Author(s): Patrick Carter, Daniel Wachter, Rockefeller ......Epidemiology of Burns 1-1.5% of...
Transcript of Author(s): Patrick Carter, Daniel Wachter, Rockefeller ......Epidemiology of Burns 1-1.5% of...
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Advanced Emergency Trauma Course
GhanaEmergencyMedicineCollaborativePatrickCarter,MD∙DanielWachter,MD∙RockefellerOteng,MD∙CarlSeger,MD
Burns
Presenter:CarlSeger,MD
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Epidemiology of Burns
1-1.5%ofpopulationseesMDforburns/yearinUS
1.25-2.5millionburnseachyear 500,000EDvisits,50,000admits,5,000deaths
Mostburnscoverlessthan5-10%ofbodysurfacearea
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Types of Burns
Thermal Chemical Electrical
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Thermal Burns
Contact Flame Heat Scalding
Medscape
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Chemical Burns
Bothacidsandbasescanbedefinedascaustics,whichcausesignificanttissuedamageoncontact.
ACIDSproduceacoagulationnecrosisbydenaturingproteins,formingacoagulum(eg.eschar)thatlimitsthepenetrationoftheacid.
BASEStypicallyproduceamoresevereinjuryknownasliquefactionnecrosis
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Chemical Burns
Acids• Toiletbowlcleaners,draincleaners,metalcleaners,automobilebatteryfluid,fertilizermanufacturing,rustremovers,tirecleaners,tilecleaners,glassetching,dentalwork,refrigerant,andhairwaveneutralizers
Bases• Draincleaners,bleach,ovencleaners,mortar,plaster,andcement
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Electrical Burns LOW-VOLTAGE• Electricburnsalmostexclusivelyinvolveeitherthehandsororalcavity.
HIGH-VOLTAGE• Inburnsfromanelectricarc,thecurrentcoursesexternaltothebodyfromthecontactpointtotheground• Electriccurrentthatpassesbetweenthepowersourceandtheanatomicpointofcontact(entrancewound),andbetweenthepatient(exitwound)andthegroundingmechanism,causinghiddendestructionofdeepertissues
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General Skin Anatomy and Physiology
SkinLayers• Epidermis• Dermis
SkinFunction• Protection
Pathogens Waterloss
• Tempregulation• Sensation• VitaminDSynthesis
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NationalCancerInstitute,SEER
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Classification
TraditionalClassification• 1stdegree• 2nddegree• 3rddegree
CurrentClassification• Superficialpartialthickness• Deeppartialthickness• FullThickness
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Burn Classification
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K.Aainsqatsi,Wikipedia
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1st Degree
Redness Dryskin Painfultotouch Painlasts48to72hrs Peelingskin
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SourceUndetermined
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2nd Degree; Partial Thickness
Involvesthetoplayersofskin.
Theskinisredandblistered.
Usuallypainful. Takesupto3-4weekstoheal.
Mayscar.
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
SourceUndetermined
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3rd degree; Full thickness burns
Destroysalllaysofskinandunderlyingstructures.
Maylookbrownorblackandtissueunderneathmaybewhite.
Usuallynotpainful.
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SourceUndetermined
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Pathophysiology of Burns Cellulardamageat>45°C Dependentontemperatureandduration
• Singeretal.AcadEmergMed2000;7:1
Threezonesofinjury– Centralzoneofnecrosis Zoneofstasis(atriskofnecrosis) Zoneofhyperemia• JacksonBrJSurg1953;40:588BurnPathophysiology
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Pathophysiology of Burns Thermalinjurytriggersintenseinflammatoryresponse• Initialreleaseofhistamine,bradykinin• Increasedcapillarypermeabilitywiththirdspacing• ProgressivevascularocclusionbyPMN,RBCs• Releaseoffreeradicals,proteases
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Clinical Evaluation
History• Historyofevents–closedspace,toxicfumes• Evaluateforinconsistenciesorpatternssuggestingchildabuse(immersioninjuries)• PMH:AMPLE,Tetanusimmunizationstatus
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Clinical Evaluation • PhysicalExam
Assessforinhalationinjury• Signsnotalwayspresent• Singednasalhair• Carbonaceoussputum• Cough• Hoarseness• Dyspnea• AMS
• AssessSeverityofInjuryGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
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Clinical Evaluation
DetermineSeverityofInjury• Size• Depth/Degree• Location-
Hands,face,genitals,feet,circumfrential• Ruleof9’s
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Rule of 9’s
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Burnsurgery.org
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Initial Burn Management
ABCs Identifyandtreatassociatedinjuries Removesource,protectrescue Initialcoolingwithcoolwater(notcold) Coverwithdressing,leaveblistersintact Brushoffanymetalothermaterial Irrigationforchemicalburns
