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Burns

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  • 1. BURNS
  • 2. Epidemiology
    • Incidence varies between cultures
    • Majority in children are scalds
    • Adolescents experimenting
  • 3. Epidemiology
    • Flame burns in adults
    • Most electrical & chemical burns in adults
    • Mental diseases , epilepsy, alcohol & drug abuse
  • 4.
    • On arrival burn case treated as trauma
    • ABC
    • Soot ,charring around nose – think of inhalation injury
  • 5. Assessment of burns area
    • Wallace’s rule of nine
    • Adult >20% ,child >10% needs IVF
    • i/v access for analgesia
  • 6. Prognosis
    • Percentage body surface area burned
    • Age & percentage add together to a score of 100 , considered fatal
  • 7. Assessment of burn depth
    • Temperature of burning agent
    • Mode of transmission of heat
    • Duration of contact
  • 8. Skin anatomy
    • Epidermis waterproof
    • Replaced from the basal layer
    • Dermis-thicker strength & integrity
    • Contains the adnexal structures
  • 9. Superficial burns Epidermal burns
    • Heal by epithelialisation alone
    • Red & painful
    • Blisters not present
  • 10. Superficial burns superficial dermal
    • Blistered
    • Painful
    • Heal by epithelialisation in 14 days
  • 11. Deep burns
    • Adnexal structures lost
    • Heal by second intention
    • scarring
  • 12. Deep burns
    • Blistered
    • Blotchy red appearance
    • No capillary return on pressure
    • Absent sensation to pin prick
  • 13. Full thickness burns
    • White/ charred appearance
    • No sensation
    • Charred layer consists of denatured contracted dermis - eschar
  • 14. Pathophysiology
    • Injuries to skin
    • Injury to airway & lungs
    • Inflammation & circulatory changes
    • Other effects
  • 15. Injuries to skin
    • MC organ affected is skin
    • Area affected
    • Depth
  • 16. Inhalational injury
    • Hot gases cause injury to upper airway
    • Stridor, hoarseness, cough, resp. obstruction
    • CO causes chemical burn
    dr shabeel’s presentations
  • 17. Injury to airway & lungs
    • damage airway & lungs
    • Airway injury suspected in face & neck burns
    • Person trapped in burning vehicles,house , plane etc
  • 18. Injury to airway
    • Burns above larynx
    • Below larynx
    • Metabolic poisoning
    • Inhalational injury
    • Mechanical block on rib movement
  • 19. Above larynx
    • Hot gases burn nose , mouth, tongue , palate & larynx
    • Linings start swelling
    • May block the airway
  • 20. Below larynx
    • Rare as heat is absorbed in supra glotic area
    • But steam has a large latent heat of evaporation
    • Epithelium swells & detaches
    • This cast block the airway
    dr shabeel’s presentations
  • 21. Metabolic poisoning
    • CO –product of incomplete combustion
    • Affinity 240 times than Hb for O2
    • Blocks transport of O2
    • Carboxy Hb > 10% is dangerous
    • Need pure O2 >24 hrs
    • Death occurs with 60%
  • 22.
    • Another metabolic toxin is hydrogen cyanide
    • Metabolic acidosis by blocking mitochondrial respiration
  • 23. Inhalation
    • Caused by minute particles within smoke
    • Stick to moist lining alveoli
    • Chemical pneumonitis
  • 24.
