Transcript initial management of burns

INITIAL MANAGEMENT OF
THERMAL INJURIES
DR L.N.KAHORO
PLASTIC SURGEON
KNH
INTRODUCTION
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THERMAL INJURIES ARE A MAJOR CAUSE
OF MORBIDITY AND MORTALITY
IN KNH TOTAL BURN ADMISSION PER
YEAR AVERAGE 1000; OF THESE ABOUT
400 ARE SEVERE BURNS THAT REQUIRE
ADMISSION TO BU; ≥30% IN ADULTS AND
≥20% IN CHILDREN
BURNS OF ≥ 20% ARE CONSIDERED
SEVERE BURNS
CARE OF THE BURN
PATIENT
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EARLY CARE WILL DICTATE
CLINICAL COURSE AND OUTCOME
AND THUS THOROUGH
UNDERSTANDING OF PRINCIPLES IS
ESSENTIAL
MOST EARLY CARE OCCURS IN
NON-BURN CENTERS
EARLY CARE IS THE SAME AS FOR
ALL TRAUMA PATIENTS
FOLLOW ATLS PRINCIPLES
PRIMARY SURVEY
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A=AIRWAY AND CERVICAL CORD CONTROL
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IDENTIFY INHALATON INJURY
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LOOK FOR THE FOLLOWING S/S
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HISTORY OF IMPAIRED MENTATION AND/OR CONFINEMENT IN
AN ENCLOSED BURNING ENVIRONMENT
HISTORY OF EXPLOSION WITH BURNS TO TORSO AND HEAD
HEAD AND/OR NECK BURNS
SINGEING OF NASAL HAIRS AND EYEBROWS
PERIORAL AND ORAL BURNS
CARBONACEOUS SPUTUM
HOARSENESS OF VOICE
STRIDOR
PROPHYLACTIC INTUBATION IS VERY IMPORTANT
MUST RULE OUT CERVICAL CORD INJURY
INITIAL ASSESSMENT AND MANAGEMENT
OF THE AIRWAY
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If Stridor Retraction or Respiratory Distress present or Deep Burns: Face,
Neck
*Intubate now!
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*Use adequate size tube
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*Humidified oxygen
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*Elevate Head
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*Transport to Burn Center
If Sridor retraction or respiratory Distress absent and no deep burns face
and /or neck
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*Provide 100% Oxygen
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*Look for Signs of Airway Injury
- Oropharyngeal erythema
- Hoarseness
- Pulmonary status
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* Can perform laryngoscopy
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* If edema present, intubate now
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* Transfer to Burn Center if history or findings are positive for smoke
inhalation injury
REMEMBER: DETERIORATION IS OFTEN DELAYED IN ONSET.
B=BREATHING
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MAKE SURE PT IS BREATHING
RULE OUT ANY CONCOMITANT
CHEST INJURY
DO CHEST ESCHAROTOMIES IF 3ᵒ OR
4ᵒ BURNS THAT ARE TIGHT AND
RESTRICTING CHEST MOVEMENT
DO BASELINE ABGS
INTUBATE AND MECHANICALLY
VENTILATE IF NEEDED
C=CIRCULATION
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FLUID RESUSCITATION IS VITAL IN BURNS
NO FLUIDS IN 50% BURNS PT IN 4 HRS EQUALS ARF
PARKLANDS FORMULA STILL BEST
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USE CRYSTALLOIDS USUALLY RINGERS LACTATE IN FIRST 24HRS AND CONSIDER
ALBUMIN OR FFP AFTER THIS PERIOD
INSERT URINARY CATHETER AND MONITOR HRLY URINE OUTPUT TO MAINTAIN AT
1ML/KG/HR FOR CHILDREN WITH WEIHGT ≤30KG AND 0.5ML/KG/HR FOR ADULTS
ADD MAINTAINANCE FLUID AS 5%DEXTROSE FOR CHIDREN DUE TO THEIR
REDUCED GLYCOGEN STORES
ADJUST FLUID BASED ON PATIENT RESPONSE
MUST GET IV ACESS
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4MLS X %TBSA X KG BODY WEIGHT
GIVE HALF THIS AMOUNT IN IST 8 HRS AND THE REST IN THE NEXT 16HRS
WIDE BORE PERIPHERAL ACESS G16 AND BIGGER
CVP
VENOUS ACESS CAN BE DONE THROUGH BURNED SKIN IF NO OTHER ALTERNATIVE
MUST RESTORE CIRCULATION IN AT RISK EXTREMETIES DUE TO A TIGHT ESCHAR.
