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Burns management

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Burns Management

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Burns management

  1. 1. Management of the burn patient NATHAN STEWART ADAPTED FROM PRESENTATION BY DR ALAN PHIPPS
  2. 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. 3. Progress in Burn Care Fluid resuscitation Dedicated burns units Antimicrobials Intensive care Nutrition Early excision Skin cover Specialisation 3
  4. 4. Classification of burns Thermal  hot  cold 4
  5. 5. Classification of burns Thermal  immersion  cascade scalds 5
  6. 6. Classification of burns Thermal  contact  flame  flash 6
  7. 7. Classification of burns Chemical  acid  alkali  organic chemicals 7
  8. 8. Classification of burns Electrical  low voltage  high tension  lightning 8
  9. 9. Classification of burns Friction Radiation 9
  10. 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. 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. 12 Minor burns
  13. 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. 14. Dressings for Burns
  15. 15. 15 Major burns
  16. 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. 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. 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. 19. Burns Resuscitation: Monitoring  Physiology: URINE OUTPUT Haematocrit Blood Gases Urine Osmolality Electrolytes & Urea Nutritional Status Cardiovascular Function
  20. 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. 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. 22. Lower airway/pulmonary problems Primary burn damage Pulmonary oedema ARDS 22
  23. 23. Burn Resuscitation: Airway INVESTIGATIONS  Blood Gases  Carboxyhaemaglobin  Chest X-ray
  24. 24. Burn Resuscitation: Airway TREATMENT  FiO2 40 - 60%  Nebulisers - - ? 100% Saline Salbutamol / Terbutaline  Oro/Nasal Intubation  Tracheostomy
  25. 25. Burn Resuscitation: Breathing  COAD - Hypoxic Drive  MECHANICAL:  Upper Airway Swelling  Chest Wall Constriction
  26. 26. Burn Shock Likely if burned area more than  15% body surface in adults  10% body surface in children (and elderly) 26
  27. 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. 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. 29. Burn Resuscitation: Burn Depth  Erythema - ignore  Superficial Partial Thickness  Deep Partial Thickness  Full Thickness
  30. 30. Rule of nine 30
  31. 31. Management of the burned patient Full “primary and secondary” surveys Check for other injuries 31
  32. 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. 33. Depths of burn 33
  34. 34. Assessment of burn depth Clinical examination: 50-75% accurate Pinprick test Repeated examination 34
  35. 35. Assessment of burn depth 35 Easy when very superficial or full-thickness Harder when intermediate or mixed
  36. 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. 37. Timing of surgery “Ultraconservative” Conservative Early Acute 37
  38. 38. Urgent surgery High-tension electrical injury Deep encircling burns - escharotomy  limbs  trunk 38
  39. 39. For small burns Excision and grafting as soon as clearly non-healing 39
  40. 40. Early excision of burns Tangential excision to viable tissue on day 3-5 Janzekovic (1970) Jackson & Stone (1972) 40
  41. 41. Tangential burn excision and split skin grafting 41
  42. 42. Excision to fascia 42
  43. 43. Early burn surgery Superior outcomes where suitably equipped  mortality  length of hospital stay  morbidity during acute burn  scar quality 43
  44. 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. 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. 46. Scar management The potential problem 46
  47. 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. 48. Scar management Splintage 48
  49. 49. Pressure garments Almost universally used Apparently effective Many published observations 49
  50. 50. Pressure garments Aids to compliance 50
  51. 51. Conformers and splints 51
  52. 52. Silicone gel Mechanism not fully known - not pressure 52

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