Burns-Binod timalsina

Key points

1. Follow American Burn Association criteria for transfer of a patient to a regional burn center.

2. Never administer prophylactic antibiotics other than tetanus vaccination.

3. Early excision and grafting of full-thickness and deep partial thickness burns improve outcomes.

4. Intravenous fluid resuscitation for patients with burns greater than 20% of total body surface area (children with burns >15% of total body surface area) should be titrated to mean arterial pressure (MAP) greater than 60 mmHg and urine output greater than 30 mL/h.

Initial evaluationA. Airway management, B. Evaluation of other injuries,C. Estimation of burn size, D. Diagnosis of CO and E. cyanide poisoning.

Classification of BurnsBurns are commonly classified as • Thermal, • Electrical, or • Chemical burns

Thermal burns• Thermal burns consisting of flame, contact, or scald burns. • Flame burns are not only the most common cause for hospital

admission of burns, but also have the highest mortality.• This is primarily related to their association with structural fires

and the accompanying inhalation injury and/or CO poisoning.

Electrical Burns

• Electrical burns have special concerns including the potential for cardiac arrhythmias and compartment syndromes with concurrent rhabdomyolysis.

• A baseline ECG is recommended in all patients with an electrical injury, and a normal ECG in a low-voltage injury may preclude hospital admission.

• Long-term neurologic and visual symptoms are not uncommon with high-voltage electrical injuries, and ophthalmologic and neurologic consultation should be obtained to better define a patient’s baseline function.

Chemical burns

• Chemical burns are less common but potentially severe burns.• The most important components of initial therapy are careful

removal of the toxic substance from the patient and irrigation of the affected area with water for a minimum of 30 minutes, except in cases of concrete powder or powdered forms of lye, which should be swept from the patient to avoid activating the aluminum hydroxide with water.

• The offending agents in chemical burns can be systemically absorbed and may cause specific metabolic derangements.

• Formic acid has been known to cause hemolysis and hemoglobinuria, and hydrofluoric acid causes hypocalcemia.

Burn depth• Superficial (first-degree), • Partial-thickness (second-degree), • Full thickness (third-degree), and • Fourth-degree burns, which affect underlying soft tissue.

Burn depth• Clinically, first-degree burns are painful but do not blister,

• Second-degree burns have dermal involvement and are extremely painful with weeping and blisters, and

• Third degree burns are leathery, painless, and non blanching.

Burn depth

Management Immediate care

Assessment of burn wound

Fluid resuscitation

Treatment of burn wound

Pre hospitalEnsure rescuer safety – house fire , chemical , electrical

Stop the burning process – stop, drop & roll

Check for other injuries

Cool the burn wound Cool the burn wound – minimum 10mts to an hour

Oxygen

elevate

Hospital careAirway

Breathing

Circulation

Disability

Exposure with environmental control

Fluid resuscitation

Airway Burned airway causes obstruction

Endo tracheal tube for 48 hours

Symptoms of laryngeal edema appear late Intubation will be difficult after symptoms appear

Crico thyroidotomy needed in late diagnosis

Recognition of potentially burned airway

Breathing Inhalation injury

Thermal burns to lower airway

Metabolic poisoning

Mechanical block to rib movement

Inhalation injury

Observe anyone trapped in a fire

Presence of soot in nose & oro pharynx

Chest x-ray - patchy consolidation

Treatment Secure the airway

Physiotherapy, nebulisation, warm humidified oxygen

Monitor the progress

IPPV for severe cases

Burns of lower airway

Steam injury

Supportive management

Like inhalational injury

Metabolic poisoning

Fire within a closed space

Altered consciousness

ABG Metabolic acidosis

High inspired O2 for 24 hrs if >10%

Displacement from Hb

Assessment of burn wound

Size

depth

Size Formally assessed in a controlled environment

Allows areas to be exposed & any soot / debris to be washed off

Do not cause hypothermia Patients whole hand – 1% of TBSA

Lund & Browder chart

Wallace rule of nine - approximate

Depth

Superficial partial thickness

Deep partial thickness

Full thickness

Fluid resuscitationMaintain the intravascular volume

Needed in a child with > 10%

15% in adults If oral water should not be salt free

Stress hormones – anti diuresis

Hypo natremia & water intoxication Resuscitation volume – area burned

Maximum loss in 8hrs

Lasts 24 – 36 hrs

Fluids

Ringer lactate / Hartmans

Human albumin solution / FFP

Hypertonic saline

Parkland formula

% burns x body wt x 4

Half in first 8hrs

Half over next 16 hrs

Monitoring

Key is urine output

0.5 -1 ml /kg body wt / hr

If output low increase the infusion rate by 50%

Should not be over resuscitated Acid base balance

Hematocrit measurement

CVP monitoring

Treatment of burn wound

Eshcarotomy

Full thickness

Superficial partial

Eshcarotomy

Circumferential full thickness burns of limbs

Incised in mid axial line to avoid nerves

Management of burn wound same

Full thickness1% silver sulphadiazine

Silver nitrate solution 0.5%

Mefenide acetate

Serum nitrate

Superficial burns

Honey

Boiled potato peel

Synthetic biological dressings

Thank you !!!