clinically?
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- It can be tricky, especially early on.
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Experience helps, but there are tools now too,
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like laser Doppler imaging, which NICE has approved.
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It gives a more objective measure
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of blood flow in the wound bed.
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- How do we categorize depth clinically though?
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- Broadly, superficial or deep.
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superficial burns involve the epidermis,
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maybe the epidermis.
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- Like sunburn.
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- Epidermal burns are like sunburn, yeah.
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Red, painful, no blisters, they heal well.
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Superficial dermal burns go a bit deeper,
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they blister, they're very painful,
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but they still blanch, capillary refill is normal.
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They usually heal without scarring,
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mostly by re-epithelialization.
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- Okay, and deep burns.
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- They involve deeper layers of the dermis
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or even full thickness down to fat or muscle.
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These almost always need surgery.
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How do they look?
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- Deep dermal burns might be red or blotchy,
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maybe fewer blisters.
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Capillary refill is often sluggish or absent.
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Full thickness burns look different.
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Often white, waxy, leathery, or charred.
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No blisters, no capillary refill,
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and often less painful
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because the nerve endings are destroyed.
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- Right, the lack of pain can be misleading.
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- Very much so.
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- Okay, assessment, complete extent, and depth estimated.
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Let's talk management.
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Non-pharmacological first, fluids seen key.
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Top of the list for significant burns,
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we're talking deep partial or full thickness burns
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covering more than say 20% TBSA in adults
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or maybe 10, 15% in children.
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- And the formula, Parkland or Luton?
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- The ATLS guidelines generally recommend using a formula
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like the modified Parkland.
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For adults, it's typically two milliliter
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of lactated ringer solution per kilogram of body weight
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per percentage TBSA burned.
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- So two times weight in kilogram times percent TBSA.
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- Exactly.
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That gives you the total volume estimated for the first 24 hours after the injury occurred.
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Not from when they arrived.
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Crucially no, from the time of the burn.
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And the rate is important too.
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How do we give it?
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You aim to give the first half of that calculated volume over the first 8 hours post-injury.
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And the remaining half over the next 16 hours.
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Are there different volumes for kids or specific injuries?
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Yes, for children we often use 3 millikiligy percent TBSA.
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And for electrical burns, it's higher still, often 4 millikiligy percent TBSA, because
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of that potential for deeper, hidden muscle damage.
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But it's not just plug in the numbers and walk away, right?
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Absolutely not.
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The formula is just a starting point, an estimate.
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You must titrate the fluid rate based on the patient's response.
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How do we monitor that?
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urine output is the key guide in most cases.
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Aim for about 0.5 milliliters per kilogram per hour in adults.
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And kids?
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Aim for 1 milliliter per kilogram per hour in children under 30 kilograms.
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You adjust the infusion rate up or down to hit that target.
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bullec
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metabolic state, we need to control the room temperature maybe around 33 degrees
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Celsius to minimize heat loss and metabolic stress. Nutrition. Early feeding
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is vital for major burns. Get a nasogastric tube in if they can't eat and
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start enteral feeding soon. It helps maintain gut function and provides the
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huge amount of calories they need. An initial wound care, just cover it up.
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Gently clean the wound maybe with saline or very dilute like more 0.1%
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core hexadean, then apply simple non-accurate dressing. What about cling
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film. I've seen that used. It can be a good temporary dressing, especially during transfer.
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It's clean, non-adherent, reduces evaporative losses, and allows assessment. But critically,
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don't wrap it circumferentially or too tightly. Risk of constriction of swelling occurs. Exactly.
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And don't forget, early physiotherapy and occupational therapy involvement. Essential
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for function long term. What about chemical burns specifically?
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Number one is remove contaminated clothing safely then copious irrigation with water
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Lots and lots of water to dilute and wash off the chemical for how long often for extended periods 30 minutes or more
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Specific advice might be needed depending on the chemical check manufacturer data or toxicology resources
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Hydrofluoric acid is a particularly nasty one needing specific treatment with calcium glucanid
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Okay, and when do these patients need transferring to a specialist burns unit?
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There are clear referral criteria, generally adults with over 10% TBSA, kids with over 5%,
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extremes of age.
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Any specific burn types or locations?
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Yes. Full thickness burns over 5% TBSA.
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Burns to special areas face, hands, feet, perineum, major joints, circumferential burns
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of limbs or the chest.
