Lecture on Burns Aetiology classification & management

A comprejhensive lecture on burn, its pathophysiology, management and pictorial examples.

1. MANAGEMENT OF BURNS Dr Rizwan plastic and recon surgeon

2. OBJECTIVE Understand Burns Assess a case of Burns Make treatment plan for Burns patient

3. SUPERFICIAL 1 ST DEGREE DEEP 3 RD DEGREE SUPERFICIAL PARTIAL 2 ND DEGREE DEEP PARTIAL 2 ND DEGREE

4. 1 ST 2 ND 3 RD

5. RULE OF 9 FOR ADULTS

6. ASSESSMENT OF SEVERITY Minor Burns < 15 % TBSA with < 2 % full thickness Moderate burns Partial thickness burns 15-25% TBSA with 2-10% full thickness Major burns > 25 % TBSA or >10 % full thickness involvement of hands, feet, face or genitalia

7. CRITERIA FOR TRANSFER The American Burn Association guidelines: Partial-thickness and full-thickness burns greater than 10% of the TBSA in patients under 10 years of age or over 50 years of age. Partial-thickness and full-thickness burns greater than 20% TBSA in other age groups. Partial-thickness and full-thickness burns involving the face,eyes,ears,hands,feet,genitalia,or perineum or those that involve skin overlying major joints .

8. CRITERIA FOR TRANSFER( contd ) Full-thickness burns greater than 5% TBSA in any age group. Significant electrical burns including lightning injury(significant volumes of tissue beneath the surface may be injured and result in acute renal failure and other complications)

9. STABILIZING THE BURN PATIENT

10. A. Airway Early airway maintenance is important in cases of inhalation injury. Prompt decision regarding: Elective endotracheal intubation Tracheostomy

11. Breathing The initial treatment of injuries is based on the patient’s sign and symptoms,which are results of the following possible injuries. Direct thermal injury, producing upper airway edema and/or obstruction. Inhalation of products of incomplete combustion (carbon particles)and toxic fumes,leading to chemical tracheo -bronchitis, edema,and pneumonia. Carbon monoxide poisoning(CO has a half life of 4 hrs when the patient is breathing room air and 40 mins while on 100% O 2. ) Monitor ABG’s.Mechanical ventilation may be indicated

12. Circulating Blood Volume Any resuscitation formula provides only an estimate of fluid need. Fluid requirement calculations for infusion rates are based on the time from injury,not from the time fluid resuscitation is initiated. The amount of fluid given should be adjusted according to the individual patient’s response,i.e . urinary output, vital signs, and general condition. A good rule of thumb is to infuse fluid to maintain a urine out put of 1.0 ml / kg / hr

13. D. FLUID CALCULATION PARKLAND/BAXTER FORMULA 4 ml x Weight in kg x TBSA Ringers lactate solution ( crystalloid only in first 24 hrs) 50% in first 8 hrs 50% in next 16 hrs Colloids / plasma(FFP) / D5Ns / Blood in next 24 hrs Special circumstances------ old age, comorbid conditions, burns > 50%

14. Physical Examination The following must be done to plan and direct patient management: Estimate extent and depth of burn. Assess for associated injuries. Weigh the patient. Prevent hypothermia

15. Blood Obtain samples for CBC,type and cross match/screening , Carboxyhemoglobin , Serum glucose, Urea, creatinine , Electrolytes liver function tests Hepatitis B & C screening pregnancy test in all females of childbearing age. Arterial blood gases X-rays chest film. Other x-rays if indicated should be obtained.

16. Gastric Tube Insertion: Insert an NG tube in cases over 20% burns. Analgesia: Narcotics, Analgesics,and Sedatives. Antibiotics : Are not indicated in the early post burn period. Only after 48 hrs. Antacids/ iv H2 blockers

17. Circumferential Extremity Burns: Maintenance of Peripheral Circulation Remove all jewelry Assess the status of distal circulation. perform Escharotomies . Fasciotomy is seldom required. Except with associated skeletal trauma,crush injury, high –voltage electrical injury,or burns involving tissue beneath the investing fascia .

18. ESCHAROTOMIES

19. SPECIAL BURN REQUIREMENTS Chemical Burns: : Remove all chemicals with copious amounts of water preferably with a hose. Wash 20 30 min. Electrical Burns: Are more serious and require ECG monitoring,prevention of ARF due to myoglobinuria by maintaining urine out put above 100 ml/hr. and early extensive fasciotomies and debridement

20. WOUND MANAGEMENT CLOSED TECHNIQUE OPEN TECHNIQUE HYDROTHEAPY TOPICAL MEDICATION SILVER SULPHADIAZINE ( flemazine , dermazine , quench) AQUEOUS 0.5% SILVER NITRATE SOLUTION MAFENIDE PETROLEUM JELLY HYDROCOLLOIDS CALCIUM ALGINATE BIOBRANE INTEGRA

21. IDEAL BURN DRESSING After washing thoroughly. Parrafin gauze Flemazine Absorbant gauze Layer of cotton Bandage

22. FREQUENCY: Daily or or alternate day IMPORTANT: No flemazine on face and genitalia Use polyfax / Neomycin / fucidin ointment HANDS: In a polythene bag

23. Hypercatabolic state Need double calories and double proteins Regular physiotherapy

24. THERMAL BURNS

25. NAZIA 18YRS PREGNANT 45% BURNS

26. CHEMICAL BURNS

27. ELECTRIC BURNS

28. EARLY EXCISION AND GRAFTING

29. RECONSTRUCTIONS