DO ESCAROTOMIES TO RELIEVE THE TISSUE PRESSURE
Resuscitation Fine Points
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MORE IS NOT
BETTER!!!
CRYSTALLOID … NOT
COLLOID & ONLY LR
GOAL IS
NORMOTENSIVE,
PERFUSED, URINATING
PT.
< 4 CC OF LR /KG/%TBSA
 CENTRAL
MONITORING
ESCHAROTOMIES
ACS IS
UNACCEPTABLE!!!
RESUSCITATION EXAMPLE
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50 % BURN IN A 70 KG ADULT
4 X 50 = 200 X 70 = 14000 / 2 = 7000 / 8 = 875 ML/HR
START LACTATED RINGERS SOLUTION
GOAL IS 30 - 50 CC OF URINE / HOUR
URINE OUTPUT GREATER THAN GOAL
DECREASE FLUID RATE BY 10%
URINE OUTPUT LESS THAN GOAL
INCREASE FLUID RATE BY 10%
AVOID FLUID BOLUSES
THEY ONLY INCREASE EDEMA
C=CIRCULATION
Example of escharotomy of an upper limb with deep burns
D=DISABILITY
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CHECK FOR ANYOTHER DISABILITY
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ASSOCIATED INJURIES THAT MAY
TAKE PRECEDENCE IN MANAGEMENT
SUCH AS HEAD, ABD ,CHEST OF
MUSCULOSKELETAL TRAUMA
ESPECIALLY IN BURNS WHERE
EXPLOSION OCCURRED OR IN MOB
JUSTICE PTS
LOSS OF CONSCIOUSNESS OR
DEPRESSED MENTATION RULE OUT
CO POISONING
E=EXPOSURE/ENVIRONMENT
CONTROL
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EXPOSE THE BURNS PT IN ORDER TO EXAMINE
FURTHER.
REMOVE ALL CLOTHES AND JEWERELY
CAREFULLY REMOVE CLOTHES THAT WERE BURNED
BY CHEMICAL; BRUSH OFF POWDER CHEMICAL
BEFORE REMOVAL; AVOID DIRECT CONTACT WITH
CHEMICAL
RINSE AREAS AFFECTED BY CHEMICAL BURNS WITH
COPIOUS AMOUNTS OF WATER
CONTROL THE ENVIRONMENT BY HEATING THE
ROOM OR ADEQUATELY COVERING PT WITH CLEAN
LINEN TO PREVENT HYPOTHERMIA
SECONDARY SURVEY
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THOROUGH HISTORY
HEAD TO TOE EXAM
DOCUMENTATION
BASELINE INVESTIGATIONS
WOUND CARE
TREATMENT
HISTORY
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DETAILED ACCOUNT OF INCIDENT
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MECHANISM OF BURN SHOULD
CORELATE WITH CLINICAL
PRESENTATION
AMPLE
TIME OF INCIDENT
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IMP. FLUID RESUSCITATION PERIOD
BEGINS AT TIME 0 OF BURNS
HEAD TO TOE EXAM
•DETERMINE BURN WOUND DEPTH
• 1ᵒ
•2ᵒ SUPERFICIAL
•2ᵒ DEEP
•3ᵒ
•4ᵒ
HEAD TO TOE EXAM
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DETERMINE %TBSA
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RULES OF 9’S IN ADULTS
RULES OF 7’S IN OLDER CHILDREN
LUND AND BROWDER CHARTS
PT’S PALM AND FINGERS = 1%
ESTIMATING THE TBSA OF A
BURN
DOCUMENTATION
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DETAILS AND TIME OF INJURY
AMOUNT OF FLUIDS INFUSED
INTERVENTIONS DONE
TREATMENTS GIVEN