    • Intense edema
    • Decreasing gaseous exchange
    • Bacterial pneumonia
  • 25. Mechanical block on rib movement
    • Burned skin – thick & stiff
    • Stop movement of ribs
    • Common in large full thickness burn across the chest
  • 26. Inflammation & circulatory changes
    • Burned skin activate a web inflammatory cascades
    • Pain - Release of neuro peptides & activation of compliments
    • Hageman s factor – protease driven cascades
  • 27. Inflammation & circulatory changes
    • Compliments – degranulation of mast cells
    • Coats the proteins burned
    • Attracts neutrophils – degranulate – free radicals & proteases
  • 28. Inflammation & circulatory changes
    • Mast cells release primary cytokines – TNF alfa
    • Secondary cytokines
    • Alter the permeability of vessels
  • 29. Inflammation & circulatory changes
    • Large protien molecules escape
    • Oncotic pressure again increases
    • More flow of water into extra vascular space
  • 30. Inflammation & circulatory changes
    • Water ,solutes, proteins – ECF
    • Occurs in first 36 hrs
    • 10-15% burns – shock
    • >25% loss occurs in remote vessels
  • 31. Other effects
    • Immune system & infection
    • Changes in intestine
    • Peripheral circulation
  • 32. Immune system & infection
    • Inflammatory changes affect immune system
    • CMI reduced in large burns
    • Bacterial & fungal infection
  • 33. Changes in intestine
    • Micro vascular damage & ischemia of gut mucosa
    • Motility & absorption affected
    • Failure to enteral feeding
    • Translocation of gut bacteria
  • 34.
    • Septicemia
    • Abdominal compartment syndrome- mucosal swelling, stasis, peritoneal edema
    • Splinting of diaphragm
  • 35. Peripheral circulation
    • Full thickness burns- coagulation of collagen
    • Elasticity of skin lost
    • Circumferential burn of the limb act as tourniquet
  • 36. Regional problems Circulation
    • May affect the limb circulation
    • Not by direct damage to main vessel
    • edema - venous obstruction
    • Muscle compartment syndrome
  • 37. Effects of burn injury
    • Local
    • Regional
    • Systemic
  • 38. Local effects
    • Tissue damage
    • Inflammation
    • Infection
  • 39. Tissue damage
    • Heating -> cell rupture / necrosis
    • Cells of periphery injured
    • Denaturation of collagen
  • 40. Tissue damage
    • Capillaries thrombosed in severe cases
    • Increased damage in less severe case
    • Tissues become edematous
  • 41. Inflammation
    • Marked response
    • Erythema in least burned areas
    • Neurovascular response like Lewis triple response
  • 42.
    • Severe – cytokines
    • Phagocytose necrotic cells
    • Damaged tissues separate by de sloughing in 3 wks
  • 43. Infection
    • Damaged tissue – nidus of infection
    • Colonization in 24 – 48 hrs
    • Bacteremia is a common cause of fatality
  • 44. Systemic effects
    • Fluid loss
    • Multiple organ failure
    • Inhalational injury
    • Systemic complications
  • 45. Fluid loss
    • External loss
    • Internal loss as edema
    • Mediated by cytokines
  • 46. Management
    • Immediate care
    • Assessment of burn wound
    • Fluid resuscitation
    • Treatment of burn wound
  • 47. Immediate care
    • Pre hospital
    • Hospital care
  • 48. Pre hospital
    • Ensure rescuer safety – house fire , chemical , electrical
    • Stop the burning process – stop, drop & roll
    • Check for other injuries
    • Cool the burn wound
  • 49. Pre hospital
    • Cool the burn wound – minimum 10mts to an hour
    • Oxygen
    • elevate
  • 50. Hospital care
    • Airway
    • Breathing
    • Circulation
    • Disability
    • Exposure with environmental control
    • Fluid resuscitation
  • 51. Major determinants of outcome
    • Percentage area
    • Depth
    • Inhalational injury
  • 52. Criteria for admission
    • Inhalational injury
    • Fluid resuscitation
    • Needing surgery
    • Suspicion of non accidental cause
    • Extremes of age
    • Associated potential sequelae
  • 53. Airway
    • Burned airway causes obstruction
    • Endo tracheal tube for 48 hours
    • Symptoms of laryngeal edema appear late
  • 54. Airway
    • Intubation will be difficult after symptoms appear
    • Crico thyroidotomy needed in late diagnosis
    • Recognition of potentially burned airway
  • 55. Breathing
    • Inhalational injury
    • Thermal burns to lower airway
    • Metabolic poisoning
    • Mechanical block to rib movement
  • 56. Inhalational injury
    • Observe anyone trapped in a fire
    • Presence of soot in nose & oro pharynx
    • Chest x-ray - patchy consolidation
  • 57. Clinical features
    • Progressive increase in resp effort & rate
    • Rising pulse , anxiety , confusion
    • Decreasing oxygen saturation
  • 58. Treatment
    • Secure the airway
    • Physiotherapy, nebulisation, warm humidified oxygen
    • Monitor the progress
    • IPPV for severe cases
  • 59. Burns of lower airway
    • Steam injury
    • Supportive management
    • Like inhalational injury
  • 60. Metabolic poisoning
    • Fire within a closed space
    • Altered consciousness
    • ABG
  • 61.
