BURN MANAGEMENT

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short notes on burn management

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Short notes on BURN MANAGEMENT:

Short notes on BURN MANAGEMENT By Dr.Mohammed Abd alhussein Plastic and reconstructive surgery resident

INHALATION INJURY:

INHALATION INJURY Definition: The inhalation of the products of combustion. Direct thermal injury to the lungs occurs rarely and usually only in the case of steam burns . Carbon monoxide inhalation is particularly devastating because carbon monoxide will bind to hemoglobin and interfere with the delivery of oxygen. Diagnosis: is best made by consideration of the circumstances surrounding the burn injury and findings on physical examination.

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On physical examination, the presence of carbonaceous sputum, raw oral and nasal mucosa, and soot on the vocal cords (on laryngoscopy ) all signify inhalation injury. In addition, patients may have a cough , hoarse voice, and difficulty breathing. The presence of singed nasal and facial hair may be suggestive of inhalation injury but, alone, is not diagnostic.

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INVESTIGATION: Arterial blood gas analysis. carboxyhemoglobin level . Chest radiographs are of little usefulness. Radionuclide studies have been used to diagnose inhalation injury but they might not add much more reliable diagnostic information beyond good clinical evaluation. Bronchoscopy .

Management of inhalation injury:

Management of inhalation injury usually supportive . Patients with signs and symptoms of inhalation injury may require intubation . In general, it is better to secure a patient’s airway early in the postburn period, particularly if the patient will require large volumes of fluid resuscitation . Aggressive pulmonary toilet, bronchodilators, and clearing of secretions are all essential components of patient management .

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Steroids are not beneficial in the treatment of inhalation injury and the use of prophylactic antibiotics should be avoided . Hyperbaric oxygen can reduce the half-life of carbon oxide from 40 minutes on 100% FiO2 (fraction of inspired oxygen) to 20 minutes. However, hyperbaric oxygen is not without risk. Hyperbaric oxygen can cause pneumothorax and perforation of the tympanic membranes.

Nutrition:

Nutrition Increased nutritional requirement in burne patient may be due to: Hypermetabolism and hypercatabolism . nutritional requirements to heal burn wounds, skin grafts, and donor sites.

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Most patients with burns of under 20% TBSA can obtain enough calories on their own. patients with larger burns and patients who will be intubated for several days should have an enteral feeding tube placed on admission.

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Ileus following burn injury commonly occurs , and it may take days for the return of gastrointestinal function . However, ileus can be prevented by starting feeds in the immediate postinjury period . Conistibation :Because of the high levels of narcotics patients receive, routine use of stool softeners should also begin on admission to prevent constipation and feed intolerance.

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Parenteral nutrition : is associated with higher rates of infection, attributable, in part, to the prolonged need for central venous access. Parenteral nutrition should only be used in cases when the patient has: a prolonged paralytic ileus . pancreatitis. bowel obstruction. other contraindication to enteral feeding.

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estimation of caloric requirements: The Curreri formula: differs for children and adults as follows: Adult: 25 kcal × weight (kg) + 40 kcal × %TBSA Children: 60 kcal × weight (kg) + 35 kcal × %TBSA

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2.The Harris-Benedict formula provides an estimate of basal energy expenditure (BEE): Men: 66 .5 + 13.8 × weight (kg) + 5 × height (cm) −6 .76 × age (years) Women: 65 .5 + 9.6 × weight (kg) + 1.85 × height (cm) −4 .68 × age (years)4

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Because the Curreri formula generally overestimates caloric requirements, particularly in the elderly, and the Harris-Benedict formula underestimates caloric requirements, an average of the two is often used. Indirect calorimetry using a metabolic chart can be used for patients on a ventilator. The metabolic chart will provide an estimate of energy expenditure by measuring oxygen consumption and carbon dioxide production.

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Protein requirements: Patients with normal renal function should receive 2 g of protein per kilogram per day. Supplemental vitamins and minerals : should also be provided to optimize wound healing. Vitamins A and C, as well as zinc, have known benefits in wound healing. the use of vitamin E, selenium, and iron supplements have also been described.

Gastrointestinal Prophylaxis:

Gastrointestinal Prophylaxis Stress ulcers (Curling ulcers) were once a common complication following severe burn injury. Stress ulcer prophylaxis is only necessary in: those patients who are not taking oral diet or enteral feeds . in patients with previous history of peptic ulcer disease.

