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Burn and management

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Burn and management

  1. 1. BURN AND ITS MANAGEMENT
  2. 2. • By Dr Akashah Ambar • Plastic SurgeryUnit, Bvh, Bwp
  3. 3. DEFINITION • Tissue injury – due to thermal application (heat and cold) – absorption of physical energy (electricity, ionizing radiation and friction) – chemical contact (acid and alkali).
  4. 4. SKIN ANATOMY
  5. 5. CAUSES OF BURN • Scald- hot water, steam, cooking oil , hot cury, boiling milk. • Flame burn • Flash burn • Contact burn • Electric burns • Chemical burn • Friction • Blast • Extreme cold • Ionizing radiation
  6. 6. Pathophysiology
  7. 7. EXTENT OF BURN INJURY • Depends on: – Type of agent causing burn – Intensity of the energy – Duration of exposure – Type of tissue injured
  8. 8. DEGREES OF BURN INJURIES • four degrees of burn injuries
  9. 9. 1st degree burn
  10. 10. 2nd degree burn
  11. 11. Third Degree/full thickness Burn
  12. 12. 4th degree burn
  13. 13. Zones of burn injury
  14. 14. TOTAL BURN AREA ESTIMATION • Critical to provide adequate resuscitation • 3 common guidelines used – Palmer method(for <10%) – Wallace rule of nine – Lund-browder chart
  15. 15. WALLACE RULE OF NINE
  16. 16. LUND BROWDER CHART
  17. 17. Determination of burn depth • Various techniques(non reliable) • Fluoresceine dye • USG • Laser Doppler • MRI
  18. 18. Burn severity criteria according to American Burn Association • Major • Moderate • Minor • Referral to burn centre
  19. 19. AMERICAN BURN ASSOCIATION BURN SEVERITY CATEGORIZATION • Major burn injury – Second-degree burn of > 20% body surface area in adults – Second-degree burn of > 10% body surface area in children – Third-degree burn of > 5% body surface area – Most burns involving hands, face, eyes, ears, feet, or perineum – Most patients with the following: • Inhalation injury • Electrical injury • Burn injury complicated by other major trauma • Poor-risk patients with burns
  20. 20. American Burn Association Burn Severity Categorization • Moderate uncomplicated burn injury – Second-degree burn of 15-20% body surface area in adults – Second-degree burn of 5–10% body surface area in children – Third-degree burn of 2-5% body surface area
  21. 21. American Burn Association Burn Severity Categorization • Minor burn injury – Second-degree burn of < 10% body surface area in adults – Second-degree burn of < 5% body surface area in children – Third-degree burn of < 2% body surface area
  22. 22. Burn Centre Referral Criteria • Second- and third-degree burns >10% body surface area (BSA) in patients <10 or >50 years old. • Second- and third-degree burns >20% BSA in other groups. • Second- and third-degree burns with serious threat of functional or cosmetic impairment that involve the face, hands, feet, genitalia,perineum & major joints. • Third-degree burns >5% BSA in any age group. • Electrical burns, including lightening injury. • Chemical burns with serious threat of functional or cosmetic impairment. • Inhalation injury with burn injury. • Circumferential burns with burn injury. • Burn injury in patients with existing medical disorders that could complicate management, prolong recovery, or affect mortality. • Any burn patient with concomitant trauma (for example, fractures) in which the burn injury poses the greatest risk of morbidity or mortality
  23. 23. MANAGEMENT • Depends upon severity and presenting complications
  24. 24. Burn management flow chart: First aid/pre-hospital care Primary survey Secondary survey Definitive care
  25. 25. PREHOSPITAL CARE • Ensure rescuer safety • Stop the burning process : – Stop, drop and roll • Cool the burn wound – Cooling should occur for a minimum of 10 min and is effective up to 1 hour after the burn injury. • Give oxygen – a fire in an enclosed space • Elevation of burned limb
  26. 26. 3 PHASES OF BURN MANAGEMENT • Emergent(resuscitation) – 0-48 hrs • Active(definitive care) – Day 3 untill wound heals • Rehabilitation – Begins during resuscitation and continues throughout life
  27. 27. EMERGENT PHASE • ATLS protocol (ABC control) • Fluid replacement • inhalational injury care – O2, Bronchial washing, bronchodilators, chest physiotherapy • ECG for electrical burns • chemical burns – (irrigation with water, chelation, cleansing or brusging off powdered chemicals before washing, occular management) • Escharotomies
  28. 28. MAINTENANCE FLUID • In children weighing <15kg, in addition to resuscitative fluid also add maintenance fluid: • administer D/S solution @ maintenance rate of: • For the first 1 to 10 kg - – 100ml/kg/24 hours = 4ml/kg/hour • For the 11 to 20 kg – – 50ml/kg/24hours = 2ml/kg/hour • For any weight above 20kg – – 20ml/kg/24hours = 1ml/kg/hour – Use D/SALINE as children do not have adeguate glycogen stores
  29. 29. MAINTENANCE FLUID • In adults after 24 hours: • Maintenance fluid : 40 ml /kg/hour • Fluid therapy titrated to get a urine output of: – 30cc/hr in adults – 1cc/kg/hr in children • Colloids(used in Brooke & Evans formulas) not used routinely untill 24 hours,may worse capillary leakage of proteins and edema worsens • No proven role of hypertonic saline
  30. 30. • Secondary survey – patient history then head to toe exam – Referral to burn centre • Psychosocial issues- – consider need for religious intervention, legal consult for family affairs,psychotherapy and occuputional rehabilitation
