Burns Management

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MANAGEMENT OF :

MANAGEMENT OF By, Dr Zubair M. Patankar Pediatric Resident B.M.C.H Baljurshi MANAGEMENT OF

History of FIRE::

History of FIRE: Ancient Greeks considered fire one of the major elements in the universe, alongside water, earth and air. Fire has savaged man’s ancestors since he appeared on earth. No doubt its benefits were first discovered by accident, but knowledge of its spread slowly.

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Going back to 400,000 years ago, homo-sapiens (man) used fire to drive away carnivores animals, or cold and to soften flesh to eat. Man has knowingly risked his life to reap the benefits by fire, but many paid price in suffering, scarring, and even death.

CHEMISTRY OF FIRE::

CHEMISTRY OF FIRE: Fire can be felt, can be seen in a matter of CHANGING FORMS- its one part of a chemical reaction. volatile gases (smoke) are hot enough (about 500 degrees F (260 degrees C) for wood), the compound molecules break apart, and the atoms recombine with the oxygen to form water, carbon dioxide and other products. In other words, they BURN.

EVOLUTION OFFIRE::

EVOLUTION OFFIRE: Man has knowingly risked his life reap the benefits by fire, but many paid price in suffering ,scarring, & even death. Egg; coming back to 4000 BC around ,Men in Egypt found that by heating copper in furnace.

To start with just to make a brief about what are the types of burns that are encountered?:

To start with just to make a brief about what are the types of burns that are encountered? Ordinary burns Scalds Chemical burns Electrical burns Radiation burns Cold burns (frostbite)

Pathology of burns:

Pathology of burns Local changes Systemic changes

Local changes :

Local changes Severity of burns Extent of burns Vascular changes Infection

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EXTENT OF BURNS PALM OF PATIENT HAND RULE OF NINE LUND AND BROWDER CHART

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Trunk Extre mity Head and neck Anterior Posterior Upper Lower Genitalia Adult 9 18 18 9 18 1 Infant 18 18 18 9 14 - Rule of nines estimation for percentage of body surface area

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FACTORS THAT INFULENCE THE OUTCOME IN BURN PATIENT Burn size of > 40 % total body surface area (TBSA) Patient age greater than 60 years Presence of inhalation injury to lungs

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Mortality rates associated with burn injury Number of Risk Factors present Mortality 0 0.3% 1 3% 2 33% 3 90%

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RATIONAL WAY OF MANAGEMENT OF BURNS FIVE PHASES ARE INVOLVED BURN FIRST AID PREHOSPITAL CARE EMERGENCY DEPARTMENT TRANSPORT TO BURN DEPARMENT STABILIZATION IN BURN UNIT OR PATIENT ROOM

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TO START WITH THE FIRST OPTION THAT IS FIRST AID, WHAT CAN THE RESPONDERS DO WHEN WITNESSING A BURN INJURY ? WHAT ACTIONS ARE NEEDED FROM PREHOSPITAL PROVIDERS (i.e., AFTER THE PREHOSPITAL CREW ARRIVES, WHAT ARE THEIR PRIORITES). ???????

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PHYSICAL EXAMINATION: The big question is what to do? WHEN THE PATIENT AND ATTENDERS ARE IN PANIC STATE. YOU! DON’T PANIC GO TO THE BASICS AND KEEP YOUR MIND COOL. “URGENCY IN CARING FOR THE VICTIM AND NOT THE WOUND, IS PIVOTIAL FOR THE ULTIMATE SURVIVAL OF THE PATIENT. ITS SAME ABCDEF DID YOU GET IT

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A = AIRWAY B = BREATHING C = CIRCULATION D = NEUROLOGIC DEFECIT E = EXPOSURE F = FLUID THERAPY

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ASSESSMENT AND MANAGEMENT OF BURN INJURIES ASSESSMENT THE MECHANISM OF INJURY ASSOCIATED INJURIES PATIENT AGE STATE OF HEALTH PREHOSPITAL TREATMENT

