Burn lecture.ppt
- 2. BURN INJURIES & ITS MANAGEMENT BY:MR Samir Ismail 4/1/2011 2
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- 4. GOALS Prevent complications Vital signs hourly Assess respiratory function Tetanus booster Anti-infective Analgesics No aspirin Strict surgical asepsis Prevent contractures- physiotherapy 4/1/2011 4
- 5. DIFINTION Physical trauma due to effect of heat resulting of various degrees of coagulation of tissue protein 4/1/2011 5
- 6. CLASSIFICATION According to the mechanism of injury AETIOLOGY 1-Fire - flame , flash burn 2-Contact burn 3-Chemical 4-Electrical 5-Radition 6- Scalds -caused by liquid , steam
- 7. Classification of burn according to mechanism of injury used as indicator of out come and hospitalization admission
- 8. BURNS Results in 10-20 thousand deaths annually Survival best at ages 15-45 Children, elderly, and diabetics have poor prognosis. Survival best burns cover less than 20% of TBA 4/1/2011 8
- 9. Burns are classified according to the surface area involved and according to the depth of the burnt tissues. 4/1/2011 9
- 10. CLASSIFICATION ACCORDING TO DEPTH OF INJURY 1- first degree burn :- There is minor epithelial injury of the epidermis There is redness , tenderness and pain Blistering not occurs Tow point discrimination are intact Healing without scar Caused by flash and sunburn Blanching on pressure.
- 11. Radiation burns UV light X-rays sunlamps radiation therapy 4/1/2011 11
- 12. 2-Second degree :- Superficial partial thickness and deep partial thickness , it tow type In this type some portion of the skin remain intact allowing epithelial repair of the burn without skin graft . Superficial partial thickness involve the epidermis and superficial dermis Heal in 2-3 wk without scaring
- 13. Deep partial thickness extent into deep dermis The capillary refill is slow skin color is mixture of red and white Heal within 3-6 week Sever pain. Vesicle formation.
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- 18. Third degree :- Is full thickness burn destroy both epidermis and dermis The capillary network of the dermis is completely destroyed burn skin is white Anesthetic skinno sensation Heal by contraction >1cmskin graft l.
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- 20. Causes scald – flame – chemical – electrical. 4 Fourth degree burn: It‘s full thickness burn destroy the skin and subcutaneous tissue with involvement of fascia, muscle , bone. It‘s due to prolong exposure to usual causes of 3rd degree burn.
- 21. Fourth-degree burns epidermis, dermis and underlying tissue symptoms black skin no sensation example - flames 4/1/2011 21
- 22. Classification according to severity of burn:- 1-Major burn:- Is partial thickness burn involving >25%TBSA in adult or 20% in child <10yr or older than 50yr Full thickness burn involving >10%TBSA. burn involving the ,face , eyes ,ears ,hand ,feet or perineum that may result in functioning or cosmetic impairment Burn complicated by inhalation injury
- 23. 2-Moderate burn :- Partial thickness burn of 15-25% in adult or 10-20% in child Full thickness burn 2-10%without functional or cosmetic problem
- 24. 3-Minor burn :- Burn<15%in adult or 10%in child Full thickness burn <2 % TBSA without functional or cosmetic problem
- 25. Radiation burns UV light X-rays sunlamps radiation therapy 4/1/2011 25
- 27. Chemical burns strong acids strong bases solvents 4/1/2011 27
- 29. ELECTRICAL BURN accidental electrical contact depend on: strength of electrical current duration of contact common causes : workplace injuries rare causes: lightning 4/1/2011 29
- 30. Thermal burns flames hot liquids hot objects gases 4/1/2011 30
- 31. BURN WOUND ASSESSMENT Classified according to depth of injury and extent of body surface area involved Burn wounds differentiated depending on the level of dermis and subcutaneous tissue involved 1. superficial (first-degree) 2. deep (second-degree) 3. full thickness (third and fourth degree) 4/1/2011 31
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- 33. CLASSIFICATION Burn assessment as follow 1- According to the surface area: A. In small burns the best measurement is to cut a piece of clean paper the size of the patient’s whole hands (digit and palm) which represent 1% TBSA and match this to the area
