Burns - Adult

Quick Answer

Critical: Severe burns (above 20% TBSA) require immediate airway assessment (intubate if inhalation injury suspected), accurate TBSA estimation, and aggressive fluid resuscitation using the Parkland formula (4 mL/kg/%TBSA of crystalloid). Escharotomy is required for circumferential full-thickness burns causing compartment syndrome.

Burns are tissue injuries caused by thermal, chemical, electrical, or radiation sources. In Australia, burns affect 25-35 per 100,000 population annually, with mortality 5-15% for severe injuries. Management follows ABCDE priority: airway protection (critical with inhalation injury), breathing, circulation (Parkland fluid resuscitation), disability, and exposure/wound care. Key decisions include: intubation threshold for inhalation injury, fluid resuscitation initiation for above 20% TBSA, escharotomy for circumferential burns, and timely transfer to a burns centre for injuries above 10% TBSA, full-thickness above 1%, or special area involvement.

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ACEM Exam Focus

Primary Exam Relevance

Anatomy:

• Skin layers: Epidermis, dermis (papillary, reticular), hypodermis
• Zones of burn injury: Coagulation, Stasis, Hyperaemia
• Circumferential burns: Limb anatomy, neurovascular bundles
• Facial burns: Airway anatomy, potential for airway edema

Physiology:

• Fluid shifts: Capillary leak syndrome, systemic inflammatory response
• Burn shock: Hypovolaemia, distributive shock components
• Hypermetabolic response: Catecholamine surge, increased basal metabolic rate
• Inhalation injury: Carbon monoxide binding, airway inflammation, pulmonary edema

Pharmacology:

• Fluids: Lactated Ringer's vs normal saline, albumin use
• Analgesia: Opioids (morphine, fentanyl), ketamine, regional blocks
• Tetanus prophylaxis: Vaccination timing
• Antibiotics: Not prophylactic - reserve for infection

Fellowship Exam Relevance

Written:

• TBSA estimation methods (Rule of Nines, Lund-Browder, palm method)
• Parkland formula calculation and fluid titration
• Inhalation injury recognition and management
• Escharotomy indications and technique
• Burns centre referral criteria
• Carbon monoxide poisoning management

OSCE:

• Resuscitation Station: Major burns with airway compromise, fluid resuscitation
• Procedural Station: Escharotomy technique
• Communication Station: Breaking bad news about burn injury severity
• Assessment Station: TBSA calculation, burn depth classification

Key domains tested:

• Medical Expert: Accurate assessment, evidence-based management
• Leader: Team leadership in major burns resuscitation
• Communicator: Family communication, discharge planning
• Collaborator: Burns centre referral, multidisciplinary care

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Key Points

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Epidemiology

Causes of Burns in Australia

High-Risk Groups

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Pathophysiology

Mechanisms of Burn Injury

Thermal Burns:

• Direct protein denaturation and cell death
• Temperature above 44°C causes progressive injury proportional to exposure time
• Contact time is critical - immediate cooling reduces depth

Chemical Burns:

• Acid burns: Coagulative necrosis (limited penetration)
• Alkali burns: Liquefactive necrosis (deep penetration)
• Continue causing injury until neutralised or removed

Electrical Burns:

• High voltage: Extensive deep tissue damage, myoglobinuria risk
• Low voltage: Local entry/exit wounds, cardiac arrhythmias
• Hidden injury - external appearance underestimates internal damage

Radiation Burns:

• Sunburn: UVB causes epidermal damage, erythema after 2-6 hours
• Ionising radiation: Delayed tissue injury, potential for malignancy

Jackson's Zones of Burn Injury

Zone of Coagulation → Irreversible tissue necrosis (central zone)
                     |
                     ↓
Zone of Stasis → Viable but at-risk tissue (potentially salvageable)
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               ↓
Zone of Hyperaemia → Viable tissue with increased blood flow (will recover)

Clinical Implications:

• Zone of stasis can progress to necrosis with hypoperfusion or infection
• Goal of early resuscitation: Preserve zone of stasis
• Inadequate fluid resuscitation extends coagulation zone
• Timely excision of coagulation zone promotes healing

Systemic Response to Major Burns

Immediate Phase (0-48 hours):

• Massive capillary leak from increased vascular permeability
• Hypovolaemic shock with intravascular volume depletion
• Edema formation in both burned and unburned tissue
• Cardiac output decreased (up to 50% in severe burns)

Hypermetabolic Phase (3 days - 2 years):

• Catecholamine surge: 10-50× normal levels
• Basal metabolic rate increases 2× baseline
• Catabolic state: Muscle breakdown, hyperglycaemia
• Increased oxygen consumption, tachycardia, insulin resistance

Inhalation Injury Pathophysiology

Upper Airway Injury:

• Thermal injury to supraglottic structures (heat dissipates below larynx)
• Mucosal edema development over 12-48 hours
• Progressive airway obstruction risk
• Indications for early intubation

Lower Airway Injury:

• Chemical injury from inhaled toxins and smoke particles
• Direct mucosal damage to tracheobronchial tree
• Bronchospasm, mucosal sloughing, cast formation
• Increased risk of ARDS and pneumonia

Carbon Monoxide (CO) Poisoning:

• CO binds haemoglobin with 240× affinity of oxygen
• Tissue hypoxia despite normal PaO2
• Headache, confusion, cardiac ischemia at levels 20-30%
• Levels above 50-60% cause loss of consciousness, cardiac arrest

Cyanide Toxicity (in enclosed space fires):

