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Burn Management Management Management1111
- 1. Burn Management DR NasrAl-Qadasi
- 2. Skin Anatomy: Twolayers : - Epidermis - Dermis
- 3. Skin Anatomy: Epidermis -Outer cells are dead. - Act as protection and form water tight seal. - Deeper layers divide to produce the stratum cornium and also contain pigment to protect against UV radiation Dermis - Consists of tough, elastic connective tissue which contains specialized structures
- 4. Dermis -Specialized Structures: - Nerve endings - Blood vessels - Sweat glands - Oil glands - keep skin waterproof, usually discharges around hair shafts - Hair follicles - produce hair from hair root or papilla • Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and cause goose flesh
- 5. Skin physiology: * Skinis the largest organ; it is complex and multifunctional, containing many specialized cells that are adapted to different functions .
- 6. Skin physiology: • Largestbody organ. Much more than a passive organ. - Protects underlying tissues from injury. - Temperature regulation. - Acts as water tight seal, keeping body fluids in. - Sensory organ. - Vitamin - D formation
- 7. • Burn woundsoccur when there is contact between tissue and an energy source, such as heat, chemicals, electrical current, or radiation. • The effects of the burn are influenced by the: intensity of the energy duration of exposure type of tissue injured
- 8. Types of BurnInjury • Thermal burns: flame, flash, contact with hot objects. • Scald burns: hot fluids. • Chemical burns: necrotizing substances (acids, alkali). • Electrical burns: intense heat from an electrical current • Smoke & inhalation injury: inhaling hot air or noxious chemicals • Cold thermal injury: frostbite.
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- 11. Chemical Burn examples: cleaningagents... Remember…. • Tissue destruction may continue for up to 72 hours. • It is important to remove the person from the burning agent or vice versa. • The latter is accomplished by lavaging the affected area with copious amounts of water.
- 12. Smoke and InhalationInjury
- 13. Smoke and InhalationInjury • Can damage the tissues of the respiratory tract • Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.
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- 15. Electrical Burns • Injuryfrom electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current. • The severity depends on: Øamount of voltage Øtissue resistance Øcurrent pathways Øsurface area in contact with the current Ølength of time the current flow.
- 16. Electrical injury cancause: • Fractures of long bones and vertebra • Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury • Severe metabolic acidosis--can develop in minutes • Myoglobinuria--acute renal tubular necrosis.
- 17. Cold Thermal Injury(Frostbite)
- 18. Classification of BurnInjury Severity is determined by: – depth of burn – extend of burn calculated in percent of total body surface (TBSA) – location of burn – patient risk factors
- 19. First degree burn •Involves only the epidermis • Tissue will blanch with pressure • Tissue is erythematous and often painful • Involves minimal tissue damage • Sunburn
- 20. Second degree burn •Referred to as partial- thickness burns • Involve the epidermis and portions of the dermis • Often involve other structures such as sweat glands, hair follicles, etc. • Blisters and very painful • Edema and decreased blood flow in tissue can convert to a full-thickness burn
- 21. Third degree burn •Referred to as full- thickness burns • Charred skin or translucent white color • Coagulated vessels visible • Area insensate – patient still c/o pain from surrounding second degree burn area • Complete destruction of tissue and structures
- 22. Fourth degree burn •Involves subcutaneous tissue, tendons and bone
- 23. Depth of Burns Medicolegalclassification clinical classification Erythema Super. Dermal Deep Dermal Full Thickness 1st 2nd 3rd
- 24. Extend of Burns Lund-BrowderChart Rule of Nines Age in years 0 1 5 10 15 Adult A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½ B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾ C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½
- 25. -Minor<15% in adultand <10% in child -Intermediate 15-30% in adult & 10—30 % in children -Major >30%
- 26. COMPLICATION • SYSTEMIC:- Shock :1- neurognic 2- hypovolimic 3- septic Respiratory: asphyxia, laryngial odema, pneumonia,ARDS Renal: oligouria, ARF, electrolyte imbalance. Cardiac: decreased c.o ,anemia , hypoproteinemia hypofibrinogenaemia Endocrine: increase catecholamin., cortisol,ADH, protien catabolism GIT: stress ulcer, paralytic ileus, hepatic dysfunction , etc. Multiorgan failure.
