Burns , Guidelines, protocols and Management.pptx

Burns and Management

1. BURNS & PREVENTION PRESENTED BY : Prateek Verma

2. PATHOPHYSIOLOGY INJURY TO AIRWAYS- Swelling of the supra glottic airway and respiratory epithelium resulting in airway blockage Inhaled poisons like CO cause metabolic poisoning Mechanical blockage to rib movement in full thickness b urns Chemical pneumonitis following inhalational injury

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4. ET I OLOGY Thermal burns: Scalds Flame burns Flash burns Contact burns Electrical burns Chemical burns Radiation burns

5. PATHOPHYSIOLOGY ( cont ) INFLAMMATORY AND CIRCULATORY CHANGES- Burns activates a web of inflammatory cascades Vascular permeability increased Water, solutes and proteins move from intra to extra vascular space Volume of fluid directly proportional to amount of fluid burnt

6. PATHOPHYSIOLOGY ( cont ) Increased susceptibility to infections Malabsorption from the gut

7. PRE HOSPITAL CARE Ensure rescuer safety Stop the burning process Check or other injuries Cool the burn wound Give oxygen Elevation of the affected limb

8. Initial evaluation Airway Breathing Circulation Detailed history Exposure = Extent of burns/ Rule out other injuries Fluid resuscitation

9. MAJOR DETERMINANTS OF OUTCOME OF BURN Percentage surface area involved Depth involved Inhalational injury

10. Determination of Burn Extent and Depth TBSA burned Calculation: Using patients hand Rule of nines Lund and Browder charts

11. LUND AND BROWDER CHART

12. Depth of burn injury

13. First degree

14. 2nd degree superficial

15. 2nd degree Deep

16. Third degree

17. 4th degree

18. C riteria for transfer to burns unit

19. AIRWAY Danger sign when- Symptoms of laryngeal edema- change in voice, stridor History of being trapped in the presence of smoke and hot gases in a closed room Burns involving head , face and neck Burns on palate or nasal mucosa or loss of all hairs in nose. Prophylactic intubation is safest

20. BURNS ON BUCCAL AND NASAL MUCOSA

21. BREATHING Hypoxia Metabolic poisoning due to Carbon monoxide Eschar around chest

22. Use of intravenous fluid resuscitation reserved for patients with burns more than 15-20% Awake and alert patients less than 20% = oral rehydration encouraged. Parkland formula: 4cc x weight in kilograms x %TBSA burn in 24 hours First 8 hours = Half of calculated volume Next 16 hours = Other half Fluid Resuscitation

23. Choice of fluids Ringer Lactate is used. Normal saline not used due to risk of inducing hyperchloremic acidosis. Children <15kg receive Maintenance IV fluid with dextrose fluid since they do not have enough glycogen stores. Colloids Hypertonic saline

24. Colloids Only after first 12 hours of burn because before this time fluid shift causes leakage of proteins from the cells Muir and Barclay formula- 0.5 x % of body surface area burnt x weight one portion ( 6 portions in 36 hours ) Eg - Human albumin solution ( best ), dextran

25. Monitoring of Resuscitation Urine output best indicator (0.5-1.0 ML/kg) Others: Tachycardia, serial lactate and Hematocrit measurements. Risks: Under-Resuscitation and Over Resuscitation

26. TREATING BURN WOUND

27. Wound care Clean with water Blisters debrided. Prevent Infection and Hypothermia. Topical Wound Agents (depends on depth): Left open = First degree Collagen dressing = second degree Superficial Antibiotic creams = Second degree deep onwards

28. Prophylactic Systemic Antibiotics have no role Topical agents are better. SSD (Silver Sulpha diazine) : Broad spectrum antimicrobial coverage. Forms Pseudoeschar. S/E = Leukopenia. C/I = Sulfa Allergy. Mafenide : Penetrates eschar. S/E = Metabolic Acidosis and Painful application Silver Nitrate : Need for dressing every 4 hours; S/E = Black staining. Osmolar dilution resulting in hyponatremia and hypochloremia. Methemoglobinemia. Bacitracin, Neomycin, Polymyxin B Mupirocin

29. ESCHAROTOMY Eschar: Leathery eschar of full thickness burn can form a constricting band that compromises limb perfusion/ ventilation of patient Circumferential full thickness burns lead to compartment syndrome then requires emergency surgery ( escharotomy ) Escharotomy cause large amount of blood loss so adequate amount should be available for transfusion

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31. Nutrition Hypermetabolism and hypercatabolism seen Increased nutritional needs of patient Oral and Enteral feeds Parenteral = only when enteral not possible. Curreri Formula:(Caloric Requirement) Adults = 25kcal x Weight (kg) + 40kcal x %TBSA Children = 60kcal x Weight (kg) + 35kcal x %TBSA

32. Protein s- 20% of kilocalories should be provided Supplemental vitamins and minerals Monitor albumin levels Blood glucose level monitoring

33. Infection Risk of infection: Prolonged ICU / Intubation / Ventilation Potential colonisation of burn eschar Indwelling vascular and bladder catheters Burn patients are Immunocompromised Treatment: Antibiotics (Culture driven)

34. PAIN Acute- Small and superficial burns- NSAIDs, Topical cooling Large burns- I ntra venous Opiates Avoid Intramuscular injections over acute burns of more than 10%TBSA Subacute- Large burns require continuous analgesia Powerful short acting analgesics for dressing care

35. Surgical Management Delayed reconstruction and scar management Tangential shaving Debridement of necrotic tissue Hemostasis/ Blood replacement Skin Grafts: STSG/ Meshed

36. Chemical Burns Acid burns Alkali burns Treatment: Removal of inciting agents Copious irrigation with water No Neutralisation

37. Late Effects of Burn injury Hypertrophic Scarring Post burn contracture

38. Hypertrophic scars

39. Post burn Contractures