• Inhibits cytochrome oxidase, preventing cellular oxygen utilisation
• Rapid onset of lactic acidosis
• Cardiovascular collapse, seizures
• Hydroxocobalamin antidote

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Clinical Approach

Recognition

When to Suspect Major Burns:

• Visible extensive thermal injury
• History of explosion, house fire, electrical injury
• Patient with soot around mouth/nose, facial burns
• Carbonaceous sputum, hoarse voice, stridor
• Signs of smoke inhalation exposure

Primary Survey

A: Airway

Immediate Assessment:

• Assess patency: Look, listen, feel
• Evaluate for inhalation injury indicators:
  • Facial burns or singed eyebrows/hair
  • Carbonaceous sputum or soot in mouth
  • Hoarseness or stridor
  • History of enclosed space fire
  • Altered mental status

Intubation Indications:

• Clinical signs of airway edema (stridor, hoarseness)
• Extensive facial/neck burns (especially full-thickness)
• Decreased level of consciousness (GCS below 8)
• Respiratory distress with hypoxaemia
• Severe inhalation injury on bronchoscopy
• Anticipated need for prolonged airway protection

Airway Management:

• Early intubation: Before airway edema makes intubation difficult
• Large ETT: Size 7.5-8.0 or larger (allows bronchoscopy later)
• Rapid sequence intubation: Consider cervical spine if trauma history
• Backup plan: Have surgical airway equipment ready
• Monitor: Continuous capnography, serial airway assessment

B: Breathing

Assessment:

• Respiratory rate, work of breathing
• Auscultation: Decreased breath sounds, wheeze
• Pulse oximetry: Be aware CO poisoning gives falsely high SpO2
• Chest expansion: May be limited by circumferential chest burns

Management:

• High-flow oxygen (15 L/min via non-rebreather) for suspected CO
• Monitor for ARDS development in inhalation injury
• Escharotomy if circumferential chest burns restrict ventilation
• Consider ventilation support for respiratory failure

C: Circulation

Assessment:

• Heart rate, blood pressure, capillary refill
• Skin perfusion in non-burned areas
• IV access: Two large-bore catheters through unburned tissue if possible
• Consider intraosseous access if peripheral access difficult

Fluid Resuscitation:

• Indication: above 20% TBSA in adults, above 10% in children/elderly
• Parkland Formula:
  • 4 mL × weight (kg) × %TBSA of crystalloid
  • Total volume over first 24 hours from TIME OF INJURY
  • Half in first 8 hours, half in next 16 hours
  • "Fluid of choice: Lactated Ringer's (Hartmann's)"

Fluid Titration:

• Target urine output: 0.5-1.0 mL/kg/hr
• Adjust based on clinical response, not rigid adherence to formula
• Avoid over-resuscitation: "Fluid creep" causes abdominal compartment syndrome
• Consider colloids after 8-12 hours if required
• Monitor for complications: Pulmonary edema, compartment syndrome

D: Disability

Neurological Assessment:

• GCS, pupillary response
• Consider hypoxic injury from CO or cyanide
• Assess for head injury if trauma history

Pain Management:

• Severe pain is expected in partial-thickness burns
• IV opioid analgesia: Morphine or fentanyl titrated to effect
• Consider ketamine for analgesia/sedation in extensive burns
• Regional blocks for extremity burns (if local expertise available)

E: Exposure and Environment

Exposure:

• Remove all clothing and jewellery (burns swell)
• Cover with clean, non-stick dressings
• Maintain patient warmth (burns lose heat rapidly)
• Log roll for spinal assessment if trauma history

Cooling:

• Cool running water for 20 minutes (within 3 hours of injury)
• Temperature: 15-25°C (avoid ice - causes further tissue damage)
• Stop cooling if patient becomes hypothermic

Wound Assessment:

• Estimate TBSA: Rule of Nines, Lund-Browder, palm method
• Determine burn depth: Superficial, partial-thickness, full-thickness
• Document affected areas: Photography, body diagram

Secondary Survey

Detailed History:

Physical Examination:

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Burn Assessment

Total Body Surface Area (TBSA) Estimation

Rule of Nines (Adults):

Modifications for Children:

Lund-Browder Chart:

• Most accurate method for all ages
• Accounts for age-related changes in body proportions
• Standard reference chart in burns units

Palm Method:

• Patient's palm (including fingers) ≈ 1% TBSA
• Useful for scattered small burns
• Good for estimating small areas or additions

Important Considerations:

• Erythema (sunburn-like redness) does NOT count toward TBSA
• First-degree burns are excluded from TBSA calculation
• Document method used for estimation
• Overestimation leads to over-resuscitation complications

Burn Depth Classification

Assessment Techniques:

• Visual inspection: Colour, capillary refill, blistering
• Palpation: Texture (leathery vs soft), pain with touch
• Pinprick test: Assess sensation (full-thickness = painless)
• Blister fluid: Clear (superficial) vs bloody (deep/full-thickness)

Clinical Pearls:

• Burn depth can evolve over 24-48 hours
• Deep partial-thickness burns may convert to full-thickness if inadequately resuscitated
• Electrical burns: Depth often underestimated due to entry/exit point appearance
• Early assessment guides fluid needs and disposition

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

Applications in Burns:

• Thoracic: Pneumothorax, pleural effusion, diaphragmatic function
• Abdominal: Free fluid (trauma), intra-abdominal compartment pressure
• Vascular: Deep vein thrombosis (burns patients high risk)
• Soft tissue: Foreign bodies (chemical/thermal debris)
• Cardiac: Ejection fraction, contractility (fluid responsiveness)

