Critical care in burns patients

1. Dr. ZIKRULLAH.
1

2. Definition of Burn
• Damage to body tissues caused by heat, chemicals,
electricity, sunlight, or radiation.
• Scalds from hot liquids & steam, building fires &,
flammable liquids & gases are the most common
causes.
2

3. Causes of Burn Injuries
• Electrical burns
- Lightening
• Radiation burns
• Thermal burns
- Skin injury
- Inhalation injury
• Chemical burns
- Skin Injury
- Inhalation injury
- Injury to mucous
membrane
3

4. AT RISK:
• Fire/Combustion
– Firefighter
– Industrial Worker
– Occupant of burning structures
• Chemical Exposure
– Industrial Worker
• Electrical Exposure
– Electrician
– Electrical Power Distribution Worker
4

5. • Superficial (1st degree)
– Least destruction
– Only epidermis injured
• Partial-thickness ( 2nd degree )
• Epidermis destroyed
• Varying depths of dermis damaged/destroyed
– Superficial partial-thickness
• Erythematous and moist with vesicles
• painful
Burn Classifications
5

6. –Deep partial-thickness
• Red and waxy without blisters
• Moderate edema, lesser degree of pain
• Hypoxia and ischemia can cause extension of
wound
• Full-thickness (3rd degree)
– Entire epidermis and dermis involved
– No viable epithelial cells, grafts required
– Hard, dry leathery eschar
6

7. • Deep full-thickness (4th degree)
– Extend beyond skin into underlying fascia and
tissues
– Muscle, bone and tendon damage with exposure
to surface
– Blackened and depressed, little or no sensation
– Early excision and grafting beneficial
7

8. • Superficial partial-thickness • Deep partial-thickness
8

9. Full Thickness Deep Full Thickness
9

10. NOTE:
• Often it is not possible to predict the exact depth of a
burn in the acute phase.
• Some 2nd degree burns will convert to 3rd when
infection sets in.
• When in doubt call it 3rd degree.
10

11. • Zone of Coagulation
– Inner Zone
– Area of cellular death (necrosis)
• Zone of Stasis
– Area surrounding zone of coagulation
– Cellular injury: decreased blood flow &
inflammation
– Potentially salvable; susceptible to additional
injury
Zones of Burn Injury
11

12. • Zone of Hyperemia
– Peripheral area of burn
– Area of least cellular injury & increased blood flow
– Complete recovery of this tissue likely.
12

13. • Tissue destruction can lead to:
– Fluid & electrolyte derangements
– Protein losses
– Sepsis
– Multiple system disturbances
• Metabolic
• Endocrine
• Respiratory
• Cardiac
• Hematologic
• Renal
• Immune
Pathophysiology of burn injury
13

14. • Extent of local and systemic disruption depends on
– Age
– General health status
– Extent of injury
– Depth of injury
– Area of body injured
(Morbidity & mortality of burn clients is related to
Fluid/electrolyte derangements in acute cases
A lack of or delay in healing in delayed cases)
14

15. • Fluid Shift
– Period of inflammatory response
– Vessels adjacent to burn injury dilate → ↑
capillary hydrostatic pressure and ↑ capillary
permeability
– Continuous leak of plasma from intravascular
space into interstitial space
– Associated imbalances of fluids, electrolytes and
acid-base occur
Fluid/Electrolyte Changes
15

16. – Hemoconcentration
– Lasts 24-36 hours
• Fluid remobilization
– Capillary leak ceases and fluid shifts back into the
circulation
– Restores fluid balance and renal perfusion
– Increased urine formation & diuresis
– Continued electrolyte imbalances
• Hyponatremia
• Hypokalemia
– Hemodilution
16

17. • Electrolyte derangements:
- Tissue destruction => hyperkalemia
( acute resuscitation phase)
- Later,
Renal wasting
+ Hypokalemia
Gastric losses
- Due to topical medications
Mafenide acetate inhibits carbonic anhydrase
 hyperchloremic acidosis.
Silver nitrate  ↓ Na, K & Cl.
significant methemoglobinemia
(rare) 17

18. Eschar formation
– Skin denaturing
• hard and leathery
– Skin constricts over wound
• increased pressure underneath
• restricts blood flow
– Respiratory compromise
• secondary to circumferential eschar around the thorax
– Circulatory compromise
• secondary to circumferential eschar around extremity
18

