case presentation on 2nd and 3rd degree burns

1. BURNS AND ITS
MANAGEMENT
Maj Mamta Sharma

2. INTRODUCTION
• About 180000 deaths
occur each year
globally and majority of
these occur in low &
middle income
countries
• In India,over 100000
people are moderately
or severely burnt every
year
-WHO

3. DEFINITION
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
-WHO

4. PATHOPHYSIOLOGY
• Increased vascular permeability
• Rapid edema formation
• Vasodilation
• Decreased perfusion
• Hypovolemia
• Burn shock

5. CLASSIFICATION
Based on etiology
Based on depth
Based on extent of TBSA

6. BASED ON ETIOLOGY
Thermal Electrical Chemical
Inhalation
Radiation
Exposure

7. DEPTH OF BURNS
First degree
Second
degree
Third degree

8. FIRST DEGREE BURNS
• Minor epithelial damage
• Redness,tenderness
• Pain
• No blister formation
• Healing after several
days
• Minimum risk of
infection

9. SECOND DEGREE BURNS
Superficial or Deep Partial thickness burns
• Involve epidermis and dermis
• Red and shiny fluid filled blisters
• Mild to moderate edema
• Heal in 3-6 weeks

10. THIRD DEGREE BURNS
Full thickness burns
• Destroy both epidermis
and dermis
• Dry and dark skin
• White or leathery
appearance
• Insensitive to pain

12. EXTENT OF BODY SURFACE AREA
INJURED
RULE OF NINE
LUND AND BROWDER
METHOD
PALM METHOD

14. RULE OF
NINE-
CHILD

16. RULE OF NINE

17. CLASSIFICATION OF BURN
SEVERITY
MAJOR BURN INJURY MODERATE BURN
INJURY
MINOR BURN INJURY
• Partial thickness burns
>25% TBSA Adults
20% TBSA Children
or older adults
• Full thickness burns
10% TBSA
• Involve face,eye,ears,
hand,feet or perineum
• Inhalation injury
• Partial thickness burns
15-25% TBSA Adults
10-20% TBSA Children
or older adults
• Full thickness burns
2-10% TBSA
• Partial thickness burns
< 15% TBSA Adults
10% TBSA Children
or older adults
• Full thickness burns
< 2% TBSA
• No serious threat
• Specialised burn center • Hospitalised for initial
care but not necessary
at burn center
• Outpatient setting

18. MANAGEMENT

19. PRE HOSPITAL MANAGEMENT
• Remove source of injury
• Stop burn process
• Remove clothing or restrictive objects
• Do not break blisters
• Cover the wound
• Prevent contamination
• Do not apply lotion, powder or sticky agents
• Assess for life threatening injuries

21. EMERGENT/
RESUSCITATIVE PHASE
GOAL
• Secure Airway and
Breathing
• Support Circulation
• Maintain vital organ function
and perfusion

22. EMERGENT PHASE(contd...)
1) Initial evaluation
- Respiratory,cardiovascular status
- Extent of burn injury
- Depth of burn
- TBSA calculation
- Possibilities of medicolegal case
- AMPLE history
2) Fluid Resuscitation

23. FLUID RESUSCITATION
• <20% TBSA - oral and IV fluid
• Larger burns - Parkland formula
- Galveston formula
• Restore effective plasma volume
• Maintain vital organ function

24. PARKLAND FORMULA
• Initial 24 hours
– Ringer lactate
– 4ml x TBSA(%) x Body weight (kg)
• 50% in first 8 hours
• 50% in next 16 hours
• Next 24 hours
– Colloids (5% Albumin) 0.5 ml/kg/%burns

25. PARKLAND FORMULA
70
10.080 L

26. NURSING RESPONSIBILITY
• Holistic approach
• Asepsis
• IV cannula
• Catheterize patient
• Estimate patient weight
• Monitor fluid intake and urine output
– Adults 0.5ml/kg/hr
– Children 1ml/kg/hr
• Monitor sensorium
• Monitor vital organs

27. ACUTE/
INTERMEDIATE PHASE
GOAL
• Supportive care
• Prevention of
infection and burn
wound care
• Nutritional therapy

28. SUPPORTIVE CARE
• Pain management
– Morphine - severely burned adults (50mg/hr)
– Midazolam or Fentanyl (additional analgesia)
• Prevent GI erosions and ulcers
– Antacids and H2 receptor antagonists
• Venous thromboembolic prophylaxis

29. BURN WOUND MANAGEMENT
• Tetanus prophylaxis
• Asepsis
• Clean wound with NS
• Remove ruptured blisters
• Cover with topical
antimicrobial dressing
• Daily dressing
• Surgical debridement
and grafting

30. DRESSING
• Silver sulphadiazine
• Polysporin
• Bacitram
• Mafenide
• Acticoat
• Occlusive dressing
• Biobrane
• Synthetic dressing

31. NUTRITIONAL THERAPY
• Initiate oral/enteral feeding within 24 hours
• Maintain weight within 5-10% preburn weight
• High calorie and protein diet
• Calorie requirements
– Curreri Formula
Adults- 25 kcal/kg actual BW + 40 kcal/
%TBSA burn
Example : (25 x 70 + 40 x 36) kcal
= 3190 kcal/day

32. NUTRITIONAL THERAPY(contd...)
• High carbohydrate
• Low Fat
• Protein - 1.5-2.0 g/kg/day
• Micronutrients and vitamins
– Vit A,C,D
– Iron,Zinc,Copper

34. NURSING RESPONSIBILITY
• Barrier nursing
• Monitor wound infection
• Monitor laboratory values
• Early immobilisation
• Elevation of injured part
• Monitor diet
• Review potential complications

35. REHABILITATION PHASE
GOAL
• Optimal long term function
• Prevention of deformity
• Minimize loss of range of motion
• Enhancing quality of life
• 3 parts - Critically ill patients
- Hospitalised patients
- Prior to hospital discharge

36. REHABILITATION PHASE
ACUTE OR EARLY
STAGE
• Passive range of
motion
• Positioning and
splinting
• Elevation of
extremities
• Prevention of
pressure sores

37. REHABILITATION PHASE
LATER STAGE
• Increase active ROM
• Training in activities of
daily living(ADL)
• Preparation for work,
play or school
• Patient education
• Family counselling and
support services

38. UPPER & LOWER EXTREMITY
REHABILITATION

39. SCAR MANAGEMENT & EXTREME
PRURITIS
• Scar massage
• Compression
garments
• Surgery
• Steroid injections
• Topical cream
• Topical antihistamines
creams

40. REHABILITATION PHASE
• Incisional release and
grafting
• Excisional release
and grafting
• Z-plasty
• Random flaps

41. NURSING RESPONSIBILITY
• Patient education
• Family counselling
and support
• Peer group support
• Reintegration

42. CONCLUSION
Every intervention influences the scar worn for life.
Everyone who assists in the management of burn
patient becomes an important part in their life.