Case Audit

Mixed degree
burns
Dr Hareesh Kumar R
Dept of General Surgery
Case History

● 37 year old female

● Schizoaffective disorder on irregular medication
● Suicidal
● Ingestion of lysol 100ml
● Self inflicted burns to the body
● Severe pain
● Taken to apollo hospitals initial care given
● Brought to SMF by own request
Examination

● Conscious, oriented
● Vitals HR 110 /mt BP 100/60
● Temp 100 deg F
● Oral cavity Normal
● Systemic examination : Unremarkable
● Examination of trunk and torso

Mixed degree burns variable from first to third degree

(20%)

1. Lower abdomen 4%
2. Both thighs 14%
3. Right Hand 2%
INVESTIGATIOMS

● Hb 11.2
● TC 12600 85%Polymorph predominance
● Sr Na. 136
● Sr K. 3.3
● ECG Sinus rhytm
Management

● Fluid resuscitation by Parkland formula given

● Serial potassium monitoring and IV correction given for
hypokalemia
● Urine output monitored
● Antacids, analgesics, antibiotics given
● Trial of oral fluids given and advanced serially
● MGE consult advised mucoprotective agents and UGIE at a later
date
● Psychiatrist consult started on Lonazepam and Risperidone
● Maintenance fluid given post parkland formula
Operative management

● Day 1 Wound wash with collagen dressing application under

GA
● Day 3 Tangential excision of slough and necrosis, debridement
and SSG under SA
● Post debridement blood loss transfusion done as per Hb and
PCV
● Maintainence IV continued
Post Operative period

● Adequately hydrated
● Antibiotic continued
● Temperature spike after 2 days
● Mobilised
● Loose stools after 3days
● Developed tachycardia and respiratory distress
● started on supplemental oxygen
● Physician consult taken
● ABG revealed respiratory acidosis, hypotension, decreasing
urine output
● Shifted to Intensive care
Course in ICU

● Hypotension started on. Vasopressors

● Worsening respiratiry acidosis, ET ventialation connected
● TC 2600 sr K+ 3.01
● Persistent hypotension
● Sepstic shock
● Asystole within 12hrs of reception to ICU
● Failed CPR
● Death
BURNS

1. Flame: damage from superheated, oxidized air

2. Scald: damage from contact with hot liquids
3. Contact: damage from contact with hot or cold solid materials
4. Chemicals: contact with noxious chemicals
5. Electricity: conduction of electrical current through tissues
Classification
Treatment of Burns

1. Prehospital care
2. Primary Survey
3. Secondary Survey
4. Definitive care
Prehospital care

● Removal of the source

● Inhalation injury - 100% O2 supplementation
● Remove burning cloths and ornaments
● Universal precautions if possible
● Safety of care giver
● Room temperature water within 15mins
● Avoid hypothermia
Primary survey

1. Identify immediate Life threatening conditions

2. Airway evaluation and protection
3. Breathing pattern
4. Circulation - State of shock
5. Exposure
Secondary survey

● Head to toe evaluation

● Assessment of Degree of burns
● Spine stabilisation in trauma

Definitive care
1. Cover the wounds
2. Fluid resuscitation
3. Wound Management
Fluid resuscitation

● 2 large bore IV access

● Crystalloids preferably Ringer Lactate
Wound Care

1. Cover the wounds

2. Antimicrobials
a. Topical
b. Systemic
3. Operative management
Operative management

● Aggressive early excision of the burn tissue and early wound

closure
● significant improvement of mortality rates and substantially
lower costs
● Decreased severity of hypertrophic scarring, joint contractures,
and stiffness
● Quicker rehabilitation
● Partial-thickness wounds preserve viable dermis
● Full-thickness injury, all necrotic and infected tissue removed
Techniques

1. Tangential excision : Depth 0.005 to 0.010 inch until a viable dermal bed is reached, till
punctate bleeding.
2. Full-thickness excision. 0.015 to 0.030 inch, serial passes are made excising the
full-thickness wound.
3. Fascial excision burn extending down through the fat into muscle, when the patient
presents late with large infected wounds and life-threatening invasive fungal infections.

Skin Cover

1. Biological dressings
2. Autograft
3. Allo graft
1. Prevent infection
2. Serial wound dressings
3. Nutritional support
4. Physical rehabilitation
5. Counselling
Post operative Complications

1. Sepsis due to infection

2. MODS
● Sepsis
● Inflammatory cascade burden
Conclusion

First 48 hrs - Shock - Failed resuscitation

After 48 hrs -Sepsis/SIRS - Failed metabolism