Manag. of Burn

8/2/2019 Manag. of Burn

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Burn management

Supervised by Pro.Salah al Qaryote

Done by : kr


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1.Ensure rescuer safety esp. in home fire & electrical injuries

2.Stop the burning process stop , drop , roll

3. Check for other injuries airways , breathing , circulation

4. Cool burnt wounds ( this will delay micro vascular damage at 15 C but avoidhypothermia & provides analgesia ) .

5. Give O2 , anyone involved in a fire in an a closed space should receive oxygen esp. in

altered conscious level .

6. Elevate limbs , setting a patent up with a burned airway may prove life-saving in the

event of a delay in transfer to hospital care coz it will reduce swelling and discomfort

Immediate care of burnt patients

Pre hospital care :


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Hospital Care

A = a irways

B = b reathing & ventilation

C = c irculation

D = d isability ( neurological status )

E = e xposure with environmental control

F = f luid resuscitation


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Major determinants of any burn injury :

1. Percentage of total body surface area burned

2.Presence of inhalation

3. Depth of burns


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1.Suspected airway injury or inhalation injury

2. Any burn likely to require fluid resuscitation

3. Any burn likely to need surgery

4. Critical sites hand , face , feet , perineum burns

5. Inadvisable to go home in case of psychiatric or social background

6. Suspicion of non accidental injury

7. Burn in a patient at extreme of age

8. Burn with associated sequelae ;high tension electricity .etc

Acute admission in case of :


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RESUSCITATION AND MANAGEMENT

The 1 st priority must be :

Maintenance of a patent airway

Effective ventilation

Support of the systemic circulation


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Airway :

Initial management of the burned airway:

Early elective intubation is needed

Intubation becomes difficult if delayed by swelling


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Recognition of potentially burned airways :

1. History of being trapped in presence of smoke or hot gases

2.Burnt palate or nasal mucosa , loss of hair in the nose

3.Deep burns around mouth & neck

THE KEY IN AIRWAY BURN MANAGEMENT IS THE HISTORY AND

EARLY SIGN RATHER THAN THE SYMPTOMS


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Indications for intubation :

Unconscious ptn

Ptns in respiratory distress

Ptns who have suffered severe burns

Ptns who are hemodynamically unstable despite fluid resuscitation

Where there is any Q of an inhalation injury

Upper airway burn


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CIRCULATION

Two large bore IV canulas

Avoid inserting IV lines in burn areas esp. limbs due to tourniquet effect of eschar

Patients with burns alone are often hypertensive

signs of systemic hypovolmia in a burn patient should raise suspicion of another occult injury


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Any Hx of a fire within enclosed space and any Hx of altered

consciousness are an important clues to a metabolic poisoning.

Measure blood gases if carboxyhaemoglbin levels raised above 10%

TX is O2 for 24 hours to speed its displacement from HB

Metabolic poisoning


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1. History is imp. ( temperature , time , burning material)

2. Superficial burns have capillary filling

3. Deep partial thickness burns do not blanch out but have some

sensation

4. Full thickness burns feel lethargy & have no sensation

Assessment of burn depth :


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FLUID MANAGEMENT The goal of IVF

Restore and maintain adequate tissue perfusion and oxygenation

Avoid organ ischemia

Preserve heat-injured but viable soft tissue

Minimize exogenous contribution to edema


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Fluid loss.

This shift of fluid is called third space loss Causes edema of theinterstitium

Depletion of the intra-vascular compartment will cause shock

Burn shock is seen in adults with more than 15% burns and children withmore than 10% .

Non burnt areas will show edema the cause here is generalized hypo-protienemia and circulating vasoactive mediators.


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Fluid loss, cont.:

Rate of loss maximum over the first few hours.Gradually declines over the next 1 to 2 days.In severe burn the loss continue to 3 rd day.The loss related to size of burned area.The loss not related to the depth of burn.Most formula depends on seize and Wt.

Fluid requirement calculations for infusion rates are based on the time frominjury, not from the time fluid resuscitation is initiated.


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1.) Crystalloid resuscitation :

1. Ringer's lactate is commonly used , effective as colloid in maintenance of IV

fluid

2. It used because that even the large protein molecules leak out of capillaries

Non burnt capillaries continue to save proteins

PARKLAND formula for replacement of fluids :

TBSA weight (kg) 4 = volume (in ml )

Fluid resuscitation :


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2. ) Hyper tonic saline

Human albumin solution ( HAS) ,commonly used colloid

Effective in TX burn shocks

Produces hyperosmolarity & hypernatraemia

Causes less tissue edema by reducing the shift of intracellular water to

extracellular

Decrease escharotomies & allow intubation to occur


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3.) Colloid resuscitation :

Transport of plasma proteins needed to maintain inward oncotic pressure .

It should be given after 1 st 12 hours of burns because before that , massive

fluid shifting cause protein to leak out of cells .

Muir & Barclay formula for colloid :

0.5 percentage of body surface area burnt weight = one portion

In a role of 4/4/4 , 6/6 , 12 hours respectively , one portion in each period .



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Start with crystalloids in the 1st 12-24 hrs then give colloids.

Due to leaky capillaries .


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MONITORING1 HR

Pulse rate is a better indicator than BP


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MONITORING3 urine output

With crystalloid resuscitation regimens such as the parkland formula , urineoutput remains an excellent guidelines for the adequacy of resuscitation.

Target : 0.5 to 1 cc/kg/hr in the adult1-2 cc/kg/hr in the child.


