5. TheCase:
GeneralData
Name: JT
Sex: Male
Address: Brgy. San Miguel
Sto. Tomas Batangas
Age: 71 years old
Birthdate: 07-10-1951
Religion: Roman Catholic
Occupation: none, former college
professor
Date of Admission: Sept. 03, 2022
12. General Survey: Awake, Alert, Coherent, Oriented and Conversational attends to question and respond
appropriately. mesomorph body habitus, in severe pain.
Anthropometric
Measurements:
H: 170 cm W: 65.1 kg BMI: 22.49
Vital signs: BP: 140/80 PR: 85 RR:20 Temp: 36.9 O2 Sat: 99% Pain: 8/10
HEENT: pink conjunctiva, normal sclera, No lymphadenopathy, moist oral mucosa, no signs of dehydration
Chest/Lungs: Lungs resonant, Clear breath sounds, Symmetrical chest expansion. (-) crackles, (-) wheezes
Heart: Normal Regular Rate and Rhythm, Normal S1 and S2, (-) S3 and S4, (-) murmurs
Abdomen Soft, flabby, Normoactive bowel sounds, (-) tenderness upon light and deep palpation
Neurologic
GCS15:E:4V:5M:6;Motor:RUE:5LUE:5RLE:5LLE:5;Sensory:RUE:100LUE:100RLE:100LLE:100
DTR:RUE:2+LUE:2+RLE:2+LLE:2+
PhysicalExamination
13. Physical
Examination
Abdomen
Approximately 7-8cm avulsed wound with a depth of 0.5 - 1cm on the posterior
part of the right lower leg with ill define borders and margin. Flaps of soft tissue
(skin,muscle) withactivebleeding.
Extremities
Neurological
Examination
15. Rabies
Rabies is a viral infection of wild and domestic mammals,
transmitted to humans by the saliva of infected animals through
bites, scratches or licks on broken skin or mucous membranes.
19. AnimalBites:CategoryI
• Feeding or touching an animal
• Licking of intact skin
• Exposure to patient with signs of rabies by sharing or drinking utensils
• Casual contact with patients with signs of rabies
20. AnimalBites:CategoryII
• Nibbling or nipping of uncovered skin with bruising
• Minor scratches or abrasions; or abrasions without bleeding
• Licks on broken skin
21. AnimalBites:CategoryIII
• Transdermal bites or scratches
• Contamination of mucous membranes with saliva
• Exposure to rabies patient through bites, contamination of mucous
membrane or open skin lesions with body fluids through splattering, mouth
to mouth resuscitation, licks of eyes, lips, vulva, sexual activity,
exchanging kisses on the mouth or other direct mucous membrane contact
with saliva
• Handing of infected carcass or ingestion of raw infected meat
• All category II exposures on head and neck areas.
• All animal bites in forest or in the wild should be treated as Category
III exposures.
25. CategoryII:Management
Immediate Vaccination
Start Rabies vaccine immediately (active immunization)
- Purified Verocell Immune Rabies Vaccine (PVRV) 0.5 ml/vial
- Purified Duck Embryo Vaccine (PDEV) 1.0ml/vial
* Intramuscular (IM) schedule (deltoid region): administered on days 0, 3, 7,14, and 30
1. Complete Regimen until day 28/30
2. May omit day 28/30
Local treatment of wound
26. CategoryIII:Management
Immediate Vaccination: start Rabies vaccine immediately (active immunization)
Administration of Rabies Immunoglobulin (passive immunization)
Includes either:
- Human Rabies Immune Globulin (HRIG) 20 IU/kg
- Equine Rabies Immune Globulin (ERIG) 40 IU/kg (heterologous)
1. Complete Regimen until day 28/30
2. May omit day 28/30
Local treatment of wound
27. Post-exposureTreatment
Local treatment of wound and anti-tetanus
Immunization therapy
- Day 0: give PRVR + RIG (Category 1 and 2 do not need RIG)
- Day 3, 7, 14, 30 PRVR
Antibiotic Therapy
Treatment may be discontinued if :
- Animal involved remains healthy for 10 days
- Animal is killed and found to be negative for rabies by laboratory examination
28. Surgical Management
Some wounds can be sutured within several hours of the injury, after the wound is
thoroughly cleaned. Wounds to the face are usually closed immediately to avoid
developing a scar.
Immediate suturing may not be recommended for wounds at high risk of becoming
infected, including: Crush injuries, punctured wound, Bites involving hands, dog bite
wounds that occur several hours earlier, cat or human bites, except to the face, bite
wounds in people who have a weakend immune system.
