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Management of burns

This topic is oriented mainly on the Bailey & Love - 26th edition.
This will be of immense help for the MBBS - Students for the Theory as well as Clinical application.

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Management of burns

  1. 1. MANAGEMENT OF BURNS Dr. Murali. U. M.S; M.B.A Assoc. Prof. of Surgery
  2. 2. Learning Outcomes  List out the Criteria for admission of Burns patient.  Outline the fluid resuscitative methods of burns.  Evaluate the definitive & local management of burns.  Discuss about the effects of Non-thermal burn injury.
  3. 3. Objectives  Immediate Care & Criteria  Fluids & Others  LocalTreatment  Surgical options  Non –Thermal injury
  4. 4. Immediate [ Pre-hospital Care ]  Remove from source of injury  Clothing to be removed  Cool the burn wound – 10 mts – no cold H2o  Check for other injury  Ensure rescuer safety  Elevation
  5. 5. Hospital Care  A – Airway / Assessment  B – Breathing & ventilation  C – Circulation  D - Disability  E – Exposure  F – Fluid resuscitation  G – Girth ( Circumference )  H – Hand  I - Inhalation injury
  6. 6. Criteria – Admission  Airway burns of any type  Burns in extremes of age  Burns requiring FR & Surgery  Pts. social background is not good  All electric / deep chemical burns
  7. 7. Outcome – Major Determinants  Percentage surface area involved  Depth of burns  Presence of an inhalational injury
  8. 8. Area – Lund & Browder Chart Age-yrs 0 1 5 10 15 Adult A-Head 9 8 6 5 4 3 B-Thigh 2 3 4 4 4 4 C-Leg 2 2 3 3 3 3
  9. 9. Area – Wallace’s – “ Rule of 9 ”
  10. 10. Depth of Burns Depth Cause Surface/colour Pain sensation Superficial Sun, flash, minor scald Dry, minor blisters, erythema, brisk capillary return Painful Partial thickness- superficial (superficial dermal) Scald Moist, reddened with broken blisters, brisk capillary return Painful Partial thickness- deep (deep dermal) Scald, minor flame contact Moist white slough, red mottled, sluggish capillary return Painless Full thickness Flame, severe scald or flame contact Dry, charred whitish.Absent capillary return Painless
  11. 11. Burn causes – Likely depth Cause of Burn Depth of Burn Scald Superficial Flash Burns Deep Dermal Flame Burns Mixed deep dermal + Full thickness Alkali Burns Deep dermal + Full thickness Acid Burns Weak – Superficial / Strong – Deep dermal Electric Burns Full thickness
  12. 12. Inhalation Injury – Dangers  Inhaled hot gases - supraglottic airway burns & laryngeal oedema  Inhaled steam - subglottic burns and loss of respiratory epithelium  Inhaled smoke particles - chemical alveolitis and respiratory failure  Inhaled poisons, such as carbonmonoxide, can cause metabolic poisoning  Full-thickness burns to the chest can cause mechanical blockage to rib movement.
  13. 13. Inhalation Injury RECOGNITION INITIAL MANAGEMENT  A history of being trapped in the presence of smoke or hot gases.  Burns on the palate or nasal mucosa, or loss of all the hairs in the nose.  Deep burns around the mouth and neck.  Presents as Hoarseness of voice / Stridor.  Early elective intubation is safest  Delay can make intubation very difficult due to swelling  Be ready to perform an emergency cricothyroidotomy if intubation is delayed
  14. 14. Fluid Resuscitation  Children > 10%TBSA / Adults > 15%TBSA  IV access - Central vein access  Ringer lactate without dextrose fluid of choice  Monitor urinary output
  15. 15. Fluids used  First 24 hrs = Crystalloids – given / Saline, RL, Hartmann’s fluid ( PASSTHROUGH CAPILLARY WALL EASILY )  After 24 hrs upto 30 – 48 hrs = Colloids Plasma , Dextrans , Haemaccel (TO COMPENSATE PLASMA LOSS )  Blood transfusion – after 48 hrs
  16. 16. Parkland Formula – Commonly used  4ml x % burn x kg = volume [ml] - 24 hrs  Max. % = 50%  First 8 hrs ½ of vol. – Rest in next 16 hrs  Next 24 hrs = ½ of first day fluids
  17. 17. Muir & Burclay Formula – Colloids  0.5 x % burn x wt.kg = 1 portion  3 portions = first 12 hrs  2 portions = second 12 hrs  1 portion = third 12 hrs
  18. 18. Fluids – Children - DNS  100 ml / kg for 24 hours for the first 10 kg.  50 ml kg / for the next 10 kg.  20 ml kg / for 24 hours for each kilogram over 20 kg body weight.
  19. 19. Other General Measures  Monitoring the patient  Catheterization – Monitor urine output  Tetanus toxoid / H2 blockers  NGT – Aspiration & Enteral feeding  Antibiotics – Culture  TPN – If necessary  Intensive nursing care
  20. 20. Eschar - Treatment  Charred, denatured, full thickness deep burns with contracted dermis  Circumferential eschar – Limbs / Neck ↓  Tourniquet effect – compartment syndrome ↓  Incising the whole length of full thickness burns in midaxial line - Escharotomy
  21. 21. Full Thickness & Deep dermal burns  1% silver sulphadiazine cream  0.5% silver nitrate solution  Sulfamylon - Mafenide acetate cream  Cerum nitrate
