Burns management
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Burns Management

Burns Management

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Burns management Presentation Transcript

  • 1. Management of the burn patient NATHAN STEWART ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS
  • 2.  In 1997-2005 the rate of total Burn Injury related deaths for Australia was 0.5 per 100,000 persons.  In 2003-04 the age-adjusted hospitalisation rate of fire, burn and scald related injury in Australia was 31.9 cases per 100,000 population per year.  During the period of 2001-02, throughout Australia, burns and scalds were responsible for 6,248 hospitalisations in public hospitals with the average length of stay being 7.1 days incurring an estimated cost of $132 million.
  • 3. Progress in Burn Care Fluid resuscitation Dedicated burns units Antimicrobials Intensive care Nutrition Early excision Skin cover Specialisation 3
  • 4. Classification of burns Thermal  hot  cold 4
  • 5. Classification of burns Thermal  immersion  cascade scalds 5
  • 6. Classification of burns Thermal  contact  flame  flash 6
  • 7. Classification of burns Chemical  acid  alkali  organic chemicals 7
  • 8. Classification of burns Electrical  low voltage  high tension  lightning 8
  • 9. Classification of burns Friction Radiation 9
  • 10. Everybody Every intervention influences the scar worn for life, therefore, everyone who assists in the management of that patient becomes a member of the burn care team
  • 11. First Aid for burns Remove from burn source Cold water - except when in contact with electricity This has the most effect on the final outcome! Still some effectiveness up to 4 hours post burn. At least 20 minutes of cold running water. Remove clothes. Need to avoid Hypothermia though! Gels e.g. Burnshield Cling film & dry clean sheet No ointments, creams, powders, butter, etc. etc. 11
  • 12. 12 Minor burns
  • 13. Minor burns Defined by exclusion of  area more than 5% of body surface  deep  infected  problem area - face, hands, perineum, feet  inhalation injury  other injury or underlying medical problem  suspected non-accidental injury 13
  • 14. Dressings for Burns
  • 15. 15 Major burns
  • 16. Burns Resuscitation: At the Scene     Remove Patient & Self from Injury Source Extinguish actively burning material & Cool burn (Tap Water) ABC: Airway, Breathing, Circulation (ATLS) Brief HISTORY: Time of Injury - For resuscitation Nature of Injury- Flame, Indoors, Chemicals  Brief EXAMINATION: Area) Burn Size (% Total Body Surface Burn DEPTH: Erythema (ignore) Superficial Partial Thickness Deep Partaial Thickness Full Thickness
  • 17. Burns Resuscitation: In the A&E Department  ATLS: ABC & Secondary Survey  Brief HISTORY & EXAMINATION  Airway/ Breathing Control  FLUID RESUSCITATION  Baseline Investigations:  FBC  U&Es  Carboxyhaemaglobin  Calculate the burn depth - IVI* Chest Xray Blood Gases Toxicology
  • 18. Burns Resuscitation: In the Burns Unit  ATLS: ABC + Secondary Survey  Full HISTORY:  Full EXAMINATION: % Burn (TBSA) Body Mass (Kgm)  Resuscitation History: Crystalloid Fluids - - Colloid  Reveiwed Protocol: Trials, Advances, Units, etc.  MONITORING
  • 19. Burns Resuscitation: Monitoring  Physiology: URINE OUTPUT Haematocrit Blood Gases Urine Osmolality Electrolytes & Urea Nutritional Status Cardiovascular Function
  • 20. Burn Resuscitation: A Team Effort         Anaesthetist Surgeon Intensivist Microbiologist Paediatrician Haematologist Chemical Pathologist etc  Specialist Nurse  Physiotherapist  Occupational Therapist  Theatre Nurse  Ward Clerk  Secretary  Play Therapist  etc