29. Tetanus
Tetanus is a severe infection due to the bacillus Clostridium tetani, found in soil,
and human and animal waste. The infection is noncontagious.
Clostridium tetani is introduced into the body through a wound and produces a
toxin whose action on the central nervous system is responsible for the
symptoms of tetanus.
34. Tetanus:Nonpharmacologic
Management
• Entry wound should be identified, cleaned, and debrided
• Secure airway early and mechanical ventilation
• Patient should ideally nursed in calm, quite, dark
environments, with close cardiovascular monitoring
35. CaseManagement
Medical: Tetanus Prophylaxis
1. Tetanus Toxoid (Imatet) 0.5 ml/ vial # 1
Sig. Inject Intramuscularly (deltoid region)
2. Human tetanus Immunoglobulin ( Tetagam) 250 IU pre-filled syringe # 1
Sig. Inject Intramuscularly (deltoid region)
Medical: Rabies post exposure treatment
3. Purified Verocell Rabies Vaccine (Speeda) 2.5 IU
Sig. Inject Intramuscularly, administered on day 0, 3, 7, 14, and 30
4. Equine Rabies immune Globulin ( Equirab) 1000 IU/5ml
Sig. Half infiltrate wound and other half Inject Intramuscularly
36. CaseManagement
Medical: Antimicrobial therapy
1. Amoxicillin +Clavulanic acid (Augmentin) 625mg/ tablet # 14 tabs
Sig. Take 1 tablet every 12 hours before meals for 7 days
Medical: Analgesic
1. Celecoxib (Coxidia) 200mg/ capsule # 10 caps
Sig. take 1 capsule twice a day after meals for 5 days
or
2. Tramadol HCl + Paracetamol 37.5mg/325mg/tablet # 15 tabs
Sig. take 1 tablet every 4 hours as necessary for pain.
37. Management
Supportive: Wound management
• Prolonged cleansing of the wound or contact site for 15 minutes
• For skin: use soap, rinse copiously with running water, remove all foreign material;
application of a disinfectant (povidone iodine 10% or other)
• For mucous membranes rinse thoroughly with water or 0.9% sodium chloride.
• Local cleansing is indicated even if the patient presents late
Surgical : Tertiary healing or Delayed Primary closure
• Wound is initially managed as secondary intention, then wound is closed after a few
days when wound is clean and granulation tissue is abundant.
• Wound is first cleaned and observed for few days
40. EstimationofBurnSize
- Burn size is expressed as percent total body area burned(%TBSA)
- Count only those area with partial (second degree) or full thickness (third degree)
burns
- For estimating smaller, irregular placed burns: consider the area of the open hand of
the patient to be approximately 1% of TBSA
- Tools available to estimate burn size ( Rule of Nines Lund and Browder Chart)
41. EstimationofBurnSize
- Assesses the percentage burn, used to help
guide fluid resuscitation
- The number corresponds to the % involvement
(Usually 9%) for the body part
- Zones can be broken down into smaller sections
or added together.
Example: a 24 year old male, with burn injury to both legs, groin, chest,
and abdomen. What is the total body surface area burned?
Solution: (18% x 2) + (1%) +(9%) + (9%)= 55% TBSA
45. InitialManagement
Primary survey and Concurrent Resuscitation:
- A: Airway
- B: Breathing
- C: Circulation
- D: Disability
- E: Environment control and exposure
- F: Fluid Resuscitation
Secondary survey ( Burn-specific):
- History
- Detection of the mechanism of injury
- Time of injury
- Consideration of abuse
- Height and weight
- Possibility of carbon monoxide intoxication
- Facial burns
- Tetanus immune status
46. Management
Classification of Burns Definitive care
Minor Burns • Cool wound with tap water
• Tetanus prophylaxis
• Wound care, debridement of dead tissue, proper
analgesic
• Apply bland ointment and nonstick porous gauze
• Systemic prophylactic antibiotics not required
• May be sent home with proper follow-up
Moderate and major or critical
burns
• Use sterile gloves when handling patients
• Suspect inhalation injury
• Intubate patient if burns is greater than or equal
to 50% BSA
• Fluid resuscitation
• Insert foley catheter, NGT
• Get baseline weight
• Tetanus prophylaxis, H2- blockers
• Escharotomy
47. FluidResuscitation
- Most common cause of mortality in the 1st 48 hours following injury is
inadequate fluid resuscitation
- Most Common Formula used : Parkland or Baxter formula (for initial 24
hours)
- IVF requirement= TBSA burned (%) x weight (kg) x 4ml/kg
Example: A 75 kg adult sustain a 20% body surface area burn, what is the IV
fluid requirement for this patient?
