major and minor burn managment
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MANAGEMENT OF THE ACUTE SEVERE BURN
MANAGEMENT of BURNs
ScaldFlameContactElectricalChemicalFrictionRadiationFrost burns
Causes of Burns
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High incidence of burns in children under 5
Second peak in young men 15 35 years
Rising incidence in elderly population Age Distribution
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Jacksons model of burn
Zone of CoagulationZone of StasisZone of HyperaemiaBurn Pathophysiology
Better picture4
Burn wound conversion
Over 48 hours
Immediate treatment givenFirst aidTotal Body Surface AreaResuscitation
DepthLocation of BurnAgentAgePast Medical HistoryFactors determining the severity of the burn
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First Aid Primary SurveySecondary SurveyINITIAL Management
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Stop the burning process
Stop, drop, and roll
Remove clothing and jewellery
Remove from source of heat
First Aid
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Cool the burn surface
Immediate cool running water
For 20 minutes
Within 3 hours of injury
No ice
First aid for ALL burns
First Aid
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Airway management with C spine controlBreathing and ventilationCirculation with haemorrhage controlDisability / neurological statusExposure + environmental controlFluid resuscitation Primary Survey
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Cervical spine protectionAirway CompromiseMay not be initially obviousRapidly changingPotentially fatalConsequence of direct injury or oedema PRIMARY SURVEY AIRWAY
Classification
Airway injury above larynx
Airway injury below larynx
Systemic Intoxication Injuries Inhalation InjuryIncreases mortality by ~ 1.7 times
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Flame burns
History of burns in enclosed space
Explosions
Burns to face, neck or upper torso
Unconscious patient
Suspect an inhalational injury
Singed nasal hairCarbonaceous sputum or soot in oropharynxSwelling of oropharynxChange in voice hoarsenessCoughStridorDyspnoeaTachypnoeaReduced GCS
Signs of airway injury
If potential compromise:Sit patient uprightReduce oedemaCareful fluid administrationHigh flow humidified oxygenFrequent reassessmentDiscuss with Burns unitIntubate if airway compromised
AIRWAY COMPROMISED
Examine the chestPossible other injuriesProvide high flow oxygen Measure respiratory rateDeep Circumferential chest burnsDo they need an escharotomy?PRIMARY SURVEY BREATHING
Carbon monoxide has greater affinity for haemoglobin than oxygenReduces oxygen carrying capacity of bloodPatients are classically cherry redOften confused and disorientatedPulse oximetry normalTreat with high flow O2CARBON MONOXIDE POISONINGCarboxyhaemoglobin %Symptoms0 - 15None15 -20Headache Confusion20 -40NauseaFatigueDisorientationIrritability40 - 60HallucinationAtaxiaSyncopeConvulsionsComa> 60Death
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Inhaled products of combustionPlastics, wool, silk, nylon, nitriles, rubber, paper20 times more toxic than Carbon MonoxideCan cause immediate respiratory arrestCan result in reduced GCS
Treat with high flow oxygenCYANIDE18
Assess circulation and perfusionUnburnt skin colour, temperature and capillary refillPulse and Blood Pressure
Obtain IV accessInsert 2 large bore cannulaeIdeally through unburnt skinCommence IV fluids
Primary Survey - Circulation
Circumferential full thickness burns Is the circulation compromised or likely to become compromised?Elevate the affected areaReduces swelling Half hourly neurovascular observationsMay require EscharotomiesCall Burns Consultant for advicePrimary Survey - Circulation
Escharatomies
Neurovascular observations to digits if circumferential full thickness burns to limbs and to ventilation if on trunk21
Assess ConsciousnessAVPUGCSAltered consciousness can be sign of Hypoxia Hypovolaemia CO intoxicationLook at Pupillary ResponsePrimary Survey - Disability
Remove clothing and jewellery
Assess the Burn Size
Look for other injuries
Keep patient warmPRIMARY SURVEY EXPOSURE / ENVIRONMENTAL CONTROL
Rule of Nines for adults
Lund and Browder chart
Patients palm represents 1% TBSAEstimation of the Area of the burn
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AREAAGE 0151015ADULTA = OF HEAD986543B = OF ONE THIGH234444C = OF ONE LEG222333
Lund and Browder Chart
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Clean skin before assessing the burn
Examination of the burn
The same arm 30 minutes after debridement
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What colour is the burn?
Does it have a capillary return? If so is it normal?
Is there sensation? Is it normal?
