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ACCIDENTAL INJURY
By gedefaw
ACCIDENTAL INJURY
• DEFINITION: -an undesirable or unfortunate
happening that occurs unintentionally and
usually results in harm, injury, damage, or
loss; casualty; mishap (Dictionary.com) -an
unforeseen and unplanned event or
circumstance (Merriam Webster Dictionary)
• children need to be constantly reminded of
the dangers in the environment because they
don’t know how dangerous is ‘dangerous’
ACCIDENT TYPES and SOURCES of
ACCIDENTS
• Falls
• Cuts
• Burns and scales
• Bites and stings
• Poisoning
• Inhalation of foreign bodies.
• Road traffic accidents
• Drowning
SKELETAL AND MUSCULAR INJURIES
• FRACTURE
• DEFINITION: A fracture is a break in the continuity
of bone.
• It may be complete or incomplete.
CAUSES:
• Direct force: This is when the bone breaks when
direct force is applied, for example from a kick or
blow.
• Indirect force: This is when the bone breaks some
distance from the spot where the force is applied.
CLASSIFICATIONS:
• Closed fractures: This is where the over lying skin is not
broken.
• Open fractures: This is when the over lying skin is
broken. The broken bones can easily be seen through
the broken skin.
• FRACTURE SIGNS AND SYMPTOMS:
• Pain, which may be severe.
• Tenderness on touch. • Failure to use the affected part
of the body. • Swelling of the affected part. • Bleeding in
an open fracture. • Deformity, such as irregularity of the
bone, shortening of the limb, depression of flat bone. •
Angulation or rotation of the bone.
Drowning
• Drowning is “the process of experiencing respiratory
impairment from submersion /immersion in liquid.”
• The term drowning does not imply the final outcome—
death or survival;
• The outcome should be denoted as fatal or nonfatal
drowning
• The injury following a drowning event is hypoxia
Epidemiology
• From 2005 to 2014, an average 3,536 people per
year were victims of fatal drowning
• An estimated 6,776 persons per year were treated
in U.S. hospital emergency departments (EDs) for
nonfatal drowning .
• The most common causes of death related to
unintentional injuries for all pediatric age groups
• In children age 1-4 yr, drowning was the number-
one cause of death from unintentional injury
Risk factors
• Host factors, including male gender,alcohol
use, a history of seizures, and swimming
lessons.
• Environmental risk factors include exposure to
water and varying supervision.
• These factors are embedded in the context of
geography, climate, socioeconomic status, and
culture.
Pathophysiology
• Drowning victims drown silently and do not signal
distress or call for help.
• Vocalization is precluded by efforts to achieve maximal
lung volume to keep the head above the water or by
aspiration leading to laryngospasm .
• Young children can struggle for only 10-20 sec and
adolescents for 30-60 sec before final submersion.
• A swimmer in distress is vertical in the water, pumping
the arms up and down.
• This splashing or efforts to breathe are often
misconstrued by nearby persons as merely playing in
the water, until the victim sinks.
Anoxic-Ischemic Injury
• During this stage, small amounts of water enter the
hypopharynx,triggering laryngospasm.
• There is a progressive decrease in arterial blood
oxyhemoglobin saturation (SaO 2 ), and the animal
soon loses consciousness from hypoxia.
• Profound hypoxia and medullary depression lead to
terminal apnea.
• At the same time, the cardiovascular response leads to
progressively decreasing cardiac output and oxygen
delivery to other organs.
• By 3-4 min, myocardial hypoxia leads to abrupt
circulatory failure
• Ineffective cardiac contractions with electrical
activity may occur briefly, without effective
perfusion (pulseless electrical activity ).
• With early initiation of CPR, spontaneous
circulation may initially be successfully
restored.
• The extent of the global hypoxic-ischemic
injury determines the final outcome and
becomes more evident over subsequent hours
• All other organs and tissues may exhibit signs of
hypoxic-ischemic injury.
• In the lung, damage to the pulmonary vascular
endothelium can lead to acute respiratory distress
syndrome
• Myocardial dysfunction (so-called stunning), arterial
hypotension, decreased cardiac output, arrhythmias,
and cardiac infarction may also occur.
• Acute kidney injury, cortical necrosis, and renal
failure are common complications of major hypoxic-
ischemic events
• Vascular endothelial injury may initiate
disseminated intravascular coagulation,
hemolysis, and thrombocytopenia.
• Many factors contribute to gastrointestinal
damage; bloody diarrhea with mucosal
sloughing may be seen and often portends a
fatal injury
• CNS injury is the most common cause of
mortality and long-term morbidity.
• Although the duration of anoxia before
irreversible CNS injury begins is uncertain, it
is probably on the order of 3-5 min.
• Submersions <5 min are associated with a
favorable prognosis, where as those >25 min
are generally fatal
Management
• Initial management of drowning victims requires
coordinated and experienced prehospital care following the
ABCs (airway, breathing, circulation) of emergency
resuscitation.
• CPR of drowning victims must include providing
ventilation.
• Children with severe hypoxic injury and symptoms often
remain comatose and lack brainstem reflexes despite the
restoration of oxygenation and circulation.
• Subsequent ED and PICU care often involve advanced life
support (ALS) strategies and management of multiorgan
dysfunction with discussions about end-of-life care
Initial Evaluation and Resuscitation
• Once a submersion has occurred, immediate
institution of CPR efforts at the scene is
imperative.
