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Kriska Shalin L. Joaquin. Burns. Objectives. At the end of this session the group is expected: To be able to identify the salient features in the history and physical examination of a burn patient To discuss the approach to management of burn patients - PowerPoint PPT Presentation
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BurnsKriska Shalin L. Joaquin
Objectives
At the end of this session the group is expected:
To be able to identify the salient features in the history and physical examination of a burn patient
To discuss the approach to management of burn patients
To know the anatomy of the skin - review To discuss the pathophysiology of burns To discuss prevention and psychosocial
dimension
Patient data
WN 34/M Micronesian 17-November-1977 Single Electrician Weno City, Micronesia Can speak English, limited
Chief Complaint
Electric burn
History of Present Illness1 month prior (33 days)
Patient was working on an electric post with his hands
lasted minutes ? Sustaining burns on
Left forearm and Left thigh
Immediately brought to the hospital in Micronesia
History of Present Illness
Findings: 3x4 cm deep tissue burns on
dorsum of left arm and forearm, erythematous, hyperemic, tender
(+) limitation of movement 3x4 cm deep tissue burns
dorsum of left thigh, erythematous, hyperemic, tender
(+) limitation of movement
History of Present Illness17th hospital day Fasciotomy and
debridement was done Arranged for transfer to
this institution for skin grafting
(+) some degree of necrosis on Lateral aspect of Left thigh, referral to this institution32nd hospital day Transfer to this institution
Past Medical History
No known co-morbidities No previous hospitalizations No previous surgeries No known allergies to food or drugs
Family History
(-) HTN (-) DM (-) Allergies
Personal/Social
Electrician Denies smoking Occasional alcohol drinker Denies illicit drug use
Review of Systems
No fever No weight changes No cough/colds No vomiting/diarrhea/constipation No heat/cold intolerance
Physical Examination
Conscious and coherent, could not understand English very well
HR 84 RR 16 T 37.0 Weight 81 kg Height 178 cm VAS 0/10
Skin (+) graphic tattoos on left shoulder
(+) ulceration on left arm and forearm, with length of about 1 foot, dry, well circumscribed but irregular borders
(+) deep ulceration of the lateral aspect of the left thigh, 1x1 feet, non-foul smelling, no discharge, minimal bleeding
Head and Neck
Normocephalic head Anicteric sclerae, pink palpebral
conjunctivae Ears symmetric, (-) discharge Nasal septum midline, (-) nasal
discharge (-) tonsillopharyngeal congestion
Neck lymph nodes not palpable, thyroid not enlarged
Chest and Lungs
Symmetric chest expansion (-) retractions, no use of accessory
muscles Clear breath sounds (-) wheezes, rales
Heart
Adynamic precordium Normal rate Regular rhythm Good S1 and S2 No murmurs, no skip beats
Abdomen
Flat abdomen Normoactive bowel sounds Soft, non-tender No organomegaly
Genitourinary and DRE
Not examined
Salient Features
SUBJECTIVE 34/M electrician Electric burn On his 42nd
hospital day
OBJECTIVE• 14% TSBA
electric burns, full thickness
• Fasciotomy and wound debridement done
• Stable VS• Left arm• Lateral left thigh
Primary impression
Electrical burns, 14% TBSA Full thickness type, Right arm, forearm, and thigh secondary to Electrical Injury with Partial disability
Course in the Wards: SUBJECTIVE
OBJECTIVE ASSESSMENT
PLAN
1 No subjective complaints
Stable VS(+) deep ulcer on left arm and left thigh
Electric burns, 14% TBSA , full thicknessS/P Fasciotomy S/P Wound debridement
CBCWound GSCSBUNCreaNaK
2 No subjective complaints
(+) pus from wound on left thigh
Organism: Enterococcus gallinarum
PT normalAPTT normal
Electric burns, 14% TBSA , full thicknessS/P Fasciotomy S/P Wound debridement
For wound debridementBUN 0.82Crea 13.45Na 137K 3.7CBC 140/0.42/8.6/0.61/0.22/210
Course in the Wards: SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
3 No subjective complaints
Stable VS
Wound GSCS: (+) Candida tropicalis
Electric burns, 14% TBSA , full thickness
4 No subjective complaints
Stable VS
Wound GSCS: (+0 Stenotophomonas maltophila
Electric burns, 14% TBSA , full thicknessS/P Wound debridement
Wound debridement done
5 No subjective complaints
Stable VS Electric burns, 14% TBSA , full thickness
Course in the wardsSUBJECTIVE
OBJECTIVE ASSESSMENT
PLAN
6 No subjective complaints
