BURNS.pptx

Burns

1. BURNS

2. INTRODUCTION DEFINITION CLASSIFICATION PATHOPHYSIOLOGIC EFFECTS OF BURNS CRITERIA FOR ADMISSION IN-PATIENT MANAGEMENT COMPLICATIONS

3. INTRODUCTION History of modern burn resuscitation – Patients with large burns survived the event but died from shock in the observation period. Ability to treat burns has improved due to: - Better understanding of burn shock -Advances in fluid therapy -Improved ability to excise dead tissue -Use of biologic dressings

4. ANATOMY $ PHYSIOLOGY OF THE SKIN Components of the skin -Epidermis -Dermis -Subcutaneous tissue Functions of the skin - Protection -Prevent fluid & protein loss -Temperature regulation -Sensation via nerve endings

5. Based on the above functions, victims may have: - Difficulty with thermoregulation - Inability to sweat - Impaired vasoconstriction and vasodilatation - Inability to grow hair -Little or no sensation

6. Pathophysiologic effects of burns Pathologic progression (Jackson) - Zone of coagulation - Zone of stasis - Zone of hyperemia Vascular injury - Increased capillary permeability - Damage of rbcs General metabolic response - Hypermetabolism -negative nitrogen balance -Exaggerated stress response -Increased cortisol and catecholamine release

7. DEFINITION Body injury resulting from cellular damage to hyperthermia or hypothermia Cellular damage occurs when the energetic portion of electromagnetic fields acts on cells

8. CLASSIFICATION According to cause According to depth According to size According to the America Burn Association

9. According to cause Chemical Electrical Thermal

10. Chemical -Caustics -Severity depends on type of caustic(pH), the concentration, the amount, the physical form, period of time contact (Direct toxic effects on metabolic processes) -Usually superficial and are treated by flushing the area copiously then treating it as a thermal burn Electrical -Electrical energy+poorly conducting body tissues= Thermal energy -Severity depends on amount of voltage, tissue resistance, current pathways, S.A in contact with the current & length of time the current flow was sustained -Misleading appearance. After 24h of conservative mngmt , determine the limits of destruction then debride the tissue Thermal -Flame(Adults), flash, scald(Children), direct contact with hot objects (80%) -Severity depends on the temperature and duration of exposure to flame – 44 degrees -Vigorous fluid resuscitation needed

11. INHALATIONAL BURNS Produces injury through several mechanisms - Thermal injury to the upper airway - Irritation or chemical injury to the airway from soot - Asphyxiation - CO toxicity Supraglottic , subglottic or global Hx of having been injured in an enclosed space for more than 10 mins Presentation - Facial burns - Blistering or edema of the oropharynx - Hoarseness of voice - Carbonaceous sputum - Signs of respiratory distress Management (Intubation, oxygen, bronchodilators, investigations)

12. ACCORDING TO DEPTH Current designation of burn depths are: - First degree - Superficial or epidermal - Second degree- Superficial & deep - Third degree- Full thickness burns The term fourth degree is still used to describe the most severe burns that extend to the muscle, bone and joints

13. 1 st degree / Epidermal Epidermis only involved Caused by UV light or very short flash or flame exposure Skin is red, dry and hypersensitive thus painful No treatmentrequired except analgesia Leaves no scar on healing by day 6 Over the next two to three days the pain & erythema subside & by about day 4 the injured epithelium peels away from the newly healed epidermis

14. 2 nd Degree SUPERFICIAL SECOND DEGREE - Epidermis plus the upper 1/3 of the dermis - Commonly caused by scalds (Spill or a splash) - Red, moist, weeping cob blisters that blanch with pressure - Burns that initially appear to be only epidermal in depth may be determined to be partial thickness 12-24 hrs later - Painful due to nerve exposure and heals between 10 and 14 days - Leaves no scarring on healing but there are potential pigment changes

15. DEEP SECOND DEGREE - Epidermis and upper 2/3 of dermis - Damage hair follicles & glandular tissue - Caused by scald, flame, chemicals, oil & grease -Don’t blanch with pressure; Cheesy white, wet or waxy dry; Painful to pressure only -Healing takes 14-21 days -Invariably result in hypertrophic scarring and risk of contractures

16. 3 rd Degree/Full thickness burns Extend through & destroy all layers of the dermis, sometimes reaching the underlying subcutaneous tissue Burn eschar, the dead & denatured dermis, is usually intact & can compromise viability of a limb if circumferential Anaesthetic or hypoesthetic Skin appearance varies from waxy white to leathery gray to charred and black. Skin is dry and inelastic and doesn’t blanch with pressure. Hair can easily be pulled out from the follicles & vesicles and blisters don’t develop. Eschar eventually separates from the underlying tissue to reaveal a bed of unhealed granulation tissue – w/out surgery wound heals by wound contracture with epithelialization around the wound edges

17. 4 th Degree burns Muscle involvement

18. 5 th Degree Bone involvement – especially common in epileptics who convulse while burning

19. ACCORDING TO SIZE Essential in guiding therapy & determining when to transfer a patient to ICU/Burn center Expressed as the TBSA (%age) Superficial burns aren’t included in this assessment. 3 methods - Rule of palms - Wallace rule of nine -Lund Browder chart

20. Rule of palms/Palmar method Used to approximate small or patchy burns using the surface area of the patient’s palm The palm of the patient’s hand, excluding the fingers is 0.5% of TBSA and the entire palmar suface including the fingers is 1% in both children and adults