First degree burn Second degree burn Third degree burns:

Assessment of depth and extent of burns: (Same as explained in the local changes i.e. severity and extent ) First degree burn Second degree burn Third degree burns

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Burn depth Level of injury Clinical features Treatment Usual result Superficial partial thickness Papillary dermis Blisters erythematic capillary refill intact pain sensation Tetanus prophylaxis Cleaning(e.g. chlorhexidine gluconate) Topical agent(e.g. 1% silver sulfadiazine)sterile gauze dressing Physical therapy Splints as necessary Epithelialization in 7-21 days Hypertrophic scar rare Return of full function Deep partial thickness Reticular dermis Blisters pale white or yellow color Absent pain sensation As for superficial partial-thickness burns Early surgical excision and skin grafting an option Epithelialization in 21-60 days in the absence of surgery Hypertrophic scar common Earlier return of function with surgical therapy Full thickness Subcutaneous fat, fascia, muscle or bone Blisters may be absent. Leathery, in classic, wrinkled appearance over bony prominences No capillary refill Thromboses subcutaneous vessels may be visible Absent pain sensation As for superficial partial-thickness burns Wound excision and grafting at earliest feasible time Functional limitation more frequent Hypertrophic scar mainly at graft margins Treatment algorithm for the three clinically important burn depths Monafo WW. Initial management of burns N Engl J Med 1996;335:1581

Every century has introduction of new applications for on burn wounds. By 5000 BC , extracts of barks & leaves of trees & shrubs Used in china. 2000 yrs later, animal fats advocated in Egypt. Vinegar introduced by Galen, still useful. But till to date surgeons, first-aiders still advocate immediate cooling of burnt part with water, first recognized as being useful in ninth century by Arabic physician, RHASES.:

Every century has introduction of new applications for on burn wounds. By 5000 BC , extracts of barks & leaves of trees & shrubs Used in china. 2000 yrs later, animal fats advocated in Egypt. Vinegar introduced by Galen, still useful. But till to date surgeons, first-aiders still advocate immediate cooling of burnt part with water, first recognized as being useful in ninth century by Arabic physician, RHASES.

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Management EMERGENCY ROOM Resuscitation Oxygen Intravenous access Fluids

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Modified parkland formula Brooke’s formula Modified parkland formula the estimated crystalloid requirement for the first 24 hours after injury is calculated based on patient weight and BSA burn percentage. LACATED RINGER SOLUTION VOLUME IN FIRST 24 HRS = 4ML * % BSA (ii, iii, & iv degree only)* body weight in kgs. One half of the calculated volume is given in the first 8 hrs after injury, and the remaining volume is infused over the next 16 hrs. Fluid resuscitation calculations are based on the time of injury, not the time when the patient is evaluated. BROOKES FORMULA : In first 24hrs Ringer lactate solution is given at a rate of 1.5ml/kg/ % burn , colloid containing fluid 0.5ml/kg/% burn and 2000ml of 5% dextrose solution. In 2nd 24 hrs ½ o ¾ of the first 24hrs requirement of Ringer’s lactate and colloid containing fluid, whereas same 2000ml of dextrose saline are given .

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SCOPE FOR COLLIOD- CONTANING SOLUTIONS Foleys Catheter Nasogastric tube Escharotomy Monitors

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Laboratory examination: Complete blood cell count Blood grouping and cross matching Renal function (blood urea creatinine) Arterial blood gases Urine analysis X- Ray chest ECG especially in case of electrical injuries

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Analgesic : Pain! Pain! Pain! Is the complaint of all the burn patients. Intravenous analgesia every 1 to 2 hrs to manage pain Fortwin Phenargan But check for hypotension, over sedation and respiratory depression. Photographs or diagrams : of the BSA involvement and thickness of burns are useful in documenting the injury. They are for intercommunication with treating team and also for medico-legal aspect. Early Irrigation and debridement : are performed using normal saline and sterile instruments to remove all loose epidermal skin layers, followed by the application of topical antimicrobial agents and sterile dressings. What to do for blisters? It is good to leave it so that healing takes place in sterile environment. But if the get ruptured, if they are thinned walled and more than 2 cm, it is better to go ahead with debridement to prevent infection.

