Sunday, March 15, 2015
DEGREES OF BURN AND MANAGEMENT
- BURNS & SCALDS
- ELECTRICAL BURNS
- CHEMICAL BURNS
- RADIATION
- LIGHTENING
PRE-HOSPITAL CARE
- Remove patient from source
- Extinguish burning clothes
- Careful with electric source
- CPR
- If hospital is 30- 45 min away try to start IV
- Cold soaks ↓ pain but ↓ heat, so avoid hypothermia
- Cover the areas with clean sheets
- 100% O2 if suspected CO poisoning
- Check for respiratory burns
IN EMERGENCY
- ABC
- Assess the percentage and degree of burn
- Start IV line and infuse Ringer’s Lactate and calculate the fluid requirement
- Take patient’s weight
- Catheterize
- Oxygen if required
- TT injection
- Morphine
- Wound care- clean with saline and apply 1%silver sulphadiazene
- No role of prophylactic antibiotic
ASSESSMENT OF BURNS
Wallace’s Rule of Nine-in adults each upper extremity, and the head and neck are 9% TBSA, lower extremities, anterior and posterior trunk each are 18% while genitalia and perineum forms 1% of TBSA
Infant head is 18 % and lower limb is 14%, for each year after one year 1% to be taken off the head and neck area and added to the lower limbcs
Patient’s palm as 1 %
FLUID RESUSCITATION
- Modified Parkland’s formula
- 4ml X Body weight X % Burns ( 50 % )
- Ringer’s lactate to be given. 50% in first eight hours from the time of burns
- 50% in next 16 hours
- Response- 1ml/Kg/hr urine output. 50-70ml in adults
DEGREES OF BURN
FIRST DEGREE
- Sunlight exposure or burn by hot tea cup
- Injury confined to epidermis
- Red and dry
- Very painful
- Heals in 3-6 days without scarring
- Not included while calculating fluid requirement for burns
SECOND DEGREE SUPERFICIAL
- Hot liquid or flash flame
- Pink or mottled red in appearance
- Blisters or bulla, soft and moist
- Painful
- 7-10 days to heal and may have hypo or hyper pigmented areas
SECOND DEGREE DEEP
- Chalky white
- Soft and moist
- Sensation is obtunded
- More than 21 days to heal
- Heals with lot of scarring and contractures
THIRD DEGREE BURN
- Prolonged exposure or electric burn
- Dry and parchment like
- Translucent, can see fat and thrombosed veins
- No sensation
- Needs debridement of eschar and skin grafting
MAJOR BURNS
Partial thickness greater than 25%
Partial or full thickness burns of face, hands, genitalia and feet
Third degree burn greater than 10% area
Burns complicated by
Respiratory tract injury
Major soft tissue injury
Fractures
Electrical burns
MODERATE
Second degree burns 15-25%
Third degree less than 10% except hands, face and feet
MINOR
Second degree less than 15 %
Third degree less than 2 %
PATHOPHYSIOLOGY
Jackson’s three zones
- Zone of coagulation
- Zone of stasis
- Zone of hyperaemia
CVS- shift of fluid, ↓cardiac output, greater than 25 % burn even non burned tissue also swell
LUNGS- hyperventilation, ↓ protein, poor lung function
GIT- ileus, mucosal ischaemia, curling’s ulcers, translocation of bacteria
RENAL- renin- angiotensin- aldosterone system activated, ↓ urine output, ATN
IMMUNE SYSTEM- destruction of barrier, depression of cellular immunity
BODY TEMP. – loss of protective mechanism, heat loss & hypothermia, ↑ spike after dressing due to pyrogens such as interleukin-1
WOUND CARE
Clean with surgical detergent or clean water shower or water tank and twice daily dressing with 1% SSD
BIOLOGICAL DRESSINGS
Allograft, skin substitutes- collagen amino acid films
Amnion, porcine skin, integra, homograft, Burn mesh
Local care
Dressings
Open- neck, hand,
occlusive,
Biological
Early surgical excision and grafting
Tangential excision
ANTIBACTERIALS
Sulfonamide
Thick application
Twice daily
Good penetration
Silver Nitrate
Bacteriostatic
Black discoloration
Thick pads required
Leaching of Na, K, Cl, Mg and Ca
Poor penetration
Silve sulphadizene
1968 Charles Fox
Silver nitrate and acid sulphadizene
Bacteriostatic
Good penetration
Gentamicin
2.2% Cerium nitrate and SSD
NUTRITION
Metabolic needs ↑ by two to three fold
CURARIE FORMULA
25KCal x Body weight + 40KCal x % Burns
Supplement Vit C, zinc and B complex
INFECTION ( Clinical)
Conversion of 2o - 3o
Focal dark brown or black discoloration
Degeneration of wound with neoeschar
Rapid separation of eschar
Hemorrhagic discoloration of subeschar fat
Erythematous wound margin
Metastatic septic lesion in unburned tissue
INFECTION ( Histological)
Organism in unburned tissue
Hemorrhage in unburned tissue
↑ inflammatory reaction in adjacent tissue
Small vessel thrombosis or ischaemic necrosis of unburned tissue
Perineural and intralymphatic migration of organism
Vasculitis and perivascular cuffing of organisms
Other septic complications
- Pneumonia
- Sup. Thrombophlebitis
- Endocarditis
- Sepsis
Verduria
FASCIOTOMY, ESCHAROTOMY, ESCHARECTOMY, SKIN GRAFTING
Eschar is the burnt dead skin
Fascia is the deeper tissue covering the muscles
Burn wound excision
↓ hospital stay
↓ sepsis ( greater than 30% increased chance of sepsis)
Better cover, early healing, ↓ scar
Rapid restoration of function
ESCHAROTOMY
- If vascular or respiratory compromise due to thick constricting eschar
- Escharotomy done at the neutral lines.
- If no improvement do fasciotomy( mostly in electric burns)
ESCHARECTOMY
Surgical removal of eschar
Early- done in 7- 12 days
Late- separates after two weeks.
Prepares bed for early grafting
Tangential excision and grafting
In second degree deep burns
Done on 2nd to 5th day
After 7 days it softens
Not more than 20% in one sitting
SEQUENTIAL EXCISION
- Done in deep second degree and third degree burns
- Blood loss 5% area one unit blood required
- Eschar sequentially removed with a guarded knife and grafted
Pinch, mesh, stamp, sheet
Thin, Intermediate, Thick ( Split thickness graft)
Full thickness graft
Priority areas
face, hands, axilla, cubital and popliteal fossa
Autograft, homograft, heterograft
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- Low voltage ( greater than 1000 volts )
- High voltage ( less than 1000 volts )
- Conversion of electrical energy to heat is governed by Ohm’s law
- C= V/R current in amperes
- Joule’s Law- J= C2RT relation between current and heat production
- Bone offers the most resistance
- Current takes the shortest path
- Body acts as volume conductor
- Arc injury is very deep
- “no release” phenomenon
- Skeletal injury due to fall.
- Cardiac- arrest, VT, AF, SVT, RBBB
- Renal- ARF, Myoglobinuria
- CNS- convulsions, coma, paraplegia
- Abdomen- Splenic injury
MANAGEMENT
General
Deep burns- maintain urine output of 2ml/kg/hr
Mannitol 12.5 gm/hour
50ml 7.5% NaHCO3 ( 45 mEq)
Cardiac monitoring ( CPK-MB)
