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    by: debdoot

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    1 : MANAGEMENT of BURN Dr. Debdoot Soren MS (Surgery) Sr. Medical Officer (Surgery) NTPC Ltd, Farakka Dr. Sudip Ghose MD(Medicine) Sr. Specialist (Medicine) NTPC Ltd,Farakka PRESENTED BY LIFELINE
    2 : TOPICS Problem statement Types of burn ABA referral criteria Factors affecting burns Emergency Care: Care at the scene Care at ER Transport of the patient Post admission management Complications Our Experience
    3 : Problem Statement as in NTPC HOSPITAL, Farakka Total number of burn cases reported during 2008-09 : 53 >5% Burn : Total cases 10 >10% Burn : 6 cases Hospitalized in our hospital : 6 (1 case had to be refd later) Referred cases : 4 Mortality : 1
    4 : Types of Burn Thermal Scalds Flame burns Flash burns Contact burns Electrical Chemical Cold
    5 : Referral Criteria (According to ABA) Partial thickness & full thickness burns >10% TBSA in pts <10 or >50 yrs of age Partial thickness & full thickness burns >20% TBSA Partial thickness & full thickness burns involving face, hands, feet, genitalia, perineum or major joints Full thickness burns >5% TBSA
    6 : & Electrical burns including lightning injury Chemical injury Inhalational injury Burn injury in pts with pre existing medical disorders Any burn with concomitant trauma in which injury poses the greatest risk of morbidity or mortality
    7 : & Burn injury in children admitted to a hospital without qualified personnel or equipment for pediatric care Burn injury in patients requiring special social emotional and/ or long term rehabilitative support, including cases involving suspected child abuse
    8 : Factors affecting BURNS Age <8 yrs, most are scalds >8 yrs & adults, mostly flame related Work Chemical Electric Flash burn Molten or hot metals
    9 : Factors affecting BURNS Property of causative material Temperature applied Duration of contact Viscosity/ Particles Thickness of the skin Clothing
    11 : Care at the Scene Airway Extinguish flames O2 inhalation 100% Consider intubation Transport Assess for other injuries I V line RL @1 L/h for a severe case Wrap in clean blanket/ sheet Remove constricting clothing/ ornaments
    12 : Care at the Scene Cold application Cold water @ 150 C is ideal Iced water is not to be used
    13 : Care at ER Ignore burn ABC protocol as usual Assessment of other life threatening injuries Only next comes “Burn management”
    14 : Care at ER Emergency assessment of inhalation injury History esp. flame bun in closed space Inspection of mouth & pharynx Hoarseness, wheeze, copious mucus, carbonaceous sputum Absence of signs does not rule out Carboxyhemoglobin measurement ABG analysis Intubation if necessary
    15 : Care at ER Immediate fluid resuscitation (Due to loss & extravasation of fluid to extravascular space) Assessment of TBSA IV fluid to all adults >15% burn & all children >10% burn Two channels for 30-50% burn Additional CV line for >50% burn
    16 : Care at ER Choice: RL (preferably) or NS Amount: Parkland formula % TBSA burn X wt in kg X 4 = vol in ml I/2 this vol given in first 8 h I/2 left in next 16 h
    17 : Care at ER Maintenance fluid: DNS 100ml/ kg in 24 h for first 10 kg 50ml/ kg for the next 10 kg 20ml/ kg for the next each kg
    18 : Care at ER Assessment of TBSA
    19 : Care at ER Catheterization per urethra All patients >30% burn Perineal burns 10- 30% burn, if poor output In children >15% Hourly monitoring of urine output Goal: 30ml/ h in adult(0.5ml/ kg) 1ml/ kg in a child
    20 : Care at ER Tetanus Prophylaxis Toxoid & Immunoglobin Gastric decompression, if Severe burn Accompanied nausea/ vomiting Distended abdomen Paralytic ileus Analgesic: Opoid (preferably)
    21 : Care at ER Other measures IV antibiotics PPI Ondansetron SOS All routine investigations & Psychological care with counseling
    22 : Care at ER Escharotomy for full thickness circumferential burns to prevent compartment syndrome
    23 : Care at ER ESCHAROTOMIES
    24 : TRANSPORT
    25 : Criteria for Referral Any burn with associated injuries which can not be dealt in present set up Any burn >20% in adults Any burn >10% in children <10 yrs age Any full thickness burn >5% Any burn with concomitant medical disorder which can not be dealt in present medical set up Administrative decision
    26 : How to transport Preferably by ambulance in an AC environment Condition is stable & pt is able to sustain the journey First aid for associated injuries Need for Oxygen, I V fluid requirement & accompanying medical personnel should be assessed Preferably cover up with sterile dressing INTERIOR
    28 : Pathogenesis of Injury Heat Induced Injury Rapid protein denaturation and Cell damage Inflammatory Mediator Injury Protease- Injuring Healing Tissue and Deactivating Growth Oxidants- Injuring Cells, Denaturing Proteins, and Activating Inflammation Consumption of Wound Oxygen by Neutrophils Leading to Tissue Hypoxia Increasing Stimulus to Fibrosis Ischemia Induced Injury