19. • Cardiac
– Decreased CO, decreased BP
– Due to decreased blood volume, & myocardial
depressant factor
– Need fluid resuscitation and support with O2
• Pulmonary
– FRC reduced,
– Both lung compliance & chest wall compliance
reduced
– Need aggressive pulmonary toilet & oxygenation
Other System Changes
19

20. • Gastrointestinal
– Decreased or absent motility (may need NG tube)
– Curling’s ulcer formation
– H2 histamine blockers, mucoprotectants &
enteral nutrition
• Metabolic
Hypermetabolic state
• Increased oxygen and calorie requirements
• Increase in core body temperature
20

21. • Immunologic
– Loss of protective barrier
– Increased risk of infection
– Suppression of humoral & cell-mediated immune
responses
Other System Changes
21

22. • Treatment of burns is directly related to the severity
of injury!
• Severity is determined by:
– Depth of burn & Total body surface (TBSA) burned
– Location of burn
All burns of the face, hands, feet,perineum are
considered severe !!
– Client’s Age
– Other preexisting medical conditions / trauma.
Severity of burn injuries
22

23. Rule of nines
• 9 Head
• 9 Each upper limb
• 18 Front trunk
• 18 Back trunk
• 18 Each lower limb
• 1 perineum
Estimation of burn size
% burns
23

24. Rule of fives ( child )
• 20 Head
• 10 Each upper limb
• 20 Front trunk
• 20 Back trunk
• 10 Each lower limb
% burns
24

25. Palm Rule:
• The person’s palm represents 1% of his/her body.
Lund Browder Chart :
• more complicated and time consuming method to
estimate BSA burned
BUT MORE ACCURATE!!
25

26. 26

27. 27

28. • Emergent/Resuscitative
– First 48 hours
• Acute
– Approximately 48 hours after injury to complete
wound closure
• Rehabilitative
– Begins with wound closure and ends when client
returns to highest possible level of functioning
Phases of burn injury
28

29. • The most effective treatment of a burn injury is to
prevent it from occurring !!
– Proper education and supervision of children
– Safety measures for the elderly
– Working smoke detectors in the home
• Three Phases of Burn Care
– Resuscitation
– Acute
– Rehabilitation
Management of burn injuries
29

30. At the Site
• Remove to safe area, if possible
• Stop the burning process
– Extinguish fire - cool smoldering areas
– Remove clothing and jewellery
– Cut around areas where clothing is stuck to skin
– Cool adherent substances (Tar, Plastic)
30

31. Burn Center Referrals
• Partial thickness burns > 10% TBSA
• All full-thickness burns.
• All burns of the face, hands, feet, perineum.
• All electrical, inhalation & chemical burn injuries.
• All burn injuries in poor-risk client or with concurrent
trauma.
31

32. • Cold water lavage (temp ~15°C) for ~20 mins
(caution in children).
• Appropriate analgesia:
- Avoid IM injections!!!
- Intravenous titration:
Ketamine 0.5mg/kg ivi.
Morphine 0.2mg/kg every 5 mins
- Cover wound
- Keep warm
First Aid Measures for Minor burns
32

33. • ABC’s of burn resuscitation:
– Airway
– Breathing
– Circulation
Acute Stabilization & Resuscitation
33

34. Airway and Breathing
34

35. Indications for intubation
• Airway obstruction
• Depressed level of consciousness
• Circumferential nasolabial burns
• Hypoxia
• CO poisoning
• Upper airway edema
• Subglottic thermal and chemical burns
• Chest wall restriction
35

36. Modes of securing Airway
• Nasal/Oral Intubation
• Needle cricothyroidotomy
• Surgical cricothyroidotomy
• Surgical tracheostomy
36

37. Airway Management
• Patients with injury of the upper airway need to be
intubated as soon as possible; a delay in performing
the intubation can result in total obstruction of the
upper airway.
• The intubation can be performed by direct
laryngoscopy with a regular laryngoscope, intubation
stylet, or FOB through an LMA-Fastrach (intubating
laryngeal mask airway [ILMA]).
37

38. • In the presence of facial burns and when the fasting
status of the patient is unknown or questionable, a
rapid sequence intubation should be performed.
• Succinylcholine is considered safe to administer in the
first 24 hours after a burn injury.
• In patient with third- to fourth-degree burns of the
neck, laryngoscopy may be impossible because of the
rigidity of the cervical tissue, an incision in neck can
facilitate laryngoscopy in such cases.
38

