burn and scald

1

Burn and Scald

22

Burn & ScaldBurn & Scald

EtiologyEtiology A A burnburn injury occurs as a result of destruction of injury occurs as a result of destruction of

the skin from direct or indirect thermal force. the skin from direct or indirect thermal force. Burn are caused by exposure to heat, electric Burn are caused by exposure to heat, electric

current, radiation or chemical.current, radiation or chemical.

Scald burnScald burn result from exposure to moist heat result from exposure to moist heat (steam or hot fluids) and involve superficial. (steam or hot fluids) and involve superficial.

33

Types of burn injuryTypes of burn injury

1.1. Thermal burns.Thermal burns.

2.2. Chemical burnsChemical burns

3.3. Electrical burns Electrical burns

4.4. Radiation burns.Radiation burns.

44

Types of burn injuryTypes of burn injury Thermal burnsThermal burns-exposure to dry heat (flames) or moist heat -exposure to dry heat (flames) or moist heat

(steam and hot liquids).(steam and hot liquids).-Most common burn injuries -Most common burn injuries Chemical burnsChemical burns-Direct skin contact with either acid or alkaline -Direct skin contact with either acid or alkaline

agentsagents-destroys tissue protein, leading to necrosis.-destroys tissue protein, leading to necrosis.-Burn cause by alkalis are more difficult to -Burn cause by alkalis are more difficult to

neutralize than are burns caused by acid.neutralize than are burns caused by acid.-Alkalis tends to have deeper penetration.-Alkalis tends to have deeper penetration.

55

Chemical burnsChemical burns

66

Types of burn injuryTypes of burn injury

Electrical burnsElectrical burns..-severity depends on the type and duration -severity depends on the type and duration

of current, and amount of voltage.of current, and amount of voltage.-difficult to assess, due to electrical insulator.-difficult to assess, due to electrical insulator. Radiation burns.Radiation burns.-sunburn or radiation treatment of cancer.-sunburn or radiation treatment of cancer.-involve outermost layers tends to be -involve outermost layers tends to be

superficial.superficial.-all function skin is intact.-all function skin is intact.

77

Electrical hand burn.Electrical hand burn.

88

Burn & Scald:EpidemiologyBurn & Scald:Epidemiology

1 million people suffer thermal injury each 1 million people suffer thermal injury each year in U.S.year in U.S.

45,000 persons are admitted to hospital.45,000 persons are admitted to hospital. ↑↑45,000 persons die as a result of burn 45,000 persons die as a result of burn

injury.injury. The direct cost of treating a burn injury can The direct cost of treating a burn injury can

be high.be high. Cost are higher for large burns.Cost are higher for large burns.

99

BurnBurn

• The depth of a burn is dependent on the temperature of the burning agent and the length of time.

• Tissue damage may occur at temperatures of 48°c.

• Irreversible damage to the dermis occurs at 70°.• Burn injuries are described as:-

1.Superficial (first-degree burns)

2.Superficial or deep partial thickness (second-degree burns).

3.Full thickness (third-degree burn)

1313

Burn:ClassificationBurn:Classification

1. Superficial (first-degree burns)• Involve only the epidermal layer of the skin.• sunburns are commonly first-degree burns.

2. Superficial or deep partial thickness (second-degree burns).

• Destruction of the epidermis and varying depths of the dermis.

• Usually painful because nerve endings have been injured & exposed.

• Ability to heal because epithelial cells is not destroyed.

14

1° burn

2° burn

15

Superficial burn (1° burn)

16

Partial thickness (2°burn)

17

Burn:Classification

• Present of blisters indicates superficial partial-thickness injury.

• Blister may ↑size because continuous exudation and collection of tissue fluid.

• Healing phase of partial thickness, itching and dryness because ↑vascularization of sebaceous glands, ↓reduction of secretions and ↑perspiration.

