Management of Burns

Management of Burns:

Management of Burns Dr. Altaf Ahmed Malik

Slide 2:

Burn injury is coagulation necrosis of tissues as a result of application of heat (in any form) or caustic chemicals; electricity; or radiation.

Prehospital care:

Prehospital care Patient be removed from source of injury & the burning process stopped All rings, watches, jewelry, & belts are removed because they retain heat & can produce a tourniquet-like effect. Room temperature water can be poured on the wound within 15 mins of injury to decrease the depth of wound.

Remove all clothing:

Remove all clothing To halt continued burn from melted synthetic compounds or chemicals To assess full extent of body surface involvement Irrigate injuries with water or saline to remove harmful residues

Assessment of Burn Patient :

Assessment of Burn Patient Patient’s Bio-data Injury Date & Time: Assessment Date & Time:

Slide 6:

Mechanism of injury Associated injuries State of health Pre-hospital treatment Primary survey Secondary survey

Primary survey:

Primary survey Immediately life-threatening conditions are quickly identified and treated Airway Breathing Circulation

Airway :

Airway Findings suggestive of airway injury include h/o burn in an enclosed structure or explosion Physical signs include hoarseness, stridor , facial burns, singed nasal hairs, carbonaceous sputum, tachypnea & presence of soot/carbon in oropharynx ** Early endotracheal intubation is preferable

Slide 9:

Amount of edema can be immense (even without facial burns) Depression of mental status can worsen problem Edema peaks at 12 to 24 hours Pediatric patients even more concerning

Breathing:

Breathing Chest is exposed in order to assess breathing Look for effort, depth of respiration & auscultation of breath sounds Severely burned patients develop early respiratory insufficiency & respiratory failure

Circulation:

Circulation Blood pressure may be difficult to mearure in patients with edematous & charred extremities Pulse rate can be used as an indirect measure of circulation until better monitors can be established like urinary output, arterial pressure measurements Burn injury causes a combination of hypo- volemic & distributive shock Circulatory support in the form of aggressive & prompt fluid resuscitation is a cornerstone of early burn management.

Secondary survey:

Secondary survey Head to toe examination Obtain detailed history and examine rest of body. Ask about allergies, meds, medical conditions. Look for other injuries. Burn specific secondary survey Burn site Burn depth Burn size ( TBSA )

Depth of burn:

Depth of burn First degree— injury localized to the epidermis Superficial second degree— injury to the epidermis and superficial dermis Deep second degree— injury through the epidermis and deep into the dermis Third degree— full-thickness injury through the epidermis and dermis into subcutaneous fat Fourth degree— injury through the skin and subcutaneous fat into underlying muscle or bone

Slide 14:

Epidermal Superficial Dermal Mid Dermal Deep Dermal Full Thickness

First degree burn:

First degree burn Injuries confined to epidermis Painful & erythematous Blanch to touch Have an in-tact epidermal barrier Do not result in scarring Treatment is aimed at comfort with topical soothing agents +/- NSAIDs Examples : Sun-burn, minor scald from a kitchen accident

Superficial Second degree burn:

Superficial Second degree burn Injury involves all epidermis and superficial part of the dermis. Spares hair follicles, sweat glands etc. Capillary return normal. Expect blistering and peeling in a few days Erythematous & blanch to touch Very painful/sensitive. No or minimal scarring. Spontaneously re- epithelialize from retained epidermal structuresin 7-14 days

Deep second degree burn:

Deep second degree burn Injury to deeper layers of dermis –reticular dermis Appears pale & mottled Do not blanch to touch Capillary return sluggish or absent Less painful, remain painful to pinprick Takes 14 to 35 days to heal by re-epithelialisation from hair follicles & sweat gland keratinocytes often with severe scarring Contractures possible Require excision & skin grafting

Third degree burn:

Third degree burn Hard leathery eschar that is painless & black white or cherry red Sensation and capillary refill will be absent Outer edges might be partial thickness Little spontaneous healing will occur, only from skin edges Require excision & skin grafting

Fourth degree burn:

Fourth degree burn Involves structures beneath the skin- muscle, bone. *** Burn depth is most accurately assessed by the judgment of experienced practitioners ***New technologies like multisensor heatable laser dopler flowmeter hold promise for quantitatively determining burn depth

Slide 20:

Burns are Dynamic The first impression may not be the most accurate Day 1 Day 3 Day 2

Estimation of burn size:

Estimation of burn size Do not include areas of erythema in calculations (note separately) Rule of nines Use a body chart – Lund and Browder Berkow Diagram

Rule of 9s:

Rule of 9s ABA

Burn size in small children:

Burn size in small children The head accounts for about 18% (instead of 9%). The legs account for about 13% (instead of 18%).

