dr kamal murdia on burns

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Burn Injuries Early management Dr. Kamal Murdia MBBS, MS (surgery), M.Ch. (plastic surgery) MBACS (London,UK) Specialist plastic surgeon drkamalmurdia@hotmail.com :

B urn Injuries Early management D r. Kamal Murdia MBBS, MS (surgery), M.Ch. (plastic surgery) MBACS (London,UK) Specialist plastic surgeon drkamalmurdia@hotmail.com

Types of Burn Injuries:

Types of Burn Injuries Thermal burn (dry / wet) Flame / scalds (temp of 64 degree c ) Chemical burn Acids/ Alkalis/ phosphorous Electrical burn - low / high voltage Radiation- ionizing / non ionizing Lightening


Skin mother best nurse- skin best covering Largest organ 8 lbs, capillaries 60 k miles Burn injuries to skin result in - fluid loss - electrolyte loss protein loss (immunity) hypothermia loss of barrier and infection

Basic burn’s management:

Basic burn’s management How big is the injury (Simple or with other injury) Assess % of burn, degree of burn Lab and clinical work up , Fluid therapy Analgesia Dressing, ointments Special types of burn inhalation, electrical, chemical, radiation, lightening and m/m Take home points and conclusion

Burn Patient Severity:

Burn Patient Severity Factors to Consider Body surface area burned Degree of burn ( 1* 2* 3* ) Age: Adult ( 55yrs ) vs Pediatric (2yrs) Preexisting medical conditions Associated Trauma blast injury fall injury airway compromise child abuse

Prevent hypothermia:

Prevent hypothermia But burned patients lose body heat quickly, so keep patient warm. Avoid too much cold washes. To keep victim warm, use whatever means available: blankets heating lamps sterile sheets

Body Surface Area Estimation:

Body Surface Area Estimation Rule of Nines Adult Palm Rule 1%

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%).

Burn Classifications:

Burn Classifications 2nd degree (partial thickness ) Epidermis and part of the dermis. Moist, shiny appearance Salmon pink to red color Painful -minimal scaring may be + If blister it ls 2nd degree Usually heal in ~7-21 days

Burn Classifications:

Burn Classifications 2nd Degree Burn (Partial Thickness Burn) Leave blisters intact, as a covering / to reduce pain

Burn Classifications:

Burn Classifications 3rd Degree Burn (Full Thickness ) Leathery or charred Painless Pain if present is due to second degree burn also present Requires skin graft Scaring ++

Blisters – what to do:

Blisters – what to do puncture the blister (no. 11 blade) drain fluid and let blister skin remain Intact but deflated blister prevents pain (by covering raw area) Temporary barrier for infection 2-3 days later debride it

Critical Burn Criteria:

Critical Burn Criteria More than 20% pediatric, 30% adult Burns with respiratory injury Hands, face, feet, or genitalia Burns complicated by other trauma Underlying health problems Electrical and deep chemical burns

At the scene- common sense:

At the scene- common sense Stop burn process Isolate the patient Brief history ABC… If smoke / inhalation injury take steps Other injuries e.g. ortho –abdominal Shock may be due to other injuries…imp

Pre hospital management:

Pre hospital management an An unconscious patient is unconscious from something other than the burn skin injury…e.g. smoke- co –cn poisoning etc. (important…)


CRITERIA FOR ADMISSION 15% Partial or full thickness burn in adults and 10% in children Suspected airway or inhalational injury Significant burns of hands, face, feet or perineum, genitalia. Chemical burns High tension Electric burns Major associated life threatening injuries

Burns - Acute Care:

Burns - Acute Care A - Airway,Appearance, Assess B - Breathing C - Circulation D – Disability/Detailed H/O E – Expose/Examine Look for occult injuries F- Fluids G- girth (circumferential) H- hand I – Inhalation injury

Slide 19:


Slide 20:


I.V. fluids in Burns:

I.V. fluids in Burns Adult above 15% and kids above 10% ,Admit give IV fluids. Do not give colloids in first 24 hrs only lactated Ringer in first 24 hrs

Slide 22:

FLUID THERAPY….. In patients with large burns, do not initially spend much time carefully calculating fluids . Instead, start an IV and start giving Ringer rather rapidly while exam is being performed. 500cc/hr in adult & 100 cc/hr in kids above 1 year is a simple rule to remember. Later do the calculations.