Are there blisters?Assessment of the burn
Superficial Burns
Assessment of Superficial BurnsAppearanceCapillary RefillSensationHealing timeScarringDry and RedNo BlistersBlanchesYesWithin 7 daysNo
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Superficial Dermal BurnsAssessment of Superficial Dermal BurnsAppearanceCapillary RefillSensationHealing timeScarringPale PinkBlistersBlanchesVery PainfulWithin 14 daysColour match defectLow risk of scar
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MID DERMAL BURNSAssessment of Mid Dermal BurnsAppearanceCapillary RefillSensationHealing timeScarring
Dark PinkLarge BlistersSluggish Painful14 21 daysModerate risk of hypertrophic scarring
Deep Dermal BurnsAssessment of Deep Dermal BurnsAppearanceCapillary RefillSensationHealing timeScarring
Blotchy RedFixed StainedNoMaybe - reducedOver 21 daysHigh chance of hypertrophic scar
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Full Thickness Burns
Assessment of Full Thickness BurnsAppearanceCapillary RefillSensationWill it heal?Scarring?White/leatheryBlack/charredNo blistersNoNoNoYes
When to start IV fluid resuscitationIn Adults > 15% tbsaIn Children 18 months and older >10% tbsaIn Children less than 18 months >8% tbsa
PRIMARY SURVEY FLUID RESUSCIATION
2mls x % tbsa x weight (kg)Hartmanns solutionCalculated from time of burn First half over initial 8 hoursSecond half over next 16 hours
Plus daily maintenance fluids = 2000mlPRIMARY SURVEY FLUID RESUSCIATION
Closest isotonically to the burn fluid that is being lost
Sodium chloride 0.6%Sodium lactate 0.25%Potassium chloride 0.04% Calcium chloride 0.027%
Ultimately any crystalloid fluid will doWHY HARTMANNS?
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Insert Urinary Catheter
Monitor urinary output
Aim for 0.5-1ml/kg/hour
Adjust fluids accordingly
Inhalation and electrical injury 2ml/kg/hour
PRIMARY SURVEY FLUID RESUSCITATION
Need new pics36
82 kg man sustains 50% TBSA flame burn at 2am admitted today to your hospital 8am. How much fluid does he require?
2 x 50 x 82 = 8200mls of Hartmann solution 4,100 mls in first 8 hours i.e. by 1000 am4,100 mls in next 16 hours i.e. by 0200am the next day
Working Example2mls x % tbsa x patients weight (kg)
If the first 8 hour period has lapse at time of admission, please titrate the initial 8 hour volume to be infused within a time frame that is suitable for the patients condition ie do not run an excessive amount of fluid in a matter of minutes or hours without considering the pts general condition37
Adult 2000ml in 24 hours
Children1st 10kg 100mls /kg2nd 20kg 50mls /kgOver 20kg 20mls /kgMAINTANENCE FLUID
Burning agentBurning circumstancesDuration of burningClothing alightInhalation injuryImmediate First aid Type and length
Medical HistoryMedicationsAllergiesTetanus statusAlcohol and drug useSmokingOccupationSecondary Survey: History, Assessment
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Pulse Blood Pressure(CVP) Urine output aiming for 0.5 ml / kgSpecific Gravity - 1020Electrolytes
Oxygen saturation if indicatedArterial blood gases if indicated MONITORING OF PATIENT
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Urinary CatheterNasogastric Tube Pain ReliefClean and Dress WoundKeep warmOedema Control elevation and compression TetanusADJUNCTS
Nanocrystalline impregnated silver mesh, sustained released
For ALL burns in first 48 hoursActicoat
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Moisten Acticoat with water
Can apply Flaminal or Intrasite under
Secondary dressing wet gauze, jelonet, dry gauzeORDuodermACTICOAT DRESSINGS
AnatomyBody surface areaSkin thicknessAirwayPhysiologyFluid managementNutrition
Psychology
EpidemiologyIncidenceAetiologyAge distribution
Burn pattern
burns in children
Children are not small adults!
Non accidental injuriesSuspicious Features
Delay in presentationIncompatible historyInconsistent historyOther signs of traumaPattern of injuryDemeanor Interaction
Toxin mediated diseaseCommon from Staph aureus or Group A StrepCan occur from small burnYoung children usually affectedDue to lack of antibodiesTOXIC SHOCK SYNDROME
Symptoms often presents like childhood viral illness
PyrexiaRashVomiting or diarrhoeaPoor peripheral perfusionHypotension
TOXIC SHOCK SYNDROME
ELECTRICAL INJURIES
Low Voltage 1000VLightning
VoltageSkinDeep TissueCardiac ArrhythmiasLow Voltage1000VFlashover burnFull thickness entrance and exit woundsMuscle damage with rhabdomyolysisCompartment syndromeTransthoracic current may cause myocardial damage and delayed arrythmias
LightningSuperficial or dermal flashoverExit burns on feetEar drum perforation and corneal damageRespiratory arrest
Electrical burnsTaken from EMSB course
Ensure you are wearing correct PPEFirst aidRemove contaminated clothingBrush off dry powderCopious irrigation
Check pH Keep irrigating until pH normalChemical burns
Small burns (2%) can be fatalAction of