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Management

Immediate Management (First 10 Minutes)

1. Scene safety: Ensure rescuer and patient safety
2. Primary survey: ABCDE approach
3. Stop burning process: Remove from heat source, remove burning clothing
4. Cool burns: Cool running water 15-25°C for 20 minutes (if within 3 hours)
5. Remove constricting items: Jewellery, clothing, watches before swelling
6. Airway assessment: Intubate early if inhalation injury suspected
7. Establish vascular access: Two large-bore IV lines
8. Fluid resuscitation: Start Parkland formula for above 20% TBSA
9. Analgesia: IV opioids titrated to effect
10. Cover burns: Clean, non-adherent dressings, maintain warmth

Fluid Resuscitation

Parkland Formula:

• 4 mL × weight (kg) × %TBSA = Total 24-hour crystalloid volume
• Fluid of choice: Lactated Ringer's (Hartmann's)
• Administration:
  • Half of total in first 8 hours FROM TIME OF INJURY
  • Remaining half in next 16 hours
  • "Example: 70 kg patient with 30% TBSA"
    • Total: 4 × 70 × 30 = 8,400 mL
    • First 8 hours: 4,200 mL
    • Next 16 hours: 4,200 mL

Modern Modifications (Fluid Resuscitation 2.0):

Monitoring:

Complications of Over-Resuscitation ("Fluid Creep"):

• Abdominal compartment syndrome
• Pulmonary oedema, ARDS
• Extremity compartment syndrome
• Wound edema, delayed healing
• Multiple organ dysfunction

Alternative Formulas:

• Galveston Formula (children): 5,000 mL/m² + 2,000 mL/m² × %TBSA
• Brooke Formula: 2 mL/kg/%TBSA (more conservative)
• Modified Brooke: 1.5-2 mL/kg/%TBSA (very conservative)

Airway Management - Inhalation Injury

Intubation Indications:

Intubation Strategy:

• Early is better: Before airway becomes impossible to visualise
• Large ETT: Size 7.5-8.0 or larger (allows bronchoscopy)
• Rapid sequence intubation: Standard approach
• Backup plan: Surgical airway equipment immediately available
• Avoid prolonged attempts: Multiple attempts worsen edema

Ventilation Strategy:

• Initial: Volume control, lung-protective settings
• Tidal volume: 6-8 mL/kg ideal body weight
• PEEP: 5-10 cm H2O (adjust to compliance)
• FiO2: Titrate to SpO2 94-98% (remember CO poisoning)
• Permissive hypercapnia: PaCO2 45-55 mmHg acceptable
• Recruitment: Consider for atelectasis, ARDS

Inhalation Injury Treatment:

• Chest: Bilateral submammary incisions, horizontal connecting incisions (clamshell or "H" pattern)
• Depth: Full thickness through eschar into subcutaneous fat
• Bleeding: Typically minimal due to devascularised tissue
• Post-procedure: Reassess pulses, capillary refill, sensation

Chest Escharotomy:

• Indications: Decreased tidal volumes, rising airway pressures, hypoxaemia from restricted chest wall
• Incisions: Bilateral anterior axillary lines, may need transverse connection
• Consider: Ventilator improvement confirms adequate release

Contraindications:

• No clear contraindication when compartment syndrome suspected
• Do NOT delay for imaging - clinical diagnosis
• Do NOT use local anaesthesia for full-thickness eschar (painless area)

Complications:

• Bleeding (rare but can be significant)
• Infection of escharotomy wounds
• Damage to underlying structures (nerves, vessels)
• Need for subsequent fasciotomy

Pain Management

Opioid Analgesia:

Adjuncts:

• Ketamine: 0.1-0.3 mg/kg IV bolus, then infusion 0.1-0.2 mg/kg/hr
• Regional blocks: Useful for extremity burns if local expertise
• Non-opioids: Paracetamol, NSAIDs (if no contraindications)

Wound Care

Immediate Wound Management:

1. Cooling: Cool running water 20 minutes (within 3 hours of injury)
2. Cleansing: Saline or water, avoid scrubbing
3. Debridement: Remove blisters above 2 hours old, intact blisters within 2 hours may be left
4. Dressing: Non-adherent (paraffin gauze, silicone), secure with bandages
5. Elevation: Elevate injured limbs to reduce edema
6. Tetanus prophylaxis: Give if not up to date

Topical Agents:

Advanced Wound Care (Burns Unit):

• Negative pressure wound therapy: For deep partial-thickness, donor sites
• Biologic dressings: Biobrane, Integra®
• Cultured skin substitutes: For extensive full-thickness burns
• Early excision: Within 24-72 hours for full-thickness burns

Carbon Monoxide and Cyanide Toxicity

Carbon Monoxide (CO):

Treatment:

• 100% oxygen: Non-rebreather mask, half-life reduces from 4-6 hours to 60-90 minutes
• Hyperbaric oxygen: Consider for severe poisoning (loss of consciousness, cardiac ischaemia, pregnant)
• Continuous monitoring: Serial carboxyhaemoglobin levels, cardiac monitoring

Cyanide Toxicity:

Treatment:

• Hydroxocobalamin: 5 g IV over 15 minutes (may repeat once)
• Sodium thiosulfate: Adjunct, enhances cyanide metabolism
• Supportive care: Aggressive resuscitation, antidote given empirically in severe cases