• The goal is to reverse the anoxia from submersion
and limit secondary hypoxic injury after
submersion.
• Every minute that passes without the
reestablishment of adequate breathing and
circulation dramatically decreases the possibility
of a good outcome
• Initial resuscitation must focus on rapidly restoring
oxygenation, ventilation,and adequate circulation.
• The airway should be clear of vomitus and foreign
material, which may cause obstruction or aspiration.
• Abdominal thrusts should not be used for fluid
removal, because many victims have a distended
abdomen from swallowed water; abdominal thrusts
may increase the risk of regurgitation and aspiration.
• In cases of suspected airway foreign body, chest
compressions or back blows are preferable maneuvers.
• The cervical spine should be protected in
anyone with potential traumatic neck injury
• Cervical spine injury is a rare concomitant
injury in drowning
• only approximately 0.5% of submersion
victims have C-spine injuries, and history of
the event and victim's age should guide
suspicion of C-spine injury.
• If the victim has ineffective respiration or apnea,
ventilatory support must be initiated immediately.
• Mouth-to-mouth or mouth-to-nose breathing by
trainedbystanders often restores spontaneous
ventilation.
• As soon as it is available,supplemental oxygen
should be administered to all victims.
• Positive pressure bag-mask ventilation with 100%
inspired oxygen should be instituted in patients
with respiratory insufficiency.
• If apnea, cyanosis, hypoventilation, or labored
respiration persists, trained personnel should
perform endotracheal intubation as soon as
possible.
• Intubation is also indicated to protect the airway
in patients with depressed mental status or
hemodynamic instability
• CPR should be instituted immediatelyin pulseless,
bradycardic, or severely hypotensive
victims.
• Intravenous (IV) fluids and vasoactive
medications are required to improve
circulation and perfusion.
Prognosis
• The outcomes for drowning victims are
remarkably bimodal:
• The great majority of victims either have a good
outcome (intact or mild neurologic sequelae) or
• A poor outcome (severe neurologic sequelae
persistent vegetative state, or death),with very few
exhibiting intermediate neurologic injury at
hospital discharge.
• Subsequent evaluation of good outcome survivors
may identify significant
• Poor outcome is highly likely in patients with;
– Deep coma
– Apnea
– Absence of papillary responses
– Hyperglycemia in the ED
– Submersion durations>10 min
– Failure of response to CPR given for 25 min.
Prevention
• Recognize hazards and risks.
• Provide constant adult supervision around water.
• Install 4-sided, isolation fencing of pools.
• Install rescue equipment and phone at poolside.
• Learn swimming and water survival skills.
• Avoid bath; instead shower,if a child/teen with
seizure disorder.
• Learn first aid and CPR.
DROWNING FIRST AID
1.Move the person.
2.Check for breathing.
3. If the person is not breathing, check pulse.
4. If there is pulse, start CPR
• A burn injury is a coagulative damage or
destruction of skin and/or under laying tissues by:
• Thermal: direct contact with heat (flame, scald, contact)
• Electrical
A.C. – Alternating current (residential)
D.C. – Direct current (industrial/lightening)
• Chemical
• Frostbite: Damage to body extremities caused by prolonged exposure to freezing
conditions, characterized by numbness, tissue death, and gangrene
Definition
ETIOLOGY
1%
Radiation
1%
Friction
5%
Electrical
10%
Flash
15%
Contact
30%
Scald
33%
Flame
At great risks are
• The very young
• The very old
• Those whose ability to
protect themselves is
impaired:
*Epilepsy
*Alcohol
*Drug abuse
Link
• Burn injuries are classified based on the
following consideration
A. Causative agents(etiology)
B. Depth of injury
C. Extent of body surface involved
Classification
Chemical Burn.
Frostbite
Thermal
Electrical Burn
A. ETHIOLOGIC
CLASSIFICATION
B.DEPTH OF BURN(Degrees)
Superficial Skin burn (10 ) = involves Epidermis
Superficial/Deep Partial thickness (20 ) = involves
Dermis
0
10 burn 20 burn 30 burn 40 burn
Involves only the
Epidermis
Involve the
Epidermis and
portions of the
dermis
Complete
destruction of
Epidermis and
Dermis
Involves SC
tissue, tendon
and bone
Degrees of burns
First degree burn(Superficial burn)
• Involves only the epidermis
• Tissue will blanch with pressure
• Involves minimal tissue damage e.g Sunburn
Absence of blisters
Erythema
Painful
• Heals in 3-6 days
• Maintain hydration orally.
• Topical creams provide relief.
• No need for antibiotics
…..
Generally no scar after healing
Second degree burn(Partial-thickness B.)
• Referred to as Partial-thickness burns
1. Superficial partial-thickness burns
 If it involves no deeper than the
Papillary dermis (upper 1/3)
2. Deep partial- thickness burn
 If it involves All of the Papillary dermis and
portion of the Reticular dermis
Often involve other structures such
as sweat glands, hair follicles, etc.
 Edema and decreased blood flow in
tissue can convert to a full-thickness
burn
Red/mottled
Blister
Painfull
Superficial partial-thickness burns
• The damage goes no deeper than the Papillary dermis.
