Burns management in emergency room.. Starts with ABCDE rule then fluid resuscitation and airway management

1. BURNS AND
TRACHEOSTOMY

2. History
 18 year old male who is an industrial worker from Thrissur was referred to our
ED on July 13th 2023.He was rescued from an industrial fire accident at his
work site where he was found to be enclosed in a room with burns over the
face ,neck ,anterior aspect of chest and anterior aspect of both upper limbs
and lower limbs.There was hoarseness of voice and cough with black coloured
sputum.
No h/o dyspnea or stridor.
PAST H/O:No h/o any comorbidities or previous Sx h/o
PERSONAL H/O:No addictions or allergies.Had normal appetite and regular bowel
and bladder habits before the accident.
FAMILY H/O: No relevant family h/o

3.  GENERAL EXAMINATION
Conscious and oriented GCS-15/15
VITALS-PR-90 bt/min
BP-100/60mmHg in the Rt arm in the supine position
SPO2-96% with O2 via face mask @ 5L/min
Wt-60Kg Ht-165cms BMI-22kg/m2

4.  AIRWAY EXAMINATION
Mouth Opening <2F
Oral Cavity:Edematous tongue and lips
Nasal Cavity:Patent with signs of charring of nares
MMPG:Couldn’t be assessed
TMJ-Restricted due to pain
TMD-Approximately 6.5cms
SMD-Approximately 12cms
Neck-Movement restricted due to pain
Spine-Not assessed

5.  LOCAL EXAMINATION
INSPECTION-Red coloured areas of burns with blisters over the face and neck
Black coloured patchy areas of burns over the anterior aspect of the
chest,both upper limbs and lower limbs.
PALPATION -Tenderness present over the face and neck
Sternal notch palpable
Thyroid,cricoid,cricothyroidmembrane is discernible.
SUMMARY
18 yr old male presented with burns over face,neck ,anterior aspect of upper
limb ,lower limb and chest with inhalational injury with involvement of
approximately 44% of the TBSA affected according to the Wallace Rule.

6. ASSESSMENT OF BURNS
 According to TBSA affected
 Wallace Rule of Nine
 Palmar Surface Area Method
 Lund and Browder Diagram
 Depth Of Burns
 Inhalational Injury

7. Wallace rule of 9

8. LUND AND BROWDER

10. FLUID RESUSCITATION

11. TRACHEOSTOMY
TYPES
 EMERGENCY
 ELECTIVE
 PERMANENT
 PERCUTANEOUS DILATATIONAL TRACHEOSTOMY
 MINI TRACHEOSTOMY( CRICHOTHYROIDOTOMY)
Acc to the Site:
High,Mid,Low Tracheostomy

12. COMPLICATIONS
 IMMEDIATE- Haemorrhage,Apnea,Aspiration,Recurrent laryngeal Nerve
Injury,Pneunmothorax,Injury to esophagus
 INTERMEDIATE- Bleeding,Displacement of Tube,Blocking of
Tube,Subcutaneous Emphysema,Tracheitis,Tracheobronchitis,Local
Wound infection and Granulation
 LATE- Hemorrhage,laryngeal stenosis,TEF,Problems of
Decannulation,Tracheostomy Scar,Keloid

13. Parts Of The Tube

14. TYPES OF TRACHEOSTOMY TUBES
 Acc to material-PVC,Silicon,Combination of these two,Metallic
 Number of Lumen-Single,Dual
 Cuffed and Uncuffed
 Fenestrated and Unfenestrated
 Speaking Valves

15. CARE OF TRACHEOSTOMY TUBE
 Humidification
 Suctioning
 Cleaning of inner cannula
 Maintaining Optimal Cuff Pressure
 Site Care and Dressing Change
 Tracheostomy Ties Care
 Change of Tracheostomy Tube
 Communication and proper weaning Plan
 Decannulation

16. DECANNULATION CRITERIA
 When ventilatory support is no longer needed
 Patient can control their own airway
 Absence of Distress
 Stable ABG
 Hemodynamic Stability
 Adequate swallowing
 Able to expectorate

18. ALTERED PHARMACOLOGY IN BURNS
Can Succinylcholine be used for muscle relaxation to a patient with burns?
 Contraindicated from 2nd day after burns to two years
 Hyperkalemia
 Most dangerous period is thought to be between 4days to 10 weeks
Use of NDMR in patients with Burns
 Increased resistance to NDMR in patients with burns(1 week to 8 weeks)
 Proliferation of Ach receptors