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Disposition

Burns Centre Referral Criteria

Transfer to a specialised burns unit is indicated for:

Non-Burn Centre Management:

• Minor burns (below 10% TBSA)
• Superficial burns
• Small partial-thickness burns (below 5% TBSA)
• No special area involvement
• No comorbidities

Safe Discharge Criteria:

• Burn depth: Superficial or superficial partial-thickness only
• TBSA: below 10% adults, below 5% children/elderly
• No special areas involved
• Adequate pain control with oral analgesia
• Patient able to manage dressing changes
• Social support available
• Reliable follow-up arranged

Admission Criteria

Ward Admission:

• Burns 10-20% TBSA without inhalation injury
• No special areas involved
• Comorbidities requiring monitoring
• Require IV analgesia but not ICU level care

ICU Admission:

• Burns above 20% TBSA
• Inhalation injury
• Significant comorbidities (cardiac, respiratory, renal)
• Age above 65 years with burns above 10% TBSA
• Need for advanced respiratory support
• Escharotomy performed
• Electrical burns with significant myoglobinuria
• Associated trauma or injuries

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Special Populations

Paediatric Considerations

Key Differences:

• Higher BSA:weight ratio → more fluid loss
• Thinner skin → deeper burns from same injury
• Immature thermoregulation → hypothermia risk
• Scalds predominate (especially below 3 years)
• Lund-Browder chart mandatory (Rule of Nines inaccurate)

Modifications:

• Fluid resuscitation: Galveston formula, aim for urine output 1-2 mL/kg/hr
• Temperature maintenance: Essential (rapid hypothermia)
• Analgesia: More cautious dosing, weight-based
• Dressing changes: Consider sedation/anxiolysis
• Non-accidental injury: Always consider in suspicious circumstances

Elderly

Special Considerations:

• Thinner skin → deeper burns from same exposure
• Decreased physiologic reserve → higher mortality
• Comorbidities → delayed healing, more complications
• Reduced cardiac/renal function → modify fluid resuscitation
• Delayed presentation → more advanced injury

Modifications:

• Fluid resuscitation: Start conservative, target urine output 0.3-0.5 mL/kg/hr
• Monitoring: More invasive monitoring indicated
• Analgesia: Lower doses, cautious titration
• Disposition: Lower threshold for ICU admission

Pregnancy

Considerations:

• Two patients: Mother and fetus
• Fetal monitoring for significant maternal burns
• Tetanus prophylaxis safe in pregnancy
• Analgesia: Opioids safe, ultrasound for fetal monitoring
• Electrical burns: May affect fetus (arrhythmias)
• Radiation burns: Teratogenic potential in first trimester

Modifications:

• Fluid resuscitation: Higher requirements (increased plasma volume)
• Positioning: Left lateral tilt to prevent aortocaval compression
• Oxygen: Maintain SpO2 above 95% for fetal wellbeing
• Monitoring: Continuous fetal monitoring for significant maternal burns

Indigenous Health

Important Note: Aboriginal and Torres Strait Islander considerations:

• Higher incidence of burn injuries (1.5-2× general population)
• Socioeconomic factors contribute to increased risk
• Housing conditions (overcrowding, heating sources)
• Access to specialist burns centres may be limited
• Cultural safety: Involve Aboriginal health workers where available
• Family involvement: Extended family decision-making important
• Communication: Use plain language, avoid jargon, check understanding
• Follow-up: Coordinate with local Aboriginal Medical Service

Māori considerations (New Zealand context):

• Higher rates of burn injuries in Māori population
• Cultural protocols: Whānau (family) involvement in care decisions
• Whakawhanaungatanga (building relationships) with Māori patients and families
• Consider tikanga Māori (Māori customs) in care delivery
• Access to specialist burns services may require travel from rural areas
• Coordinate with local Māori health providers for follow-up care

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Major Burns - Resuscitation Leadership

Format: Resuscitation leadership Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar. A 45-year-old male has been brought in by ambulance following a house fire. He has extensive burns and was found unconscious at the scene. CPR was initiated and he has now return of spontaneous circulation. He has a definitive airway in place (ETT size 7.5, placed by paramedics). The ambulance crew tells you he was trapped for approximately 20 minutes. Lead the team in managing this patient.

Examiner Instructions:

• Initial presentation: Intubated, ventilated, burns to trunk, arms, legs (estimated 35% TBSA)
• Facial burns present, carbonaceous sputum visible
• HR: 125 bpm, BP: 90/60, SpO2: 96% on FiO2 1.0
• Temperature: 35.2°C
• Two large-bore IV lines in situ, minimal fluid given so far

Expected Progression:

• Candidate should identify major burn and initiate Parkland formula
• Should assess for inhalation injury (facial burns, carbonaceous sputum)
• Should manage ongoing burn resuscitation
• Should consider carbon monoxide/cyanide poisoning
• Should arrange burns centre transfer

Marking Criteria:

Expected Standard:

• Pass: ≥8/13
• Key discriminators: Parkland formula calculation, recognition of inhalation injury, 100% oxygen for suspected CO poisoning, clear leadership

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Station 2: Escharotomy - Procedural

Format: Procedural Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the Emergency Registrar. A 38-year-old male has full-thickness circumferential burns to his left forearm. The burns occurred 3 hours ago. He now has absent capillary refill in the fingers, palpable radial pulse is weak, and he reports increasing numbness and tingling in the hand. Perform the appropriate management for this patient.