Calculate fluid requirements:

Calculate fluid requirements PARKLAND FORMULA wt in kg x % burn x 4cc = x First 24 hours post-burn(x). half - 8 hrs (x/2) rest half- in next 16 hrs(x/2) Next 24hrs half of first day(x/2) First 8hrs…next 16 hrs…next 24 hrs

Fluid requirements in children:

Fluid requirements in children Parkland formula+ normal requirements In children, normal maintenance rate: 10 kg - about 40 cc / hr 20 kg - about 60 cc / hr 30 kg - about 70 cc / hr Wt of paed. pt = age x 2+ 8 Expected urine output For child: 1cc/kg/hr - For infant:2cc/kg/hr for adult 30-50 cc / hr regulate fluid accordingly

Analgesia- tetanus prophylaxis:

Analgesia- tetanus prophylaxis Analgesia Morphine Sulfate 2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressure, IV. , constipation 0.1 mg/kg for pediatric Mg/age (e.g. 3 year 3 mg, 2 year 2 mg) May require large but tolerable total doses IM /SC morphine injections not given in burns area (why?)


ANALGESIA IN BURNS Morphine good analgesic but causes respiratory depression Pethidine 1/5 as effective as morphine and has addiction risks Dose of pethidine 0.5mg -2 mg / kg wt.

Important :

Important If burn over 25% NPO / insert RT / Foley catheter (for hourly urine output). If patient looses more than 10 % wt. in 5-6 days, needs nutritional support (parentral) formula Adult-25 cal / kg /day +40 cal/% burn/day Child-60 cal /kg /day +35 cal/% burn / day . .


Face Be VERY concerned for the airway!! Eyelids, lips and ears often swell alarmingly. Cleanse eyes with warm water or saline. Contact lens- keep in mind Apply antibiotic ointment or liquid tears until lids are no longer swollen shut.

Edema Formation:

Edema Formation Amount of edema can be immense Edema peaks at 12 to 24 hours Pediatric patients even more concerning

Burn ointments:

Burn ointments - Bacitracin – fucidin for face Few side effects Avoid silver ointments on face- why flamazine for trunk, neck, extremities Does not penetrate eschar very well Side effects: neutropenia /thrombocytopenia.

Burn ointments:

Burn ointments MEBO ointment – moist exposed burn ointment made of 5 % sitosterol, beeswax, amino acids fatty, acids –good for healing (special burn ointment) Contratubex ointment - kappa extract, allantoin and heparin.- prevents scars


DRESSING THE WOUND TOPICAL ANTIBIOTICS - silver sulfadiazine cream - mafenide cream NON-ADHERENT - paraffin gauze LOOSE BULKY DRESSING 1 st layer` paraffin gauze 2 nd layer` cotton 3 rd layer` crepe bandage ELEVATION OF LIMBS

Special types of burn:

Special types of burn Circumferential burn Inhalation burn Electrical burn Chemical burn


Escharotomy Escharotomy = cut burned skin to relieve underlying pressure Similar to bivalving a tight cast. Cut along inside and outside of limb Knife can be used, or cautery. Use local or no anesthesia. (Full-thickness burn should have no sensation, but underlying tissues do!)

Hands and feet:

Hands and feet Allow use of the hands in dressings by day. Splint in functional position by night. Keep elevated to reduce swelling. Very important to preserve function / elevate

Carbon monoxide poisoning:

Carbon monoxide poisoning CO by product of partial combustion 210 times affinity for Hb. than oxygen Pt. unconscious, headache, confusion, CNS changes, coma If G coma scale less than 8 intubate

Inhalation injury:

Inhalation injury Increasing hoarseness is sign of airway obstruction Give O2 and ventilate put on pulse oximeter Intubate- inhalation burn, rest distress, large burn.. (why) Hyperbaric O2( in co or cn poisoning )

Electrical Burns:

Electrical Burns Low voltage and high voltage dividing line is 1000 volts Burns internally what comes in way, Cardiac -ECG, muscle damage- myoglobin –smoky urine-

Radiation Exposure Management:

Radiation Exposure Management SAFETY!!! Two Most Useful Tools for Radiation Incident Management Protective Equipment

Take home points 1:

Take home points 1 Hypothermia Early shock and unconscious… not due to burn …look for occult injuries. 500 cc/hr in adult 100 cc/hr in kids < 1 yr Child face is 18%, lower limb 13% Palm is 1% of body surface Morphine in kids mg = age (2mg=2year) Wt of child= age x 2 + 8 = wt in kg

Take home points 2:

Take home points 2 Circumference burn – escharotomy Hand – elevate, position of function (glass) CO- hyperbaric oxygen Chemical burn-wash for 30 mts For Phosphorous water is petrol Lightening- hear it –clear it, see it-flee it, don’t go out at least ½ hr. Kitchen is source of max. causalities

Take home point 3:

Take home point 3 75% of burns in children are preventable 56% of burns in kids is due to hot water, tea , milk (scald burns) Burn’s affect looks/profession/personal life Life is never the same after a gross burn injury Prevent burns-that’s the best management


summary Be cool, use common sense Take brief history - type ABC DEFGHI Admit if over 15 % in adult , 10 % kids Fluids Analgesia Infection – antibiotics , ointment- dressings Inform relatives about possible prognosis



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