IVF requirement = (20%) x 75kg x 4 ml/kg = 6000 mL/ cc
48. Wounddressing
- Performed in a sterile area
- Give patient a full body bath using warm water and soap
- Debride the burned areas, removing dead skin and unroofing blisters
- Wash the burn areas with betadine soap and rinse with sterile water
- Dress wounds with a topical antibacterial or another dressing modalities
52. References:
- Artz CP; Moncrief JA. The Treatment of Burns, Philadelphia, WB Saunders Company; 1969.
- Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery 10th Edition. New York, NY:
McGraw Hill Professional; 2015.
- Centers for Disease Control and Prevention
(http://www.cdc.gov/VACCINes/pubs/pinkbook/downloads/tetanus)
Editor's Notes
Good evening everyone this presentation is all about of animal bites, tetanus and burn injuries.
Once again good evening I am Christian S. Catibog a Surgery Clerk from LPU SC College of Medicine
This is the content of the presenattion
Lets start this presentation by Presenting the case of JT, 71 years old, male from Brgy. San Miguel Sto. Tomas Batangas a Roman catholic, a former college professor, admitted in the ER last Sept 03,2022 at around 6: 45 pm
With a chief complaint of Dog bite- on the posterior part of the right lower leg
For the history of present illness, the nature of incidence is animal bite/ dog bite, that happened 3:30 om of sept 03 2022 at their home in san miguel sto tomas.
For the patient Past medical History, The patient has hypertension, year of diagnosis was not recalled, the patient was uncompliant to medication since 2015, the patient also has dyslipidemia also uncompliant to medication, No known allergies to food and drugs. no history of tetanus toxoid TIG, anti rabies vaccination.
The patient has a family history of (+) hypertension noth parents , tuberculosis father . His parents has diabetes.
For the personal and social history. JT has 2 daughters, he is living with his wife , he was a former college instructor. he is a non smoker, occasional alcohol drinker. he stated no illicit drug use and his diet is composed of vegetables and meat. No other medication taken
Based on the history and physical examination findings the primary impression is avulsion injury of the porterior part of the lower leg (Right) secondary to Dog bite: Category 3 exposure
Rabies is a viral infection of wild and domestic mammals, transmitted to humans by the saliva of infected animals through bites, scratches or licks on broken skin or mucous membranes.
In endemic areas (Africa and Asia), 99% of cases are due to dog bites and 40% of cases are children under 15 years of age [1] .
In endemic areas (Africa and Asia), The vast majority of animal bites are caused by dogs (85 to 90 percent), with the remainder caused by cats (5 to 10 percent) and rodents (2 to 3 percent). Children are bitten more often than adults.
Rabies is considered to be a neglected disease, which is 100% fatal though 100% preventable. It is not among the leading causes of mortality and morbidity in the country but it is regarded as a significant public health problem because (1) it is one of the most acutely fatal infection and (2) it is responsible for the death of 200-300 Filipinos annually.
in the pathogenesis of the rabies virus first there will be a viral inoculation from a rabid dog bite or a rabid animal. seecond, virus replicates in the musccle, and then the virus binds to nicotinic acetylcholine receptors at the neuromuscular junctions, fourth virus travel within axons in peripheral nerves through axonal transport and the there will be replication that takes place in the motor neuron of the spinal cord and ganglia that travels to the brain. resulting to infection of the brain neurons leading to fatal inflammation. virus enters salivary glands and other organs of the victim.
The incubation period averages 20 to 90 days from exposure (75% of patients), but can be shorter (in severe exposure, e.g. bites to face, head and hands; multiple bites), or longer (20% of patients develop symptoms between 90 days and 1 year, and 5% more than 1 year after exposure).
Prodromal phase: itching or paraesthesiae or neuropathic pain around the site of exposure, and non-specific symptoms (fever, malaise, etc.).
Neurologic phase:
Encephalitic form (furious form): psychomotor agitation or hydrophobia (throat spasms and panic, triggered by attempting to drink or sight/sound/touch of water) and aerophobia (similar response to a draft of air); sometimes seizures. The patient is calm and lucid between episodes. Infection evolves to paralysis and coma.
Paralytic form (less common, 20% of cases): progressive ascending paralysis resembling Guillain-Barré syndrome; evolves to coma.
