Lecture four burns first Aid


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This lecture introduces pharmacists to burn care. Although there are advances in burn treatments most of the information provided in this presentation remain the standard of care for the patient.

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Lecture four burns first Aid

  1. 1. Burns First Aid and Treatment Options Anas Bahnassi PhD 4
  2. 2. Anas Bahnassi PhD CDM CDE 2
  3. 3. Introduction: 3Anas Bahnassi PhD CDM CDE Local response to the burn injury Zone of coagulation: cell death and immediate coagulation of cellular proteins Zone of stasis: damage in microcirculation resulting in compromised circulation, untreated it will lead to necrosis Zone of hyperaemia: damage causing production of inflammatory mediators leading to dilatation of blood vessels
  4. 4. Introduction: 4Anas Bahnassi PhD CDM CDE General response to the burn injury Skin is the largest organ in the body and isolates chemically, thermally, biologically and mechanically the inside from the outside • A burn destroys these functions • A burn is three dimensional, it opens up a surface and leads to: • Loss of water, electrolytes, proteins and heat due to vascular permeability, which results in the formation of edema • in burns > 20% TBSA, effects on the whole body are: • hypovolemia (= shock phase = first 48 hours) • immunosuppression leading to infection • impairment of barrier function of the gut leading to translocation of bacteria (it is therefore important to start enteral feeding early) • systemic inflammatory response post burn affects the lungs resulting in Adult Respiratory Distress Syndrome (ARDS), even in the absence of inhalation injury
  5. 5. Initial Assessment of Burns • Primary Survey: A. Airways: • Secure the airway first. • Get history as much as reasonably possible before intubation • Soot or singed nasal hairs? Anas Bahnassi PhD CDM CDE 5 Escharotomy B. Breathing: • High flow Oxygen for all. • Escharotomy? • Listen: verify breath sounds • Assess rate & depth
  6. 6. Initial Assessment of Burns • Primary Survey: C. Circulation: • Monitor Blood Pressure, Pulse, and Skin color. • Establish IV access. • Warm IV fluids. • Monitor peripheral pulses in circumferential burns. Anas Bahnassi PhD CDM CDE 6
  7. 7. Initial Assessment of Burns • Primary Survey: D. Disability: • Associated Injuries? • CO poisoning? • Substance abuse? • Hypoxia? • Pre-existing medical condition Anas Bahnassi PhD CDM CDE 7 E. Exposure: • Remove clothes and jewelry. • Ensure warm environment. • Clean dry blankets. • It is OK to use water to stop the burning process and clean but not at the expense of reducing body core temperature.
  8. 8. Initial Assessment of Burns • Secondary Survey: – Repeat primary survey. – Complete History of Present Illness (HPI). • What type of burn (flame, chemical, scald) • Duration of exposure • What time did burn occur? • What treatment already provided? (chemical brushed off, water to cool, etc) • Did burn occur in house fire/enclosed space? (think inhalation injury) Anas Bahnassi PhD CDM CDE 8
  9. 9. Initial Assessment of Burns • Secondary Survey: – Order labs and x rays • CBC, BUN, Cr, Lytes • Carboxyhemoglobin • Chest X-ray (CXR) • Blood gas • Insert Foley • EKG (especially in electrical injury) – Special considerations; • Abuse patterns – Children, elderly • Concomitant trauma – C-spine precautions – Trauma protocols if trauma is majority of injuries* Anas Bahnassi PhD CDM CDE 9
  10. 10. Initial Assessment of Burns • Secondary Survey: – Determine TBSA • Use Lund Browder chart. • Can start with patients palm = 1% of patients BSA • A good online program is sagediagram.com. – Need patient weight and height and age for this program. Can print out a graphic with parkland calculations. Anas Bahnassi PhD CDM CDE 10 Sagediagram Sample
  11. 11. Major Steps in Burn Treatment • IV fluids for burns > 10% TBSA • Wound cleaning, dressing, and serial assessment (Use Hibiclens and sterile water (not saline – it stings more when mixed with Hibiclens). • Supportive measures • Transfer or referral of selected patients to burn centers • Surgery and physical therapy for deep partial- thickness and full-thickness burns Anas Bahnassi PhD CDM CDE 11
  12. 12. Commence Fluid Resuscitation Adults • Fluid resuscitation is recommended for the following injuries: – Adults (>15%TBSA burn) – Children (>10%TBSA burn) • The goal of fluid resuscitation is to anticipate prevent hypovolaemic shock. • A variety of fluids have been recommended for use, such as plasma, human albumin solution (HAS), dextran and Hartmann’s solution. • Parkland Formula: The amount of fluid given in the first 24h (mls)= 3 – 4 mls/kg/TBSA% Rate: ½ in the first 8h ¼ in the second 8 hrs ¼ in the third 8 hrs Anas Bahnassi PhD CDM CDE 12 4mls/kg/%TBSA is recommended if the patient has an inhalation injury, presentation is delayed, has associated trauma or has a high voltage electrical injury http://www.merckmanuals.com/professional/clinical_calculators/v4742853.html
