(Courtesy of Dr Sandeep Gadgil)
Burns Education Day – Summary
On 14thNovember we had the pleasure of hosting members of the Concord Hospital Burns team for our Burns Education Day.
NSW Ambulance Burns Audit
Dr Clare Richmond kicked us off with data on burns patients from the last 3 years, prepared by Dr Efrem Colonetti. The key findings for this period (2015 to 2018) were:
- 241 burns patients, 141 were intubated, 46 by the retrieval team
- 8 escharotomies were performed by the retrieval team
- 58% of cases were flame burns, 19% were flash / explosion
- 67% of burns case sheets had a documented TBSA
- 73% of those with documented TBSA were consistent with hospital findings
- 95% of the burns patients did not have any significant concomitant trauma
These findings were compared with the Audit published by Dr Brian Burns last year (https://www.researchgate.net/publication/317316935_A_review_of_the_burns_caseload_of_a_physician-based_helicopter_emergency_medical_service).
The main take home points highlighted by Clare were to ensure documentation of TBSA and airway findings, assess for concomitant trauma and consider transfer to Concord if nil significant trauma. We were reminded of the feature on the ITIM app to assist in TBSA burns calculations (https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/ed-applications/trauma-apps)
Concord burns team
We had a fantastic set of presentations from the burns team covering burns assessment, pathophysiology, first aid, fluid resuscitation, airway considerations and surgical options. Throughout the day, the team emphasised that they want to be consulted early in relation to burns patients. For those interested in learning more about burns management they recommended the EMSB course (https://anzba.org.au/education/emsb/).
Dr Justine O’Hara (Plastics / Burns Surgeon) discussed the assessment and initial management of burns and provided some key messages:
- Accurate assessment of burns area and depth can be difficult
- Importance of good first aid (running or sprayed / sponged tap water for 20 minutes)
- No ice or iced water, no antibiotics
- Appropriately dress burns, do not debride (covering with cling wrap is ok)
- Know the NSW burns transfer guidelines
- If large burns (>15%) – IV fluids, analgesia, IDC & retrieve to burns unit
She also described a range of current and emerging surgical options (traditional debridement, fascial excision, hydrosurgical debridement) and wound closure options (allografts, xenografts and cultured epithelial autografts).
Dr Mark Kol (Intensivist) gave an overview of fluid management and the pathophysiology of shock in a burns patient. Points he highlighted were that fluid resuscitation in burns improves outcomes, the modified parkland formula (3ml/kg/%TBSA with half in the 1st8 hours) was an appropriate starting point with lactated ringers being the preferred fluid. Ongoing fluids are titrated to clinical endpoints, with urine output being commonly used.
He also gave a summary of the ventilation strategies used to manage the ARDS-like picture seen in burns patients.
Dr Kar-Soon Lim (Anaesthetist) spoke about airway considerations in burns patients. His take home points were:
- In large TBSA burns, the airway will swell even without airway burns (consider early intubation)
- An endotracheal tube is the definitive airway – have a low threshold for front of neck access if failed intubation (LMA likely to fail)
- Use normal sized tubes (larger ETTs are not necessary and may cause future vocal cord morbidity)
- Consider the need for chest escharotomy with trunk burns that are difficult to ventilate
Dr Andrea Issler-Fisher (Plastics / Burns Surgeon) gave an excellent description of burns wounds and the assessment of burn depth in relation to skin layers. She also described the indications and technique for performing an escharotomy (if in doubt, do it!) and contrasted this with performing fasciotomy (preferably in theatre by a surgeon).
The afternoon was spent with small group interactive workshops led by the Burns team consolidating three main topics covered in the morning lectures – airway considerations, fluid management and escharotomy. They provided valuable insights and tips from the Burns team and nicely rounded out a day addressing burns care in both the pre-hospital and hospital settings.