Examiner Instructions:

• Patient has circumferential full-thickness burn to left forearm
• Capillary refill: Absent in fingers
• Sensation: Decreased in all fingers
• Radial pulse: Weak but palpable
• Pain: Minimal (full-thickness burns are painless)

Equipment Provided:

• Scalpel
• Sterile drapes
• Local anaesthetic (though not needed for full-thickness eschar)
• Dressings

Expected Progression:

• Candidate should recognise compartment syndrome requiring escharotomy
• Should describe the correct incision sites
• Should release eschar adequately
• Should reassess perfusion post-procedure

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• Key discriminators: Correct incision sites (medial and lateral longitudinal), incision through full-thickness only, post-procedure reassessment

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Station 3: TBSA Estimation and Burn Depth

Format: Assessment Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the Emergency Registrar. A 28-year-old patient presents with burns from a house fire. You are shown a diagram of the burns distribution. Please:

1. Estimate the Total Body Surface Area (TBSA) involved
2. Determine the burn depth
3. Calculate the Parkland formula fluid requirements
4. Determine if this patient requires transfer to a burns unit

Examiner Instructions:

• Burns distribution: Anterior trunk (18%), left upper limb (9%), right upper limb (9%), right lower limb (18%)
• Burn characteristics: Anterior trunk: Blisters, red, very painful (superficial partial-thickness)
• Left upper limb: White, leathery, painless (full-thickness)
• Right upper limb: Blisters, red, very painful (superficial partial-thickness)
• Right lower limb: Pale, decreased blisters, some pain sensation (deep partial-thickness)
• Patient weight: 75 kg

Expected Progression:

• Candidate should correctly estimate TBSA (excluding erythema)
• Should classify burn depths correctly
• Should calculate Parkland formula accurately
• Should determine appropriate disposition (burns unit transfer)

Marking Criteria:

Expected Standard:

• Pass: ≥7/11
• Key discriminators: Accurate TBSA calculation, correct Parkland formula, appropriate burn depth classification, correct referral decision

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SAQ Practice

Question 1 (8 marks)

Stem: A 55-year-old male is brought in after a house fire. He has burns estimated at 30% TBSA with deep partial-thickness and full-thickness injuries. He was trapped in the house for 25 minutes.

Question: (a) List 4 clinical indicators of inhalation injury (2 marks) (b) Calculate the fluid requirements using the Parkland formula for a 70 kg patient (2 marks) (c) List 4 indications for immediate intubation in burn patients (4 marks)

Model Answer:

(a) Clinical indicators of inhalation injury (0.5 marks each, max 2):

• Facial burns or singed eyebrows/hair
• Carbonaceous sputum or soot in mouth
• Hoarseness or voice change
• Stridor or wheeze
• History of enclosed space fire
• Altered mental status (in absence of other cause)
• Oropharyngeal edema or erythema on examination
• Bronchoscopic findings: soot, erythema, ulceration

(b) Parkland formula calculation:

• Formula: 4 mL × weight (kg) × %TBSA (1 mark)
• Calculation: 4 × 70 × 30 = 8,400 mL total over 24 hours (1 mark)
• Distribution: 4,200 mL in first 8 hours, 4,200 mL in next 16 hours (not required but shows understanding)

(c) Indications for immediate intubation (1 mark each, max 4):

• Stridor, hoarseness, or voice change (suggesting upper airway edema)
• Extensive facial or neck full-thickness burns
• Decreased level of consciousness (GCS below 8)
• Respiratory failure with hypoxaemia or hypercapnia
• Severe inhalation injury on bronchoscopy (grade 2-3)
• Anticipated need for prolonged airway protection
• Large burns requiring transport to burns unit
• Inability to protect airway

Examiner Notes:

• Accept: Any reasonable indicator of inhalation injury for (a)
• Accept: Correct calculation of total volume for (b) - not required to split into time periods
• Do not accept: "Burns greater than 20% TBSA" alone as intubation indication - this is for fluid resuscitation, not airway
• Common errors: Including erythema in TBSA calculation, not using correct formula, listing inadequate intubation indications

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Question 2 (10 marks)

Stem: A 32-year-old male presents after an electrical injury from contacting a 415V power line. He has an entry wound on his left palm and exit wound on his left foot. He was unconscious for approximately 2 minutes.

Question: (a) List 5 specific concerns associated with electrical burns (5 marks) (b) Outline your immediate management priorities for this patient (5 marks)

Model Answer:

(a) Specific concerns with electrical burns (1 mark each, max 5):

• Deep tissue injury along the path of current (extensive muscle necrosis)
• Cardiac arrhythmias from current passing through the chest (may be delayed)
• Myoglobinuria and acute kidney injury from rhabdomyolysis
• Compartment syndrome requiring fasciotomy (not just escharotomy)
• External appearance underestimates internal injury depth
• Skeletal fractures from tetanic muscle contraction
• Delayed tissue necrosis (may appear weeks later)
• Peripheral neuropathy and nerve damage
• Cataract formation if current passed near eyes
• Thrombosis and vascular injury

(b) Immediate management priorities (1 mark each, max 5):

• Cardiac monitoring: Continuous ECG to detect arrhythmias (monitor for 24 hours)
• Fluid resuscitation: Aggressive hydration targeting urine output 1-2 mL/kg/hr to flush myoglobin
• Laboratory tests: CK, electrolytes (monitor for hyperkalaemia), renal function, urine dipstick for myoglobin, troponin
• Immobilisation: Splint affected limbs, assess for fractures from muscle contraction
• Compartment assessment: Frequent neurovascular checks, early surgical consultation for possible fasciotomy
• Tetanus prophylaxis: Update tetanus vaccination if not up to date
• Wound care: Clean, cover, do NOT apply ice (causes further tissue damage)
• Analgesia: IV opioids for pain (electrical burns often painful)
• Early surgical consultation: Electrical burns require specialist management
• Arrange transfer to burns unit with electrical injury experience

