Burns

This presentation include-
Definition, Etiology, risk factors, classification, types, pathophysiology, assessment, rule of nine, burn management fluid therapy, surgical management, prevention, complication,

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1. BURNS -VIPIN PATIDAR www.vipinpatidar.wordpress.com

2. DEFINITION:- Burns are the tissue injury caused by the contact with flame, chemicals, electricity, and radiation. A burn is an injury caused by an exogenous agent that produces a characteristic reaction to local tissues which may vary from mild erythema to full thickness destruction of the skin and deeper tissues. www.vipinpatidar.wordpress.com

3. ETIOLOGY Thermal injury (Scald injury): From moist heat. They are the commonest cause for burn injury in children under 3 years of age. E.g. Hot water, tea etc. Flame injury: Use of alternative heating devices such as kerosene stove, chimney, electrical wiring, smoking combination with alcohol. Electrical injury: It is caused by high voltage electric contacts e.g. infants chewing electric cords, accidental contacts with high tension wires www.vipinpatidar.wordpress.com

4. Continue….. Chemical and contact injury : it can result from chemicals like acid, spirit, petroleum products, etc in full thickness burn. Radiation injury: childhood to adolescents by U.V. rays medical therapies. www.vipinpatidar.wordpress.com

5. Classification of Burns According to Depth of burns : According to causes: 1. Superficial burns (1st degree) 1) Thermal Burns: 2. Partial thickness burns (2nd degree) 2) Chemical Burns: a) Superficial partial thickness: 3) Electrical Burns: b) Deep partial thickness: 4) Radiation Burns: 3. Full thickness burns (3rd degree) 5) Inhalation injuries 4. Fourth degree burn: i ) Smoke inhalation ii) Carbon Monoxide According to severity of burns: 1) minor burn 2) moderate burn 3) major burn www.vipinpatidar.wordpress.com

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7. 1) Superficial burn (1 st degree) Only the epidermis Red and tender. Painful Dry (no blisters) Mild discomfort some good over the counter (OTC) topical creams used. Aloe vera , Lidocaine According to Depth of burns: www.vipinpatidar.wordpress.com

8. 2) Superficial partial-thickness burn (Superficial 2 nd degree burn) Epidermis and part of the dermis Blistered, red or White , blanches with pressure Painful Blisters (wet) Often seen with scalding injuries Sensitive to light touch or pinprick Treated on outpatient basis, heal time 1-3 weeks According to Depth of burns: www.vipinpatidar.wordpress.com

9. 3) Deep partial-thickness Epidermis and most of the dermis Appears white or poor vascularized , may not blister Less sensitive to light touch than superficial form Extensive time to heal (3-4 weeks) Often require excision of the wound and skin grafting According to Depth of burns: www.vipinpatidar.wordpress.com

10. 4) Full-thickness (3 rd degree) Epidermis, dermis and into subcutaneous tissue, Full-thickness extends to muscle or bone Dry, leathery. Typically no blistering Commonly seen when clothes are caught on fire or skin is directly exposed to flame Extensive healing time and need for skin grafting According to Depth of burns: www.vipinpatidar.wordpress.com

11. According to severity of burns: Minor Burns Partial thickness burns are no greater than 15% of the TBSA in the adult Full thickness burns are < 2% of the TBSA in the adult Burn areas do not involve the eyes, ears, hands, face, feet, or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 The client has no pre-existing medical condition at the time of the burn injury No other injury occurred with the burn www.vipinpatidar.wordpress.com

12. According to severity of burns: 2. Moderate Burns Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult Full thickness burns are 2% to 10% of the TBSA in the adult Burn areas do not involve the eyes, ears, hands, face, feet, or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury No other complicated injury occurred with the burn www.vipinpatidar.wordpress.com

13. According to severity of burns: 3. Major Burns Partial thickness burns are > 25% of the TBSA in the adult Full thickness burns are > 10% of the TBSA Burn areas involve the eyes, ears, hands, face, feet, or perineum The burn injury was an electrical or inhalation injury The client is older than 60 The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury Burns are accompanied by other injuries www.vipinpatidar.wordpress.com

14. PATHOPHYSIOLOGY OF BURNS BURN ↑ Vascular permeability ↓ Cardiac output ↑ Peripheral resistance ↑ Viscosity ↑ Hematocrit ↓ IV volume Edema www.vipinpatidar.wordpress.com

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16. ASSESSMENT OF BURNS Body Surface Area Rule of Nines Best used for large surface areas Tool to measure extent of burn Rule of Palms Irregular or splash burns Best used for burns <10% BSA Lund and Brower chart www.vipinpatidar.wordpress.com

17. Burn Surface Area Estimation 1. Rule of Nines www.vipinpatidar.wordpress.com

18. 2. Rule of Palms A burn equivalent to the size of the patient’s hand is equal to 1% body surface area (BSA). www.vipinpatidar.wordpress.com

19. 3 Lund and Brower chart www.vipinpatidar.wordpress.com

20. Burns management phases of burn care www.vipinpatidar.wordpress.com PHASE DURATION Emergency/ resuscitative From onset of injury to completion of fluid resuscitation. Acute/ intermediate From beginning of diuresis to near completion of wound care. Rehabilitation From major wound closure to return to individual’s optimal level

21. Priorities… First aid. Prevention of shock Prevention of respiratory disorder Wound assessment and initial care Wound care and closure Prevention of complication Nutritional support Physical, occupational, vocational rehabilitation. Cosmetic reconstruction Psychological counseling. www.vipinpatidar.wordpress.com