RESULTS OF BASELINE
INVESTIGATIONS AND VITAL SIGNS
DOCUMENTATION
BASELINE INVESTIGATIONS
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ABGS
HGRAM
U/E/CREAT
SERUM GLUCOSE
CHEST XRAY/CERVICAL XRAY IF
NECESSARY
WOUND CARE
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COVER WITH CLEAN LINEN
KEEP WARM
DEFINITIVE WOUND CARE TO BE DECIDED IN
THE RECEIVING WARD
NON ADHESIVE DRESSING ,GAUZE AND CREPE
BANDAGE FOR 2ᵒBURNS
SILVER SULPHADIAZINE CREAM,GAUZE AND
CREPE BANDAGE FOR 3ᵒ AND DEEPER BURNS
EARLY EXCISION AND GRAFTING ≤ 7 DAYS
POST BURN HAS REDUCED MORTALITY
TREATMENT AND OTHER
INTERVENTIONS
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TUBES-NGT, URINARY
CATHETER,INTRAVENOUS CATHETER, ETT,
EARLY ENTERAL NUTRITION IS VERY
IMPORTANT
PHYSIOTHERAPY AND SPLINTING FROM DAY 1
DRUGS
 T. T INJ
 ANALGESICS- NO IM ROUTE; IV OR ORAL IF
TOLERATED
 NO PROPHYLACTIC ANTIBIOTICS
CHEMICAL BURNS
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SEVERITY DEPENDS ON : TYPE OF
CHEMICAL,CONCENTRATION,QUAN
TITY AND CONTACT TIME
WATER LAVAGE FOR BURN
WOUNDS IS THE MOST IMP
IMMEDIATE INTERVENTION
IRRIGATION LONGER IN ALKALI
BURNS AND BURNS TO THE EYES
EVEN UPTO 8 HRS
ELECRICAL BURNS
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DEPTH DEPENDS ON VOLTAGE AND RESISTANCE OF
TISSUE.BONE› FAT ›TENDON › SKIN › MUSCLE › BLOOD
›NERVE
DIVIDED INTO HIGH VOLTAGE ˃ 1000V AND LOW
VOLTAGE ˂1000V
INJURY MAY BE HIDDEN. RELATIVELY NORMAL SKIN
MAY HIDE MUSCLE NECROSIS
IV FLUID RESUSCITATION VOLUMES SHOULD BE
INCREASED TO MAINTAIN URINE OUTPUT OF AT LEAST
100MLS /HR IN ADULT
WATCH OUT FOR MUOGLOBINURIA AND MAY NEED
INTERVENTION WITH MANNITOL
MAY AFFECT OTHER SYSTEMS
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NERVOUS SYSTEM
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CARDIAC- DO CARDIAC MONOTORING
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MUSCULOSKELETAL- FRACTURES AND
DISLOCATIONS
IF HIGH VOLTAGE INJURY IN EXTEREMITIES PT WILL
NEED FASCIOTOMY URGENTLY
ELECTRICAL INJURIES
EXAMPLE OF HIGH VOLTAGE BURN IN AN UPPER
EXTREMITY THAT WILL NEED FASCIOTOMY
EXAMPLE OF LOWER LIMB
FASCIOTOMY FOR
ELECTRICAL BURN
DECREASED MORTALITY FROM
MAJOR THERMAL INJURY HAS BEEN
DUE TO ADVANCES IN:
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RESUSCITATION
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CONTROL OF INFECTION
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SUPPORT OF THE HYPERMETABOLIC
RESPONSE TO TRAUMA
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EARLY CLOSURE OF THE BURN WOUND
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MANAGEMENT OF INHALATION INJURY