Biological Dressings ::

Moist dressings : Collagen dressings; Can be applied to partial thickness burns to provide pain relief form air exposure. the wounds dressed with Collagen healed significantly faster than those dressed with Honey-Ghee (P-value<0.0001). This can be explained by collagen’s non-inflammatory properties; fibroblast facilitation and microvascular cell migration; and its facilitation of synthesis of neodermal collagen matrices. 4,5,6 Collagen being an animal protein that is an integral part of skin, acts as an artificial dermis. Biological Dressings : Potato peel dressings: covered with dressings made of boiled potato peels according to the method developed in Bombay. The wounds closed within 14 days and histologically complete repair of epidermis was found. The cork layer of the potato peel prevents dehydration of the wound and protects against exogenous agents

Flamazine being applied on melonin sheet. 2) Dressing being applied to the wounds. 3) 4) :

Flamazine being applied on melonin sheet. 2) Dressing being applied to the wounds. 3) 4)

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Topical Antimicrobial agents : Are the mainstay of burn management. The most common organisms complicating burn injury are Staphylococcus aureus Pseudomonas aeruginosa Enterococcus species Enterobacteriaceae Group A streptococci and Candida alb cans SYSTEMIC ANTIBIOTICS ARE NOT ADMINISTERED PROPHYLACTICALLY BUT ARE RESERVED FOR DOCUMENTED INFECTION TO AVIOD RESISTANCE . Bacterial proliferation may occur underneath the eschar at the viable-nonviable interface, resulting in subeschar suppuration and separation of the eschar.

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Some of the topical antimicrobials commonly used are SILVER SULFADIAZINE M AFENIDE ACETATE (SULFAMYLON) POLYMYXIN B SULFATE (Polysporin) SILVER NITRATE

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TETANUS PROPHYLAXIS Should be administered as tetanus toxoid 0.5ml intramuscularly, if the last booster dose was more than 5 years before the injury. If immunization status unknown, human tetanus immunoglobin 250 or 500 units to be given IM using a syringe and injection site different form those used for tetanus toxoid administration.

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CRITICAL CARE ISSUES WITH BURNS Burn wound infection Pneumonia sepsis ileus curling ulcer acalculous cholecystits superior mesenteric artery syndrome

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TO TREAT PATIENT AS INPATIENT OR OUTPATEINT! TRANSFER TO A BURN CENTER: Should follow the guidelines of the American Burn Association. These criteria reflect multiple studies showing that age and BSA burn percentage remain the two most important prognostic factors. Patient younger than 10 years or older then 50 years sustaining partial or full thickness burns to >10% BSA. Partial or full thickness burns to >20% BSA in other age groups. Specialized regions, including joints, hands, feet, perineum, genitilia, face, eyes or ears. Full thickness burns to >5% BSA. Significant inhalation, chemical, or electrical injury. Burns in combination with significant associated mechanical trauma or preexisting medical problems. Patients requiring specialized rehabilitation, psychological support, or social services ( including suspected neglect or child abuse

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NUTRITION: The daily estimated metabolic requirement (EMR) can be calculated form the CURRERI FORMULA EMR = [25 KCAL * BODY WEIGHT (KG)] + (40 KCAL * % BSA) Protein losses form metabolism and burn wound extravasation are replaced by supplying 1.5 to 2.0 g/kg pr day. Therapeutic strategies should target prevention of body weight loss of more than 10% of the patient’s baseline weight. Losses of more than 10% of lean body mass may lead to impaired immune function and delayed wound healing. Losses more than 40% lead to imminent mortality.