22. Burns management 1. Emergency first aid:- Stopping the burning process Cool the burn Remove restrictive objects. Cover the wound. Use of blanket ABCs of trauma care Transport the patients to hospital Switch off electrical supply. Wash the parts incase of chemical burns (irrigate chemical burn) www.vipinpatidar.wordpress.com

23. Continue.. 2. General protective measures:- First aid Ice packs and cold water application Loose the tightened clothing Provide patent airway Use aseptic procedures Don’t break or peal off blisters www.vipinpatidar.wordpress.com

24. Continue.. 3. Supportive management:- Analgesics and sedatives Fluid replacement therapy Transportation to hospital under medical supervision. www.vipinpatidar.wordpress.com

25. Continue. . 4. Hospital management:- General supportive measures: Assess airway Manage breathing ECG Provide feeding by nasogastric tube b) Fluid therapy: Establish central line for fluid replacement www.vipinpatidar.wordpress.com

26. FLUID THERAPY Parkland formula a. Initial 24 hours : Ringer’s lactated (RL) solution 4 ml x body weight (kg) x % burn for adults. This formula recommends no colloid in the initial 24 hours. The calculated half fluid should be given in first 8 hours and remaining fluid should be given in next 16 hours. b. Next 24 hours : Colloids given as 20–60% of calculated plasma volume. No crystalloids. Glucose in water is added in amounts required to maintain a urinary output of 0.5–1 ml/hour in adults. www.vipinpatidar.wordpress.com

27. Continue.. Brooke army formula Initial 24 hours : RL solution 1.5 ml x body weight (kg) x % burn + colloids 0.5 ml x body weight (kg) x % burn + 2000 ml glucose in water Next 24 hours : RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same amount of glucose in water as in the first 24 hours www.vipinpatidar.wordpress.com

28. Continue.. Consensus formula RL solution 2-4 ml x body weight (kg) x % burn Evans formula RL solution 1ml x body weight (kg) x % burn + colloids 1ml x body weight (kg) x % burn + 2000 ml glucose in water www.vipinpatidar.wordpress.com

29. Continue.. Assess for B.P., vitals, Hct . plasma, blood volume etc regularly Adequacy of fluid therapy is to be assessed by urinary output (1-2ml/kg/hr) Central venous pressure should be maintained 7-15 cm of H20. Prophylaxis : T.T. Hyper immune tetanus globulin with T.T. will be given 6 weeks and 6 months interval www.vipinpatidar.wordpress.com

30. Continue.. Chemotherapy: Crystalline penicillin for 5 days Wound swab culture for culture and sensitivity Antibiotics Aseptic and barrier nursing Sedation: Pethadine- 1to 2 mg/kg intravenously . www.vipinpatidar.wordpress.com

31. Continue.. e) Nutrition: Diet rich in calories and proteins because of negative nitrogen balance. Calories= 60kcal/kg + 35kcal/1% burn Protein= 3 gm/kg body wt + 1 gm/1%of burn N.G. feeding Vitamin A, Zn, Cu is important www.vipinpatidar.wordpress.com

32. Wound care and treatment Dressing: Hydrotherapy Daily cleansing and debridement are necessary to promote skin integrity May use tubs or shower carts, mobile stretchers. Wound debridement To remove tissue contaminated by bacteria and foreign bodies To remove dead tissue and promote wound healing. Three types- natural, mechanical, surgical www.vipinpatidar.wordpress.com

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34. Contd.. The choice of method depend upon injury and environment of patient. Closed method: closed wound, sealed off completely by dressing, prevent complications, and cross infection Exposed method: exposed wound, apply topical agents. www.vipinpatidar.wordpress.com

35. Contd … Topical antibiotics: decrease both risk of infection, fluid loss from burn. Silver sulfadiazine: painless, poor eschar penetration, broad antibacterial spectrum, no metabolic side effects Mafenide : Penetrates tissue well, broad spectrum antibiotics, painful on application. Bacitracin : often used for burns of face, painless, no pigment bleaching (can be seen with silver sulfadiazine) Aqueous silver nitrate 0.5%: painless application, poor eschar formation. www.vipinpatidar.wordpress.com

36. Surgical treatment Escharotomy : a surgical incision into necrotic tissue resulting from a severe burn to lessen the pressure on neurovascular structures. Incision of burnt tissue down into fat. Indications : Circumferential full thickness or 3 rd degree burns burns to limbs (longitudinal), chest (anterior axillary line, lateral cuts joined by transverse cuts & costal margin) or neck. www.vipinpatidar.wordpress.com

37. Surgical treatment 2. Fasciotomy : It is a surgical procedure that cuts away the fascia to relieve tension or pressure. Indications: skeletal trauma, crush injury, high-voltage electrical injury or if involving tissue beneath the investing fascia. 3. Grafting:  it is a transplantation of tissue from one body part to an other. Indications : Full thickness, Cosmetic review www.vipinpatidar.wordpress.com

38. COMPLICATIONS LOCAL SYSTEMIC HYPERTROPHY SCAR HYPO / HYPER PIGMENTATION CONTRACTURES SEPSIS RENAL FAILURE RESPIRATORY FAILURE MULTI ORGANS FAILURE DEATH www.vipinpatidar.wordpress.com

39. Complications Shock Septicemia Low cardiac output Acute tubular necrosis Pulmonary edema Throbophebitis Bronchopneumonia Marjolin’s ulcer (burn scar carcinoma) Septic arthritis Curling’s ulcer ( gastroduodenal hemorrhage) www.vipinpatidar.wordpress.com

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41. Prevention Proper storage of inflammable articles Use of platform when cooking, heaters Fire alarms Closure of electric sockets Need for high protein and high calorie diet Care of burn wound www.vipinpatidar.wordpress.com