manag. of burn
TRANSCRIPT
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Burn management
Supervised by Pro.Salah al Qaryote
Done by : kr
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1.Ensure rescuer safety esp. in home fire & electrical injuries
2.Stop the burning process stop , drop , roll
3. Check for other injuries airways , breathing , circulation
4. Cool burnt wounds ( this will delay micro vascular damage at 15 C but avoidhypothermia & provides analgesia ) .
5. Give O2 , anyone involved in a fire in an a closed space should receive oxygen esp. in
altered conscious level .
6. Elevate limbs , setting a patent up with a burned airway may prove life-saving in the
event of a delay in transfer to hospital care coz it will reduce swelling and discomfort
Immediate care of burnt patients
Pre hospital care :
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Hospital Care
A = a irways
B = b reathing & ventilation
C = c irculation
D = d isability ( neurological status )
E = e xposure with environmental control
F = f luid resuscitation
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Major determinants of any burn injury :
1. Percentage of total body surface area burned
2.Presence of inhalation
3. Depth of burns
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1.Suspected airway injury or inhalation injury
2. Any burn likely to require fluid resuscitation
3. Any burn likely to need surgery
4. Critical sites hand , face , feet , perineum burns
5. Inadvisable to go home in case of psychiatric or social background
6. Suspicion of non accidental injury
7. Burn in a patient at extreme of age
8. Burn with associated sequelae ;high tension electricity .etc
Acute admission in case of :
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RESUSCITATION AND MANAGEMENT
The 1 st priority must be :
Maintenance of a patent airway
Effective ventilation
Support of the systemic circulation
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Airway :
Initial management of the burned airway:
Early elective intubation is needed
Intubation becomes difficult if delayed by swelling
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Recognition of potentially burned airways :
1. History of being trapped in presence of smoke or hot gases
2.Burnt palate or nasal mucosa , loss of hair in the nose
3.Deep burns around mouth & neck
THE KEY IN AIRWAY BURN MANAGEMENT IS THE HISTORY AND
EARLY SIGN RATHER THAN THE SYMPTOMS
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Indications for intubation :
Unconscious ptn
Ptns in respiratory distress
Ptns who have suffered severe burns
Ptns who are hemodynamically unstable despite fluid resuscitation
Where there is any Q of an inhalation injury
Upper airway burn
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CIRCULATION
Two large bore IV canulas
Avoid inserting IV lines in burn areas esp. limbs due to tourniquet effect of eschar
Patients with burns alone are often hypertensive
signs of systemic hypovolmia in a burn patient should raise suspicion of another occult injury
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Any Hx of a fire within enclosed space and any Hx of altered
consciousness are an important clues to a metabolic poisoning.
Measure blood gases if carboxyhaemoglbin levels raised above 10%
TX is O2 for 24 hours to speed its displacement from HB
Metabolic poisoning
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1. History is imp. ( temperature , time , burning material)
2. Superficial burns have capillary filling
3. Deep partial thickness burns do not blanch out but have some
sensation
4. Full thickness burns feel lethargy & have no sensation
Assessment of burn depth :
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FLUID MANAGEMENT The goal of IVF
Restore and maintain adequate tissue perfusion and oxygenation
Avoid organ ischemia
Preserve heat-injured but viable soft tissue
Minimize exogenous contribution to edema
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Fluid loss.
This shift of fluid is called third space loss Causes edema of theinterstitium
Depletion of the intra-vascular compartment will cause shock
Burn shock is seen in adults with more than 15% burns and children withmore than 10% .
Non burnt areas will show edema the cause here is generalized hypo-protienemia and circulating vasoactive mediators.
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Fluid loss, cont.:
Rate of loss maximum over the first few hours.Gradually declines over the next 1 to 2 days.In severe burn the loss continue to 3 rd day.The loss related to size of burned area.The loss not related to the depth of burn.Most formula depends on seize and Wt.
Fluid requirement calculations for infusion rates are based on the time frominjury, not from the time fluid resuscitation is initiated.
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1.) Crystalloid resuscitation :
1. Ringer's lactate is commonly used , effective as colloid in maintenance of IV
fluid
2. It used because that even the large protein molecules leak out of capillaries
Non burnt capillaries continue to save proteins
PARKLAND formula for replacement of fluids :
TBSA weight (kg) 4 = volume (in ml )
Fluid resuscitation :
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Fluid resuscitation :
2. ) Hyper tonic saline
Human albumin solution ( HAS) ,commonly used colloid
Effective in TX burn shocks
Produces hyperosmolarity & hypernatraemia
Causes less tissue edema by reducing the shift of intracellular water to
extracellular
Decrease escharotomies & allow intubation to occur
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3.) Colloid resuscitation :
Transport of plasma proteins needed to maintain inward oncotic pressure .
It should be given after 1 st 12 hours of burns because before that , massive
fluid shifting cause protein to leak out of cells .
Muir & Barclay formula for colloid :
0.5 percentage of body surface area burnt weight = one portion
In a role of 4/4/4 , 6/6 , 12 hours respectively , one portion in each period .
Fluid resuscitation :
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Start with crystalloids in the 1st 12-24 hrs then give colloids.
Due to leaky capillaries .
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MONITORING1 HR
Pulse rate is a better indicator than BP
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MONITORING3 urine output
With crystalloid resuscitation regimens such as the parkland formula , urineoutput remains an excellent guidelines for the adequacy of resuscitation.
Target : 0.5 to 1 cc/kg/hr in the adult1-2 cc/kg/hr in the child.