    • Metabolic acidosis
    • High inspired O2 for 24 hrs if >10%
    • Displacement from Hb
  • 62. Mechanical block to rib movement
    • Eschar on the chest
    • CO2 retention & high inspiratory pressure if ventilated
    • escharotomy
  • 63. Assessment of burn wound
    • Size
    • depth
  • 64. Size
    • Formally assessed in a controlled environment
    • Allows areas to be exposed & any soot / debris to be washed off
    • Do not cause hypothermia
  • 65.
    • Patients whole hand – 1% of TBSA
    • Lund & Browder chart
    • Wallace rule of nine - approximate
  • 66. Depth
    • Superficial partial thickness
    • Deep partial thickness
    • Full thickness
  • 67. Fluid resuscitation
    • Maintain the intravascular volume
    • Needed in a child with > 10%
    • 15% in adults
  • 68.
    • If oral water should not be salt free
    • Stress hormones – anti diuresis
    • Hypo natremia & water intoxication
  • 69.
    • Resuscitation volume – area burned
    • Maximum loss in 8hrs
    • Lasts 24 – 36 hrs
  • 70. Fluids
    • Ringer lactate / Hartmans
    • Human albumin solution / FFP
    • Hypertonic saline
  • 71. Parkland formula
    • % burns x body wt x 4
    • Half in first 8hrs
    • Half over next 16 hrs
  • 72.
    • Maintanance fluid given for children as DNS
    • 100ml/kg for 24 hrs for 10Kg
    • 50ml/kg for next 10 kg
    • 20ml/kg for each Kg over 20Kg
  • 73. Monitoring
    • Key is urine output
    • 0.5 -1 ml /kg body wt / hr
    • If output low increase the infusion rate by 50%
    • Should not be over resuscitated
  • 74. Monitoring
    • Acid base balance
    • Hematocrit measurement
    • CVP monitoring
  • 75. Treatment of burn wound
    • Eshcarotomy
    • Full thickness
    • Superficial partial
  • 76. Eshcarotomy
    • Circumferential full thickness burns of limbs
    • Incised in mid axial line to avoid nerves
    • Management of burn wound same
  • 77. Full thickness
    • 1% silver sulphadiazine
    • Silver nitrate solution 0.5%
    • Mefenide acetate
    • Serum nitrate
  • 78. 1% silver sulphadiazine
    • Broad spectrum prophylaxis
    • Pseudomona
    • MRSA
  • 79. Silver nitrate solution 0.5%
    • Highly effective – pseudomonas
    • Poor against some gram negative aerobes
    • Needs change every 2 -4 hr
    • Black staining
  • 80. Mefenide acetate
    • Popular in USA
    • Painful
    • 5% solution
    • Metabolic acidosis
  • 81. Serum nitrate
    • Hard effect on the burned skin
    • Especially in elderly
    • Reduces the CMI suppression
  • 82. Superficial burns
    • Honey
    • Boiled potato peel
    • Synthetic biological dressings

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