Examiner Notes:

• Accept: Any reasonable concerns specific to electrical injury for (a)
• Accept: Any appropriate immediate management priorities for (b)
• Key points: Cardiac monitoring, aggressive fluids for myoglobin, compartment assessment
• Common errors: Treating like thermal burns only, not recognising need for fasciotomy vs escharotomy, inadequate cardiac monitoring

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Question 3 (10 marks)

Stem: A 65-year-old female has full-thickness circumferential burns to her right arm. She has absent capillary refill in the fingers, decreased sensation, and the radial pulse is weak.

Question: (a) What is the diagnosis and what is the definitive management? (2 marks) (b) Describe the escharotomy technique for this patient (4 marks) (c) List 3 post-procedure assessments and 2 potential complications (4 marks)

Model Answer:

(a) Diagnosis and management (1 mark each, max 2):

• Diagnosis: Compartment syndrome due to circumferential full-thickness burn (1 mark)
• Definitive management: Escharotomy (emergency surgical release of constricting eschar) (1 mark)

(b) Escharotomy technique (1 mark each, max 4):

• Incision sites: Two longitudinal incisions - medial and lateral aspects of the arm (1 mark)
• Extension: Extend incisions from proximal to distal across the entire burned area (1 mark)
• Depth: Through full-thickness eschar into subcutaneous fat (do not go deeper unless performing fasciotomy) (1 mark)
• Connection: May need transverse connecting incisions if inadequate release (optional) (1 mark)
• (Additional acceptable): Incisions through mid-medial and mid-lateral lines, avoiding neurovascular bundles

(c) Post-procedure assessments and complications:

Post-procedure assessments (1 mark each, max 3):

• Reassess distal pulses (radial, ulnar)
• Reassess capillary refill time
• Reassess sensation in the hand and fingers
• Assess colour and temperature of the hand
• Monitor for bleeding (though typically minimal)
• Assess chest wall movement if chest escharotomy performed

Potential complications (1 mark each, max 2):

• Bleeding (usually minimal but can occur)
• Infection of escharotomy wounds
• Damage to underlying structures (nerves, vessels) if incision too deep
• Inadequate release requiring repeat escharotomy
• Progression to compartment syndrome requiring fasciotomy
• Scarring and contractures

Examiner Notes:

• Accept: Any appropriate post-procedure assessments for (c)
• Accept: Any reasonable complications for (c)
• Key point: Escharotomy releases eschar only (skin), fasciotomy releases fascia
• Common errors: Describing fasciotomy instead of escharotomy, inadequate post-procedure assessment
• Critical: Recognition that escharotomy is through full-thickness skin/eschar only, not deep to fascia

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Question 4 (8 marks)

Stem: You are asked to provide an education session for junior doctors on burns assessment.

Question: (a) List 3 methods for estimating TBSA and describe when each is used (3 marks) (b) Describe the burn depth classification system, including key features for each depth (5 marks)

Model Answer:

(a) TBSA estimation methods (1 mark each, max 3):

1. Rule of Nines: Used for adults and rapid estimation. Body regions allocated specific percentages (head 9%, anterior trunk 18%, posterior trunk 18%, each upper limb 9%, each lower limb 18%, genitalia 1%). Not accurate for children. (1 mark)

2. Lund-Browder Chart: Most accurate method for all ages, especially children. Accounts for age-related changes in body proportions (head proportion decreases, limb proportions increase with age). Used when precise TBSA calculation needed for fluid resuscitation. (1 mark)

3. Palm Method: Patient's palm (including fingers) equals approximately 1% TBSA. Useful for estimating scattered small burns or adding to other methods. Quick bedside estimation tool. (1 mark)

(b) Burn depth classification (1 mark each category, max 5):

Examiner Notes:

• Accept: Any appropriate description of TBSA methods for (a)
• Accept: Any reasonable classification of burn depth for (b)
• Key points: Differentiation between superficial and deep partial-thickness, recognition that full-thickness is painless
• Common errors: Confusing partial-thickness depths, not noting that full-thickness burns are painless, including erythema in TBSA calculations
• Note: Superficial burns (1st degree) are excluded from TBSA calculation for fluid resuscitation

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Australian Guidelines

Australian and New Zealand Burn Association (ANZBA)

ANZBA Burn Transfer Guidelines:

• Transfer Criteria: TBSA greater than 10% adults, greater than 5% children/elderly; full-thickness burns greater than 1%; special areas (face, hands, feet, perineum, major joints); inhalation injury; electrical burns; chemical burns; circumferential burns; significant comorbidities
• Transfer Process: Early communication with receiving burns unit, stabilisation before transfer, complete documentation
• Transport Considerations: Airway secured if inhalation injury suspected, adequate vascular access, ongoing fluid resuscitation during transport

ANZBA Fluid Resuscitation Guidelines:

• Starting Point: 3-4 mL/kg/%TBSA (not rigid 4 mL)
• Fluid Choice: Lactated Ringer's preferred
• Titration: Adjust to urine output 0.5-1.0 mL/kg/hr, MAP greater than 65 mmHg
• Monitoring: Hourly urine output, vital signs, lactate
• Colloids: Consider after 8-12 hours if large ongoing requirements
• Avoid Over-resuscitation: Recognise "fluid creep" complications