    29 : Pathogenesis of Injury Continuing Burn Injury…. Ongoing inflammation caused by Necrotic tissue Bacteria on surface Caustic topical agents Surface exudate Excess wound proteolytic activity Activated by surface insults Continued damage to viable cells and new tissue growth Damage to wound surface and matrix denaturation of growth factors Excess oxidant release Injuring viable cells
    30 : Metabolic Changes Burn Shock Hypovolemic Shock Histotoxic Shock Cardiotoxic Shock Hypermetabolism Raised Gluconeogenesis & Glycogenolysis Lipolysis Proteolysis Altered Neuroendocrine Response Elevated Catecholamines Attenuated GH level
    31 : Re-assess size of the Burn Single most important factor in prediction of burn related mortality need for specialized care the type & likelihood of complications
    32 : Assessment of Burn depth Primary determinant of mortality long term appearance functional outcome Dependant on temperature of the burn source skin thickness duration of contact heat dissipating capacity of the skin
    33 : Assessment of Burn depth Determining depth Clinical observation re-assessment every day Detection of dead cells/ denatured collagen Biopsy US Vital dyes Detection of blood flow changes Fluorometry Doppler Thermography Analysis of color changes: light reflectance methods Physical change evaluation: NMR
    34 : Assessment of Burn depth Keratin Epidermis Dermis Subcutaneous tissue Muscle NORMAL SKIN
    35 : Assessment of Burn depth 1st degree: Epidermal burn Do not blister Erythematous Painful Heals in 2-3 days Desquamates on 4th day
    36 : Assessment of Burn depth 2nd degree: Superficial partial thickness burn Forms blisters Wound is pink & wet Hypersensitive Blanches on pressure Heals in <3 wks Rarely heals with hypertrophic scars & altered pigmentation Deep partial thickness burn up to reticular dermis Forms blisters Mottled pink & white Discomfort, not pain Slow capillary refill Sensation reduced Heals with scar in 3-9 wks
    37 : Assessment of Burn depth 3rd degree: Full thickness Appear white/ cherry red/ black ± blisters Leathery, firm & depressed Insensate Classical eschar May appear mottled/ translucent
    38 : Assessment of Burn depth 4th degree: Involve all layers of skin, subcutaneous tissue & deeper structures Charred Seen esp. in electrical, contact, immersion burns or in unconscious pts
    40 : Essential measures High Protein diet : Preferably orally Fluid maintenance : monitoring output Antibiotic coverage : IV Cefuroxim Adequate analgesia Coverage for stress ulcers Blood Transfusion >10% in a child >20% in adults @ 1% blood vol/ 1% TBSA on 2nd day or resuscitation is over Must consider high energy requirement
    41 : Inhalation Injury: CO Poisoning Properties of CO 200 times affinity for Hb than O2 Makes COHb, leading to difficulty in O2 delivery to tissues T½ of COHb is approx 4 h, decreases with O2 therapy Symptoms depend on relative concentration in blood <10% - no symptoms ±20% - headache, nausea, vomiting, loss of manual dexterity ±30% - weak, confused & lethargic 40- 60% - coma >60% - death
    42 : Inhalation Injury: CO Poisoning Diagnosis & Treatment 100% oxygen via a nonrebreather mask Arterial COHb level HBO, only when COHb >25% neurologic deficit exists TBSA<15% Pulmonary function is stable
    43 : Inhalation Injury: Thermal airway injury Rare Usually limited to upper airway Immediate intubation ± tracheostomy INTUBATION TRACHEOSTOMY
    44 : Inhalation Injury: Smoke inhalation Upper airway Rapid endotracheal intubation Tracheostomy is not an emergency Steroids don’t help Lower airway & alveoli : Chemical Tracheobroncheolitis Oxygen Intubation> Cricothyroidotomy> Tracheostomy
    45 : CHEMICAL BURNS Usually deeper than it looks Appearance is often brown to gray Continue to get deeper & later appearance is usually worse Severe persistent pain : ongoing skin damage Some chemicals (e.g. Phenol/ Gasoline) causes only skin irritations, but may lead to systemic poisoning Continuous water irrigation should be initiated Continue irrigation through transport Solid chemicals should be brushed prior to irrigation                                                                     Deep Lime Powder burn Deep Hot Tar Burn
    46 : COLD INJURIES Hypothermia When the body core temperature falls below 98oF Shivering, Stumbling, in-coordination, confusion, apathy, Unconsciousness Keeping the patient dry Applying external heat Transporting the patient Frostbite Localized cold injury results from local freezing and interference with circulation Superficial/ Deep frostbite depending upon severity Rapid re-warming with water bath at 104-1080 F
    47 : COLD INJURIES Frostbites
    48 : ELECTRICAL BURNS Stop the Burning Process Neutralize the heat source Remove smoldering clothing Electrical burn to muscle acts like a crush injury Components to the injury: First component -injury caused by the electrical current itself. Second component -injury from arcing. (Ionization of air particles associated with a voltage drop) Third component- skin burn caused by a flash   Fourth component -traumatic injury caused by the intense muscle spasm with the current or from a fall.
