Transcript Burn 1 - HKCEM

HKCEM College Tutorial
Burn 1
AUTHOR
DR. AXEL YC SIU
REVISED BY
DR. CHAN MING YIN
JULY, 2013
Case
▪ A 35 year old man was sent to the ED after
rescue from a household fire accident
What is your first priority of management?
▪ ABC
▪ Assessment of airway to rule out potential
airway burn
▪ Secure the airway in case of imminent
airway compromise
How would you assess the airway?
Airway Assessment
▪History
▪ Duration of exposure?
▪ Closed or entrapped environment?
▪ Any history of loss of consciousness?
▪ Fire involved chemical?
▪ Explosion e.g. LP gas
Airway Assessment
▪ Physical assessment
▪ Facial and neck burn
▪ Oro-pharyngeal +/- carbon deposits
▪ Singed nasal hair +/- eyebrows
▪ Carbonaceous sputum
▪ Hoarseness of voice
▪ Stridor
Case Progress
▪ Initial assessment showed BP 144/75mmHg, pulse
115/min, RR 28/min and SaO2 92% on 100%O2
▪ There was singed nasal hair and audible stridor.
How would you manage this patient?
Management on Compromised Airway
▪ Confirmation of airway burn
▪ 100% O2 by mask
▪ Secure the airway by endotracheal
intubation with rapid sequence intubation
▪ Close monitor vital signs
Case Progress
▪ After intubation, you noticed that
the SpO2 was still 93% in 100%O2 and the
high pressure alarm was on
▪ What are the possible reasons?
Possible Causes for
Persistent Hypoxaemia with High Airway Pressure
▪ D isplacement of tube
▪ O bstruction
▪ P neumothorax
▪ E quipment problem
▪ Lower airway burn
▪ Circumferential chest burn
Circumferential Full Thickness Burn
▪Please describe how would you
manage a circumferential full
thickness chest burn.
Escharotomy
▪ No analgesics is required
▪ Drape and sterilize
▪ Incise along the anterior axillary
line from supraclavicular region
down below the costal margin
▪ Additional horizontal incision may
be made along the subclavicular
and subcostal region
Deep to bleeding tissue!
Describe the fluid management
for
this patient
Fluid Management
▪ There are different fluid regimes for burn
▪ Modified Parkland Formula is commonly used:
▪ 2-4mL x TBA 2 degree or above Burn(%) x BW
Ringer Lactate Solution
▪ ½ to be given in the first 8 hours from time of
injury
▪ The rest to be given in the following 16 hours
What factors will affect your management of burn wounds?
Age
Depth
Extent
Location
Mechanism e.g. chemical, electrical
How do you estimate burn depth and burn area?
Depth of Burn Estimation
▪ 1st Degree Burn
▪ Involves epidermis
▪ 2nd Degree Burn
▪ Superficial partial thickness = epidermis with superficial dermis
▪ Deep partial thickness = epidermis with deep dermis
▪ 3rd Degree Burn
▪ Full thickness burn with damage to nerve ending
▪ 4th Degree Burn
▪ Full thickness burn involving underlying muscle or bone
BMJ 2004;329:158–60 Management of burn injuries of various depths
First degree
▪ Includes only the outer layer of skin, the epidermis
▪ Skin is usually red and very painful
▪ Typical example: sunburn
▪ Blistering may occur but is not common
▪ Dry in appearance
▪ Healing occurs within one week, injured epithelium peels
away from the healthy skin
▪ Hospitalization is for pain control and maybe fluid
imbalance
Second degree: Can be classified as superficial
partial thickness or deep partial thickness
▪ Superficial partial thickness
▪
▪
▪
▪
▪
upper dermis and the epidermis
Blistering is common
Wound will be pink, red in color, painful and wet appearing
Wound will blanch when pressure is applied
Healing is expected within two weeks by regeneration of epidermis
▪ Deep partial thickness
▪
▪
▪
▪
▪
Can be red or white in appearance, but will appear dry.
Involves the destruction of the entire epidermis and most of the dermis
Sensation can be present, but diminished
Blanching is sluggish or absent
may need excision & skin grafting to heal especially over functional or cosmetically
sensitive areas
Third degree
▪ All layers of the skin is destroyed
▪ Extend into the subcutaneous tissues
▪ Areas can appear, black or white and will be dry
▪ Can appear leathery in texture
▪ Will not blanch when pressure is applied
▪ No pain
Fourth degree
▪ Full thickness that extends into muscle and bone
Total Body Surface Burn Estimation
▪ Include 2-4 degree burn only ( not 1 degree)
▪ Standard Burn Chart (e.g. Lund and Browder
Chart)
▪ Rule of Nines
▪ Palm size estimation ( own palm size = 1%
excluding fingers)
Rule of Nines
Wound care
▪ Irrigate with copious NS for
chemical agent (do not use
neutralising agent)
▪ Cold stress should be avoided
( prevent hypothermia)
▪ Protect wound with clean
dressing
Miscellaneous Management
▪ Foley catheter should be inserted for urine output
monitoring in major burn patient
▪ Nasogastric or orogastric tube to relieve gastric
distension after intubation
▪ ATT prophylaxis if indicated
▪ Morphine by titration for pain after ABC taken
care of.
Baseline investigation
▪ Chest X-ray
▪ CBP, electrolytes and ABG
▪ Carboxyhaemoglobin as indicated
▪ Methaemoglobin as indicated
▪ Electrocardiogram for electrical burn
▪ X-match for major burn patients
What are the criteria for hospitalisation?
Extent of Burn
▪ Second degree and third degree burns of more
than 10% TBA in patients under 10 or over 50
years old
▪ Second degree and third degree burns of more
than 20% TBA in all other age group
▪ Third degree burns of more than 5% TBA in any
age group
Type of Burn
▪ Scald
▪ Flame burn
▪ Chemical burn
▪ Electrical burn
▪ Radiation burn
▪ Inhalation injury
▪ Circumferential burns
Special Area
▪Face
▪Hands
▪Feet
▪Perineum
Decreased host resistance
▪Diabetes Mellitus
▪AIDS
▪Alcoholism
Others
▪Burn patients with co-existing
trauma
▪Suspected child abuse
▪Inadequate care at home
Back to Case
▪ 30% 2-3degree burn with inhalation injury
▪ Intubated and ventilated, given Parkland formula IVF, wound
covered with dressing.
▪ Transfer to Burn unit?
▪ COHb 35%
▪ Troponin I elevated
▪ History of LOC now GCS 15/15. BP/P stable
▪ Hyperbaric oxygen therapy?
Thank You