- 34. B. In large burns the Lund and Browder chart is useful which maps out the percentage TBSA of sections of our anatomy
- 35. C. Rule of nine: which is adequate for the first approximation only it states that each upper limb is 9%, each lower limb 18%, the trunk 18% each side and the head and neck 9%
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- 39. Full Thickness Burn Partial Thickness Burn White or black Mottled red Dry Moist due to exudation of plasma Possible visible thrombosed SC vessels Blisters surrounded by erythema Painless due to loss of terminal nerve endings Painful and sensitive Granulation tissue formation and scar separation starts after 3 weeks Heals within 3 weeks
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- 41. CALCULATION OF BURNED BODY SURFACE AREA Calculation of Burned Body Surface Area 4/1/2011 41
- 42. TOTAL BODY SURFACE AREA (TBSA) Superficial burns are not involved in the calculation Lund and Browder Chart is the most accurate because it adjusts for age Rule of nines divides the body – adequate for initial assessment for adult burns 4/1/2011 42
- 43. LUND BROWDER CHART USED FOR DETERMINING BSA 4/1/2011 43 Evans, 18.1, 2007)
- 44. RULES OF NINES Head & Neck = 9% Each upper extremity (Arms) = 9% Each lower extremity (Legs) = 18% Anterior trunk= 18% Posterior trunk = 18% Genitalia (perineum) = 1% 4/1/2011 44
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- 46. GOALS Prevent complications Vital signs hourly Assess respiratory function Tetanus booster Anti-infective Analgesics No aspirin Strict surgical asepsis Prevent contractures Emotional support 4/1/2011 46
- 47. MANAGEMENT OF THE BURNED PATIENT First aid: Stop the burning process: Flames from burning clothing or from burning inflammable substances on the skin surface should be stoped by wrapping the patient afire blanket or any other readily available garment such as the bystander's own clothing. With electrical burns it is important that any live current is switched off, and with chemical burns the first-aid worker must avoid contact with the chemical. Burned or water-soaked clothing should be removed.
- 48. Cool the burn surface: Immediate cooling of the part is beneficial and should continue for 20 minutes. With scalds, irrigation with cold water under a tap is best and many a child has had scald damage successfully limited by pouring a readily available jug of cold water or milk immediately over the scalded area. Irrigation in cold water is particularly valuable for chemical burns. Hypothermia must be avoided. Don not uses ice or iced water. The burn should then be wrapped in any clean linen ' and the patient transported immediately to hospital.
- 49. Fluid – major burn nil by mouth, get an I.V going Emergency examination and treatment: The order of priorities in the management of major burn injury is: A: airway maintenance; B: breathing and ventilation; C: circulation; D: disability – neurological status; E: exposure and environment control – keep warm; F: fluid resuscitation
- 50. GUIDELINES FOR MANAGEMENT Admit: criteria for admission Any burn over 10% in area extrem ages. IV fluids for burns over 15%. Burns in special areas face, neck, hands, feet, perineum. Electrical burns any burn with history of smoke inhalation. Chemical burns. Full thickness where grafting is indicated. circumferential burn of thorax or extremities
- 51. S , co-existing major trauma or significant pre-existing medical conditions. At all ages2nd&3rd degree burns more than 20%. At all ages group 3rd degree brunt's 5_10%. Pregnancy. Burn incluk,de major joint 4/1/2011 51
- 52. ON ADMISSION: Get a history, include time and place of burn, causing agent, details of the accident (can provide clue to the depth of burn). Age of patient, weight, general health (heart, lung, kidney). Ask for possibility of inhalation injury. Look for co-factors that can affect courses e.g. drug addiction, immune , urine output since injury. Medication given, tetanus status. The burn wound should never take precedence over potential life threatening complications.
- 53. EXAMINATION Estimate area of burn, how much is full thickness. Look for signs of respiratory burns. Examine eyes. Look for circumferential burns on chest, limbs. Complete full physical examination
- 54. Fluid resuscitation: It is important at an early stage to secure large bore intravenous lines.