Diagnosis is often difficult: there may be no history of scratch or bite (exposure through licking) or wounds may have healed; a reliable history may be difficult to obtain
animal bites are categorized based on the severity of exposure
For category 1, exposure includes
Feeding or touching an animal
Licking of intact skin
Exposure to patient with signs of rabies by sharing or drinking utensils
Casual contact with patients with signs of rabies
for category 2 exposure, it includes
Nibbling or nipping of uncovered skin with bruising
Minor scratches or abrasions; or abrasions without bleeding it includes wounds that are induced to bleed
Licks on broken skin
lastly, category 3 it includes exposure through
Transdermal bites or scratches such as punctured wounds, lacerations and abrasions
Contamination of mucous membranes with saliva like licks
Exposure to rabies patient through bites, contamination of mucous membrane or open skin lesions with body fluids (except blood and feces) through splattering, mouth to mouth resuscitation, licks of eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva
Handing of infected carcass or ingestion of raw infected meat like here in our province some locals eat dog meat they are fond eating calderetang aso
All category II exposures on head and neck areas.
All animal bites in forest or in the wild should be treated as Category III exposures.
examples of category 3 exposure of animal bites
the following slides will show mNgwmwnt of potential rabies exposure.
in management of category 1 exposure , no vaccine or rabies immune globulin needed. but careful observation and and awareness about signs and symptoms of the infection is essential.
in management of category 2 exposure, immediate vaccination is needed, start rabies vaccine immediately (active immunization)
it includes either:
- Purified Verocell Immune Rabies Vaccine (PVRV) 0.5 ml/vial
- Purified Duck Embryo Vaccine (PDEV) 1.0ml/vial
* given Intramuscularly (IM) (deltoid region): administered on days 0, 3, 7,14, and 30 post exposure
Complete Regimen until day 28/30 if
- was proven in the laboratory to have rabies or has signs and symptoms of rabies or died or was killed without laboratory testing or cannot be observed for 14 days.
May omit day 28/30 if
- animal is alive and remains healthy after 14 day observation period. or animal under observation died within 14 days but had no signs of rabies and was IFAT negative.
In managing category 3 exposure, immediate vaccination is a must, 1. start rabies vaccine immediately either PVRV or PDEV and the administration of rabies immunoglobulin (for passive immunization)
Rabies immunoglobulin includes either:
Human Rabies Immune Globulin (HRIG) 20 IU/kg
Equine Rabies Immune Globulin (ERIG) 40 IU/kg (heterologous)
Complete Regimen until day 28/30
May omit day 28/30
Local treatment of wound
this slide shows the overview of post exposure treatment for animal bites
Local treatment of wound and anti-tetanus this will be discussed later
Immunization therapy - we already discussed it a while ago
Day 0: give PRVR + RIG (Category 1 and 2 do not need RIG)
Day 3, 7, 14, 30 PRVR
Antibiotic Therapy- because The most common complication of an animal bite is infection. Antibiotics are generally recommended to prevent infection in people with high-risk wounds, , and for people with other health problems, such as a weakened immune system or diabetes, which could increase the risk of serious infection.
Treatment may be discontinued if :
Animal involved remains healthy for 10 days
Animal is killed and found to be negative for rabies by laboratory examination
For these kind of wound, healing by tertiary intention is the appropriate technique.
which means Wound is initially managed as secondary intention means left open with dressing changes , then wound is closed after a few days when wound is clean and granulation tissue is abundant.
Wound is first cleaned and observed for few days to ensure no infection is apparent, then it is surgically closed
In association to animal bite tetanus or tetanus infection should be considered due to the possibility of wound exposure to an invading bacterial oraganism. Tetanus is a severe infection due to the bacillus Clostridium tetani, found in soil, and human and animal waste.
Clostridium tetani is introduced into the body through a wound and produces a toxin whose action on the central nervous system is responsible for the symptoms of tetanus.
Generalised tetanus is the most frequent and severe form of the infection. It presents as muscular rigidity, which progresses rapidly to involve the entire body, and muscle spasms, which are very painful. Level of consciousness is not altered.