  • 21. Burn Resuscitation: Airway  HISTORY  EXAMINATION Confusion / Altered Consciousness Fire in an ENCLOSED SPACE e.g. House fire Burns to Face / Oropharynx Car fire Toxic fumes (Industrial) Hoarseness / Stridor / Exp rhonchi Soot in nostrils or Sputum Dysphagia / Drooling
  • 22. Lower airway/pulmonary problems Primary burn damage Pulmonary oedema ARDS 22
  • 23. Burn Resuscitation: Airway INVESTIGATIONS  Blood Gases  Carboxyhaemaglobin  Chest X-ray
  • 24. Burn Resuscitation: Airway TREATMENT  FiO2 40 - 60%  Nebulisers - - ? 100% Saline Salbutamol / Terbutaline  Oro/Nasal Intubation  Tracheostomy
  • 25. Burn Resuscitation: Breathing  COAD - Hypoxic Drive  MECHANICAL:  Upper Airway Swelling  Chest Wall Constriction
  • 26. Burn Shock Likely if burned area more than  15% body surface in adults  10% body surface in children (and elderly) 26
  • 27. Burn Resuscitation: Shock Definition (Dietzman & Lillehei (1968)) The inability of the circulatory system to meet the needs of tissues for oxygen & nutrients and the removal of their metabolites.
  • 28. Parkland formula for fluid resuscitation 4ml Hartmann’s solution per 1% burn per kg body weight   half in first 8hrs post-burn half in the following 16hrs = 0.25ml/%burn/kg/hr in first 8 hrs from time of burn colloid in second 24hrs 28
  • 29. Burn Resuscitation: Burn Depth  Erythema - ignore  Superficial Partial Thickness  Deep Partial Thickness  Full Thickness
  • 30. Rule of nine 30
  • 31. Management of the burned patient Full “primary and secondary” surveys Check for other injuries 31
  • 32. Managing the burn wound - considerations Surgery vs. spontaneous healing Mechanisms of healing Pathological zones in the burn Determination of burn depth Influence of dressings 32
  • 33. Depths of burn 33
  • 34. Assessment of burn depth Clinical examination: 50-75% accurate Pinprick test Repeated examination 34
  • 35. Assessment of burn depth 35 Easy when very superficial or full-thickness Harder when intermediate or mixed
  • 36. Why excise the burn? Burn wound is a focus for sepsis Burn stimulates inflammatory mediators Deep burns cannot heal without grafts Possible effect on future scar quality but Non full-thickness burns may heal spontaneously Superficial burns heal with acceptable scars Excised burn wound must be closed Major burn surgery is hazardous 36
  • 37. Timing of surgery “Ultraconservative” Conservative Early Acute 37
  • 38. Urgent surgery High-tension electrical injury Deep encircling burns - escharotomy  limbs  trunk 38
  • 39. For small burns Excision and grafting as soon as clearly non-healing 39
  • 40. Early excision of burns Tangential excision to viable tissue on day 3-5 Janzekovic (1970) Jackson & Stone (1972) 40
  • 41. Tangential burn excision and split skin grafting 41
  • 42. Excision to fascia 42
  • 43. Early burn surgery Superior outcomes where suitably equipped  mortality  length of hospital stay  morbidity during acute burn  scar quality 43
  • 44. Desirable surgical management Excision of all non-shallow burns as soon as practicable in as few stages as possible Closure of excised wounds with autograft, allograft or artificial material Definitive wound closure 44
  • 45. Large area burns - the problem Area / mass of necrotic tissue Shortage of donor sites Infection Systemic effects (SIRS, ARDS) Associated problems of inhalation 45
  • 46. Scar management The potential problem 46
  • 47. Scar management Pre-emptive measures  prompt surgery  splintage & physiotherapy Pressure garments and conformers Silicone gel and contact media Medical and surgical treatment 47
  • 48. Scar management Splintage 48
  • 49. Pressure garments Almost universally used Apparently effective Many published observations 49
  • 50. Pressure garments Aids to compliance 50
  • 51. Conformers and splints 51
  • 52. Silicone gel Mechanism not fully known - not pressure 52