- 27. LOCAL:- • Early : Infection Constrictingscar Late : Psychological phobia, anxiety depression ,introversion as disability ,disfigurement , low income Somatic scarring , contracture , malignant degeneration ,hyperpigmentation , hyperkeratosis , alopecia
- 28. Location of Burns •Vital organs of burn: • Face, neck • Chest • Perineum • Hand • Joint regions • Other areas
- 29. Patient risk factors •Associated trauma • Inhalation injuries • Circumferential burns • Electricity • Age (young or old) • Pre-existing disease • Abuse
- 30. Lab studies Severe burns: •CBC • Chemistry profile • ABG with carboxyhemoglobin • Coagulation profile • U/A • Type and Screen • CPK and urine myoglobin (with electrical injuries) • 12 Lead ECG
- 31. Imaging studies • CXR •Plain Films / CT scan: Dependent upon history and physical findings
- 32. Phases of BurnManagement _prehospital management –emergent (resuscitative) –acute –rehabilitative
- 33. Pre-hospital Care • Removefrom area! Stop the burn! • If thermal burn is large--FOCUS on the ABC’s A=airway-check for patency, soot around nares, or signed nasal hair B=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of pulses
- 34. Other precautions... • Burntoo large--don’t immerse in water due to extensive heat loss • Never pack in ice • P’t. should be wrapped in dry clean material to decrease contamination of wound and increase warmth.
- 35. Emergent Phase (ResuscitativePhase) • Lasts from onset to 5 or more days but usually lasts 24-48 hours • begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins • Greatest initial threat is hypovolemic shock to a major burn patient!
- 36. Management in theemergent phase is... • Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn) • Ventilator. • 6-12 hours later: Bronchoscopy to assess lower respiratory tract • chest physiotherapy and suction
- 37. Complications during emergentphase of burn injury are 3 major organ systems... –Cardiovascular –Respiratory –Renal systems
- 38. Fluid Therapy • 1or 2 large bore IV lines • Fluid replacement based on: – size/depth of burn – age of pt. – individualized considerations. • options- RL, D5NS, dextan, albumin, etc. • there are formula’s for replacement: – Parkland formula – Brooke formula
- 39. Evans formula :- 1stday 1ml/kg/ %burn normal salin+ 1ml/kg/% burn coloid + 2000ccglucos 2nd day 0.5ml/kg/%burn saline+ 0.5ml/kg/% burn coloid + 2000cc Brooks formula:- 1st day 2-3ml/kg * % burn RL + 2000CC GLUCOSE 2ND DAY 1ml/kg * % burn RL + 0.5 ML/KG *% BURN COLLOID +2000cc glucose Half the above formulae given during 1st 8 hours ,then other half given during next 16 hours It is to be noted that in all formulae , that maximum percent of burn calculated is 50% to avoid serious over transfusion
- 40. Assessing adequacy of resuscitation •Peripheral blood pressure: may be difficult to obtain – often misleading • Urine Output: Best indicator unless ARF occurs • A-line: May be inaccurate due to vasospasm • CVP: Better indicator of fluid status • Heart rate: Valuable in early post burn period – should be around 120/min. • > HR indicates need for > fluids or pain control • Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre-existing cardiac disease)
- 41. Wound care • Escharotomy/ Fasciotomy • Escharectomy + homograft • Dressing / hydrotherapy • Debridement • Application of autograft • Splinting • PB contractures management
- 42. Escharotomy • Circumferential full thicknessburns – Chest – Arms – Legs • Medial/Lateral incision thru burned skin
- 43. Wound Care continued... •Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed • appropriate use of sterile vs. nonsterile techniques • keep room warm • careful handwashing • any bathing areas disinfected before and after bathing
- 44. Other care measuresinclude • Face – eye – ear • Hands & arms • Perineum • Physiotherapy
- 45. Drug Therapy • Analgesicsand Sedatives • Tetanus immunization • Antimicrobial agents: Silver sulfadiazine Nutritional Therapy • Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition.
- 46. IN YOUR MINDS: • Burn wound either heals by primary intention or by grafting. • Scars may form & contractures. • Mature healing is reached in 6 months to 2 years • Avoid direct sunlight for 1 year on burn • new skin sensitive to trauma
- 47. Care of BU R N S B - breathing U - urine output R - rule of nines resuscitation of fluid N - nutrition S - shock silvadene
- 48. Associated Trauma • SpinalInjuries • Airway Trauma • Chest Trauma/Baro Trauma • Abd. Trauma • CHI • Open wounds/Fractures/Shrapnel • Shock • If you find a Hypotensive acute burn Patient, there is something else you are missing!
- 49. Aims from semner *Understandthe basic anatomy and *function of the skin *Identify the types of common burn trauma *Accurately assess the burn severity, and common progression of patient condition *Identify co morbid factors
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