Stable VS Electric burns, 14% TBSA , full thickness
For repeat wound debridement
7 No subjective complaints
Stable VS Electric burns, 14% TBSA , full thickness
For repeat wound debridement
8 No subjective complaints
Stable VS Electric burns, 14% TBSA , full thickness
Repeat wound debridement doneFor skin grafting on Day 11
Patient is currently on his 42nd hospital day,( 10th hospital day in this institution)for skin grafting tomorrow
DISCUSSION
SKIN•Largest and most complex organ•FUNCTION – protective barrier- Regional variation•LAYERS• Epidermis• Basement membrane• Dermis
BURNS
90% of burns are preventable Nearly one half are smoking related
or due to substance abuse Advances in medicine have
decreased mortality, hospital stay Quality of burn care measured by
survival and long-term function and appearance
surgeon's goal: well-healed, durable skin with normal function and near-normal appearance
In children <8 : SCALD BURNS Older children and adults: FLAME-
RELATED Work-related: Chemicals, hot liquids,
electricity, molten/hot metals
TYPES
SCALD BURNS FLAME BURNS FLASH BURNS CONTACT BURN
Hospital admission & Burn Referral Any patient who has a symptomatic
inhalation injury Rule of thumb:
If burns cover more than 5-10% TSBA Otherwise healthy patients, with a place
to go and someone to stay with them could be observed 1-2 hours then discharged
Burn Center Referral Criteria
1. Partial-thickness and full-thickness burns totaling greater than 10% TBSA in patients under 10 or over 50 years of age.
2. Partial-thickness and full-thickness burns totaling greater than 20% TBSA in other age groups.
3. Partial-thickness and full-thickness burns involving the face, hands, feet, genitalia, perineum, or major joints.
4. Full-thickness burns greater than 5% TBSA in any age group.
5. Electrical burns, including lightning injury.
6. Chemical burns 7. Inhalation injury. 8. Burn injury in patients with preexisting medical
disorders that could complicate management, prolong the recovery period, or affect mortality.
9. Any burn with concomitant trauma 10. Burn injury in children admitted to a hospital
without qualified personnel or equipment for pediatric care.
11. Burn injury in patients requiring special social, emotional, and/or long-term rehabilitative support
Emergency Care
ABC: airway, breathing, circulation Suspect inhalational injury to anyone with
flame burn Inspect mouth and pharynx Hoarseness and wheezes Copious mucus production and
carbonaceous sputum Carboxyhemoglobin levels Decreased P:F ration – early indicator
(<300, <250 intubate
Fluid Resuscitation in the ER (>20%TBSA) IV LR 1000 mL/h in adults IV LR 20mL/kg in children Foley catheter▪ 30ml/h in adults, 1.0ml/kg/h in children
Patients <50% TBSA, begin with 2 large-bore peripheral IV lines avoiding the lower extremities
>50% (including extremes of age, inhalation injuries) – additional central venous access
>65% refer immediately to a burn center, requires ICU
Tetanus Prophylaxis for those without previous immunization
within 5 years, unknown status – hyperimmune serum
Gastric decompression – NGT Pain control – IV Psychosocial care Care of Burn Wound – after all
assessments
ESCHAROTOMY Thoracic escharotomy-seldom required Extremities – to prevent neuromuscular and
vascular compromise
Assess skin color, sensation, CRT, peripheral pulses q1 hour
WOF: cyanosis, deep tissue pain, progressive paresthesia, progressive decrease or absence of pulses, sensation of cold
BURN SEVERITY
Size and depth of the burn, and the body part involved
TSBA – single most important factor in prognosis
Burn size
Rule of nines Upper extremity – 9%
each Lower extremity – 18%
each Anterior trunk – 18% Posterior trunk – 18% Head and neck – 9% Perineum – 1%
Burn depth
Primary determinant of patient’s long-term appearance and functional outcome
Burns that heal within 3 weeks usually do so without hypertrophic scarring or functional impairment
Early excision and grafting Dependent on:
temperature, skin thickness, duration of contact, heat-dissipating capability of skin
SHALLOW BURNS
First degree – Epidermal burns Do not blister Erythematous Painful Desquamates on
4th day
Second degree –Superficial partial-thickness Upper layers of dermis Blisters with fluid
accumulation Pink and wet Hypersensitive Blanch with pressure Heals in 3 weeks if
infection is prevented
DEEP BURNS Second degree- Deep
Partial thickness Reticular layers Blister Mottled pink and white Discomfort rather than