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AirwayManagement• Secureairwayearly• Signsofimpendingairwayobstruction
Hoarseness,Stridor,Facialedema• EndotrachealintubationorsurgicalairwayifETnotpossible• Give100%O2forsuspectedsmokeinhalation
Acute Management
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Chemical Burns
Brushoffdrymaterialfirst
Takeoffanyclothingthatcaneasilyberemoved
Flushwithwaterforatleast20-30minutes
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FluidResuscitation• ParklandFormula• UrineOutput• PediatricConsiderations
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Acute Management
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Parkland Formula
4x(%bodysurfaceburned)xwtinKg Thisequalstheamountoffluid(inml)toreplaceina24hrperiod
Thefirsthalfinthefirst8hrs Therestinthenext16hrs
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Acute management
GeneralWoundCarePrinciples• BiologicalDressing• WoundDebridement
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Acute management
TopicalAgents• Silvadinecream• Coveringthewoundwithcleanlinens
Analgesia• Oftenverypainfulandrequirelargeamountofpainmedication
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Do’s and Don’ts of Burn Care
Do’s• Brushoffdrychemicalwhileinaprotectivesuit• Flushwithcoolwater• Coverwoundwithdrydressing• Keepvictimcomfortable
Don’ts• Applyice• Touchtheburn• Removepiecesofclothfromburnedarea• Cleansevereburns• Breakblisters• Useointmentonsevereburns
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Acute management
Escharotomy• Deepcircumferentialburnsoverneck,chestlimbs• CompromisedABC’s• Maybelifeorlimbthreatening• IncisionofeschartosubQfat• Avoidmajorvesselsandnerves• Anestheticsusuallynotrequired
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Escharotomy
MedscapeGhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
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Acute management
InhalationalInjuries• GeneralEvaluationandManagement• CarbonMonoxide
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Inhalational Injuries
Responsibleformostdeaths Evolutionmayrequireseveraldays Exposureofairwaysandlungstotoxicchemicals
Tracheobronchitis Airwayobstruction Pulmonaryedemawithin2-3days
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Inhalation Injury
CarbonMonoxide• HashigheraffinityforhemoglobinthanO2.• COpoisoningcanleadtoAMS,myocardialischemia,andseverelongtermneurologicsequelae• O2inhigherconcentrationsacceleratesCOelimination• Canalsotreatwithamylnitrate,sodiumnitrite,sodiumthiosulfate
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Complications of Burn Care
Infection AirwayConsiderations CircumferentialBurns
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Indications for Admission
Adults>15%2°DegreeBurns Children>10%2°DegreeBurns 3°burns>2% Face,hands,feet,perineum Seriousunderlyingdiseases Socialconsiderations
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When does Cold Injury Occur? TheFactorsthatcontributetoColdInjury• Temperature• Durationofexposure• Immobilization• Moisture• Vasculardisease• Openwounds
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Recognize local cold injuries
Frostnip-Mildform,doesnotresultintissuedestruction,verypainful
Frostbite-intracellularicecrystals,cangetreperfusioninjury,Classifiedbasedoffofdepth
Medscape
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Frostbite
Medscape
GhanaEmergencyMedicineCollaborativeAdvancedEmergencyTraumaCourse
Medscape
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Treating cold injuries
Donotdelay Removeclothing Warmedblankets Rewarmfrozenpart Preservedamagedtissue Preventinfection Elevatedexposedpart Analgesics,tetanus,andantibiotics
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Recognize hypothermia
Rapidorslowdropincoretemperatureto<35degreesC
Elderlyandchildrenatgreaterrisk Low-rangethermometerrequired
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Hypothermia clinical signs
Temperature<35degreesC DepressedLevelofconsciousness Gray,cyanotic Variablevitalsigns Absenceofcardiorespiratoryactivity
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Treating Hypothermia
ABCDE’s Rewarm Assessforassociateddisorders Bloodanalyses,includingK+andC++
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Treating hypothermia
Passiveexternalrewarming:Warmenviroment,blankets,IVfluids
Activecorerewarming:surgicalrewarmingtechniques
Notdeaduntilwarmanddead
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Questions?
Dkscully(flickr)
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References Schwartz,L.,Balakrishnan,C.ThermalBurns.inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1220-1226.
Harchelroad,F.,Rottinghaus,D.ChemicalBurns,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1226-1231
Fish,R.ElectricalInjuriesandLightningInjuries,inEmergencyMedicine:AComprehensiveGuide.Tintinalli,Editor.2004,McGraw-Hill.p.1231-1238
AmericanCollegeofSurgeons.Injuriesduetoburnsandcold,inAdvancedTraumaLifeSupportforDoctors7thedition.2004.p.231-241.
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