39. • Extensive or circumferential third- to fourth-degree
burns to the chest wall can cause severe restrictive
insufficiency and may require immediate escharotomy
of the anterior chest wall.
• The size of an ET should be reduced by half or even a full
size smaller than the previous ET.
• To bridge the time in establishing a definite airway, an
LMA or Combitube can maintain oxygenation and
ventilation of the patient.
39

40. 40

41. Tube fixation
• The fixation of the ET is a challenge in the burned
patient.
• The ideal fixation secures the tube safely without
additional injury to the tissue of the face and is flexible
enough to adjust to edema formation.
• Suturing the tube to the gums, wiring the tube around a
tooth, and circumferential fixation or devices that allow
frequent adjustment are examples.
41

42. • The usual forms of adhesive tape are not effective in
the burned patient because they do not adhere
adequately even to nonburned skin. Usually, a soft
sling ribbon is used. It is tied at the back of the head
(not the neck), and gauze padding should be added
to avoid constriction of soft tissues.
42

43. Surgical airway
• The primary purpose of a cricothyroidotomy is to
provide an emergency breathing passage for a
patient with extensive burns in and around face and
mouth making larygoscopy and intubation difficult to
perform.
• Cricothyrotomy is an emergency procedure involving
incising or puncturing the cricothyroid membrane to
access the trachea for ventilation purposes
• NEEDLE CRICOTHYROIDOTOMY
• SURGICAL CRICOTHYROIDOTOMY
43

44. 44

45. 45

46. Tracheostomy
• creation of permanent or semi permanent opening in
trachea. Tracheostomy should be performed in a patient
still requiring ventilation through an endotracheal tube
for more than a week.
46

47. Inhalational injury
• The leading cause of death from fires.
• Higher mortality than burn patients without
inhalation injury.
• Three types:
(a) heat injury to the airways
(b) exposure to toxic gases
(c) chemical burn with deposition of carbon
particles in the lower airways.
47

48. • Ensure clear airway
• Suspect inhalation injury if:
– fire in confined space
– h/o loss of consciousness/disorientation
– soot in nostrils/ sputum/ mouth
– singed nasal/ facial hair
– burns on face/ tongue/ pharynx
– stridor or hoarseness
48

49. • Pulmonary response – complex; depends upon
(a) duration of exposure
(b) composition of materials burned
(c) underlying lung disease, if any.
• Diagnosis:
Flexible bronchoscopy – erythema, oedema,
mucosal ulcerations, & carbonaceous deposits.
ABG: initially normal or
mild hypoxaemia & metabolic acidosis due to CO.
49

50. Chest X ray: initially normal.
• Carbon monoxide & cyanide poisoning are common.
• HEAT INJURY
- usually confined to supraglottic structures, unless
prolonged exposure to steam.
- progressive hoarseness & stridor – ominous signs
of impending airway obstruction, may develop
over 12-18hrs.
- fluid resuscitation frequently aggravates oedema.
50

51. • When carboxy Hb > 15% in blood, diagnosed by
cooximetric measurements of blood.
• Result of combustion of synthetic materials
• Leading cause of death associated with fires
• Causes tissue hypoxia due to:
– Binds to Hb 200x more readily than O2 in alveoli
– Rate of dissociation of CO Hb slow, t1/2 =2-4hrs.
– Creates a left shift of O2 - Hb dissociation curve –
impairs O2 unloading at tissue level
CO Poisoning
51

52. • Signs and Symptoms
- High index of suspicion (most important)
- Headache, N/V, angina, tachypnea
- Cherry red appearance of mucous membranes and
nailbeds
- Persistent metabolic acidosis with adequate
volume resuscitation.
52

53. TREATMENT :
• All patients suspected of having CO Poisoning should be
given 100% O2 . The half life of CO-Hb breathing room
air is 90 minutes, whereas the half-life when breathing
90 to 100% high-flow oxygen is 30 minutes, i.e., the
concentration of carboxyhemoglobin is reduced by
approximately 50% every 30 minutes if an oxygen
concentration of 90 to 100% is used.
• Oxygen administration is required for all major burns
until carbon monoxide toxicity can be ruled out or until
carboxyhemoglobin levels return to normal.
53

54. • Hyperbaric oxygen (2 to 3 atm) produces an even
more rapid displacement and is most useful in cases
of prolonged exposure
• Endotracheal intubation and use of 90 to 100%
oxygen with mechanical ventilator assist is indicated
for those patients with impaired neurologic function
and a high carboxyhemoglobin.
54