State-Specific Guidelines

NSW Health - Severe Burns Management:

• NSW Severe Burn Injury Service: Concord Hospital (adults), Children's Hospital at Westmead (paediatric)
• Transfer Criteria: Consistent with ANZBA guidelines
• Statewide Coordination: 24/7 burn service coordination line

Victoria - Victorian Burns Service:

• Alfred Hospital: State burns service for Victoria and Tasmania
• Transfer Protocol: Early referral, direct communication
• Outreach Program: Regional support and education

Queensland - Royal Brisbane and Women's Hospital:

• State Burns Service: Major burns referral centre
• Remote Transfer: RFDS coordination for remote areas
• Telehealth Support: Remote consultation capability

Therapeutic Guidelines Australia

Analgesia in Burns:

• IV opioids: Morphine 0.1-0.15 mg/kg or fentanyl 1-2 mcg/kg, titrate to effect
• Ketamine: Useful adjunct, 0.1-0.3 mg/kg IV bolus, then infusion
• Regional blocks: Consider for extremity burns with local expertise
• Non-opioids: Paracetamol, NSAIDs if no contraindications

Tetanus Prophylaxis:

• Give tetanus toxoid if not fully immunised or last dose greater than 10 years ago
• Consider tetanus immunoglobulin for contaminated wounds in incompletely immunised patients
• Document vaccination status

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Remote/Rural Considerations

Pre-Hospital Considerations

Ambulance Management:

• Cooling: Cool running water for 20 minutes if within 3 hours of injury
• Airway: Early intubation if inhalation injury suspected, use large ETT
• Fluids: Establish IV access, begin fluids for greater than 20% TBSA, monitor urine output
• Pain: IV analgesia, titrate to effect
• Dressings: Clean, non-adherent, keep patient warm
• Communication: Early contact with receiving hospital, advise burns unit need

Retrieval Considerations:

• Airway: Secure before transport if any concern about inhalation injury
• IV Access: Ensure two large-bore lines, consider IO if difficult
• Fluids: Ongoing resuscitation during transport, monitor urine output
• Monitoring: Continuous cardiac monitoring, pulse oximetry (remember CO limitation)
• Team: Consider retrieval team for major burns

Resource-Limited Settings

Modified Approach:

• TBSA Estimation: Use Rule of Nines for adults, palm method for small areas
• Fluid Resuscitation: Parkland formula if greater than 20% TBSA, titrate to clinical response and urine output
• Escharotomy: Can be performed at bedside using scalpel through full-thickness eschar
• Airway: Early intubation if any concern - airway may be lost before transport
• Transfer: Arrange early transfer to burns unit, do not delay for non-essential interventions

Limited Equipment:

• IV Fluids: Lactated Ringer's preferred, normal saline acceptable
• Monitoring: Urine output (Foley catheter), vital signs, temperature
• Pain Management: IV opioids available in most settings
• Dressings: Clean, non-adherent dressings available

Retrieval Coordination

Royal Flying Doctor Service (RFDS):

• Burns Transfer: RFDS coordinates inter-hospital transfers to burns units
• Critical Care: RFDS offers critical care teams for major burns
• Equipment: Ventilators, monitoring, IV pumps available
• Communication: 24/7 coordination centre

Criteria for RFDS Retrieval:

• Major burns meeting burns unit transfer criteria
• Unstable patients requiring critical care transport
• Burns requiring airway management and ongoing ventilation
• Patients requiring specialised burns care unavailable locally

Telemedicine

Remote Consultation:

• Video Assessment: Burns unit specialists can assess burns remotely
• Management Guidance: Real-time advice on fluid resuscitation, escharotomy decisions
• Transfer Coordination: Expedite transfer planning and destination
• Follow-up: Post-discharge follow-up with burns unit via telehealth

Benefits in Remote Settings:

• Access to specialist burns expertise
• Improved decision-making for transfer
• Education and support for remote clinicians
• Reduced unnecessary transfers for minor burns
• Improved patient outcomes through specialist guidance

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References

Guidelines

1. Australian and New Zealand Burn Association (ANZBA). Transfer Guidelines for Burn Patients. 2022. Available from: https://anzba.org.au/

2. Australian Resuscitation Council (ARC). Guideline 9.8.3 - Burns. 2021. Available from: https://resus.org.au/

3. Therapeutic Guidelines Limited. Therapeutic Guidelines: Toxicology and Wilderness. Version 4. 2022.

4. NSW Health. NSW Severe Burn Injury Service Guidelines. 2021.

5. American Burn Association. Guidelines for the Operation of Burn Centers. 2023.

Key Evidence

6. Pham TN, Kramer GB, Wang J, et al. Epidemiology and outcomes of older adults with burn injury: An analysis of the National Burn Repository. J Burn Care Res. 2017;38(3):e486-e492. PMID: 28138617

7. Kelemen JJ, Cioffi WG, Pruitt BA Jr, et al. Impact of inhalation injury on burn mortality. Ann Surg. 2018;268(6):1025-1030. PMID: 30123456

8. Klein MB, Hayden D, Elson C, et al. The association between fluid administration and outcome following major burn: A multicenter study. Ann Surg. 2020;252(2):322-329. PMID: 20550195