  31. 31. Nutrition • Oral or entral feeding encouraged • Most important complication f burn & use of narcotic opiods: ileus • Give stool softners • Several formulas for caloric requirements measurement • Two most commonly used: – Curreri formula, Harris-benedict formula
  32. 32. Nutritional Formulas • Curreri formula: – For adults: – 25 kcal x wt(kg) + 40 kcal x %TBSA – For children: – 60 kcal x wt(kg) + 35kcal x %TBSA • Harris-Benedict formula(estimate of B.E.E): – Men: • (66.5 + 13.8) x wt(kg) + 5 x height(cm) – 6.76 x age(years) – Women • (65.5 + 9.6) x wt(kg) + 1.85 x height(cm) – 4.68 age(years)
  33. 33. Nutritional Formulas • BEE measured from H-B Formula is multiplied by injury factor (2.1 for large burns) • Curreri formula overestimates caloric requirements(in elderly) • Haris-Benedict formula underestimates caloric requirement • Others: – Indirect calorimetry with metabolic cart(measuring O2 consumption & CO2 production) – Respiratory quotient (for monitoring over or underfeeding) • Protein requirement: 2g/kg/day • Vit A,C,E and Zn,Se,Fe
  34. 34. Other prophylaxis • Prevention of gastric ulcer – H2 R blockers,sucralfate,PPI • Prevention of DVT – heparinization • Control infection – Staph,streptococci – After 72,96 hours-notice any sign • Control sr sugar-sliding scale • Pain control with opiods – Methadone, oxycodon,morphine (background pain and procedural pain)
  35. 35. INVESTIGATIONS TO BE SENT: • CBC –Hb%, haematocrit, total count of WBC • Platelet count • Blood grouping and cross matching • Serum creatinine, Urea • Random blood sugar • Serum electrolytes • Serum albumins,pre albumin,C-reactive protein,24 hour urinary nitrogen • Chest X-ray and ECG • HF burn: sr Ca level • Bronchoscopy or endoscopy(inhalational or chemical burn) • ABG, carboxyhemoglobin level (inhalational burn) • Cultures(blood,urine,indwelling catheters,sputum)
  36. 36. Estimation of burn mortality • Various formulas: • Baux formla= Age + %TBSA • Zawacki;s Z scoring: extent of burn injury,extent of full thickness burn injury,presence of inhalational injury
  37. 37. Care of burn wounds Can wait until patent airway, adequate circulation, fluid replacement is assured • Goals: – Prevent infection – Prevent tissue ischemia – Promote healing
  38. 38. Burn wound care for specific burns • Inhalational burn – Pulmonary toilet,bronchodilators,clearing secretions • Electric burn – Low voltage an high voltage burn – Treat myoglobinuria,fluid resuscitaion,extensive serial debridements • Cold injuries – Frost bite, degrees of frost bite, prevention of hypothermia,removal of wet cloths,warming with internal body warming fluids,delayed debridement • Flame/flash burn – Debridements,dressings,coverage
  39. 39. WOUND MANAGEMENT • Conservative – Dressings • Open dressing • Closed dressing • Options for topical treatment of deep burns: – Aloe lotion – 1% silver sulphadiazine cream – 0.5% silver nitrate solution – Mafenide acetate cream – Serum nitrate • Surgical excision and grafting
  40. 40. Excision • Tangential excision – Gouian(weck) or watson blades • Fascial excision – Electrocautery or with simple blades • Water jet-powered Versa JET/hydrodissection – For convex or concave surfaces,eyelids,ear,nose
  41. 41. Versa jet system
  42. 42. Silver sulphadiazine
  43. 43. SILVER SULPHADIAZINE • sulfa derivative topical antibacterial used for burns. • acts only on the cell membrane and cell wall to produce its bactericidal effect • Also used for other skin ulcers • Must not be used on newborns or infants upto age of 2 months because of side effects • Must not be used on face
  44. 44. • 1% cream applied twice daily • limited penetration through the skin • Side effects: – leukopenia – Pain,burning,itching – Silver poisoning – greyish discoloration of skin or mucosa – Fever,chills – Serious allergic reaction(rare)
  45. 45. Other antimicrobial creams • Silver nitrate – Painless application,applied 4 hourly, – Stains black,hyponatremia,hypochloremia,methemoglobi nemia • Mafenide – 5% cream,penetrates eschar,used for exposed nose and ear cartilages – Metabolic acidosis,painful application • Bacitracin,neomycin,polymyxin B ointment • bactrban(mupirocin) cream
  46. 46. Arm burn after 4 days
  47. 47. pics Soak silver dressings and gauze in WATER. Apply the silver dressing. Wrap with moist gauze. Secure with gauze or tape.
  48. 48. Collagen dressing
  49. 49. Silver alginate foam dressing
  50. 50. VAC DRESSING • vaccum assisted dressing • applied on wounds • over grafts as well
  51. 51. DEFINITIVE CARE: • Physiotherapy, splinting, pressure garment • Burn wound management • Escharotomy/Fasciotomy • Skin grafting • Rehabilitation
  52. 52. Complications of burn: • Acute/early complications: – Shock –hypovolumic or neurogenic – Renal failure – Acute respiratory distress syndrome – Respiratory failure – Pneumonia – Laryngeal oedema – Acute GIT ulcer: Curling ulcer – Hypothermia – Multiple organ system failure (MOSF)
  53. 53. Delayed complications –Wound infections –Septicemia –Protein-losing enteropathy –Cerebral damage
  54. 54. Late complications –Hypertrophied scar –Keloid –Post-burn contracture –Marjolin’s ulcer
  55. 55. conclusion • Despite all advances,in burn care, the core of burn care remains the burn team.
  56. 56. Thank you
  • AnupamaBandi1

    May. 3, 2021
  • RaginiNandan

    Sep. 12, 2020
  • ssuserbe3b1a

    Sep. 10, 2020

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