55. • Artificial ventilation if required
• Always administer O2
• Carbon Monoxide poisoning if:
– inhalation injury
– fire in confined space
– altered consciousness
If in doubt intubate!!
Breathing
55

56. • Intravenous fluid if :
– >15% burn in adults
– >10% burn in children
– Age > 65yrs or < 2yrs.
• No compromise with IV access
• Ringers lactate solution preferred
Circulation
56

57. Fluid Management
• OBJECTIVES:
• HR < 110/minute
• Normal sensorium (awake, alert, oriented)
• Urine output - 30-50 ml/hr (adult);
0.5-1 ml/kg/hr (paed)
• Resuscitation formulae provide estimates,
adjust to individual patient responses.
• Monitor for pulmonary edema.
57

58. Fluid Management
• Parkland formula
• Brooke formula
• Modified brooke formula
• Evan’s formula
• Muir & barclay formula
• Slater,s formula
• Monafo formula
58

59. 59

60. • The rule of ten : ( USAISR)
initial fluid rate in ml/hr = 10 × % TBSA
for every 10 kg above 80 kg, 100ml is
added to this rate.
( ricardo alvarado,kelvin k chung, burn
resusitation. Burns 2009;35:4-14 )
60

61. • Parkland Formula:
Fluid requirement (ml)
= 4 x % of body surface area burned x weight (kg)
• Half in first 8 hrs & remainder in following 16 hrs
(From the time of the burn,not arrival at hospital)
• Large bore IV line preferably in unburnt skin.
• Catheterise. Hourly urine volumes.
• Aim for U/O = 30 ml / hour in adult
(1ml/kg/hr in child).
61

62. • Large volumes involved – CVP monitoring
• Increased Fluid Requirements in:
- Children < 20kg
- Inhalation Injury
- Delayed Resuscitation
- Flame/ Petrol Burns
- Other trauma.
62

63. • Replacement with colloids begins in the 2nd 24hrs
usually when the capillary permeability significantly
decreases.
• Fluids containing glucose & plasma may be given to
maintain adequate intravascular volume.
63

64. Excessive fluid BAD
• Abdominal compartment syndrome
• Extremity compartment syndrome
• Pulmonary edema
• Tissue edema
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65. OTHER SUPPORTIVE MEASURES
• All patients with burns > 10%
0.5ml Tetanus toxoid.
If prior immunization absent/unclear, or
last booster > 10yrs ago,
250 U Tetanus immunoglobulin also.
• Avoid/prevent hypothermia.
• Gastric decompression with NGT in all major burns.
Also restrict oral intake until transfer is complete.
65

66. • Antibiotic use is controversial.
• Neck, oral & joint splints can prevent deformities.
• High voltage electrical burns
 myoglobinuria/haemoglobinuria
 risk of renal tubular obstruction
So, add Sodium bicarb to IV fluids as long as these
pigments appear in urine.
66

67. • Early burn wound excision significantly
reduces blood loss.
(Desai MH. Ann Surg 1990; 211: 753-62.)
• Primary excision of the burn wound.
Improved survival with early excision in major
burns
(Still JM, Jr., Law EJ. Clin Plast Surg 2000;
27(1):23-28.)
67

68. Chemical Burns Management
• Acids
– Immediate coagulation-type necrosis creating an
eschar => self-limiting injury.
• Bases (Alkali)
– Liquefactive necrosis with continued penetration
into deeper tissue resulting in extensive injury
• Dry Chemicals
– Exothermic reaction with water.
68

69. • Definitive treatment - get the chemical off!
• Begin washing immediately - remove patient’s
clothes as you wash
– Watch for the socks & shoes, they trap chemicals.
• Liquid Chemicals
– wash off with copious amounts of fluid
• Dry Chemicals
– brush away as much of the chemicals as possible
– then wash off with large quantities of water
• Flush for 20-30 minutes to remove all chemicals
69

70. • Do not attempt neutralization.
CHEMICAL BURN TO THE EYE:
• Flood eye with copious amounts of water only
– Never place chemical antidote in eyes
• Flush using LR/NS/H2O from medial to lateral for at
least 15 minutes.
• Remove contact lenses
– May trap irritants
70

71. Electric burn management
• Make sure current is off
– Lightning hazards
– Do not go near patient until current is off
• ABC’s
– Ventilate and perform CPR as needed
– Oxygen
– ECG monitoring
• Treat dysrhythmias
71