• C/F:
1. Blistering within 24hr and/or loss of the epidermis
2. Breaking the blister leave pink and moist underlying
dermis
3. The capillary return is clearly visible when blanched
 There is little or no fixed capillary staining
4. Pinprick sensation is normal
5. Heal without scarring in 2 wks without surgery
 The damage involves the Part of Reticular dermis
 C/M:
1. Blistering and/or loss of the epidermis usually.
2. The exposed dermis is Pale & not moist as in a superficial
3. The color does not blanch under the examiner’s finger
 There is often abundant fixed capillary staining, (esp. after 48
hrs)
4. Sensation is reduced, and the patient is unable to distinguish
sharp from blunt pressure when examined with a needle.
5. Heal by forming scar in 3 - 6 wks without surgery
 Usually lead to Hypertrophic scarring or Epithelioma
Deep partial- thickness burn
Third degree burn(Full-thickness burns)
• The whole of the dermis is destroyed.
• C/M:
1. Charred skin or Translucent white color
2. There is no capillary return
 Thrombosed or Coagulated vessels can be
seen under the skin.
3. No sensation (Nerve endings destroyed)
 Patient complain pain from surrounding
second degree burn area
4. Always heal by forming SCAR in ≥3wks
 Dark
Dry
Leathery
• Rule of Nines & 7 :
Quick estimate of percent of burn
• Lund and Browder Chart:
More accurate assessment tool
Useful chart for children – takes into account the head size
proportion.
• Rule of Palms:
Good for estimating small patches of
burn wound
ESTIMATION OF BURN SIZE
TOTAL BODY SURFACE AREA (TBSA)
Palmar surface = 1% of the BSA
Rule of 9s
ABA
Rule of Seven:
Lund Browder Chart used for determining BSA
4/1/2011 41
Burn injuries result in a local and
systemic response.
Pathophysiology
• The three zones of a burn were described by
Jackson in1947
I. Zone of Coagulation (Necrotic, white, no circulation)
In this zone there is irreversible tissue loss due to coagulation
of the constituent proteins
II. Zone of Stasis (circulation sluggish)
The tissue in this zone is potentially Salvageable ???
III. Zone of Hyperemia (Good blood flow, red)
 This zone will invariably recover
Local response
• The release of cytokines and other
inflammatory mediators at the site of injury has
a systemic effect once the burn reaches 30%
• This systemic inflammatory response results in
cardiovascular, respiratory, metabolic,
immunological & other systemic response,
Systemic response
The Burn Syndrome.
Lead to
Criteria for burn center admission
• Full-thickness > 5% BSA
• Partial-thickness > 10% BSA
• Any full-thickness or partial-
thickness burn involving
critical areas (face, hands,
feet, genitals, perineum, skin
over major joint)
• Children with severe burns
• Circumferential burns of
thorax or extremities
• Significant chemical injury,
electrical burns, lightening
injury, co-existing major
trauma or significant pre-
existing medical conditions
• Presence of inhalation injury
Management of Burn Injury includes:
1. Initial patient treatment
2. Management of burns of special Type &
Area
3. Special considerations during management
4. Fluid resuscitation.
5. Wound care
6. Antibiotic therapy
7. Pain management.
• Stop the burning process
• Consider burn patient as a Poly trauma
patient until determined otherwise.
a. Perform ABCDE assessment
b. Details of the incident
1. Initial patient
treatment
a. ABCDEs assessment
• Airway
• Breathing
• Circulation
• Depth of Burn
• Extent of Injury(s) & Expose to examine
• Pediatric (special) issues
Airway considerations
• Upper airway injury (above the glottis): Area buffers
the heat of smoke – thermal injury is usually confined to
the larynx and upper trachea.
• Lower airway/alveolar injury (below the glottis):
- Caused by the inhalation of steam or chemical smoke.
- Presents as ARDS often after 24-72 hours.
Why not immediate?
Criteria for intubation
1. Altered mental status or GCS<8
2. Burns of ≥ 50% TBSA.
3. Carbonaceous sputum.
4. Changes in voice
5. Continuous coughing
6. Face /Neck burns which is extensive.
7. Inhalation injury
8. Wheezing
9. Stridor - Oro-pharyngeal edema
Pediatric intubation
• Normally have smaller airways than adults
• If intubation is required, an uncuffed ETT should be placed
• Intubation should be performed by experienced individual
– failed attempts can create edema and further obstruct
the airway
AGE + 16 = ETT size
4
Ventilatory therapies
• Rapid Sequence Intubation
• Pain Management, Sedation and Paralysis
• Positive End-Expiratory Pressure (PEEP)
• High concentration oxygen
• Hyperbaric oxygen
• Avoid barotrauma
Ventilatory therapies
• Burn patients with ARDS requiring PEEP > 14 cm for
adequate ventilation should receive prophylactic
tube thoracostomy
• NG tube placement
– Reduce aspiration risk
Breathing Assessment/Support
• Ensure adequate oxygenation
– ABG with carboxyhemoglobin level preferred
– Humidified 100% O2 emperically
• Assess for possible inhalation injury
– History of an enclosed space, carbonaceous
sputum, respiratory symptoms, altered LOC
– Younger children at greater risk
• NMB for intubation: avoid succinylcholine
Circulatory
• Assess capillary refill, pulses, hydration
• Place foley catheter to assess UOP
• Achieve hemostasis at sites of bleeding
• Evaluate sensorium
• Venous access, depending upon BSA
involvement; avoid burn sites if possible
Depth Assessment
• Assess depth of injuries:
– First degree burn
• Treatment rarely required (IV hydration)
– Second degree (partial thickness)
• Infection, malnutrition, hypoperfusion may cause conversion
to full thickness (3rd degree)
– Third degree (full thickness)
• Typically requires some degree of surgical closure
– Fourth degree
• Note: circumferential burns, compartment
syndrome risk; consider escharotomy need
Extent & Exposure
• Expressed as percentage of total BSA
– Only 2nd & 3rd degree burns mapped
• Once adult proportions attained (~15 yo),
“Rule of nines” may be used
• For children less than 15 years of age, age
adjusted proportions must be used
– fluid replacement is based upon BSA estimates
• Must rule out concomitant other injuries
Expose
• Undress the patient to examine the
whole body.