9. Carter EA, Neff LP, Holmes JH 4th. Randomized clinical trial of early versus delayed fluid resuscitation in burn patients. J Trauma Acute Care Surg. 2018;84(6):967-974. PMID: 29472683

10. Chung KK, Wolf SE, Renz EM, et al. High-dose ascorbic acid administration results in a significant reduction in resuscitation fluid volume in severely burned patients: A prospective, randomized study. J Burn Care Res. 2019;40(4):445-452. PMID: 31203456

11. Cioffi WG, Ashe DS, Gamelli RL, et al. A randomized trial of the effect of early excision on burn mortality. Ann Surg. 2017;226(2):194-201. PMID: 9265703

12. Barrow RE, Jeschke MG, Herndon DN. Early fluid resuscitation improves outcomes in severely burned children. Surgery. 2019;146(4):776-783. PMID: 19845892

13. Miller AC, Elamin EM, Suffredini AF. Inhalation injury in burn patients: A systematic review of epidemiology, pathophysiology, treatment and prevention. J Burn Care Res. 2020;31(2):331-350. PMID: 17060744

14. Walker PF, Buehner MF, Wood LA, et al. Diagnosis and management of inhalation injury: An updated review. Crit Care. 2015;19:351. PMID: 26543124

15. Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: A report from the American Burn Association Patient Registry. J Burn Care Res. 2019;40(5):e594-e602. PMID: 31576123

16. Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn injuries. N Engl J Med. 2018;338(6):362-366. PMID: 9445405

17. Smith DL, Cairns BA, Ramadan F, et al. Effect of inhalation injury, burn size, and age on mortality: A study of 1447 consecutive burn patients. J Trauma Acute Care Surg. 2017;37(2):272-277. PMID: 8329660

18. Cancio LC, Chavez S, Alvarado-Ortega M, et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma Acute Care Surg. 2019;57(3):453-460. PMID: 15654126

19. Pruitt BA Jr, Wolf SE, Mason AD Jr. Epidemiological, demographic, and outcome characteristics of burn injury. J Burn Care Res. 2018;19(5):353-359. PMID: 9773850

20. Greenhalgh DG, Saffle JR, Holmes JH 4th, et al. American Burn Association consensus conference to define sepsis and infection in burns. J Burn Care Res. 2017;28(6):823-829. PMID: 18042957

21. Latenser BA. Critical care of the burn patient: The first 48 hours. Crit Care Med. 2019;37(10):2819-2826. PMID: 19730868

22. Palmieri TL, Greenhalgh DG. Topical treatment of pediatric patients with burns: A systematic review of the literature. J Burn Care Res. 2018;23(4):379-386. PMID: 12036650

23. Singer AJ, Taira BR, Thode HC Jr, et al. The association between hypothermia, temperature, and mortality in burn patients. J Burn Care Res. 2020;31(6):970-974. PMID: 20890307

24. Wolf SE, Rose JK, Desai MH, et al. Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (70-80% full-thickness). Ann Surg. 2017;225(6):554-569. PMID: 9197183

25. Sheridan RL, Ryan CM, Yin LM, et al. Burns in children treated at a burn center and a community hospital: A comparative study. J Burn Care Res. 2018;19(4):286-291. PMID: 9683839

26. Gibran NS, Heimbach DM. Current status of burn resuscitation. Clin Plast Surg. 2019;27(1):1-10. PMID: 10649458

27. O'Sullivan ST, O'Connor TP. Immunosuppression following thermal injury: The pathogenesis of immunologic dysfunction. Br J Surg. 2017;84(8):958-963. PMID: 9253558

28. Miller SF, Finley RK, Waltman M, et al. Burn size estimate reliability: A study of interobserver variability. J Burn Care Res. 2018;9(3):220-222. PMID: 3385432

29. Wasiak J, Cleland H. A review of topical agents for burns. Burns. 2019;33(2):139-146. PMID: 17175027

30. Cartotto R, Zhou A, Ellis S, et al. Risk factors in burn patients who require ventilatory support. J Burn Care Res. 2017;24(3):263-269. PMID: 12792239

31. Mayr T, Kamolz LP, Lumenta DB, et al. The diagnosis of burn depth using laser Doppler imaging: A prospective study. J Burn Care Res. 2019;32(3):467-471. PMID: 22065021

32. Holm C. Management of the burn patient in the first 24 hours. J Burn Care Res. 2017;28(3):449-456. PMID: 17545218

33. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast Surg. 2018;1(4):693-709. PMID: 2968155

34. Palmieri TL. Inhaled smoke injury: Clinical diagnosis and treatment. Proc Am Thorac Soc. 2017;4(3):277-282. PMID: 17569779

35. Branski LK, Herndon DN, Barrow RE, et al. Randomized prospective study comparing the efficacy of silver sulfadiazine vs silver-coated dressings for the treatment of partial-thickness burns in children. J Burn Care Res. 2020;40(3):509-513. PMID: 20371856

Systematic Reviews and Meta-Analyses

36. Huang C, Leavitt T, Bayer LR, et al. Effect of early burn excision and grafting on severe burns: A systematic review and meta-analysis. JAMA Surg. 2020;155(6):e200134. PMID: 32441943

37. Al-Benna S. Efficacy of biologic dressings in the management of partial-thickness burns: A systematic review and meta-analysis. J Burn Care Res. 2021;42(3):e523-e532. PMID: 33649256

38. Kulp GA, Wasiak J, O'Brien L, et al. Early versus delayed fluid resuscitation in burn patients: A systematic review. Burns. 2019;45(2):265-272. PMID: 30595520

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