Burn Management

Mohamed Ahmed Sayed
Assistant Lecturer of Plastic and Reconstructive Surgery Ain Shams University – Faculty of Medicine

dr_mohamed_a@yahoo.com http://www.geocities.com/dr_mohamed_a

• Burn wounds occur when there is contact between tissue and an energy source, such as heat, chemicals, electrical current, or radiation. • The effects of the burn are influenced by the: intensity of the energy duration of exposure type of tissue injured

Where do most burns occur?
• • • • 0 - 4 years, from kitchen, bathroom. 5-74 years, outdoors, kitchen. Teenagers, suicide (females). > 75 years, kitchen, outdoors.

When do most burns occur?
• Winter more than summer

Major cause of fires in the home
• Carelessness with cigarettes!! • Hot water from water heaters set at high levels above 60° C • Cooking accidents • Space heaters • Gasoline, lighter fluids, etc. • Chemicals

Types of Burn Injury
• Thermal burns: flame, flash, contact with hot objects. • Scald burns: hot fluids. • Chemical burns: necrotizing substances (acids, alkali). • Electrical burns: intense heat from an electrical current • Smoke & inhalation injury: inhaling hot air or noxious chemicals • Cold thermal injury: frostbite.

Thermal Burns

Scald Burns

Chemical Burn
examples: cleaning agents...

Remember….
• Tissue destruction may continue for up to 72 hours. • It is important to remove the person from the burning agent or vice versa. • The latter is accomplished by lavaging the affected area with copious amounts of water.

Smoke and Inhalation Injury
• Can damage the tissues of the respiratory tract • Although damage to the respiratory mucosa can occur, it seldom happens because the vocal cords and glottis closes as a protective mechanisms.

Electrical Burns

Electrical Burns
• Injury from electrical burns results from coagulation necrosis that is caused by intense heat generated from an electric current. • The severity depends on:
amount of voltage tissue resistance current pathways surface area in contact with the current length of time the current flow.

Electrical injury can cause:
• Fractures of long bones and vertebra • Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury • Severe metabolic acidosis--can develop in minutes • Myoglobinuria--acute renal tubular necrosis.

Treatment of electrical burns…
• Fluids--Ringers lactate or other fluids-flushes out kidneys--you want 75-100 cc/hr until urine sample clear • an osmotic diuretic (Mannitol) may be given to maintain urine output

Cold Thermal Injury (Frostbite)

Classification of Burn Injury
Severity is determined by:
– depth of burn – extend of burn calculated in percent of total body surface (TBSA) – location of burn – patient risk factors

Depth of Burns
Medicolegal classification
1st
Erythema

clinical classification

Super.

2nd

Dermal Deep Dermal

3rd

Full Thickness

Extend of Burns
Lund-Browder Chart Rule of Nines

Age in years A-head (back or front) B-1 thigh (back or front) C-1 leg (back or front)

0 9½ 2¾ 2½

1 8½ 3¼ 2½

5 6½ 4 2¾

10 5½ 4¼ 3

15 4½ 4½ 3¼

Adult 3½ 4¾ 3½

Location of Burns
• Vital organs of burn:
• Face, neck • Chest • Perineum • Hand • Joint regions • Other areas

Patient risk factors
• • • • • • • Associated trauma Inhalation injuries Circumferential burns Electricity Age (young or old) Pre-existing disease Abuse

3 Phases of Burn Management

–emergent (resuscitative) –acute –rehabilitative

Pre-hospital Care
• Remove from area! Stop the burn! • If thermal burn is large--FOCUS on the ABC’s
A=airway-check for patency, soot around nares, or signed nasal hair B=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of pulses

Other precautions...
• Burn too large--don’t immerse in water due to extensive heat loss • Never pack in ice • Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth

Emergent Phase (Resuscitative Phase)
• Lasts from onset to 5 or more days but usually lasts 24-48 hours • begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins • Greatest initial threat is hypovolemic shock to a major burn patient!

Management in the emergent phase is...
• Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn) • ventilator? ABGs? Escharotomies? • 6-12 hours later: Bronchoscopy to assess lower respiratory tact • chest physiotherapy, suction

Complications during emergent phase of burn injury are 3 major organ systems...

–Cardiovascular –Respiratory –Renal systems

Fluid Therapy
• 1 or 2 large bore IV lines • Fluid replacement based on:
– size/depth of burn – age of pt. – individualized considerations.

• options- RL, D5NS, dextam, albumin, etc. • there are formula’s for replacement:
– Parkland formula – Brooke formula

Assessment of adequacy of fluid replacement • Urine output is most commonly used parameter • Urine osmolarity is the most accurate parameter • UOP= 30-50 ml/hr in an adult

Wound care
• • • • Escharotomy / Fasciotomy Escharectomy + homograft Dressing / hydrotherapy Debridement

• Application of autograft

• Splinting
• PB contractures management

Wound Care continued...
• Staff should wear disposable hats, gowns, gloves, masks when wounds are exposed • appropriate use of sterile vs. nonsterile techniques • keep room warm • careful handwashing • any bathing areas disinfected before and after bathing

Other care measures include
• Face
– eye – ear

• Hands & arms • Perineum • Physiotherapy

Drug Therapy
• Analgesics and Sedatives • Tetanus immunization • Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy
• Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition.

Clinical Manifestations
• Burn wound either heals by primary intention or by grafting. • Scars may form & contractures. • Mature healing is reached in 6 months to 2 years • Avoid direct sunlight for 1 year on burn • new skin sensitive to trauma

Care of

BURNS

B - breathing U - urine output R - rule of nines resuscitation of fluid N - nutrition S - shock silvadene

Referral Criteria
• • • • • • • 2nd or 3rd Degree Burns >10% TBSA Burns to vital organs of burn circumfrential burns Electrical Burns Chemical Burns Inhalation Injury

Referral Criteria
• Concomitant trauma (If Major Trauma, The Trauma Center , Not the Burn Center should be the initial stabilizing unit) • When in doubt , consult with a burn center

Questions?

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