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All electrical and significant chemical burns.
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Associated injuries.
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Any burn with associated inhalation injury needs specialist care.
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in patients with significant comorbidities or burns associated with other major trauma.
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Basically, anything complex or potentially life or limb threatening.
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That's a helpful list.
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Okay, moving on to pharmacology.
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What drugs are key early on?
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Pain relief is paramount.
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Intravenous opioids titrated carefully to effect.
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That's the main pharmacological focus initially.
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What about those other things mentioned for the hypermetabolic state?
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Things like insulin therapy for hyperglycemia, maybe anabolic steroids or beta blockers to
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blunt the stress response. Those are typically considered later in the
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management of severe burns, not usually in the first few hours. And antibiotics,
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should we give them prophylactically? That's a really crucial point. No, routine
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prophylactic antibiotics are not recommended. Why not? Seems intuitive with
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the infection risk. Because it doesn't prevent infection effectively and
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massively increases the risk of selecting for resistant organisms, which
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makes treating actual infections much harder later on. Antibiotics are for
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treating confirmed infections, not for prevention in burns.
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- Got it.
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No routine prophylactic antibiotics.
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So what about surgery?
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- Surgery is a cornerstone of managing deeper burns.
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Early excision is key.
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- How early?
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- Ideally within the first 72 hours
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for deep dermal and full thickness burns.
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Taking off that dead tissue early has huge benefits.
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- Sichias.
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- Faster healing, less blood loss overall
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compared to delayed surgery, shorter hospital stays,
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better cosmetic and functional outcomes, less scarring,
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and it's even linked to improved survival in major burns.
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- And what about those tight circumferential burns?
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- If a circumferential full thickness burn on a limb
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is compromising blood flow distally,
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or one on the chest is restricting breathing,
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then an emergency eschatotomy is needed.
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- Which is?
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- It's a surgical incision through the full thickness
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of the escher, the burnt tissue,
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down to the subcutaneous fat.
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It releases the constriction,
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usually done with diathermy, to control bleeding.
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And once the dead tissue is removed,
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how do we close the wound?
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- The gold standard is usually
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a split thickness skin autographed,
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taking healthy skin from an unburned area of the patient,
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the donor site, and putting it onto the excised burn wound.
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- What if the burn is too large, not enough donor site?
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- That's a major challenge.
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We might use temporary coverings like allograft skin
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from a deceased donor or synthetic skin substitutes,
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like Integra, which acts as a dermal scaffold.
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These can buy time or help prepare the wound bed
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later autografting.
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- So that covers the acute phase.
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What about the longer term picture?
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- Burns leave lasting scars,
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both physical and psychological.
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It's a long road for many patients.
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- What are the main physical challenges?
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- Wound contracture is a huge problem.
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As the scar tissue matures, it tightens,
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which can severely limit movement, especially around joints.
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- Have you managed that?
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- Early and ongoing physiotherapy, pressure garments,
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and sometimes splinting are absolutely vital
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to minimize contractures.
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Further surgery might be needed later too.
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- And that hypermetabolic state, does it resolve quickly?
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- In very large burns, say over 40% TBSA,
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it can actually persist for up to two years
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after the injury.
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- Two years, wow.
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- Yes, meaning ongoing high nutritional needs
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and risk of muscle loss.
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So long-term outpatient follow-up is essential
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for scar management, rehabilitation,
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checking nutritional status,
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and crucially providing psychological support.
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the impact is profound.
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- It certainly sounds like it.
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Well, that was a really thorough run-through
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of managing burn injuries initially.
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We've hit on that critical first assessment,
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understanding the why with the pathophysiology,
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the key steps in resuscitation,
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like fluids using the formulas, but titrating carefully.
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- And the importance of early excision
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and knowing when to refer.
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- Absolutely.
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It really underscores how a systematic approach
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in those first hours and days
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makes such a difference to outcomes.
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- It truly does.
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Having that clear framework is fundamental
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dealing with these complex injuries.
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We really hope this deep dive has given you, our listeners, some valuable takeaways, whether
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for your exams or your day-to-day practice.
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Hopefully reinforcing some key principles.
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Definitely.
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Join us next time on MedSciMoo Surgery Podcast for another in-depth discussion on a key surgical
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topic.
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(upbeat music)