72. • Rhabdomyolysis Considerations
– Fluid?
– Dopamine?
• Assess for additional injuries
• Consider transport to trauma center
72

73. • Burn wounds consume large amounts of
energy:
– Requires massive amounts of nutrition & calories
to decrease catabolism & promote wound healing.
– High-protein & high-calorie diet
– Often requiring various supplements- vitamin A &
C.
Nutritional Support
73

74. Routes
• Oral
• Enteral
–Gut is the preferred alternative route;
started ASAP
–i.e. G-tube or J-tube
• Parenteral
–i.e. TPN and PPN
–Associated with an increased risk of
infection
74

75. • Pediatric Clients
– Thinner skin; prone to more severe injury
– Greater body surface area / to weight ratio
• Greater evaporative fluid losses → hypovolemia
• Rapid heat losses → hypothermia
– Reduce metabolic reserves; prone to hypoglycemia
– Small airways → more difficult to secure
Special Populations
75

76. – Immature immunological response → sepsis
– Consider possibility of abuse / neglect
• Geriatric Clients
– Skin is thinner; prone to more severe injury
– Decreased mobility, reaction time, vision &
hearing & sensation in hands & feet.
• Unable to escape or unable to detect severity
76

77. – Pre-existing medical conditions (i.e. PVD, heart
disease & DM) more likely;
more likely to develop complications.
– Poor immunological response → sepsis
– Consider the possibility of abuse / neglect
77

78. Role of anaesthesiologist in burn
management
• Initial resusitation, specially in airway
management.
• Intensive care management : sepsis &
multiorgan failure
• Anaesthesia for various surgical procedures
78

79. Emergency surgical procedures
• Cricothyriodotomy
• Tracheostomy
• Burn wound excision & grafting.
very early (within 24hrs of burn injury)
early (immediately after initial 48hrs of
resuscitation) – extent limited to 20%.
• Escharotomy
79

80. Perhaps the most important responsibility of the
anaesthesiologist is “management of the
patient’s airway”
• 1.Difficult airway
• 2.Use of muscle relaxants
• 3. patient positioning
• 4. IV access
• 5. Application of monitors
• 6. Hypothermia
80

81. • 1. Reduced mouth opening
• 2. Restricted neck movements
• 3. Stiff submandibular space
• 4. Scar and contractures in suprasternal area
obviates the use of lightwand /
cricothyrotomy/emergency tracheostomy.
Problems associated with facial / neck
burns
81

82. • 5. Larynx may be shifted from midline
• 6. Ineffective cricoid pressure
• 7. Application of OELM during difficult
laryngoscopy and intubation are not possible
• 8. Application of BURP
82

83. • Awake intubation (nasal/ oral)
• ILMA + ETI (if MO> 2 finger)
• LMA classic / Combitube( if tracheal stenosis
suspected secondary to inhalation burns)
• Pre-induction neck contracture release under
tumescent local anesthesia / ketamine
anaesthesia
• Elective tracheostomy /PCT
Techniques for maintaining airway
83

84. IV ACCESS
• For excision & grafting, at least 2 large bore IV lines,
an arterial line, & often a central venous or
pulmonary artery catheter are indicated.
84

85. • Applying monitors may be difficult in patient with
limb and chest wall burns.
• Whenever ECG monitoring is necessary, Needle
electrodes may be sutured in place.
• If application of BP cuff is not feasible , it mandates
the use of invasive arterial BP monitoring.
Monitors
85

86. Succinylcholine
• can cause massive release of intracellular K leading
to dangerous hyperkalemia.
(K as high as 13 meq/L).
Result: ventricular tachycardia/ fibrillation/cardiac
arrest.
• This response starts after 5-10 days post burn, lasts
up to 6 months.
Depolarising Muscle Relaxants
86

87. • The recommended limit for witholding use
= 24 hrs – 2 years post burn (irrespective of % of
burns)
• If ,any how succinylcholine has to be used, use under
continuous ECG monitoring.
87

88. • Post burn proliferation of extra-junctional nicotinic
Ach receptors .
• Higher than usual doses.
• Larger burn area => larger dose & faster recovery.
• Not seen in first post burn week.
• Not relevant in burns < 10 %.
• Normal doses of reversal agent can be used.
• Atracurium (1 mg/kg)/ vecuronium (.15 mg /kg) may
be used.
Nondepolarising Muscle Relaxants
88

89. THANKYOU
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