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Prophylactic agents include: histamine receptor blockers. sucralfate . proton pump inhibitors. Perhaps the best protection against stress ulcers is feeding the patient.it may be due to: minimizes post-traumatic gastric atony . provides continuous coating of the stomach . easier to place at the bedside than a duodenal tube.

DEEP VENOUS THROMBOSIS:

DEEP VENOUS THROMBOSIS Risk factors : Injuries to an extremity . the occasional need for prolonged bedrest : particularly in the intubated patient. indwelling catheters . prophylaxis is required in: burn patients who are hospitalized and unable to regularly ambulate.

prophylaxis:

prophylaxis subcutaneous heparin. sequential compression devices and antiembolism stockings may not be practical for use in patients with lower-extremity burns. It is also important to be aware that pediatric patients can sustain deep venous thrombosis and pulmonary embolus.

Burne Infection:

Burne Infection Risk factor: Prolonged intensive care unit stay. prolonged periods of intubation and mechanical ventilation. potential colonization of burn eschar contribute to the risk of infection. In addition indwelling;vascular and bladder catheters provide another source of invasive infection. Burn patients are also functionally immunocompromised for a number of reasons: the skin, which serves as the principal barrier between an individual and the environment is lost. Similarly, the mucosal barrier of the respiratory tract may also be injured. In addition, the cellular and humoral portions of the immune response are compromised following burn injury. Decreased production of antibodies, impaired chemotaxis , and phagocytosis .

Diagnosis of infection in the burn patient can be challenging::

Diagnosis of infection in the burn patient can be challenging: . Fevers and leukocytosis can result from the systemic inflammatory response to burn injury and not necessarily infection. Thrombocytosis is also frequently observed in stable burn patients. Nearly all patients with greater than 15% TBSA burns are febrile within the first 72 hours.

NOTE:

NOTE routine culture of these patients in this early time period is unnecessary. However, following the initial 72 to 96 hours, periodic cultures are important in making a diagnosis of infection.

WARNING SIGN OF SEPSIS :

WARNING SIGN OF SEPSIS Temperature spikes any change in the patient’s status including: hypotension, altered mental status. intolerance of tube feeds. hyper and hypoglycemia.

CULTURE SITE?:

CULTURE SITE? culturing of urine, sputum, blood, and central lines wound

common sites of infection:

common sites of infection blood, urine, lungs, patients with a prolonged intensive care unit course can also develop sinus infections, pancreatitis,cholecystitis , meningitis, and endocarditis .

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Management of infections in burn patients must be culture driven. Presumptive broad-spectrum antimicrobial coverage is fraught with potential complications, including: breeding resistant organisms increasing the risk of fungal infections.

Pain Control:

Pain Control Pain management is an important factor in caring for the burn patient. 2 types of pain are present in burn patient: Background pain is present on a daily basis with little variation. Procedural pain occurs during daily wound care and therapy. Management of burn pain: The best approach to pain management is to keep it simple.

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Drugs: Narcotics are the most commonly used analgesics. Nonsteroidal medications. Background pain is best treated with longer-acting agents e.g Methadone has a half-life of 6 hours. Oxycodone or morphine can then be used for breakthrough pain .

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For procedural pain , shorter-acting agents are probably best because wound care is usually a short-duration activity. Fentanyl is the agent of choice for procedural pain. Many patients may also benefit from low-dose benzodiazepines because wound care can be anxiety provoking for many patients. Again,the use of short-acting benzodiazepines is favorable.

SURGICAL MANAGEMENT:

SURGICAL MANAGEMENT Traditional approach: burn eschar was left on the wound, and the proteolytic enzymes produced by neutrophils and bacteria led to the separation and sloughing of the eschar . The underlying granulating wound was then skin grafted. Disadvantage: delay in management . More extensive bacterial colonization, an increased likelihood of burn-wound sepsis, multiple organ failure, and, ultimately,death . Hypertrophic scarring.

Early excision and grafting :

Early excision and grafting Advantages: increased survival. decreased infection rates. decreased length of hospital stay. decrease the risk of hypertrophic scarring

Timing of excision:

Timing of excision early staged excision should begin on post-burn day 3 for major burns that are clearly full thickness. Operations can be spaced 2 to 3 days apart until all eschar is removed and the burn wound covered.