18

Blister may ↑size because continuous exudation and collection of tissue fluid

19

Burn:Classification3.Full thickness (third-degree burn)• Destruction of the epidermis and the entire

dermis, subcutaneous layer, muscle and bone.• Nerve ending are destroyed-painless wound.• Eschar may be formed due to surface

dehydration.• Black networks of coagulate capillaries may be

seen.• Need skin grafting because the destroyed tissue

is unable to epithelialize.• Deep partial-thickness burn may convert to a

full-thickness burn because of infection, trauma or ↓blood supply.

20

3° burn

21

Eschar:composed of denatured protein

22

Full thickness (3°burn)

23

Burn and scald

Function of the skin. Protection Body temperature

regulation Cutaneous sensation. Metabolic functions (vit

D) Blood reservoir Excretion.

As a result of burns & scald normal skin structure and function are impaired.

-sweat and sebaceous glands are destroyed.

-sensory receptors is ↓.

-body fluids escape,

-lack of temperature control.

24

Pathopysiology

Local tissue response Systemic response to burn injury.

Local tissue response Damage to skin from thermal injury cause

tissue changes know as zone of injury. If the heat is severe, a zone of coagulation is

formed, in this area protein has been coagulated and the damage is irresversible.

25

Local tissue response

Therefore, blood vessels are damage, resulting in ↓perfusion.

Zon of statis Poor blood flow and tissue edema will cause

risk for death over a few hours or days. Further necrosis can happen, because other

factors e.g dehydration and infection. Due to these wound have to be clean/care,

hydration and prevention of infection are essential to limit further destruction.

26

Local tissue response

Zone of hyperemia or inflammation is at the outer edge of the burn.

Here blood flow is ↑because of vasodilation.

Vasodilation because of the release of vasoactive substances.

↑blood flow brings leukocytes and nutrients to promote wound healing.

27

Zon of injury

28

Thermal injury

InflammationVasodilatation& ↑blood flow

Leukocyctes & nutrient promote healing

Vasoactive substance

29

Normal Vasodilatation

30

Systemic response to burn injury: severe burn

• Every organ system is affected by a major burn injury.

• Systemic changes known as burn shock develop with a burn greater than 25% of the total body surface area (TBSA)-major burn injury.

• Damaged tissue released cellular mediators and vasoactive substances. E.g, histamine, serotonin & prostaglandins

31

Systemic response to burn injury

• These substances induce a systemic inflammatory response and cause vasoconstriction & capillary permeability

• Vasoconstriction occur for a short period due to vascular system attempts to compensate for fluids loss.

• Vascular permeability, resulting in hypovolemia and edema.

• This phase begins at injury, peaks in 12-24 hours, and last for 48 to 72 hours

32

EdemaOsmotic pressure ↓,Due to protein plasmaEscape out to interstitial•↓blood flow & hypovolemia

33

IntravascularNormal

34

Burn Shock First 24hours

Burn Shock after 24hours

35

Thermal injury

Inflammation

Histamine release

Vasoconstriction

↑blood pressure

↑blood flow to injury

↑capillary permeability

Fluids leakage andLoss from injurySite (edema)

↓intravascular fluid

Hypovolemic shock

↑Protein leakage

Hypoproteinemia

↓Plasma osmoticpressure

36

Factors determining severity of burns

• Size of burn• Depth of burn• Age of victim• Body part involved• Mechanism of injury• History of cardiac, pulmonary, renal, or

hepatic disease • Injuries sustained at time of burn.

37

Effects of a severe burn

1. Cardiovascular

2. Respiratory

3. Immune

4. Integumentary

5. Gastrointestinal

6. Urinary

3838

Cardiovascular systemCardiovascular system

Blood pressure falls-fluid leaks from Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein)intravascular to interstitial (sodium and protein)

When blood pressure is low, pulse rate ↑.When blood pressure is low, pulse rate ↑. Blood flow in intravascular is concentrated and Blood flow in intravascular is concentrated and

cause static.cause static. Cardiac output ↓, Cardiac output ↓, Due to that tissue perfusion ↓, Due to that tissue perfusion ↓,

3939

Hematologic changesHematologic changes

Some RBC is destroys to the burn injury.-Some RBC is destroys to the burn injury.-anemiaanemia

Thrombocytopenia, abnormal platelet Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, function, depressed fibrinogen levels, deficit plasma clotting factors.deficit plasma clotting factors.

