Burns webinar- additional questions

A number of questions in the burns webinar were not covered in the formal Q&A section, but Mr Hilal Bahia kindly answered a few more questions after the event. Many of these questions relate to specific points within the initial presentation

1. When should inhalational burn PT be shifted to icu and ventilation?
If a patient is assessed to have had an inhalation injury, either by the history of being confined in a burning room or building, or if there are any signs of inhalation injury, (such as soot around the nose or mouth, singed nasal hairs, coughing up sooty sputum, hoarseness of the voice, using accessory muscles of respiration, stridor, swelling of the face or oral mucosa), then the patient should be reviewed by an anaesthetist and admitted to ICU for observation, or possibly intubated and ventilated before the airway swells and makes intubation much more difficult.

2. What should be the sequence of management of burn injuries for the 2nd and 3rd and later?
I’m uncertain as to whether you mean 2nd and 3rd days? In which case these things depend on the size and depth of the burns. If the burns are greater than 15% in an adult, then there would be a 24 hour period of fluid resuscitation. 

You may wish to take the patient to the operating room on admission, or within 24 hours, for debridement of the burn and dressing of the wounds, although this could be combined with excision and grafting of the burn. 
Often you might plan for excisional surgery within 24-48 hours, if you hadn’t carried it out earlier. 
After that, you may need to have changes of dressing carried out in theatre, or on the ward and any remaining burns excision, if you haven’t completed all areas.

3. Is there any difference of timing when doing tangential excision in children?
No, not really. The same principles apply.

4. The palm area for %TBSA includes fingers area or not?
This depends on which text book you read. Some books say that the palm alone is 1% (1.25% with the fingers), while others claim that the palm and fingers are 1%. 
Remember that this only works for the adult patient’s own hand.

5. If the patient presents late to ER or after the 1st 24 hours then should the resuscitation fluid be given as per the formula for the 1st 24 hours?
No, not necessarily, but you should insert a infusion line and urinary catheter and check urea and electrolyte levels. You should use the urine output and U&Es to guide fluid replacement. This may be best managed by intensivists in ICU/HDU. Most patients will be severely dehydrated and need very careful fluid balance monitoring and regulation.

6. Should we go for fasciotomy in every case of full thickness circumferential or high voltage electrical burn injury of limb?
No. It depends on the site of the injury, depth of the circumferential component and tension in the tissues. If it is in a limb, then clinical assessment of the degree of tension in the limb, or alternatively a compartment pressure measurement maybe required. Often elevation of the affected limb and hourly clinical assessment by the nurses may be sufficient, however if there is any doubt, then it is advisable to carry out escharotomy to relieve the tension and pressure.

7. Your views on place of flap reconstruction in high voltage electrical burns especially in the head & neck area  and for scalp reconstruction.
Flaps may be required in any area if split skin grafts are not possible or are likely to lead to severe contractures. If the burn is down to bare tendon or bone, then a local, pedicled flap may be required. If this is not possible, then a free flap may be the only option. Burns to the neck, or across joints such as the ankle or heel of the foot may need flap coverage in order to prevent contractures causing loss of function.