Techniques of Excision:

Techniques of Excision There are two techniques of burn-wound excision are : tangential excision fascial excision.

Tangential excision:

Tangential excision . Tangential excision is performed using a Watson (shown) or Goulian knife. Tissue is serially excised until viable, bleeding tissue, which can accept a graft, is reached.

The VersaJet water dissector.:

The VersaJet water dissector. This relatively new technology can be very useful for the excision of eyelid (shown), ear, and web space burns .

fascial excision:

fascial excision

Management of Specific Areas:

Management of Specific Areas Face: Management of facial burns begins at the time of admission.

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Care should be taken to each of the following: inhalation injuries. Positioning and fixation of : endotracheal tube, nasogastric tube to minimize alar or columellar pressure necrosis. periorbital burns: an intraocular exam with a Wood lamp . If this exam is positive, an ophthalmologic consult is required. if the patient has a lagophthalmos it is important to keep the eyes well moisturized with ophthalmic ointment to prevent exposure keratitis . Tarsorrhaphy is rarely necessary in the early burn period.

Facial burns treatment:

Facial burns treatment traditional method : daily wound care until the face either healed or the underlying eschar lifted, leaving a granulating wound bed that could accept a skin graft.

Early excision and skin graft.:

Early excision and skin graft. assess patients with facial burns at day 10, at which time it is usually clear which burns will heal within 3 weeks and which will not. Patients with burns that are thought unlikely to heal within 3 weeks are scheduled for excision and grafting. It is important to note that patients with full-thickness burns with clearly no healing potential should be operated on in the 7 to 10 days if the patient is stable and there are no other more urgent areas of excision.

Neck:

Neck key to management of the neck is to make every effort to minimize wound and graft contraction. Aggressiverange -of-motion exercises are critical for patients who heal without grafting and for patients who undergo grafting. The grafts should be placed with the neck in maximal hyperextension.

Hand burns:

Hand burns The palm has excellent healing capacity and rarely require grafting. it is critical to emphasize to the patient the importance of range-of-motion exercises. Stretching should be performed on a routine basis—either during diaper changes or feeding times,to minimize contractures of the palm and digits.

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In the case of deeper palm burns, nocturnal extension splints may be necessary.It is also important to emphasize to parents to let the child use his or her hands as soon following injury as possible bulky dressings that inhibit mobility should be minimized.

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If splinting is necessary, the wrist should be placed in mild extension,the metacarpophalangeal joints in 70 degrees to 90 degrees of flexion, and the interphalangeal joints in extension and the thumb in abduction.

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If it is clear that a burn wound will not heal within 3 weeks, the best treatment is excision and grafting. burns of the hand should be grafted with sheet grafts. Hand excision, particularly of the web spaces and digits, can be challenging. Great care should be taken to not expose tendons. excision should occur under tourniquet control. If a burn is so deep that adequate excision would surely expose tendons, then flap coverage should be considered.

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Once graft healing is complete, compression gloves, which will minimize hand edema and possibly scar hypertrophy, should be worn.

Perineum:

Perineum It is not necessary to place a Foley catheter on all patients who sustain perineal burns. all patients should be given the option to void spontaneously; a catheter should be placed only if they have difficulty voiding. Deep burns to the penis and scrotum should be given ample time to heal. In fact, the scrotum is rarely grafted because it can usually heal by contraction and not leave a noticeable scar. Patients who sustain full-thickness, charred burns of the genitals and who cannot have a Foley catheter placed, should be evaluated by urologists for placement of a suprapubic tube.

Lower Extremities:

Lower Extremities Edema can delay wound healing and increase patient discomfort. The key to treating lower-extremity burn wounds is to encourage the patient to ambulate, with the appropriate support of an Ace bandage or Tubigrip . Ambulation decreases edema. In addition the patient will be able to resume a normal level of activities . . While not ambulating, leg elevation can help to minimize edema.

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If leg or foot burns require excision and grafting, the postoperative physical therapy plan should be considered. Small burns of the leg and foot can be grafted and dressed with greasy gauze and then covered with an Unna boot dressing . The Unna boot dressing provides support and immobilization of the graft and allows for early mobilization. This is an excellent dressing for both adults and children. Patients with insensate feet are poor candidates for Unna boot dressings. Patients who require grafting both above and below the knee should be fitted with knee immobilizers postoperatively to maintain knee extension.

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