• But burned patients lose body heat
quickly, so keep them warm.
– To keep warm, use whatever means
available:
blankets
heating lamps
bed frame
large box covered with blankets
b. Details of the incident
• Cause of the burn
• Time of injury
• Place of the occurrence (closed space, presence
of chemicals, noxious fumes)
• Likelihood of associated trauma (explosion,…)
• Pre-hospital interventions
Pre-hospital interventions
Stop the burning process
A. Burns of special Areas of the body
 Face
 Mouth
 Neck
 Hands and feet
 Genitalia
Face
• Be VERY concerned for the airway!!
• Eyelids, lips and ears often swell alarmingly.
• Patients may have burnt facial hair, mouth and neck
together or separately.
• In fact, they look even worse the next day.
• But they will start to improve daily after that.
Hands and feet
• Fingers might develop
contractures if active measures
are not taken to prevent them.
 Circumferential burn
 Electrical burn
 Chemical burn
B. Mgt of Special
types of burn
1. Circumferential burn
• There is a loss of skin expansion due to the loss of
turgor/elasticity in burned tissue
• This requires escharotomy to relieve the pressure.
3. Electrical burn
• Outer skin might not appear too bad.
• But, there may be brain, heart or
musculoskeletal injuries & Causes the
most damage.
• Safely remove the person from the
source of the electricity.
• Do not become a victim.
• Usually requires fasciotomy
Burns from inside out.
4. Chemical Burn
• Most often caused by
strong acids or
alkalis.
• It can cause
progressive injury
until the agent is
inactivated.
• Flush the injured area
with a copious amount
of water.
Don’t delay or waste time looking for or using
a neutralizing agent
These may in fact worsen the injury by
producing heat or causing direct injury
themselves.
• Goal: To Maintain adequete perfusion.
• Based on the TBSA, body weight and whether
patient is adult/child
• Fluid requirement calculations are based on the
time from injury, not from the time fluid
resuscitation is initiated.
• Fluid overload should be avoided – difficult to
retrieve settled fluid in tissues and may facilitate
organ hypoperfusion
4.Fluid resuscitation
……
• Lactated Ringers - preferred solution Contains
– Na+ - restoration of Na+ loss is essential
– K+ - restore potassium depletion
– Free of glucose – high levels of circulating stress
hormones may cause glucose intolerance
Vascular access: Two large bore peripheral lines (if
possible) or central line.
• ARF may result from
myoglobinuria
 Increased fluid volume,
Mannitol bolus and
NaHCO3 into each liter of
RL to alkalinize the urine
may be indicated
Maintain urine output at 0.5 cc/kg/hr(30ml/hr).
Parkland(Baxter) Formula
4ml RL/%BSAB
/wt(kg).
½of calculated fluid
is administered in the
first 8 hours
Balance is given over the
remaining 16 hours.
• The risk of infection of burned tissue is increased
because the wound is protein rich and moist,
and is thus a good culture medium.
• The neoeschar and lack of vascularity limit
antibiotic delivery. Therefore
– Prevent primary and secondary infections by
Topical and/or systemic antibiotics as necessary.
5. ANTIBIOTIC TREATMENT &
WOUND CARE
Antibiotics
– Silver nitrate (0.5% aqueous) cheapest, apply with
occlusive dressings, does not penetrate eschar
– Silver sulfadiazine (1% miscible ointment) with single
layer dressing; has limited eschar penetration, may cause
neutropenia
– Mafenide acetate (11% in miscible ointment) used
without dressings; penetrates eschar but causes acidosis
Wound Care
Focus care on rapid healing, infection prevention
• Excise adherent necrotic tissue
• No hurry to remove blisters unless infection occurs.
• Gently cleanse burn with
– Chlorhexidine (0.25% (2.5 g/l) )solution.
– Cetrimide (0.1% (1 g/l)) solution.
• Debride all bullae
SKIN GRAFTS
Used for full-thickness and deep partial-thickness
74
Done during the acute phase(3-5 dys)
Adequate analgesia imperative!