  13. 13. Commence Fluid Resuscitation Children • Maintenance fluids should also be added over and above the Modified Parklands formula for children weighing less than 30kgs. • Use 5% Dextrose in Lactated Ringer's (D5LR): hypertonic (pH: 4-6.5) – Each 100ml contains 5g of Dextrose Monohydrate, 600mg of Sodium Chloride, 310mg of Sodium Lactate Anhydrous, 30mg of Potassium Chloride, and 20mg of Calcium Chloride Dihydrate. • Parkland Formula for children: The amount of fluid given in the first 24h (mls)= 3 – 4 mls/kg/TBSA% Rate: ½ in the first 8h ¼ in the second 8 hrs ¼ in the third 8 hrs Anas Bahnassi PhD CDM CDE 13 Add maintenance fluid as follows: ƒ100mls/kg for 10 kg of weight ƒ50mls/kg next 10 kg of weight ƒ20mls/kg remaining 10 kg after
  14. 14. Example: • 23 Kg child with 20% deep burn – Resuscitation (Ringer’s Lactate) • 3 ml X 23 Kg X 20% Burn = 1380 mls – ½ in 1st 8 hrs post burn = 86 cc/hr – Maintenance (D5LR) • 1st 10 Kg: 100 cc/kg/24hr = 1,000 cc/24 hr • 2nd 10 Kg: 50 cc/kg/24hr = 500 cc/24 hr • Remaining 3 Kg: 20cc/kg/24hr = 60 cc/24 hr 1560 cc/24 hr = 65cc/hr Anas Bahnassi PhD CDM CDE 14
  15. 15. Anas Bahnassi PhD CDM CDE 15 (A) Rule of nines (for adults) and (B) Lund- Browder chart (for children) for estimating extent of burns.
  16. 16. Inhalation Injury • The three injury processes, resulting from smoke exposure, are presented in the order in which peak symptoms occur. – Carbon Monoxide Toxicity- peak symptoms immediate – Upper Airway Injury with Potential Obstruction – peak symptoms can be delayed for an hour or more – Lower Airway Injury with Impaired Gas Exchange- peak symptoms can be delayed for hours Anas Bahnassi PhD CDM CDE 16
  17. 17. Inhalation Injury Carbon Monoxide Toxicity • Diagnosis: – Pulse oximeter may be completely normal value as it only measures O2 level. – A high index of suspicion in any fire victim with a history of smoke exposure Anas Bahnassi PhD CDM CDE 17 – A carboxyhemoglobin level exceeding 10% total (Morbidity is related to peak level at scene not the first value obtained) – Unexplained metabolic acidosis
  18. 18. Anas Bahnassi PhD CDM CDE 18 Inhalation Injury Carbon Monoxide Toxicity - Symptoms Carboxyhemoglobin Normal Levels: 0-5%
  19. 19. Anas Bahnassi PhD CDM CDE 19 Inhalation Injury Carbon Monoxide Toxicity - Treatments Awake Obtunded (less than full mental capacity) High flow by mask oxygen (100%) Until carboxyhemoglobin <10% Intubate 100% oxygen via positive pressure ventilation Hyperbaria used if patient not responding to 100% Oxygen
  20. 20. Inhalation Injury Upper Airway Injury • Diagnosis: – Direct thermal damage tends to occur in the upper airway because the oropharynx has a substantial capacity to absorb heat. – Upper airway thermal injury constitutes an important indication for intubation, because it is mandatory to control the airway before airway edema develops during resuscitation. – The diagnosis of upper airway thermal injury is achieved with direct laryngoscopic visualization of the posterior oropharyngeal cavity. – The decision to intubate should be based on visual evidence of posterior pharyngeal swelling, mucosal sloughing, or carbonaceous sputum coming from below the level of the vocal cords. Anas Bahnassi PhD CDM CDE 20
  21. 21. Inhalation Injury Upper Airway Injury • Treatment: – Hospital admission for observation and provision of humidified oxygen, pulmonary toilet, bronchodilators as needed, and endotracheal intubation as indicated. – Upper airway thermal burns usually manifest within 48 hours of injury and airway swelling usually is maximal 12 to 24 hours after the injury. – A patient with an upper airway burn may require airway protection for 72 hours. Anas Bahnassi PhD CDM CDE 21
  22. 22. Inhalation Injury Upper Airway Injury • Treatment: – In a patient with a small burn (<15% TBSA), a short course of systemic or inhaled steroids may facilitate earlier resolution of airway edema, steroids are contraindicated in patients with large burns due to the risk of infection and failure to heal. – The patient can be extubated based on pulmonary weaning parameters and the presence of an air leak around the endotracheal tube. – Once it is safe to extubate, removing the endotracheal tube should be expedited because of the potential nosocomial complication of ventilator-associated pneumonia.. Anas Bahnassi PhD CDM CDE 22
  23. 23. Inhalation Injury Lower Airway Injury • Causes: – Burn injury to the tracheobronchial tree and the lung parenchyma results from combustion products in smoke and, under unique conditions, inhaled steam. – Numerous irritants in smoke or the vaporized chemical reagents in steam can cause direct mucosal injury, leading to mucosal slough and bronchial edema, bronchoconstriction, and bronchial obstruction. – This leads to exudate formation and microvascular permeability, and ultimately may progress to pulmonary edema, pneumonia, or acute respiratory distress syndrome (ARDS). Anas Bahnassi PhD CDM CDE 23
