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Burns

Burns

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Published by dhainey

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Published by: dhainey on Oct 31, 2008
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12/13/2012

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BURNS
Epidemiology:
Quality of Burn Care
SurvivalLong-term FunctionAppearance 
Surgeon’s Goal
Well-healed, durable skin with normalfunction and near-normal appearance*Depth of Injury is directly proportional to: Temperature appliedDuration of contact Thickness of the skin
Etiology:
1. Scald Burns
- usually household from hot water- most common among civiliansinjuriesespecially children
2. Flame Burns
- 2ndmost common mechanism- secondary to house fires, MVA
3. Flash Burns
- explosion of gases & othercombustible liquids- covers larger TBSA- with thermal damage to upperairway
4. Contact Burns
- contact with hot metals, plastics,glass- common in industrial accidents- often 4thdegree
5. Electrical Burns
- either occupational or householdinjuries- severity based on voltage, durationof contact & resistance of the patient
6. Chemical Burns
- due to strong acids or alkalis- industrial accidents or assaultsPHASES OF BURN INJURY
Acute Phase
Fluids & ElectrolytesPain ControlBurn Wound Care & CoverageSeptic ComplicationsNutritional Management
Chronic Phase
RehabilitationReconstructionPsychological Support
Pathophysiology of Burn Injury
1. Coagulation Necrosis2. Increased Capillary Permeability3. Hemolysis
ACUTE PHASE
Immediate Care
Rescue and First Aid = on scene- remove source of heat- CPR if necessary; O2 inhalationAssessment and Resuscitation = at the ER- ABC’s take priority- Intubation if necessaryPreparation for transfer to a burn facility
-
for burns more than 5 – 10% TBSA
Immediate first aid measures
Cooling the burned area- application of cool water
NOT
iced waterRemoval of patient’s clothing- remove source of heat &exposure of injuriesPrevention of hypothermia- wrap patient in clean blanket
Admission Criteria to a Burn Facility
Partial Thickness Burns =/> 15%Full Thickness Burns =/> 5%Burns on Face, Feet, Hands &PerineumAll Electrical & Chemical BurnsPresence of Smoke Inhalation InjuryAssociated Injuries
Admission Criteria
Child AbusePatients <10 y.o. & >50 y.o.Patients w/ Associated medicalillnessAll infected burnsDependent persons
Patient Assessment
1. History Time of InjuryPlace of InjuryMechanism of Injury2. Physical ExamPrimary Survey = ABC’s2ndary Survey = Other injuries
 
Estimation of Burn Injury Severity
Burn Size:Rule of Nines = massive burnsPatient’s Palm = patchy burnsLund-Browder Chart
 
= pediatrics
“Rule of Nines” for estimating TBSA
Anatomic Area% body surfaceHead9Rt. Upper extremity9Lt. Upper extremity9Rt. Lower extremity18Lt. Lower extremity18Anterior trunk18Posterior trunk18Perineum1 
Estimation of Burn Injury Severity
Burn Depth is dependent on:a. Temperature of burn sourceb. Thickness of the skinc. Duration of contactd. Heat dissipating capability of skin
Classification of Burn Depth1. Shallow Burns
a) Epidermal Burns(1st Degree Burns)- do not blister but erythematous- relatively painfulex. Sunburn b) Superficial Partial-Thickness Burns(2ndDegree Burns)- form blisters, pink & wet- hypersensitive to pain- blanch with pressure- spontaneously heal< 3 weeks2. Deep Burnsa)Deep Partial-Thickness Burns(2ndDegree)- blisters, mottled pink and white- capillary refill is slow to absent- less sensitive to pain- heals in 3 to 9 weeks b) Full Thickness Burns(3rdDegree)- all layers of dermis- leathery, dry white, firm & insensate- develop “ESCHAR”- heal by contracture or skin grafting c) Fourth Degree Burns
 
- full thickness skin, SQ fat,fascia & muscles- electrical, contact, immersion burns in anunconscious patient
Assessment of Burn DepthMethods:
1. Clinical observation – only 70% accurate2. Detection of Dead cells or denatured collagen- biopsy, ultrasound, use of vital dyes3. Assessment of Change in Blood Flow- fluorometry, laser Doppler,thermography4. Analysis of Wound Color- light reflectance method5. Evaluation of Physical Changes- magnetic resonance imaging
Physiologic Response to Burn InjurySYSTEMIC INFLAMMATORY RESPONSESYNDROME
 
(SIRS)
- pathologic alterations in metabolic,cardiovascular, gastrointestinal and coagulationsystems- hypermetabolism, increased cellular, endothelialand epithelial permeability- extensive microthrombosis
BURN SHOCK 
- circulatory dysfunction
 
- increase in vascular permeability & micro-vascular hydrostatic pressureMediators:1.
Histamine
– release mast cells whichdisrupts venular endothelial junctions2.
Serotonin
– increase pulmonary vascularresistance3.
Eicosanoids
– increase levels of vasodilatorPG’s
Diagnostic Work-up
Complete Blood CountUrinalysis, BUN & Serum CreatinineBaseline electrolytesArterial blood gas determinationX-rays (Chest, other areas)Electrocardiography
Fluid Resuscitation
Recommended Fluids:Plain Lactated Ringer’s Solution = 1st24hoursColloids or D5Water = after 24 hours
Fluid Computation & Administration
a) 1st24 hours“Parkland Formula” TFR = BW x TBSA x 4 mg/kg/%burns(1/2 given in1st8H; 1/2 next 16H)b) 2nd24 hoursD5W replace evaporative lossesColloids maintain plasma volumec) After 48 hoursMaintenance Fluids = 30-40cc/kg/day
Parameters for Monitoring Fluid Therapy
1. Urine OutputAdults: 0.5 cc/kg/hourPedia : 1 cc/kg/hour2. Vital SignsBlood pressure & Heart rateCentral Venous Pressure3. Sensorium
Reasons for Failed Resuscitation
1. Delayed resuscitation2. Presence of electrical burns3. Smoke inhalation injury4. Coronary artery disease
Ancillary Management Measures
1. Gastric decompression2. Pain control & sedation3. Antibiotics4. Tetanus prophylaxis
Compartment syndrome:
a) Clinical Manifestations6 P’s:PulselessnessParesis/ParalysisPallorParesthesiaPainPoikilothermiab) Definitive Treatment: ESCHAROTOMYFASCIOTOMY Inhalation injury:1.
Carbon Monoxide Poisoning
Effects:a) prevents reversible displacement of O2b) decrease O2 unloading at tissue levelc) less effective intracellular respirationd) directly toxic to cardiac & skeletalmuscles Treatment: Hyperbaric Oxygen ???2.
Thermal Airway Injury
Manifestations:- mucosal & submucosal erythema- edema, hemorrhage & ulceration- potential for upper airway obstruction Treatment: Endotracheal Intubation3.
Smoke Inhalation
Factors:a) Type and amount of smoke inhaledb) Size of particulatesc) Duration of Toxic Exposured) Magnitude of thermal injury Clinical Manifestations:a) dyspneab) burned vibrissaec) carbonaceous sputumDiagnosis:a) Chest X-rayb) Bronchoscopy

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