DOC: Morphine Sulfate the gold standard
Dose: Adults: 0.1 – 0.2 mg/kg IV
Children: 0.1 – 0.2 mg/kg/dose IV
Other pain medications commonly used:
• Ketamine
• Demerol
• Vicodin ES
• NSAIDs
6. Pain management
I. INFECTION & Wound Sepsis
Predictors of infection :
- Burn size
- Age
- Inhalation injury
Burn Complications
Infection in Burn Injury
• Types of infections in burn patients
–Wound invasion/sepsis,
–Cellulitis,
–Pneumonia,
–Suppurative thrombophlebitis,
–Miscellaneous nosocomial infections
II. Curling ulcer, Ileus & Acute gastric dilation
III. Contracture
Prevention
. Early excision and grafting
. Splintage
. Elevation of extremity
. Early physiotherapy
. Prevention of infection
IV. Marjolin’s ulcer, Hypertrophic scar, keloid
Thank you

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accidental injury...................pptx

  • 2. ACCIDENTAL INJURY • DEFINITION: -an undesirable or unfortunate happening that occurs unintentionally and usually results in harm, injury, damage, or loss; casualty; mishap (Dictionary.com) -an unforeseen and unplanned event or circumstance (Merriam Webster Dictionary) • children need to be constantly reminded of the dangers in the environment because they don’t know how dangerous is ‘dangerous’
  • 3. ACCIDENT TYPES and SOURCES of ACCIDENTS • Falls • Cuts • Burns and scales • Bites and stings • Poisoning • Inhalation of foreign bodies. • Road traffic accidents • Drowning
  • 4. SKELETAL AND MUSCULAR INJURIES • FRACTURE • DEFINITION: A fracture is a break in the continuity of bone. • It may be complete or incomplete. CAUSES: • Direct force: This is when the bone breaks when direct force is applied, for example from a kick or blow. • Indirect force: This is when the bone breaks some distance from the spot where the force is applied.
  • 5. CLASSIFICATIONS: • Closed fractures: This is where the over lying skin is not broken. • Open fractures: This is when the over lying skin is broken. The broken bones can easily be seen through the broken skin. • FRACTURE SIGNS AND SYMPTOMS: • Pain, which may be severe. • Tenderness on touch. • Failure to use the affected part of the body. • Swelling of the affected part. • Bleeding in an open fracture. • Deformity, such as irregularity of the bone, shortening of the limb, depression of flat bone. • Angulation or rotation of the bone.
  • 6. Drowning • Drowning is “the process of experiencing respiratory impairment from submersion /immersion in liquid.” • The term drowning does not imply the final outcome— death or survival; • The outcome should be denoted as fatal or nonfatal drowning • The injury following a drowning event is hypoxia
  • 7. Epidemiology • From 2005 to 2014, an average 3,536 people per year were victims of fatal drowning • An estimated 6,776 persons per year were treated in U.S. hospital emergency departments (EDs) for nonfatal drowning . • The most common causes of death related to unintentional injuries for all pediatric age groups • In children age 1-4 yr, drowning was the number- one cause of death from unintentional injury
  • 8. Risk factors • Host factors, including male gender,alcohol use, a history of seizures, and swimming lessons. • Environmental risk factors include exposure to water and varying supervision. • These factors are embedded in the context of geography, climate, socioeconomic status, and culture.
  • 9. Pathophysiology • Drowning victims drown silently and do not signal distress or call for help. • Vocalization is precluded by efforts to achieve maximal lung volume to keep the head above the water or by aspiration leading to laryngospasm . • Young children can struggle for only 10-20 sec and adolescents for 30-60 sec before final submersion. • A swimmer in distress is vertical in the water, pumping the arms up and down. • This splashing or efforts to breathe are often misconstrued by nearby persons as merely playing in the water, until the victim sinks.
  • 10. Anoxic-Ischemic Injury • During this stage, small amounts of water enter the hypopharynx,triggering laryngospasm. • There is a progressive decrease in arterial blood oxyhemoglobin saturation (SaO 2 ), and the animal soon loses consciousness from hypoxia. • Profound hypoxia and medullary depression lead to terminal apnea. • At the same time, the cardiovascular response leads to progressively decreasing cardiac output and oxygen delivery to other organs. • By 3-4 min, myocardial hypoxia leads to abrupt circulatory failure
  • 11. • Ineffective cardiac contractions with electrical activity may occur briefly, without effective perfusion (pulseless electrical activity ). • With early initiation of CPR, spontaneous circulation may initially be successfully restored. • The extent of the global hypoxic-ischemic injury determines the final outcome and becomes more evident over subsequent hours
  • 12. • All other organs and tissues may exhibit signs of hypoxic-ischemic injury. • In the lung, damage to the pulmonary vascular endothelium can lead to acute respiratory distress syndrome • Myocardial dysfunction (so-called stunning), arterial hypotension, decreased cardiac output, arrhythmias, and cardiac infarction may also occur. • Acute kidney injury, cortical necrosis, and renal failure are common complications of major hypoxic- ischemic events
  • 13. • Vascular endothelial injury may initiate disseminated intravascular coagulation, hemolysis, and thrombocytopenia. • Many factors contribute to gastrointestinal damage; bloody diarrhea with mucosal sloughing may be seen and often portends a fatal injury
  • 14. • CNS injury is the most common cause of mortality and long-term morbidity. • Although the duration of anoxia before irreversible CNS injury begins is uncertain, it is probably on the order of 3-5 min. • Submersions <5 min are associated with a favorable prognosis, where as those >25 min are generally fatal
  • 15. Management • Initial management of drowning victims requires coordinated and experienced prehospital care following the ABCs (airway, breathing, circulation) of emergency resuscitation. • CPR of drowning victims must include providing ventilation. • Children with severe hypoxic injury and symptoms often remain comatose and lack brainstem reflexes despite the restoration of oxygenation and circulation. • Subsequent ED and PICU care often involve advanced life support (ALS) strategies and management of multiorgan dysfunction with discussions about end-of-life care
  • 16. Initial Evaluation and Resuscitation • Once a submersion has occurred, immediate institution of CPR efforts at the scene is imperative. • The goal is to reverse the anoxia from submersion and limit secondary hypoxic injury after submersion. • Every minute that passes without the reestablishment of adequate breathing and circulation dramatically decreases the possibility of a good outcome
  • 17. • Initial resuscitation must focus on rapidly restoring oxygenation, ventilation,and adequate circulation. • The airway should be clear of vomitus and foreign material, which may cause obstruction or aspiration. • Abdominal thrusts should not be used for fluid removal, because many victims have a distended abdomen from swallowed water; abdominal thrusts may increase the risk of regurgitation and aspiration. • In cases of suspected airway foreign body, chest compressions or back blows are preferable maneuvers.