- 55. Pain management Adequate analgesia imperative! DOC: Morphine Sulfate Dose: Adults: 0.1 – 0.2 mg/kg IVP Children: 0.1 – 0.2 mg/kg/dose IVP / IO Other pain medications commonly used: Demerol NSAIDs 4/1/2011 55
- 56. FLUID THERAPY Occurs after initial vasoconstriction, then dilation Blood vessels dilate and leak fluid into the interstitial space Known as third spacing or capillary leak syndrome Causes decreased blood volume and blood pressure Occurs within the first 12 hours after the burn and can continue to up to 36 hours 4/1/2011 56
- 57. COMMON FLUIDS Protenate or 5% albumin in isotonic saline (1/2 given in first 8 hr; ½ given in next 16 hr) LR (Lactate Ringer) without dextrose (1/2 given in first 8 hr; ½ given in next 16 hr) Crystalloid (hypertonic saline) adjust to maintain urine output at 30 mL/hr Crystalloid only (lactated ringers) 4/1/2011 57
- 58. SKIN ASSESSMENT Assess the skin to determine the size and depth of burn injury The size of the injury is first estimated in comparison to the total body surface area (TBSA). For example, a burn that involves 40% of the TBSA is a 40% burn Use the rule of nines for clients whose weights are in normal proportion to their heights 4/1/2011 58
- 59. Parkland Formula 4 cc R/L x % burn x body wt. In kg. ½ of calculated fluid is administered in the first 8 hours Balance is given over the remaining 16 hours. Maintain urine output at 0.5 cc/kg/hr. 4/1/2011 59
- 60. Parkland Formula ARF may result from myoglobinuria Increased fluid volume, mannitol bolus and NaHCO3 into each liter of LR to alkalinize the urine may be indicated 4/1/2011 60
- 61. Assessing adequacy of resuscitation Peripheral blood pressure: may be difficult to obtain – often misleading Urine Output: Best indicator unless ARF occurs A-line: May be inaccurate due to vasospasm CVP: Better indicator of fluid status 4/1/2011 61
- 62. Assessing adequacy of resuscitation Heart rate: Valuable in early post burn period – should be around 120/min. > HR indicates need for > fluids or pain control Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre- existing cardiac disease) 4/1/2011 62
- 64. DRESSING THE BURN WOUND After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound 4/1/2011 64
- 65. DIET Initially NPO Begin oral fluids after bowel sounds return Do not give ice chips or free water lead to electrolyte imbalance High protein, high calorie 4/1/2011 65
- 66. DEBRIDEMENT Done with forceps and curved scissor or through hydrotherapy (application of water for treatment) Only loose scar removed Blisters are left alone to serve as a protector – controversial 4/1/2011 66
- 67. SKIN GRAFTS Done during the acute phase Used for full-thickness and deep partial- thickness wounds 4/1/2011 67
- 68. Lab studies Severe burns: CBC Chemistry profile ABG with carboxyhemoglobin Coagulation profile U/A Type and Screen blood. CPK and urine myoglobin (with electrical injuries) 12 Lead EKG 4/1/2011 68
- 69. Imaging studies CXR Plain Films / CT scan: Dependent upon history and physical findings 4/1/2011 69
- 70. GENERAL COMPLICATIONS: Neurogenic Shock: immediately after burn & last after 2 hrs. Olygogenic shock: occurs after several hrs & manifested by Hypotension & haemoconcentration due to loss of plasma, Fluid & electrolytes & break down of proteins. Anemia due to loss of RBCs. 4/1/2011 70
- 71. Renal failure due to deposition of pigments in the tubules due to hemolysis, anoxia following shock leading to tubular necrosis. Liver failure due to focal necrosis resulting from anoxia. Adrenal failure due to stress of burn & anorexia of shock. Hypothermia due to disturbed skin thermoregulation. A duodenal ulcer called Curling ulcer occurs in the 1st part of the duodenum during the 2nd weak of burn. Cardiac arrest &arrhythmia 4/1/2011 71
- 72. LOCAL COMPLICATIONS: Local loss of plasma → hypoproteinemia. infections. Edema of glottis → Suffocation & may require tracheostomy. pulmonary complications following inhalation of smoke. Nerve injuries → Loss of sensation. Vessels injuries → leading to gangrene. deformities of joints & muscles. Keloid formation (an ugly protruded scar). 4/1/2011 72
- 73. Circumferential burns of the chest Eschar - burned, inflexible, necrotic tissue Compromises ventilatory motion Escharotomy may be necessary Performed through non-sensitive, full-thickness Escher 4/1/2011 73
- 74. Escharotomy incision on lateral and medial surface. Incision must go through the entire depth of the burn to allow tissue expansion and a return of blood flow.
- 75. Monitoring for the onset or progress of infection should consist of: Routine temperature measurement. Frequent wound swab cultures. Wound inspection by an experienced doctor or nurse at the time of dressing change. Blood culture.
- 76. CURLING’S ULCER Acute ulcerative gastro duodenal disease Occur within 24 hours after burn Due to reduced GI blood flow and mucosal damage Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition Watch for sudden drop in hemoglobin 4/1/2011 76
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