    49 : ELECTRICAL BURNS High Voltage Injury Exposure to a voltage of 1000 volts or greater Injury is caused by passage of current Arc or flash from electrical source can cause severe skin burns Explosive force and falls can cause blunt trauma Cardiac, neurological and other injuries occur. Contact point with High Voltage Source Humerus fracture from initial muscle spasm
    50 : ELECTRICAL BURNS High Voltage Injury: Complications & possibilities Dead Muscle
    51 : ELECTRICAL BURNS Low Voltage Injury defined as less than 500 volts Occur characteristically in a home or residential environment. Current not sufficient to cause tissue damage along its course except at contact site c electrical source & at grounding site Cardiac problems are common e.g. ventricular fibrillation Muscle Spasms
    52 : Wound Management Conservative approach for burns which will heal <3 wks without scarring Strict sterility Regular dressing with standard technique Use of non adherent gauge Topical antibiotic: SSD NON ADHERENT GAUGE ATTITUDE STERILE FIELD
    53 : Wound Management FIRST DEGREE BURN No need of dressing or topical agents Use of topical or systemic anti-inflammatory agents may reduce discomfort e.g. aloe vera, NSAIDs
    54 : Wound Management SECOND DEGREE BURN (Partial thickness) Wound is cleaned Blisters are removed Non adherent gauze applied Soft gauze dressing Changed daily Bacitracin or neomycin ointment for face & perineum at least once daily Topical antibiotic: SSD Prophylactic systemic antibiotics are not needed Excellent alternative is the use of a synthetic adhesive dressing which seals the wound and decreases pain
    55 : Wound Management For deep partial thickness burns (which will take >3 wks to heal) & Full thickness burns >3 cms in diameter Timing: < 7days Must be stable to withstand Potential for significant blood loss Special consideration for pulmonary problems Hypothermia must be avoided Stress induced by surgery & anesthesia Blood loss must be replaced with blood products THIRD DEGREE BURN: Early excision & grafting
    56 : Wound Management Tangential Excision Advantages:    Optimal functional and cosmetic result    Can be performed rapidly Disadvantages:    Large blood loss    Difficult endpoint to define    Excise to excise too much or too little
    57 : Wound Management FASCIAL EXCISION Advantages Can be done rapidly with much less blood loss Well-defined endpoint of excision Can be done using tourniquets Can use wide mesh grafts Disadvantages      Risk of injury to nerves      Risk of increasing distal edema      Risk of exposing joint, tendon       Cosmetic defect
    59 : Wound Management WOUND COVER: Autograft Single sheet Meshed
    60 : Wound Management Skin Substitutes Temporary skin substitutes Help heal the partial thickness burn (or donor site) Close the clean excised wound until skin is available for grafting Permanent skin substitutes To replace lost skin providing either epidermis or dermis, or both To provide a higher quality of skin than a thin skin graft Ideal is which will be permanent, affordable, resist hypertrophic scarring, provide normal pigmentation, & grow with developing children
    61 : Wound Management Temporary skin substitutes Human Allograft (Cadaver skin) Porcine Xenograft Oasis Wound Matrix® Biobrane™ on Debrided Scald TransCyte™ on Foot Burn Human Amnion Membrane
    62 : Wound Management Permanent skin substitutes Epicel Integra Alloderm
    63 : Other Supportive Measures Regular exercise & Physiotherapy Compression stocking for healing scars
    64 : Complications Wound Conversion Desiccation Metabolic derangements Renal failure
    65 : Complications Hypertrophic scarring Hypertrophic scarring Heterotopic ossification Marjolins ulcer
    70 : INTROSPECTION Lack of infrastructure Lack of regular trauma dealing Lack of up to date knowledge Lack of professional training Lack of availability of drugs & materials Lack of attitude Too much Administrative involvement
    71 : Those who joyfully leave everything in God’s hand will eventually see God’s hand in everything …. worries end where faith begins….
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