1. Triage systems categorize trauma patients based on the urgency of their injuries to prioritize care. Mass casualty incidents require prioritizing those most likely to survive when resources are insufficient. 2. Total parenteral nutrition (TPN) provides all nutritional needs intravenously, bypassing the gastrointestinal tract. It requires a central venous catheter and careful monitoring to prevent complications. 3. Burns are classified by degree of skin layer involvement and percentage of total body surface area burned. Major burns require specialized burn unit care for infections, shock, and complications affecting multiple organ systems.

1. Triage,Burn & TPN

2. Triage
• Triage is a system to attend trauma patients, formulated by Committee of
Trauma of the American College of Surgeons. There are several
commercial systems available to label patients so emergency personnel can
see at a glance the scale of the incident. The key is to divide patients by
the urgency of care/transfer to hospital
Types of Triage System
• Multiple casualties: Staff and facilities are sufficient but priority is given to
life-threatening injuries.
• Mass casualties: Staff and facilities are not sufficient to manage. Here
those who are likely to have highest chance of survival are given priority.

3. • Goals
• Identify life-threatening
conditions.
• Decide and implement
appropriate treatment to the area
of trauma.
• First think to salvage the life, then
think to salvage the limb.
• Rapid assessment, rapid
resuscitation, rapid stabilisation.
• Optimum, complete care.
• Transport efficiently to higher
trauma centre

4. Management (A,B,C,D,E,F)
I. Primary Management
• Airway management (blocked by
food, vomitus, clot, fallen
tongue).
• Breathing
• Circulation.
• Disability and level of
consciousness assessment by
Glasgow coma scale.
• Exposure of the patient from
head to toe for final assessment.
• Fingers and tubes: Finger
evaluation, Foley’s
catheterisation.

6. Total Parenteral Nutrition
• Total parenteral nutrition (TPN) is
a method of feeding that
bypasses the gastrointestinal
tract
• All nutritional requirements are
given only through intravenous
route
• TPN is given through central vein
and not through a peripheral
vein.
• Central catheter through the
subclavian/internal jugular vein
where the tip of venous catheter
is at distal part of superior vena
cava.

7. Goals, Factors and Assessment in TPN
• To decrease adverse effects of
catabolism;
• To maintain glycogen reserve in
cardiac and respiratory muscles.
• To maintain acid, base and
electrolyte metabolism.
• Age, premorbid state, muscle mass,
weight, serum albumin should be
assessed.

8. • Requirement
• 1. Fluid requirement is assessed by—1500 ml for 20 kg weight + 20
ml/kg for additional weight.
• 2. Energy needed is calculated by calculating resting energy expenditure
(REE):
• • By simple calculation: REE in kcal/ day = 25 × weight in kg.
• • Harris Benedict equation: REE in men = 66 + (13.7×weight in kg) + (5 ×
ht in cm) – (6.7 × age in years). In women = 655 + (9.6 × weight) + (1.8 × ht)
– (4.7 × age). Activity/disease/thermal factors are also added.
• • Indirect calorimetry: It is more accurate method done using special
instrument. REE: = (3.9 × VO2) + (1.1 × VCO2) – 61.

9. S/E:
1.Air Embolism
2.Bleeding
3.Cathether
Displacement
4.Dehydration
5.Electrolyte Imbalance

10. BURNS
• Thing WE MUST KNOW= Marjolin Ulcer, how to give first aid, degree
of burns
CREST

11. Degrees of Burn******
1st Degree=epidermis(superficial thickness)
2nd Degree=epidermis and dermis (partial thickness)
3rd Degree=Full thickness
4th degree: Involves the underlying tissues—muscles, bones.

13. • Depending on thickness of skin involved
a. Partial thickness burns: It is either first or second degree burn which is red and painful, often with blisters.
b. Full thickness burns: It is third degree burns which is charred, insensitive, deep involving all layers of the skin
Depending on the Percentage of Burns Mild (Minor):
1. Partial thickness burns < 15% in adult or <10% in children
2. Full thickness burns less than 2%.
3. Can be treated on outpatient basis.
Moderate:
1. Second degree of 15-25% burns (10-20% in children).
2. Third degree between 2-10% burns.
3. Burns which are not involving eyes, ears, face, hand, feet, perineum.
Major (severe):
1. Second degree burns more than 25% in adults, in children more than 20%.
2. All third degree burns of 10% or more.
3. Burns involving eyes, ears, feet, hands, perineum.
4. All inhalation and electrical burns.
5. Burns with fractures or major mechanical trauma.

14. Pathophysiology

15. Effect of Burn Injury
1. Systemic infection like pneumonia, bacteraemia, septicaemia can occur.
2. Burns itself creates immunosuppression.
3. Sepsis is identified by fever, lethargy, leukocytosis, thrombocytopenia.
4. Infections
5. Shock due to hypovolaemia.
6. Renal failure.
7. Pulmonary oedema, respiratory infection, adult respiratory distress
syndrome (ARDS), respiratory failure.
8. Curling’s ulcer (seen in burns > 35%).

17. MANAGEMENT OF BURNS
• First Aid ****
• Stop the burning process and keep the patient away from the burning
area.
• Cool the area with tap water by continuous irrigation for 20 minutes
(not cold water as it can cause hypothermia

18. Definitive Treatment
• Admit the patient.
• Maintain airway, breathing, circulation.
• Assess the percentage, degree, and type of burn.
• Keep the patient in a clean environment.
• Sedation and proper analgesia.
• Patient should be in burns unit (ideally air-conditioned) with barrier
nursing, sterile clothes, bed sheets with all aseptic methods.

19. Fluid Resuscitation
Fluids used are normal saline, ringer lactate, Hartmann fluid,
plasma. Ringer lactate is the fluid of choice. Blood is
transfused in later period (after 48 hours).

20. CONTRACTURE IN BURN WOUND
• Burn scar contracture is the tightening of the skin after a second or third degree burn. When skin is burned, the surrounding skin
begins to pull together, resulting in a contracture. It needs to be treated as soon as possible because the scar can result in
restriction of movement around the injured area. Contracture in burns can occur anywhere. It is more common wherein
flexibility and mobility is present like along the joint, eyelids, cheeks, lips, neck, elbow, knee
Complications:
***Marjolin’s ulcer:
1. It is a very well-differentiated squamous cell carcinoma occurring in a scar ulcer due to repeated breakdown (unstable scar
of long duration).
2. It is locally malignant.
3. As there are no lymphatics in the scar, so there is no spread to lymph nodes.
4. As there are no nerves in the scar it is painless.
5. It has raised and everted edge with induration.
6. Biopsy confirms the diagnosis.
7. Treatment: Radiotherapy is not given for Marjolin’s ulcer. Treatment is either wide excision or amputation. It is curable. Once it
spreads out of the scar tissue it behaves like any other squamous cell carcinoma and so can spread to regional lymph nodes.