21. Wallace rule of nines For adult assessment, this is the most expeditious method - Each leg represents 18% of TBSA - Each arm represents 9% of TBSA - Ant. & pos. trunks each represent 18% TBSA - Head represents 9% TBSA -Perineum 1%

22. Lund-Browder Chart Most accurate Takes into account the relative percentage of BSA affected by growth Children have proportionally larger heads and smaller lower extremeties , so the percentage BSA is more accurately estimated using the following chart

23. CRITERIA FOR ADMISSION Cause - Electrical burns - Inhalational burns - Chemical burns with serious threat of fxn or cosmetic impairement Severity - Moderate & severe burns -15% superficial in adults -10% superficial in children - Non healing after 14-21 days

24. Anatomical location - Head, neck, hands, soles & perineum - Circumferential - Inhalational Patient factors - Poor social factors - Extremes of age (<4yrs & >50yrs) - obese patient with burns on both limbs -Pregnancy -Concomitant trauma -Pre-existing medical conditions

25. PRINCIPLES OF MANAGEMENT Initial evaluation & Resuscitation (ATLS) Pain control Wound cleaning & dressing Rehabilitation

26. Initial evaluation & Resuscitation First 48 hours PRIMARY SURVEY -Airway with C spine control (Look out for & manage inhalational injury) -Breathing (Chest rising & warm air on the cheek) -Circulation & hemorrhage control -Disability -Exposure

27. Lines & tubes - IV access with large bore -CVP -Urethral catheterization -NGT -Endotracheal tube

28. SECONDARY SURVEY - History and physical examination -Medical management

29. IV FLUIDS Modified Parkland’s formula 4/3 * TBSA(%age) * Weight in Kgs Crystalloids: Ringer’s lactate or Hartmann’s solution or N/S Give half within the first 8 hours (From time since burn occurred NOT admission to hospital) and the rest in the next 16 hours Give 50% more in electrical burns and inhalational injury

30. Monitoring fluid therapy Vitals URINE OUTPUT -Adults (0.5mls/kg/hour) -Children & electrical burns (1ml/kg/ hr ) - Haemoglobinuria suggests deep burns hence flush kidney with increased fluids & mannitol -Decrease in BP and urine output suggests a need for colloids -Decrease in urine output but normal BP suggests a continuous need for crystalloids

31. State of the patient – should be calm Frequent chest auscultation to detect pulmonary oedema CVP line is the best to avoid over infusion Evaluate tx every 3-4 hours

32. Causes of inadequate fluid resuscitation Inaccurate estimation of the burn size Undiagnosed inhalational injury Concomitant traumatic inury Cardiac dysfunction Refractory shock Mathematic miscalculation

33. OTHER FLUID FORMULAS Evan’s formula -First formula based on BSA damaged and body weight. -First 24h: Crystalloids 1ml/Kg/% burn plus colloids at 1ml/kg/%burn plus 2000ml D5W - Next 24h: Crystalloids at 0.5ml/kg/% burn, colloids at 0.5ml/kg/% burn and the same amount of D5W as above Thus total fluid is given in the ratio 1:1

34. Brooke formula/ Modified Brook formula Original - Initial 24h: RL soln 1.5ml/kg/%burns plus colloids 0.5ml/Kg/%burns plus 2000mL D5 -Next 24h: RL 0.5ml/kg/% burn, colloids 0.25ml/kg/% burn plus 2000mL D5 Modified Brooke - Initial 24h: No colloids. RL solution 2mL/kg/% burn in adults and 3ml/kg/% burn in children - Next 24h: Colloids at 0.3-0.5ml/kg/% burn and No crystalloids are given. D5 added in required amounts to maintain good urinary output

35. Monafo formula Recommends using a solution containing 250mEq Na, 150 mEq lactate and 100mEq Cl. Amount adjusted according to urine output In the following 24h ,the solution is titrated with 1/3 normal saline according to urinary output

36. Pain Control Give opiate analgesics IV and NSAIDS

37. Wound care & Dressing A) WOUND CARE Remove all necrotic tissue and debris Wash with warm normal saline Apply topical antibiotic - SSD (Thrombocytopenia, leucopenia, hypersensitivity rash) -Silver Nitrate- Stains tissues, hypochloraemic alkalosis and hyponatremia: Good for grafts - Mafenide 10% - Can penetrate tissue and Eschar. Good for infected wounds and eschars, very painful on application; Carbonic anhydrase inhibition causes metabolic acidosis

38. DRESSING - Open dressing -Exposure dressing – Apply soothant e.g Vaseline -Occlusive dressing- For small superficial previously debrided wounds - Apply non adherent material e.g bactigras - Change after 3 days and then apply daily upto day 21 - If there’s no healing consider grafting

39. Indications for occlusive dressing If burn is oozing too much Risk of infxn Children Comorbidities Joints Patient’s comfort

40. Inv. FHG UECS BGA Input/output chart

41. Nurtitional support Curreri formula -25KCal/kg + (40kCal * TBSA%) -Induce a hypermetabolic state hence dramatic increase in resting energy expenditure -Always give oral feeds

42. COMPLICATIONS Immediate - Pain -ARDS - Haemorrhage Early - Anemia (hemorrhage, direct injury to rbcs ) -Electrolyte imbalance -Malnutrition -Infection - Prerenal renal failure

43. Late - Contractures - Hypertrophic scars - Keloids - SCC