Slide 25:

For smaller areas: Use patient’s hand size as a guide with fingers extended and adducted = Approx. 1% of patients body area

Management:

Management Outpatient Emergency room Inpatient Follow-up

OPD management of burns:

OPD management of burns Only minor 1 st degree or 2 nd degree superficial burns should be considered Depends on various factors like patient reliability, opportunity for follow up, & accessibility to health professionals. 1. Dressings 2. Antibiotics 3. Follow-up

Emergency room:

Emergency room Resuscitation a. Oxygen should be provided to patients with all but the most minor injuries. 100% high humidity oxygen via facemask for those with possible inhalation injury b. Intravenous access . All pts with burns ≥20% BSA require iv fluids. Two 16G or larger peripheral venous catheters should be started immediately. Upper extremity for catheterisation is preferred over central line because of risk of catheter related infection. An i.v . catheter can be placed through the burn area if other suitable sites are unavailable. Avoid lower extremity to prevent phlebitic complications.

Resuscitation contd…:

Resuscitation contd … c. FLUID. Required if >10% BSA child >15% BSA adult Parkland Formula : 4 x %AGE of body surface area burned x weight in kilos gives fluid requirement in mls Half in first 8 hours and remainder in following 16 hours From the time of the burn (not arrival at hospital) Large bore IV line preferably in unburnt skin. Catheterise. Hourly urine volumes. Aim for urine output of 30mls per hour in adult (1ml/kg/hr in child) Large volumes involved – CVP monitoring

Fluids contd…:

Fluids contd … Muir & Barclay Formula 1 Ration=% of Burn x BodyWt.(kgs)/2 3 rations in first 12 hours 2 rations in next 12 hours 1 ration in next 12 hours Best solution for replacement is plasma but for fear of transfusion reactions a crystaslloid,Ringer’s lactate,is used

Fluids contd…:

Fluids contd … Brooke Formula 1.5 mL of crystalloid/kg per % TBSA burn 0.5 mL /kg of colloid per % TBSA burn 2.0 L of free water Galveston (pediatric) 5000 mL of crystalloid/m 2 burned area + 1500 mL of crystalloid/m 2 total area These guidelines are used for the initial fluid management after a burn injury. The response to fluid resuscitation should be continuously monitored, and adjustments in the rate of fluid administration should be made accordingly.

Fluid requirements in children:

Fluid requirements in children Use same formula for fluids to replace loss from burns. In children, add this amount to normal maintenance rate: 10 kg - about 40 cc / hr maintenance fluids 20 kg - about 60 cc / hr 30 kg - about 70 cc / hr Expected urine output for child: 1 cc / kg /hr for infant: 2 cc/ kg / hr

Slide 33:

How do you know if the patient is getting too much fluid, or too little? Check urine output, urine specific gravity, HCT

Resuscitation contd…:

Resuscitation contd … d. Foley catheter For monitoring hourly urine output as an index of adequate tissue perfusion In absence of underlying renal disease, a minimum urine production rate of 1 ml/kg/hr in children (wt</=30kgs) & 0.5ml/kg/hr in adults Consider reducing i.v . hydration if urine output exceeds 1.5ml/kg/hr in adults

Resuscitation contd…:

Resuscitation contd … e. NG tube insertion with intermittent suction is performed if patients are intubated or develop nausea, vomitting & abdominal distention consistent with adynamic ileus Virtually all patients with burns > 25% BSA have an adynamic ileus

Resuscitation contd…:

Resuscitation contd … f. Escharotomy May be necessary in full thickness circumferential burns of neck, torso, or extremities when increasing tissue edema impairs peripheral circulation or when chest involvement restricts respiratory efforts Indications rest on clinical grounds Assessment of peripheral circulation can be done by palpating peripheral pulses or presence of Dopler signal Infra-red Photoplethysmography or pulse oximetry has been a useful adjunct in assessing need for escharotmy More recently, laser Dopler flowmetry has been shown to be predictive of the need of escharotmy

Escharotomy contd…:

Escharotomy contd … Done at the bedside & require no anesthesia Rarely required within the first 6 hours after injury Full thickness incisions through but no deeper than the insensate burn eschar Longitudinal escharotmies are performed on the lateral or medial aspect of the extremities & the anterior axillary lines of the chest

Escharotomy - complications:

Escharotomy - complications Bleeding: might require ligation of superficial veins Injury to other structures: arteries, nerves, tendons NOT every circumferential burn requires escharotomy. In fact, most DO NOT need escharotomy. Repeatedly assess neuro-vascular status of the limb. Those that lose circulation and sensation need escharotomy.