pain Slow to absent CRT Become dry and white Heals in 3-9 weeks
DEEP BURNS Third degree – Full
thickness All layers Contracture Epithelialization of wound
margin Skin grafting White, cherry red, black With or without blisters Leathery, firm, depressed Insensate Do not blanch with pressure eschar
DEEP BURNS Fourth degree
Involves subcutaneous fat and deeper structures
Charred appearance Electrical burns,
contact burns, immersion burns, unconscious people at time of burning
Clinical observation is still most commonly used, however:
Ability to detect dead cells or denatured collagen Biopsy, utrasound, vital dyes
Assessment of changes in blood flow Fluometry, laser Doppler, thermography
Analysis of color of wounds Light reflectance methods
Evaluation of physical changes Nuclear MRI
Electrical Injury and Burns Severity depends on the
amperage of the current Pathway of the current
through victims body Duration of contact Electric burn
Electrical injury from the current
An arc or flash flame Flame injury from ignition of
clothing or surroundings
Care at the scene
Rescuer should avoid touching the victim until current is shut off
StandardABCs BLS/ACLS if necessary Rule out fractures
Don’t be fooled by the size Other systems
Cardiac Nervous Eyes - cataracts
Wound management
Immediate surgery for1. Massive deep tissue necrosis will
lead to acidosis/myoglobinuria2. Injured deep tissues undergo
significant swelling – risk of compartment syndrome
Escharotomies and fasciotomies at compartment pressure >30mmHg
Physiologic response
SIRS BURN SHOCK
Tissue trauma and hypovolemic shock Loss of microvascular integrity and
thermal injury at cellular level Histamine Serotonin Eicosanoids (PGE2 and prostacyclin
PGI2) Bradykinins
Metabolic response to Burn Injury Hypermetabolism
Hyperglycemia Lypolysis▪ Fatty acids are re-esterized into TG▪ Propanol – promising as means to manipulate
peripheral lupolysis prevents hepatic steatosis Proteolysis increased
Neuroendocrine response Cathecolamines GH attenuated Altered thyroid hormone serum concentrations
Pathophysiology of a burn shock Hypovolemic and cellular in etiology dec CO, inc ECF, dec Plasma volume, Oliguria Increase in microvascular permeability Maximal edema occurs 8-12 hours after in small
burns, 12-24 hours in major thermal injuries
>30% TBSA: systemic decrease in cell transmembrane potential
Goal – ensure end-organ perfusion, principally aimed at 24-48 h after injury
Fluid resuscitation
Crystalloid resuscitation
Lactated Ringers Na 130 mEq/L
Urinary output of 0.5ml/kg – adequate end organ perfusion 3 ml/kg x %TSBA
for the first 24 hours
PARKLAND 4 mL LR/kg x
%TSBA ½ in the First 8 hours ½ in the next 16 hour
Modified Brooke Army Hospital 2 ml LR/kg x %
TSBA over 24 hours
Colloid
Three approaches1. Protein solutions are not given in
the 1st 24 hours 2. Proteins (albumin) given beginning
of resuscitation WITH crystalloid3. Proteins should not be given
between 8-12 hours postburn because of massive fluid shifts
Maintenance fluid
1500 mL/m2 + evaporative water loss [(25 +%TBSA) x m2 x 24]
Monitor output Adults 1000-1500 ml/25h Peia 3-4ml/kg/hour over 24h
Special considerations
PEDIA <20 kg require addition of glucose-
based fluids 6ml/kg/%TBSA 2-fold increase to ensure end-organ
perfusion INHALATION INJURY
Fluid resuscitation - 1.5 times
Wound care
Small (<20%) full thickness burns and burns of indeterminate depth: Excision and Grafting
Early E&G dramatically decreases the number of painful debridements required
Patients with 20-40% TBSA will havefewer infectious wound complications with early E&G
Tangential excision
To excise layers of eschar at a tangential angle to the surface until viable tissue is reaced
Fascial excision Typically reserved for
deep full-thickness burns or with large, life-threatening full thickness burns
Electrocautery ADV
Reliable bed of known viability
Tourniquets can be used for extremities
Operative loss is less than with tangential excision
Less experience is required
DISADV Longer operative times Possibility of cosmetic
deformity Higher incidence of distl
edema Greater danger of
damage to superficial neuromuscular structures
Cutaneous denervation Over joints – ungraftable
bed
Nutritional support
TOPICAL ANTIMICROBIAL AGENTS
Public Health concern
Preventable up to 90% Smoke detectors City ordinances for buildings Protective equipment
Psychosocial
Long-term treatment Chronic implications Cosmetic Post traumatic disorder Financial aspect