C. tetani spores usually enter through contaminated wounds. Manifestations of tetanus are caused by an exotoxin (tetanospasmin) produced when bacteria lyse. The toxin enters peripheral nerve endings, binds there irreversibly, then travels retrograde along the axons and synapses, and ultimately enters the central nervous system (CNS). As a result, release of inhibitory transmitters from nerve terminals is blocked, thereby causing unopposed muscle stimulation by acetylcholine and generalized tonic spasticity, usually with superimposed intermittent tonic seizures. Disinhibition of autonomic neurons and loss of control of adrenal catecholamine release cause autonomic instability and a hypersympathetic state. Once bound, the toxin cannot be neutralized.
for prevention and control Immunisation is the only effective prevention of tetanus. Tetanus toxoid is an effective, safe, stable and inexpensive vaccine that can be given to all ages, to pregnant women and to immunocompromised individuals.
next is appropriate wound management, Wounds must be cleaned, disinfected and treated surgically if appropriate, to prevent infection and wound complications
the third one is promotion of clean delivery practices, strategy for maternal and neonatal tetanus is improving birth hygiene or practicing clean deliveries. The importance of clean practices during delivery has been emphasized for safe and complication free deliveries.
For tetanus prophylaxis , this table shows immunization components, first is tetanus toxoid it works as an active immunity. tetanus toxoid available combined with diphtheria toxoid, diohteria toxoid + pertussis vaccine. in the other hand tetanus immunoglobulin TIG or tetanus antitoxin provides temporary immunity by providing antitoxin we should ensure that protective levels of antitoxin are achieved even in an immune response has not yet occured. it includes human tetanus IG and Equine antitoxine. Here in our institution Imatet tetanus toxoid and tetagam a human tetanus immunoglobulin is usually administered to patients.
This slide reflects indications for tetanus toxoid and immunoglobulin
vaccination history is important to know and the type of wound should be assesed.
for unknown number or <3 doses received with clean, minor wounds tetanus toxoid is given, immuno globulin is not needed. however in all other wounds tetanus oxoid and TIG is both given.
In patients with history of <5 years since most recent dose, no vaccine is needed
in patients with 5-9 years since most recent dose tetanus toxoid is only needed in all other types of wound
in patienet with >= 10 years since most recent dose with minor and clean wound tetanus toxoid is needed, and patient with all other wounds tetanus toxoid is also needed.
For non pharmacologic management of tetanus
Entry wound should be identified, cleaned, and debrided of necrotic material to remove any remaining source of anaerobic fociand prevent further toxin production
Secure airway early and mechanical ventilation should be instituted if necessary
Patient should ideally nursed in calm, quite, dark environments, with close cardiovascular monitoring
Our patient can be managed medically through 1. tetanus prophylaxis.
Tetanus Toxoid (Imatet) 0.5 ml/ vial # 1
Sig. Inject Intramuscularly (deltoid region)
Human tetanus Immunoglobulin ( Tetagam) 250 IU pre-filled syringe # 1
Sig. Inject Intramuscularly (deltoid region)
2nd rabies post exposure treatment.
. Purified Verocell Rabies Vaccine (Speeda) 2.5 IU
Sig. Inject Intramuscularly, administered on day 0, 3, 7, 14, and 30
4. Equine Rabies immune Globulin ( Equirab) 1000 IU/5ml
Sig. Half infiltrate wound and other half Inject Intramuscularly
For supportive management, the wound management includes Prolonged cleansing of the wound or contact site for 15 minutes to eliminate the virus, as soon as possible after exposure, is of critical importance. For skin: use soap, rinse copiously with running water, remove all foreign material; application of a disinfectant (povidone iodine 10% or other) is an additional precaution which does not take the place of thorough wound washing. For mucous membranes (eye, mouth, etc.): rinse thoroughly with water or 0.9% sodium chloride. Local cleansing is indicated even if the patient presents late
For surgical management healing by tertiary intention is the appropriate type of wound healing for our patient.
Wound is initially managed as secondary intention means left open with dressing changes , then wound is closed after a few days when wound is clean and granulation tissue is abundant.
Wound is first cleaned and observed for few days to ensure no infection is apparent, then it is surgically closed
A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. this injuries are commonly encountered at home, industries and work place.
One way of assesing burn injury is through estimation of burn size,
Burn size is expressed as percent total body area burned(%TBSA)
Count only those area with partial (second degree) or full thickness (third degree) burns
For estimating smaller, irregular placed burns: consider the area of the open hand of the patient to be approximately 1% of TBSA
Tools available to estimate burn size ( Rule of Nines , Lund and Browder Chart for pediatric use)
In rule of nines or rule of wallace
Assesses the percentage burn, used to help guide fluid resuscitation
The number corresponds to the % involvement (Usually 9%) for the body part: 9% for each arm, 18% for each leg, 18% for the front of torso (chest, abdomen), 18 % for back and torso (Upper and lower back) 9% for head and 1% for the groin
Zones can be broken down into smaller sections or added together in example front and back of the arms are 4.5% each
Example: a 24 year old male, with burn injury to both legs, groin, chest, and abdomen. What is the total body surface area burned?
