Disaster Triage Thermal Injuries Management.ppt

Disaster Triage Thermal Injuries 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

3. Image from bailey

4. ETIOLOGY
•Thermalburns:
Scalds
Flameburns
Flashburns
Contactburns
•Electricalburns
•Chemicalburns
•Radiationburns

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. Initialevaluation
•Airway
•Breathing
•Circulation
•Detailed history
•Exposure = Extent of burns/ Rule out otherinjuries
•Fluidresuscitation

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 ofnines
•Lund and Browdercharts

11. LUND AND BROWDER CHART

12. Depth of burn injury

13. Firstdegree

14. 2nd degreesuperficial

15. 2nd degreeDeep

16. Thirddegree

17. 4thdegree

18. Criteria fortransfer 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
1.First 8 hours = Half of calculated volume
2.Next 16 hours = Other half
FluidResuscitation

24. Choice offluids
•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

25. 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

26. 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

27. TREATING BURN WOUND

28. Woundcare
•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

31. •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

32. 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

33. Image from bailey

34. Nutrition
•Hypermetabolism and hypercatabolismseen
•Increased nutritional needs ofpatient
•Oral and Enteralfeeds
•Parenteral = only when enteral notpossible.
•Curreri Formula:(CaloricRequirement)
•Adults = 25kcal x Weight (kg) + 40kcal x%TBSA
•Children = 60kcal x Weight (kg) + 35kcal x%TBSA

35. Proteins-20% of kilocalories should be provided
Supplemental vitamins andminerals
Monitor albuminlevels
Blood glucose levelmonitoring

36. 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)

37. PAIN
Acute-
•Small and superficial burns-NSAIDs, Topical cooling
•Large burns-Intra 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

38. SurgicalManagement
•Delayed reconstruction and
scar management
•Tangential shaving
•Debridement of necrotic
tissue
•Hemostasis/ Blood
replacement
•Skin Grafts: STSG/ Meshed

39. ChemicalBurns
•Acidburns
•Alkaliburns
•Treatment: Removal of incitingagents
•Copious irrigation withwater
•NoNeutralisation

40. Late Effects of Burninjury
•HypertrophicScarring
•Post burn contracture

41. Hypertrophicscars

42. Post burn Contractures