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MONITORING

4 Invasive monitoring ( CVP & Pulmonary artery CATH ) Target :

Pulm. a occlusion pressure 12-15 mm hgFew ptns will benefit from invasive hemodynamic monitoring , they include:

1. Elderly ptns with preexisting cardiac or repiratory Dis.2. Massively burned ptns with significant inhalation injury 3. Use should be reserved for the complicated or difficult resuscitations


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MONITORING ABG

Persistent metabolic acidosis inadequate perfusion an indication forincreasing fluid administration.Except in CO poisioning when the ptn may be acidotic secondary to COinhalation

HEMATOCRIT:Serial hematocrit determinations determine the adequacy of resuscitationInitial hemo concentration is followed by a later decease in hematocrit thatmainly reflects reexpansion of the intravascular compartment with fluidresuscitation


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Assessing adequacy of resuscitation

Peripheral blood pressure: may be difficult to obtain often misleading

Urine Output: Best indicatorunless ARF occurs

A-line: May be inaccurate dueto vasospasm

CVP: Better indicator of fluidstatus

Heart rate: Valuable in earlypost burn period should bearound 120/min.

> HR indicates need for > fluids or pain control

Invasive cardiac

monitoring: Indicated in aminority of patients (elderly orpre-existing cardiac disease)


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Blood transfusion

Patients requiring transfusion:

Adults .20% TBSA or more.

Children15%TBSA or more.

(whatever the depth of the burn wound)


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1. 1% sliver sulphadiazine cream against pseudomonas & MRSA

2. 0.5 % silver nitrate solution (( causes black staining ))

3. Mafenide acetate cream

4. serum ((nitrate , silver sulphadiazine)) : useful esp. in full thickness

burns , induces hard effect on burn & reduces some of cell mediated

immunosuppressant .

Topical TX of deep burns :


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Dressing should:

1. Decrease pain asssociated with dressing

2. Improve healing times

3. Decrease outpatients appointements

4. Lower overall cost

in dressing :

1. Full thickness & deep dermal burns need antibacterial dressing to delay colonization prior to

surgery

2. superficial burns will heal & need simple dressing

3. optimal healing environment make a difference to outcome

Principles of dressing :


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PAIN CONTROL:

During shock phase of burn care ,medication should be IV.

SC and IM will be absorbed variably depending on perfusion and should beavoided

Best managed with IV morphine 2-5 mg. Usually

itching :

Most burn patients have itchy wounds

TX: analgesics , anti histamines , moisturing creams


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Analgesia :

Small burns esp. superficial burns respond to oral analgesia (( paracetamol ,

NSAIDs)).

Large burns need IV opiates .

Powerful , short acting analgesics administered before dressing changes.


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10 % of adults or 15 % child burns requires additional nutritional

requirements .

20 % or more TBSA must receive nasogastric tube .

Acute burns are catabolic ; continues while wound unhealed , so

rapid excision of the burn & stable coverage ((most significant

factors )).

Nutrition and energy balance :


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Nutrition and energy balance : cont.

Hyper metabolic state

Lasts until the wound is closed

The gut of the burn patients should be used for nutrition if it isavailable

Adequate nutrition is imp. To maximize patient survival and

minimize complications.


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1. Burned patients are immunocompromised

2. burned patients are susceptible for infections by many routes

3. sterile precautions must be rigorous

4. swabs should be taken regularly

5. ((increase in WBC, thrombocytosis, increase in catabolism ))

are warnings to infections

Control of infections in burned patients :


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Cont .

Management by a combination of systemic & topical agents Infection converts:

superficial burns to partial thickness burn

partial thickness burns Deep partial thickness burns

Tetanus burn woundsPrevious immunization within 5 years requires no treatmentImmunization within 10 years tetanus toxic booster to be givenUnknown immunization status requires booster


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PE PREVENTION

Preventive efforts should be directed at patients with classical risk factors for PE :History of prior thromboembolic Dis.Obesity

Burns of the lower exteremities


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1.Any deep partial thickness & full thickness burns needs surgery except

those < 4 cm2

2. reassess burn depth which increases in the next day

3. topical dressings decrease bleeding4. all burnt tissue needs to be excised

5. stable cover should be applied at once to reduce burn load

Surgery for acute wound :


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Escharotomy

Eschar = burned skinEscharotomy = cut burned skin to relieveunderlying pressure


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ESCHAROTOMY and FASCIOTOMY:

Chest escharotomy

In case of early respiratory distress may be due to compromises of the ventilator function .In deep circumferential burn wound of thechest

Performed in an anterior auxiliary bilateral. With contact by transverse incision along the costal margin


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Cont.

Escharotomy of extremities

Remove rings ,watches,jewelry.

Skin color, sensation, capillary refill and prepheral pulses should be assessed.Escharotomy indicated when muscle compartment pressures > 30 mmHg

Circulation to distal limb is in danger due to swelling, Progressive loss of sensation/ motion in hand / foot.

Doppler U/S can be of use pre and post escharotomy


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Escharotomy - complicationsCOMPLICATIONS

Bleeding: might require ligation of superficial veins

Injury to other structures: arteries, nerves, tendons

NOT every circumferential burn requires escharotomy.

In fact, most DO NOT need escharotomy.

Repeatedly assess neuro-vascular status of the limb.

Those that lose circulation and sensation need escharotomy.


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Clinical Manifestations

Burn wound either heals by primary intention or by grafting.

Scars may form & contractures.

Mature healing is reached in 6 months to 2 years

Avoid direct sunlight for 1 year on burn

new skin sensitive to trauma


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Mortality in Burns

>20% BSA with shock and other complications/related sequelae


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Thanx a lot .

Documents

Manag. of Burn