Solution: (18% x 2) bcause both legs are affected + (1%) for the groin +(9%) for the chest + (9%)for the abdomen= 55% TBSA
In the assessment of the burn injuries through burn depth. There are four classification or category, 1st degree burn epidermal or superficial, 2nd degree burn, partial-thickness, 3rd degree burn full thickness and lastly 4th degree burn.
In superficial thickness burns, tissue damage was restricted to epidermis and upper dermis, it is commonly caused by flash flame, ultraviolet (sunburn), surface is dry, no blisters or minimal edema, it is erythematous, painful, and with 3to 6 days healing time.
Partial thickness burn involves the epidermis and part of the dermis, cause by contact with hot liquids or solids, flash flames or direct flame and UV. Surface has moist blebs, blisters, color is mttled white to pink cherry red, it is very painful, 10 to 21 days .
Full thickness burn involves epidermis, dermis and involved the subcutaneous tissue, caused by contact with hot liquids or solids falme, chemical electrical , surface is dry with leathery eschar until debridement, charred vessels are visible. Color is mixed white, waxy dark, kahki, charred. There is a decreased sensation, intact deep-pressure sensation. Healing time is more than 21 days.
Fourth degree burn are damages underlying bone, muscles, tendons, cause by prolonged contact with flame and electrical. Surface same as 3rd degree burn possibly with seen bone muscle and tendon. There is little or no pain (because nerves are destroyed) in this type of burn grafts are needed.
We also classify burn injury to its cause, like in flame burn caused by house fire or kerosene lamp. Flash buen caused by explosion of natural gas. electral burn due to electrocution caused by high voltage current, scald burn due to hot liquids, soups, and sauces. Chemical burns caused by strong acid and alkali compounds. contact burn caused by hot metals, glass and plastics, lastly radiation caused by exposure to radiation.
patient with burns are initially managed through primary survery, we identify immediate threat to life, burn is treated secondary.
in primary survery we should assess the following, airway, breathing, circulation, disability, environmental control and exposure, fluid resucitation
if the patient is stable, we then moved to secondary survey.
History
Detection of the mechanism of injury
Time of injury
Consideration of abuse
Height and weight
Possibility of carbon monoxide intoxication
Facial burns
Tetanus immune status
Priority in the management of burn in the first 48 hours is to maintain the intravascular volume once this problem is hurdled attention is now turned to the definitive management of the patients burn wound
The definitive care for minbor burns are the following
Cool wound with tap water
Tetanus prophylaxis
Wound care, debridement of dead tissue, proper analgesic
Apply bland ointment and nonstick porous gauze
Systemic prophylactic antibiotics not required
May be sent home with proper follow-up
The definitive care for moderate and major or critical burns are the following:
Use sterile gloves when handling patients
Suspect inhalation injury
Intubate patient if burns is greater than or equal to 50% BSA
Fluid resuscitation
Insert foley catheter, NGT
Get baseline weight
Tetanus prophylaxis, H2- blockers
Escharotomy
Minor burns Can be managed safely In the out patient setting
Moderate burns should be hospitalized for their initial care but not necessarily at the burn center
Major burns best managed in a specialized burn center staffed by a team of professionals with expertise in the care of burn patients including both acute care and rehabilitation.
Most common cause of mortality in the 1st 48 hours following injury is inadequate fluid resuscitation
patients with moderate and major burns will require fluid resuscitation via IV route.
Most Common Formula used for fluid requirement is : Parkland or Baxter formula (for initial 24 hours)
IVF requirement= TBSA burned (%) x weight (kg) x 4ml/kg
IVF required is 4ml/kg per % TBSA burned (lacted ringer’s)
Example: A 75 kg adult sustain a 20% body surface area burn, what is the IV fluid requirement for this patient?
IVF requirement = (20%) x 75kg x 4 ml/kg = 6000 mL/ cc
Half given during first 8 hours after burn
Remaining half over subsequent 16 hours
For local wound management
wound dressing is Performed in a sterile area
Give patient a full body bath using warm water and soap
Debride the burned areas, removing dead skin and unroofing blisters
Wash the burn areas with betadine soap and rinse with sterile water
Dress wounds with a topical antibacterial or another dressing modalities