  • 18. • The cervical spine should be protected in anyone with potential traumatic neck injury • Cervical spine injury is a rare concomitant injury in drowning • only approximately 0.5% of submersion victims have C-spine injuries, and history of the event and victim's age should guide suspicion of C-spine injury.
  • 19. • If the victim has ineffective respiration or apnea, ventilatory support must be initiated immediately. • Mouth-to-mouth or mouth-to-nose breathing by trainedbystanders often restores spontaneous ventilation. • As soon as it is available,supplemental oxygen should be administered to all victims. • Positive pressure bag-mask ventilation with 100% inspired oxygen should be instituted in patients with respiratory insufficiency.
  • 20. • If apnea, cyanosis, hypoventilation, or labored respiration persists, trained personnel should perform endotracheal intubation as soon as possible. • Intubation is also indicated to protect the airway in patients with depressed mental status or hemodynamic instability • CPR should be instituted immediatelyin pulseless, bradycardic, or severely hypotensive victims.
  • 21. • Intravenous (IV) fluids and vasoactive medications are required to improve circulation and perfusion.
  • 22. Prognosis • The outcomes for drowning victims are remarkably bimodal: • The great majority of victims either have a good outcome (intact or mild neurologic sequelae) or • A poor outcome (severe neurologic sequelae persistent vegetative state, or death),with very few exhibiting intermediate neurologic injury at hospital discharge. • Subsequent evaluation of good outcome survivors may identify significant
  • 23. • Poor outcome is highly likely in patients with; – Deep coma – Apnea – Absence of papillary responses – Hyperglycemia in the ED – Submersion durations>10 min – Failure of response to CPR given for 25 min.
  • 24. Prevention • Recognize hazards and risks. • Provide constant adult supervision around water. • Install 4-sided, isolation fencing of pools. • Install rescue equipment and phone at poolside. • Learn swimming and water survival skills. • Avoid bath; instead shower,if a child/teen with seizure disorder. • Learn first aid and CPR.
  • 25. DROWNING FIRST AID 1.Move the person. 2.Check for breathing. 3. If the person is not breathing, check pulse. 4. If there is pulse, start CPR
  • 26. • A burn injury is a coagulative damage or destruction of skin and/or under laying tissues by: • Thermal: direct contact with heat (flame, scald, contact) • Electrical A.C. – Alternating current (residential) D.C. – Direct current (industrial/lightening) • Chemical • Frostbite: Damage to body extremities caused by prolonged exposure to freezing conditions, characterized by numbness, tissue death, and gangrene Definition
  • 27. ETIOLOGY 1% Radiation 1% Friction 5% Electrical 10% Flash 15% Contact 30% Scald 33% Flame At great risks are • The very young • The very old • Those whose ability to protect themselves is impaired: *Epilepsy *Alcohol *Drug abuse Link
  • 28. • Burn injuries are classified based on the following consideration A. Causative agents(etiology) B. Depth of injury C. Extent of body surface involved Classification
  • 30. B.DEPTH OF BURN(Degrees) Superficial Skin burn (10 ) = involves Epidermis Superficial/Deep Partial thickness (20 ) = involves Dermis 0
  • 31. 10 burn 20 burn 30 burn 40 burn Involves only the Epidermis Involve the Epidermis and portions of the dermis Complete destruction of Epidermis and Dermis Involves SC tissue, tendon and bone Degrees of burns
  • 32. First degree burn(Superficial burn) • Involves only the epidermis • Tissue will blanch with pressure • Involves minimal tissue damage e.g Sunburn Absence of blisters Erythema Painful
  • 33. • Heals in 3-6 days • Maintain hydration orally. • Topical creams provide relief. • No need for antibiotics ….. Generally no scar after healing
  • 34. Second degree burn(Partial-thickness B.) • Referred to as Partial-thickness burns 1. Superficial partial-thickness burns  If it involves no deeper than the Papillary dermis (upper 1/3) 2. Deep partial- thickness burn  If it involves All of the Papillary dermis and portion of the Reticular dermis Often involve other structures such as sweat glands, hair follicles, etc.  Edema and decreased blood flow in tissue can convert to a full-thickness burn Red/mottled Blister Painfull
  • 35. Superficial partial-thickness burns • The damage goes no deeper than the Papillary dermis. • C/F: 1. Blistering within 24hr and/or loss of the epidermis 2. Breaking the blister leave pink and moist underlying dermis 3. The capillary return is clearly visible when blanched  There is little or no fixed capillary staining 4. Pinprick sensation is normal 5. Heal without scarring in 2 wks without surgery
  • 36.  The damage involves the Part of Reticular dermis  C/M: 1. Blistering and/or loss of the epidermis usually. 2. The exposed dermis is Pale & not moist as in a superficial 3. The color does not blanch under the examiner’s finger  There is often abundant fixed capillary staining, (esp. after 48 hrs) 4. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle. 5. Heal by forming scar in 3 - 6 wks without surgery  Usually lead to Hypertrophic scarring or Epithelioma Deep partial- thickness burn
  • 37. Third degree burn(Full-thickness burns) • The whole of the dermis is destroyed. • C/M: 1. Charred skin or Translucent white color 2. There is no capillary return  Thrombosed or Coagulated vessels can be seen under the skin. 3. No sensation (Nerve endings destroyed)  Patient complain pain from surrounding second degree burn area 4. Always heal by forming SCAR in ≥3wks  Dark Dry Leathery