Life span ↓RBC.Life span ↓RBC. Blood loss during diagnostic and Blood loss during diagnostic and

therapeutic procedure. therapeutic procedure.

4040

Respiration systemRespiration system

Majority of deaths from fire are due to smoke Majority of deaths from fire are due to smoke inhalation.inhalation.

Pulmonary damage can be from direct inhalation Pulmonary damage can be from direct inhalation injury or systemic respond to the injury.injury or systemic respond to the injury.

Damage to cilia and cell in the airway-Damage to cilia and cell in the airway-inflammation.inflammation.

Mucociliary transport mechanism not Mucociliary transport mechanism not functioning-bronchial congestion and infection.functioning-bronchial congestion and infection.

Pulmonary edema, fluids escape to interstitial. Pulmonary edema, fluids escape to interstitial. Airway obstruction.Airway obstruction.

4141

Factors determining inhalation injury or Factors determining inhalation injury or potential airway obstructionpotential airway obstruction

Burns to face and neckBurns to face and neck Singed hairs, nasal hair, beard, eyelids or Singed hairs, nasal hair, beard, eyelids or

eyelasheseyelashes Intraoral charcoal, especially on teeth and gumsIntraoral charcoal, especially on teeth and gums HoarsenessHoarseness Smell of smoke on victims clothes or on victim.Smell of smoke on victims clothes or on victim. Respiratory distress.Respiratory distress. Copious sputum production.Copious sputum production.

4444

Features of respiratory failureFeatures of respiratory failure

Inability to speak due to dyspnea Inability to speak due to dyspnea Sweating Sweating Apparent exhaustion/tiredApparent exhaustion/tired Tachycardia Tachycardia Tachypnea [R. Rate > 40 /min in adults ] Tachypnea [R. Rate > 40 /min in adults ]

4545

ManagementManagement

Anaesthetic consultation Anaesthetic consultation High flow oxygen High flow oxygen Tracheobronchial [ bronchoscopy] Tracheobronchial [ bronchoscopy] Physiotherapy Physiotherapy Close monitoring [preferably ICU ] Close monitoring [preferably ICU ] Ventilatory support Ventilatory support Hemodynamic support, when requiredHemodynamic support, when required

4646

GastrointestinalGastrointestinal

Burn >20% experience ↓peristalsis, gastric Burn >20% experience ↓peristalsis, gastric distention and ↑risk of aspiration.distention and ↑risk of aspiration.

Paralytic ileus due to secondary to burn trauma.Paralytic ileus due to secondary to burn trauma. Stress ulcer (stomach/duodenum) due to burn Stress ulcer (stomach/duodenum) due to burn

injury.injury. Indication of stress ulcer-malena stool or Indication of stress ulcer-malena stool or

hematemesis.hematemesis. These signs suggest gastric or duodenal erosion These signs suggest gastric or duodenal erosion

(Curling`s ulcer)(Curling`s ulcer) Gastric distention and nausea may lead to Gastric distention and nausea may lead to

vomiting.vomiting.

4747

Urinary systemUrinary system Hypovolemic state, blood flow to kidney ↓, Hypovolemic state, blood flow to kidney ↓,

causing renal ischemia.causing renal ischemia. If this continues, acute renal failure may If this continues, acute renal failure may

develop.develop. Full thickness and electrical burns, myoglobin Full thickness and electrical burns, myoglobin

(from muscle breakdown) and heamoglobin (from muscle breakdown) and heamoglobin (from RBC breakdown) are released into the (from RBC breakdown) are released into the bloodstream and occlude renal tubules.bloodstream and occlude renal tubules.

Adequate fluid replacement and diuretics can Adequate fluid replacement and diuretics can counteract this obstruction.counteract this obstruction.

