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Burns

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Burns

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

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