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MONITORING
4 Invasive monitoring ( CVP & Pulmonary artery CATH ) Target :
Pulm. a occlusion pressure 12-15 mm hgFew ptns will benefit from invasive hemodynamic monitoring , they include:
1. Elderly ptns with preexisting cardiac or repiratory Dis.2. Massively burned ptns with significant inhalation injury 3. Use should be reserved for the complicated or difficult resuscitations
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MONITORING ABG
Persistent metabolic acidosis inadequate perfusion an indication forincreasing fluid administration.Except in CO poisioning when the ptn may be acidotic secondary to COinhalation
HEMATOCRIT:Serial hematocrit determinations determine the adequacy of resuscitationInitial hemo concentration is followed by a later decease in hematocrit thatmainly reflects reexpansion of the intravascular compartment with fluidresuscitation
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Assessing adequacy of resuscitation
Peripheral blood pressure: may be difficult to obtain often misleading
Urine Output: Best indicatorunless ARF occurs
A-line: May be inaccurate dueto vasospasm
CVP: Better indicator of fluidstatus
Heart rate: Valuable in earlypost burn period should bearound 120/min.
> HR indicates need for > fluids or pain control
Invasive cardiac
monitoring: Indicated in aminority of patients (elderly orpre-existing cardiac disease)
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Blood transfusion
Patients requiring transfusion:
Adults .20% TBSA or more.
Children15%TBSA or more.
(whatever the depth of the burn wound)
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1. 1% sliver sulphadiazine cream against pseudomonas & MRSA
2. 0.5 % silver nitrate solution (( causes black staining ))
3. Mafenide acetate cream
4. serum ((nitrate , silver sulphadiazine)) : useful esp. in full thickness
burns , induces hard effect on burn & reduces some of cell mediated
immunosuppressant .
Topical TX of deep burns :
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Dressing should:
1. Decrease pain asssociated with dressing
2. Improve healing times
3. Decrease outpatients appointements
4. Lower overall cost
in dressing :
1. Full thickness & deep dermal burns need antibacterial dressing to delay colonization prior to
surgery
2. superficial burns will heal & need simple dressing
3. optimal healing environment make a difference to outcome
Principles of dressing :
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PAIN CONTROL:
During shock phase of burn care ,medication should be IV.
SC and IM will be absorbed variably depending on perfusion and should beavoided
Best managed with IV morphine 2-5 mg. Usually
itching :
Most burn patients have itchy wounds
TX: analgesics , anti histamines , moisturing creams
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Analgesia :
Small burns esp. superficial burns respond to oral analgesia (( paracetamol ,
NSAIDs)).
Large burns need IV opiates .
Powerful , short acting analgesics administered before dressing changes.
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10 % of adults or 15 % child burns requires additional nutritional
requirements .
20 % or more TBSA must receive nasogastric tube .
Acute burns are catabolic ; continues while wound unhealed , so
rapid excision of the burn & stable coverage ((most significant
factors )).
Nutrition and energy balance :
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Nutrition and energy balance : cont.
Hyper metabolic state
Lasts until the wound is closed
The gut of the burn patients should be used for nutrition if it isavailable
Adequate nutrition is imp. To maximize patient survival and
minimize complications.
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1. Burned patients are immunocompromised
2. burned patients are susceptible for infections by many routes
3. sterile precautions must be rigorous
4. swabs should be taken regularly
5. ((increase in WBC, thrombocytosis, increase in catabolism ))
are warnings to infections
Control of infections in burned patients :
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Cont .
Management by a combination of systemic & topical agents Infection converts:
superficial burns to partial thickness burn
partial thickness burns Deep partial thickness burns
Tetanus burn woundsPrevious immunization within 5 years requires no treatmentImmunization within 10 years tetanus toxic booster to be givenUnknown immunization status requires booster
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PE PREVENTION
Preventive efforts should be directed at patients with classical risk factors for PE :History of prior thromboembolic Dis.Obesity
Burns of the lower exteremities
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1.Any deep partial thickness & full thickness burns needs surgery except
those < 4 cm2
2. reassess burn depth which increases in the next day
3. topical dressings decrease bleeding4. all burnt tissue needs to be excised
5. stable cover should be applied at once to reduce burn load
Surgery for acute wound :
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Escharotomy
Eschar = burned skinEscharotomy = cut burned skin to relieveunderlying pressure
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ESCHAROTOMY and FASCIOTOMY:
Chest escharotomy
In case of early respiratory distress may be due to compromises of the ventilator function .In deep circumferential burn wound of thechest
Performed in an anterior auxiliary bilateral. With contact by transverse incision along the costal margin
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Cont.
Escharotomy of extremities
Remove rings ,watches,jewelry.
Skin color, sensation, capillary refill and prepheral pulses should be assessed.Escharotomy indicated when muscle compartment pressures > 30 mmHg
Circulation to distal limb is in danger due to swelling, Progressive loss of sensation/ motion in hand / foot.
Doppler U/S can be of use pre and post escharotomy
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Escharotomy - complicationsCOMPLICATIONS
Bleeding: might require ligation of superficial veins
Injury to other structures: arteries, nerves, tendons
NOT every circumferential burn requires escharotomy.
In fact, most DO NOT need escharotomy.
Repeatedly assess neuro-vascular status of the limb.
Those that lose circulation and sensation need escharotomy.
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Clinical Manifestations
Burn wound either heals by primary intention or by grafting.
Scars may form & contractures.
Mature healing is reached in 6 months to 2 years
Avoid direct sunlight for 1 year on burn
new skin sensitive to trauma
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Mortality in Burns
>20% BSA with shock and other complications/related sequelae
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Thanx a lot .