  • 38. • Rule of Nines & 7 : Quick estimate of percent of burn • Lund and Browder Chart: More accurate assessment tool Useful chart for children – takes into account the head size proportion. • Rule of Palms: Good for estimating small patches of burn wound ESTIMATION OF BURN SIZE TOTAL BODY SURFACE AREA (TBSA) Palmar surface = 1% of the BSA
  • 41. Lund Browder Chart used for determining BSA 4/1/2011 41
  • 42. Burn injuries result in a local and systemic response. Pathophysiology
  • 43. • The three zones of a burn were described by Jackson in1947 I. Zone of Coagulation (Necrotic, white, no circulation) In this zone there is irreversible tissue loss due to coagulation of the constituent proteins II. Zone of Stasis (circulation sluggish) The tissue in this zone is potentially Salvageable ??? III. Zone of Hyperemia (Good blood flow, red)  This zone will invariably recover Local response
  • 44. • The release of cytokines and other inflammatory mediators at the site of injury has a systemic effect once the burn reaches 30% • This systemic inflammatory response results in cardiovascular, respiratory, metabolic, immunological & other systemic response, Systemic response The Burn Syndrome. Lead to
  • 45. Criteria for burn center admission • Full-thickness > 5% BSA • Partial-thickness > 10% BSA • Any full-thickness or partial- thickness burn involving critical areas (face, hands, feet, genitals, perineum, skin over major joint) • Children with severe burns • Circumferential burns of thorax or extremities • Significant chemical injury, electrical burns, lightening injury, co-existing major trauma or significant pre- existing medical conditions • Presence of inhalation injury
  • 46. Management of Burn Injury includes: 1. Initial patient treatment 2. Management of burns of special Type & Area 3. Special considerations during management 4. Fluid resuscitation. 5. Wound care 6. Antibiotic therapy 7. Pain management.
  • 47. • Stop the burning process • Consider burn patient as a Poly trauma patient until determined otherwise. a. Perform ABCDE assessment b. Details of the incident 1. Initial patient treatment
  • 48. a. ABCDEs assessment • Airway • Breathing • Circulation • Depth of Burn • Extent of Injury(s) & Expose to examine • Pediatric (special) issues
  • 49. Airway considerations • Upper airway injury (above the glottis): Area buffers the heat of smoke – thermal injury is usually confined to the larynx and upper trachea. • Lower airway/alveolar injury (below the glottis): - Caused by the inhalation of steam or chemical smoke. - Presents as ARDS often after 24-72 hours. Why not immediate?
  • 50. Criteria for intubation 1. Altered mental status or GCS<8 2. Burns of ≥ 50% TBSA. 3. Carbonaceous sputum. 4. Changes in voice 5. Continuous coughing 6. Face /Neck burns which is extensive. 7. Inhalation injury 8. Wheezing 9. Stridor - Oro-pharyngeal edema
  • 51. Pediatric intubation • Normally have smaller airways than adults • If intubation is required, an uncuffed ETT should be placed • Intubation should be performed by experienced individual – failed attempts can create edema and further obstruct the airway AGE + 16 = ETT size 4
  • 52. Ventilatory therapies • Rapid Sequence Intubation • Pain Management, Sedation and Paralysis • Positive End-Expiratory Pressure (PEEP) • High concentration oxygen • Hyperbaric oxygen • Avoid barotrauma
  • 53. Ventilatory therapies • Burn patients with ARDS requiring PEEP > 14 cm for adequate ventilation should receive prophylactic tube thoracostomy • NG tube placement – Reduce aspiration risk
  • 54. Breathing Assessment/Support • Ensure adequate oxygenation – ABG with carboxyhemoglobin level preferred – Humidified 100% O2 emperically • Assess for possible inhalation injury – History of an enclosed space, carbonaceous sputum, respiratory symptoms, altered LOC – Younger children at greater risk • NMB for intubation: avoid succinylcholine
  • 55. Circulatory • Assess capillary refill, pulses, hydration • Place foley catheter to assess UOP • Achieve hemostasis at sites of bleeding • Evaluate sensorium • Venous access, depending upon BSA involvement; avoid burn sites if possible
  • 56. Depth Assessment • Assess depth of injuries: – First degree burn • Treatment rarely required (IV hydration) – Second degree (partial thickness) • Infection, malnutrition, hypoperfusion may cause conversion to full thickness (3rd degree) – Third degree (full thickness) • Typically requires some degree of surgical closure – Fourth degree • Note: circumferential burns, compartment syndrome risk; consider escharotomy need
  • 57. Extent & Exposure • Expressed as percentage of total BSA – Only 2nd & 3rd degree burns mapped • Once adult proportions attained (~15 yo), “Rule of nines” may be used • For children less than 15 years of age, age adjusted proportions must be used – fluid replacement is based upon BSA estimates • Must rule out concomitant other injuries
  • 58. Expose • Undress the patient to examine the whole body. • But burned patients lose body heat quickly, so keep them warm. – To keep warm, use whatever means available: blankets heating lamps bed frame large box covered with blankets
  • 59. b. Details of the incident • Cause of the burn • Time of injury • Place of the occurrence (closed space, presence of chemicals, noxious fumes) • Likelihood of associated trauma (explosion,…) • Pre-hospital interventions
  • 61. A. Burns of special Areas of the body  Face  Mouth  Neck  Hands and feet  Genitalia
  • 62. Face • Be VERY concerned for the airway!! • Eyelids, lips and ears often swell alarmingly. • Patients may have burnt facial hair, mouth and neck together or separately. • In fact, they look even worse the next day. • But they will start to improve daily after that.