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ENTERAL FEEDING OVER FEEDING TOTAL PARENATAL NUTRITION: Should be initiated after fluid resuscitation only if the patient is unable to tolerate enteral feeding. DAILY VITAMIN: Supplementation in adults should include Ascorbic acid 1.5 gm Nicotinamide 50 mg Riboflavin 50 mg Thiamine 50 mg Zinic 220 mg Patients with large burns may remain hypermetabolic for weeks to months after burn wound is closed. Hence early tapering of nutritional intake in these patients should be avoided .

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WOUND CARE: Analgesia and sedation: For dressing changes are necessary for major burns. Diazepam (0.1mg/kg IM) plus ketamine (0.5mg/kg IM). In patients with secured airways (intubated) profol has the desired effect. Daily dressing change: To assess the wound healing. Physical therapy with active range of motion is performed at this time before reapplying splints and dressings. Debridement of all nonviable tissue should take place using sterile technique and instruments when demarcation occurs. Temporary dressing for massive burns with limited donor sites Biological Synthetic Fresh or cryopreserved cadaver allografts have been the gold standards. After several days the allografts can be removed and a meshed autograft may be replaced for definitive coverage. Synthetic grafts such as Integra artificial skin, Dermagraft-TC

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OPERATIVE MANAGEMENT: EARLY TANGENTINAL EXCISION: Of burn eschar to the level of bleeding capillaries should follow the resuscitation phase. Time limit for burn wound excision is still debated but the optimal time range is 1 to 10 days. Each trip to operating theater the burn wound excision should be limited to < 20% BSA or 2 hrs operating time. Even with this limit, aggressive debridement frequently produces profound blood loss and hypothermia. SPLIT-THICKNESS SKIN GRAFTS: Are harvested at a thickness of 12 to 15 thousandths of an inch with a meshed expansion ratio from 1.5:1 to 3.0:1. FOR LARGE BURNS: That cannot be completely covered with available autograft, allograft or xenograft can be used to cover the remaining wound temporarily. In 3 to 5 days the temporary grafts can b removed and autograft should take well on the granulating dermis .

Tangential ESCHAROTOMY:

Tangential ESCHAROTOMY

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FOLLOW-UP: WOUND HEALING: Infection is minimized by using topical antimicrobial agents. Granulation tissue which fails to epithelialize at skin graft site can be cauterized using an applicator stick tipped with silver nitrate. Hypermigntation is best prevented by avoiding direct sunlight exposure for upto 1 year. If unavoidable cases topical sunscreen can be applied(zinc oxide) Scar hypertrophy is minimized by local tissue compression, tailored jobsts garments. Hypertrophy scar can be rated with Vancouver scar scale. This scale is based on four factors pigmentation, vascularity, pliability and height. Contracture are best prevented by using active range of motion. When present release (Z-plasty) or excision and skin grafting may be necessary. Pruritis can be palliated with antihistamines. Recently doxepin, an antidepressant with strong antihistamine properties, has been approved for topical application. Rehabilitation with ongoing evaluation is provided by occupation and physical therapists .

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COLD INJURY: Hypothermia and frostbite HYPOTHERMIA: Classification of hypothermia is based on core temperature (usually approximated with a rectal or esophageal thermometer). Mild hypothermia 30 to 32 degree centigrade Moderate hypothermia 30 to 32 degree centigrade Severe hypothermia <30 degree centigrade

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FROSBITE: Results from formation of intracellular ice crystals and microvascular occlusion. Classification of frostbite: First degree: hyperemia and edema, without skin necrosis. Second degree: superficial vesical formation containing clear or milky fluid surrounded by hyperaemia, edema and partial thickness necrosis. Third degree: Haemorrhagic bullae and full thickness necrosis. Fourth degree: gangrene with full-thickness involvement of skin, muscle and bone. Treatment: is rapid rewarming

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THE END THANK YOU

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