Slide 41:

2. Lab examination Baseline CBC, Type & crossmatch , electrolytes & renal indices β - hcg in women ABG evaluation Urine analysis Toxicology screen & an alcohol level when suggested by history or mental status examination Chest X-ray & ECG

Slide 42:

3. Moist dressings applied to partial thickness burns provide pain relief from air exposure 4. Analgesia 5. Photographs or diagrams of the BSA involvement 6. Early irrigation & debridement Use N.S. Nonviable tissue in the burn wound should be debrided early Debridement of burn blisters is protective to the fragile zone of stasis in the early stages of burn

Before and after debridement:

Before and after debridement Removing the blister leaves a weeping, very tender wound, that requires much care.

Slide 44:

7. Topical antimicrobial agents Mainstay of local burn wound management Systemic antibiotics reserved for documented infection Risk of infection is higher in patients with multi-organ failure or burns > 30% BSA Silver sulphadiazine most commonly used Has fewer side effects formulated as a cream Poor gram negative & anaerobic bacterial coverage, poor eschar penetration & contra-indicated in patients with Glu-6-Phosphatase deficiency Other agents include Mafenide acetate, Polymyxin B Sulfate, Silver nitrate, Acticoat , Silver- impregnated dressings ( Silverlon )

Slide 45:

8. Tetanus prophylaxis should be administered as tetanus toxoid , 0.5 ml intramuscularly, if the last booster dose was more than 5 years before the injury If immunisation status is unknown, human tetanus Igs 250-500 units, should be administered i.m . using a syringe & injection site different from those used for tetanus toxoid adm

Monitoring Guidelines :

Monitoring Guidelines Pulse: young patient – pulse less than 120, reasonable perfusion; pulse >130, increase fluid Elderly or with heart disease – pulse not accurate reflection of perfusion Electrocardiogram – particularly important for patient more than 45 years old Urine output : 0.5 to 1 cc/kg/hr is adequate in absence of diuretic such as alcohol Exception: Myoglobin or Hemoglobinuria where over 1 cc/kg/hr is indicated Peripheral perfusion: for circumferential arm, leg burns

Monitoring Guidelines:

Monitoring Guidelines Temperature : Avoid hypothermia Blood gases – high risk of hypoxemia, hypercapnia due to direct pulmonary complications of burn and treatment Acid-base – Base deficit very useful indicator of tissue oxygenation (if increasing give more fluid) Hemoglobin increasing value indicator of decreasing blood volume or greater than 5 meq/l

Monitoring Guidelines:

Monitoring Guidelines Blood pressure – only reliable as volume indicator if low Electrolytes – initial abnormality may be hyper- or hypokalemia, HCO3 value dependent on acid-base balance Prothrombin time, partial thromboplastin time, platelets – moderate burn: usually near normal More than 50% total body surface: abnormal due to consumption coagulopathy Transfer to Burn Center if a major burn is present

Critical Care Issues with burns:

Critical Care Issues with burns Stress ulcer prophylaxis Deep vein thrombosis Glucose monitoring Sepsis

INPATIENT:

INPATIENT Transfer to a burn center American Burn Association guidelines a. patients <10yrs or >50yrs sustaining 2 nd /3 rd /4 th degree burn > 10% BSA b. 2 nd or 3 rd or 4 th degree burn to >20% BSA c. Specialised regions, including joints, hands, feet, perineum, genitalia, face, eyes, or ears d. Significant inhalational, chemical or electrical injury e. Burns in combination with significant associated mechanical trauma or pre-existing medical problems f. patients requiring specialised rehab, psychological support or social services (including suspected neglect or child abuse)

Slide 51:

• Analgesia • Plastic wrap < 8hrs Or • secondary dressing >8hrs • Clean dry sheet • Keep warm, prevent hypothermia • Consult and Transfer to Burns Unit • Documentation Don’t delay transfer, doing complicated dressings Management on Transfer

Slide 52:

2. Nutrition Curreri formula Daily EMR ={2.5 kcal ×BW ( kgs )} + {40 kcal ×% BSA} Protein 1.5 – 2 g/kg/day Formulas to Predict Caloric Needs in Severely Burned Children AGE GROUP MAINTENANCE BURN WOUND NEEDS NEEDS Infants 2100 kcal/% TBSA 1000 kcal/% TBSA (0-12 mo) burned/24 hr burned/24 hr Children 1800 kcal/% TBSA 1300 kcal/% TBSA (1-12 yr) burned/24 hr burned/24 hr Adolescents 1500 kcal/% TBSA 1500 kcal/% TBSA (12-18 yr) burned/24 hr burned/24 hr

Slide 53:

Therapeutic strategies should target prevention of body wt loss of more than 10% of patients baseline body weight Increasing feeding beyond the EMR is a/w development of fatty liver, hyperglycemia & impairment of the splanchnic oxygen balance a. Enteral Preferred route b. TPN c. Daily Vitamin supplementation in adults should include 1.5g of ascorbic acid, 500mg of nicotinamide , 50mg of riboflavin, 50mg of thiamine & 220 mg of zinc

Slide 54:

3. Wound care a. Analgesia & sedation for dressing changes Valium(0.1mg/kg im ) + ketamine (0.5 mg/kg im ) in INTUBATED patients iv PROPOFOL can be given b. Daily dressing changes properly assess the continued demarcation & healing of wounds physical therapy with active range of motion is performed at this time c. Debridement

Slide 55:

d. Temporary dressings for massive burns with limited donor sites (1) Biologic- Fresh or cryopreserved cadaver allografts - gold standard Some centers are using porcine xenografts (2) Synthetic membrane Biobrane Integra artificial skin Dermagraft -TC

Slide 56:

4. Operative management a. Early tangential excision of burn eschar to the level of bleeding capillaries optimum timing range 1-10 days *** Limit burn excision to < 20% BSA or < 2hrs per sitting b. Split thickness skin grafts

Follow up:

Follow up Infection Hyperpigmentation Scar hypertrophy Contractures Pruritis Rehabilitation

Special types of burn:

Special types of burn Electrical burn Severity depends on Voltage – low voltage burn is similar to thermal burn high > 1000 v hidden destruction of deep tissue Tissue resistance, Type of current a. AC – repetitive tetanic muscle contraction cause a hand to grip the source b. DC – lightening single muscle contraction throughs the person away from source Current pathway through the body Duration of contact with an electrical source

Electric burn contd…:

Electric burn contd … Complications include cardiopulmonary arrest ( more common with AC ) thrombosis associated fractures related to fall or severe muscle contraction spinal cord injury cataracts RHABDOMYOLYSIS

Electric burn contd…:

Electric burn contd … Rhabdomyolysis : myoglobin release from injured cells of deep tissues precipitation of protein in the renal tubules can cause ARF dark urine is the 1 st clinical indication i.v . RL should be administered to maintain urine output > 100 ml/hr Concomitant administration of i.v . soda bicarb in 1L of 5% dextrose to alkalinize the urine

Slide 61:

Delayed effects may include neurologic deficits cortical encephalopathy hemiplegia aphasia brainstem dysfunction delayed peripheral nerve lesions cataracts

Chemical burns:

Chemical burns Contact with acid, alkali or petroleum compounds Cause injury by protein destruction with denaturation , oxidation, formation of protein esters or dessication of the tissue Alkali burns penetrate more than acid burns Removal of offending agent is the cornerstone of treatment Dry chemicals should be brushed off or aspirated into a closed suction container Irrigation with copious amount of water for at least 20-30 mins Neutralizing the chemicals is no longer recommended

Future burn care management:

Future burn care management Earlier detection of infection with molecular diagnostic approaches Ongoing immunologic & clinical studies on burn induced immunosuppression , cytokines & artificial bilaminate skin Newer diagnostic technologies like multisensor heatable laser dopler flowmeter .

The biggest challenge is PREVENTION EDUCATION:

The biggest challenge is PREVENTION EDUCATION

THANKS:

THANKS