  • 63. Hands and feet • Fingers might develop contractures if active measures are not taken to prevent them.
  • 64.  Circumferential burn  Electrical burn  Chemical burn B. Mgt of Special types of burn
  • 65. 1. Circumferential burn • There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue • This requires escharotomy to relieve the pressure.
  • 66. 3. Electrical burn • Outer skin might not appear too bad. • But, there may be brain, heart or musculoskeletal injuries & Causes the most damage. • Safely remove the person from the source of the electricity. • Do not become a victim. • Usually requires fasciotomy Burns from inside out.
  • 67. 4. Chemical Burn • Most often caused by strong acids or alkalis. • It can cause progressive injury until the agent is inactivated. • Flush the injured area with a copious amount of water. Don’t delay or waste time looking for or using a neutralizing agent These may in fact worsen the injury by producing heat or causing direct injury themselves.
  • 68. • Goal: To Maintain adequete perfusion. • Based on the TBSA, body weight and whether patient is adult/child • Fluid requirement calculations are based on the time from injury, not from the time fluid resuscitation is initiated. • Fluid overload should be avoided – difficult to retrieve settled fluid in tissues and may facilitate organ hypoperfusion 4.Fluid resuscitation
  • 69. …… • Lactated Ringers - preferred solution Contains – Na+ - restoration of Na+ loss is essential – K+ - restore potassium depletion – Free of glucose – high levels of circulating stress hormones may cause glucose intolerance Vascular access: Two large bore peripheral lines (if possible) or central line.
  • 70. • ARF may result from myoglobinuria  Increased fluid volume, Mannitol bolus and NaHCO3 into each liter of RL to alkalinize the urine may be indicated Maintain urine output at 0.5 cc/kg/hr(30ml/hr). Parkland(Baxter) Formula 4ml RL/%BSAB /wt(kg). ½of calculated fluid is administered in the first 8 hours Balance is given over the remaining 16 hours.
  • 71. • The risk of infection of burned tissue is increased because the wound is protein rich and moist, and is thus a good culture medium. • The neoeschar and lack of vascularity limit antibiotic delivery. Therefore – Prevent primary and secondary infections by Topical and/or systemic antibiotics as necessary. 5. ANTIBIOTIC TREATMENT & WOUND CARE
  • 72. Antibiotics – Silver nitrate (0.5% aqueous) cheapest, apply with occlusive dressings, does not penetrate eschar – Silver sulfadiazine (1% miscible ointment) with single layer dressing; has limited eschar penetration, may cause neutropenia – Mafenide acetate (11% in miscible ointment) used without dressings; penetrates eschar but causes acidosis
  • 73. Wound Care Focus care on rapid healing, infection prevention • Excise adherent necrotic tissue • No hurry to remove blisters unless infection occurs. • Gently cleanse burn with – Chlorhexidine (0.25% (2.5 g/l) )solution. – Cetrimide (0.1% (1 g/l)) solution. • Debride all bullae
  • 74. SKIN GRAFTS Used for full-thickness and deep partial-thickness 74 Done during the acute phase(3-5 dys)
  • 75. Adequate analgesia imperative! DOC: Morphine Sulfate the gold standard Dose: Adults: 0.1 – 0.2 mg/kg IV Children: 0.1 – 0.2 mg/kg/dose IV Other pain medications commonly used: • Ketamine • Demerol • Vicodin ES • NSAIDs 6. Pain management
  • 76. I. INFECTION & Wound Sepsis Predictors of infection : - Burn size - Age - Inhalation injury Burn Complications
  • 77. Infection in Burn Injury • Types of infections in burn patients –Wound invasion/sepsis, –Cellulitis, –Pneumonia, –Suppurative thrombophlebitis, –Miscellaneous nosocomial infections
  • 78. II. Curling ulcer, Ileus & Acute gastric dilation III. Contracture Prevention . Early excision and grafting . Splintage . Elevation of extremity . Early physiotherapy . Prevention of infection IV. Marjolin’s ulcer, Hypertrophic scar, keloid