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