  22. 22. Sup.Thickness & Mixed dermal burns  Heal – irrespective of dressing  Simple dressings – Vaseline gauze Silicon sheet / Hydrocolloids  Biological Natural – Aminio.memb Synthetic – Biobrane
  23. 23. Analgesia  No intramuscular, subcutaneous injections  Small burns – Paracetamol, NSAID  Large burns - Intravenous opiates
  24. 24. Nutrition  Burns patients need extra feeding  A nasogastric tube should be used in all patients with burns over 20%TBSA  A number of different formulae are available to calculate the energy requirements of patients  The nutritional balance monitored by measuring weight and nitrogen balance
  25. 25. Control of Infection  Burns patients are immunocompromised  They are susceptible to infection from many routes  Sterile precautions must be rigorous  Swabs should be taken regularly  A rise in white blood cells count, thrombocytosis and increased catabolism are warnings of infection.
  26. 26. Others  Intensive nursing care  Physiotherapy – elevation, splintages, exercise  Psychological - counseling
  27. 27. Surgery – Deep burns  Deep dermal burns – tangential shaving & SSG  All but the smallest full-thickness burns need surgery  Topical adrenaline (DILUTED) reduces bleeding  All burnt tissue needs to be excised  Stable cover should be applied at once to reduce burn load
  28. 28. Delayed Scar Management  Transposition flaps and Z-plasties with or without tissue expansion are useful  Full-thickness grafts and free flaps – needed for large or difficult areas  Hypertrophy - treated with pressure garments  Pharma.treatment of itch is important
  29. 29. Electrical Burns  LV – injuries cause small, localized, deep burns  Cause cardiac arrest without significant direct myocardial damage  HV – injuries damage by flash / conduction (internal burn)  Myocardium may be directly damaged without pacing interruption  Limbs – fasciotomies or amputation  Look for and treat acidosis and myoglobinuria
  30. 30. Chemical Burns  Acid burn occurs in skin, soft tissues and GIT.  Alkali burns occur in oral cavity and oesophagus.  Initial treatment is dilution with water (Hydrotherapy).  Late neutralisation is done, if required by 0.2% acetic acid in alkali burns. Na.bicarbonate / calcium gluconate 10% gel, topical ziphrin solution in acid burns.
  31. 31. Radiation Burns  Local burns causing ulceration need excision and vascularised flap cover- usually with free flaps.  Systemic overdose needs supportive treatment.
  32. 32. BURNS Breathing & Body image Urine Output Rule of nines & Resuscitation Nutrition Shock & Silverdiazine
  33. 33. References
  34. 34. 1.What will be the % if both legs,the groin and the front chest and abdomen were burned?  A 35%  B 45%  C 55%  D 65%
  35. 35. 2.Which of the following statements regarding burns treatment is false?  A .The simplest and most commonly used crystalloid is Ringer’s lactate.  B. Oral fluids containing no salt are essential when given as fluid replacement in burns.  C. Human albumin solution is a colloid which reduces protein leak out of cells, thereby helping to reduce oedema.  D. The Parkland formula is the most widely used formula and calculates the fluid replacement in the first 24 h.
  36. 36. 3. A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering &erythema of his face, left upper extremity, and chest with frank charring of his right upper extremity. He is agitated, hypotensive & tachycardiac. Which one of the following statements concerning this patient’s initial wound management is correct?  A .Topical antibiotics should not be used, as they will encourage growth of resistant organisms  B. Early excision of facial and hand burns is especially important  C. Escharotomy should only be performed if neurologic impairment is imminent  D. Excision of areas of third-degree or of deep second-degree burns usually takes place 3–7 days after injury  E. Split-thickness skin grafts over the eschar of third-degree burns should be performed immediately in order to prevent fluid loss.
  37. 37. 4. Which one of the following statements regarding the above burn patient is correct?  A . High-dose penicillin should be administered prophylactically  B.Tetanus prophylaxis is not necessary if the patient has been immunized in the previous 3 years  C.This burn can be estimated at 60% total body surface area using the “rule of nines”  D.The most sensitive indicator of adequacy of fluid resuscitation is heart rate  E.This patient should undergo immediate intubation for airway protection and oxygen administration
  38. 38. 3.A women weighing 45 kg, with 35% burns of II ° is brought to the casualty. What will be the fluid resuscitative methods for next 2 days.
  39. 39. “ Surgical Triad ” Measure thrice, think twice, cut once. Thank U
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This topic is oriented mainly on the Bailey & Love - 26th edition. This will be of immense help for the MBBS - Students for the Theory as well as Clinical application.

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