  24. 24. Inhalation Injury Lower Airway Injury • Diagnosis and treatment: – Significant inhalation of aerosolized toxins can reduce myocardial contractility and cause resuscitation failure. – Diagnosis of lower airway inhalation injury can be confirmed by bronchoscopy. – Still there is a need for a scoring system to correlate degree of pulmonary injury and outcome has yet to be developed. – In patients with lower airway inhalation injuries, successful treatment requires aggressive pulmonary toilet and frequent chest physiotherapy. Anas Bahnassi PhD CDM CDE 24
  25. 25. Types of Burns Anas Bahnassi PhD CDM CDE 25
  26. 26. Anas Bahnassi PhD CDM CDE 26
  27. 27. Anas Bahnassi PhD CDM CDE 27 http://www.youtube.com/watch?v=CNQ_uW66LfU Types of Burns
  28. 28. First Degree Burn • A first degree burn is confined exclusively to the outer surface and is not considered a significant burn. • No skin barrier functions are altered. • The most common form is sunburn which heals by itself in less than a week without a scar. Anas Bahnassi PhD CDM CDE 28 Treat with topical antimicrobial (Bacitracin) applied several times a day
  29. 29. Second Degree Burn • Second degree burns cause damage to the epidermis and portions of the dermis. • Since it does not extend through both layers, it is termed partial thickness. • There are a number of depths of a second degree or partial thickness burn which are used to characterize the burn. Anas Bahnassi PhD CDM CDE 29 1. Superficial Second Degree 2. Mid-Second degree-Mid partial thickness burn 3. Deep Second Degree-Deep partial thickness
  30. 30. Second Degree Burn Superficial Second Degree • Involves the entire epidermis and no more than the upper third of the dermis is heat destroyed. • Rapid healing occurs in 1-2 weeks, because of the large amount of remaining skin and good blood supply. • Scar is uncommon. • Initial pain is the MOST SEVERE of any burn, as the nerve endings of the skin are exposed to the air. Anas Bahnassi PhD CDM CDE 30 1. Debridement of affected skin to expose underlying wound. 2. Debride blisters that are limiting joint movement. 3. Clean wound and apply antimicrobial ointment such as bacitracin. 4. Excellent alternative is the use of skin substitute which seals the wound and decrease pain.
  31. 31. Second Degree Burn Mid-Second degree-Mid partial thickness burn • Destruction to about half the dermis occurs. • Healing is slower due to the fact that there is less remaining dermis and less of a blood supply. • Pain can be severe but is usually less intense than the superficial due in part by nerves that are destroyed. Anas Bahnassi PhD CDM CDE 31 1. Treatment is typically Silvadene cream and occlusive dressing with a closed dressing technique. 2. A temporary skin substitute is also a treatment of choice.
  32. 32. Second Degree Burn Deep Second Degree-Deep partial thickness • Most of the skin is destroyed except a small amount of remaining dermis. • The wound looks white or charred indicating dead tissue. • Blood flow is compromised and a layer of dead dermis or eschar adheres to the wound surface. • Pain is much less as the nerves are actually destroyed by the heat. • Usually, it is difficult to distinguish a deep dermal burn from a full thickness burn by visualization. • The presence of sensation to touch usually indicates the burn is a deep partial injury. Anas Bahnassi PhD CDM CDE 32 1. Wash with antimicrobial soap and water. 2. Apply silvadene closed dressing. 3. Often grafting is needed to speed healing. 4. Monitor for infection. 5. Often converts to full thickness injury.
  33. 33. Third Degree Burn Full thickness buns • Both layers of skin are completely destroyed leaving no cells to heal. • Any significant burn will require skin grafting. • Small burns will heal with scar. • Entire destruction of the epidermis and dermis, leaving no residual epidermal cells to repopulate. Anas Bahnassi PhD CDM CDE 33 1. Wash with antimicrobial soap and water. 2. Apply Silvadene cream with a closed dressing. 3. Grafting is treatment of choice. High risk for infection.
  34. 34. Outpatient Treatment • Only patients with superficial dermal burns / deep dermal burns (partial thickness burns) < 10% TBSA should be treated as outpatients with exception of the very young & old and those with burns in special areas. • Scalds are less likely to be deep except in children. • Estimate the extent of the burn with the palmar surface of thepatients hand (from the fingertips to the wrist), it is approximately 1% of the TBSA. • Look at the color of the burn. • Note the presence or absence of blisters. • Apply digital pressure and observe the capillary refill. • Give oral analgesics. • Clean and dress the wound. Anas Bahnassi PhD CDM CDE 34
  35. 35. Clinical Pharmacy VI: First Aid abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi PhD CDM CDE