4848

MyoglobinuriaMyoglobinuria

4949

Immunologic changesImmunologic changes

Skin barrier to invading organisms s destroyed, Skin barrier to invading organisms s destroyed, circulating levels of immunoglobulins are ↓circulating levels of immunoglobulins are ↓

Changes in WBC both quantitative and Changes in WBC both quantitative and qualitative.qualitative.

Depression of neutrophil, phagocytic and Depression of neutrophil, phagocytic and bactericidal activity is found after burn injury.bactericidal activity is found after burn injury.

All this changes in the immune system can make All this changes in the immune system can make the burn patient more susceptible to infection.the burn patient more susceptible to infection.

5050

ComplicationsComplications

EarlyEarly Hypovolemia Hypovolemia Fluid overload Fluid overload Renal dysfunction Renal dysfunction Hemoglobinuria Hemoglobinuria Stress Stress

gastroduodenal ulcers gastroduodenal ulcers

Pulmonary Pulmonary dysfunction dysfunction

Local / systemic Local / systemic sepsis sepsis

5151

ComplicationsComplications

LateLate Scarring –Scarring –

hypertrophic, keloid hypertrophic, keloid Contractures – limbs, Contractures – limbs,

neck neck

Disfigurement Disfigurement Functional disability Functional disability Posttraumatic stress Posttraumatic stress

5252

Extent of surface area burnedExtent of surface area burned Rule ofRule of ninesnines--An estimated An estimated

of the TBSA involved as a of the TBSA involved as a result of a burn.result of a burn.

The rule of nines measures The rule of nines measures the percentage of the body the percentage of the body burned by dividing the body burned by dividing the body into multiples of nine.into multiples of nine.

The initial evaluation is The initial evaluation is made upon arrival at the made upon arrival at the hospital.hospital.

5353

Rule of ninesRule of nines

5454

Lund and BrowderLund and Browder

More precise method of estimating More precise method of estimating Recognizes that the percentage of BSA of Recognizes that the percentage of BSA of

various anatomic parts.various anatomic parts. By dividing the body into very small areas and By dividing the body into very small areas and

providing an estimate of proportion of BSA providing an estimate of proportion of BSA accounted for by such body partsaccounted for by such body parts

Includes, a table indicating the adjustment for Includes, a table indicating the adjustment for different agesdifferent ages

Head and trunk represent larger proportions of Head and trunk represent larger proportions of body surface in children. body surface in children.

5656

Age in yearsAge in years 00 11 55 1010 1515 AdultAdult

A-head (back or A-head (back or front)front)

9½9½ 88½½

6½6½ 5½5½ 4½4½ 3½3½

B-1 thigh (back or B-1 thigh (back or front)front)

2¾2¾ 33¼¼

44 4¼4¼ 4½4½ 4¾4¾

C-1 leg (back or C-1 leg (back or front)front)

2½2½ 22½½

2¾2¾ 33 3¼3¼ 3½3½

Lund and Browder chartLund and Browder chart

5757

ReviewReview

Types of burn injuryTypes of burn injury Burn: ClassificationBurn: Classification Pathophysiology:- Pathophysiology:- local tissue respond (zon of injury)local tissue respond (zon of injury) systemic respond to burn injury.systemic respond to burn injury. surface area burned:-surface area burned:- Rule of nines and Lund & Bruder BrowderRule of nines and Lund & Bruder Browder

5858

Prehospital patient managementPrehospital patient management

Rescuers must ensure their own safety, Rescuers must ensure their own safety, ones safety is establish:-ones safety is establish:-

Eliminate the heat source.Eliminate the heat source. Stabilizing the victim condition.Stabilizing the victim condition. Identify the type of burn.Identify the type of burn. Preventing heat loss.Preventing heat loss. Reducing wound contamination.Reducing wound contamination. Restrict jewelry and clothing is removed Restrict jewelry and clothing is removed Preparing for emergency transport.Preparing for emergency transport.

59

Stop the burning Stop the burning process:Thermal burns.process:Thermal burns.

Stop the flame: extinguish the Stop the flame: extinguish the flame/lavage with water.flame/lavage with water.

Cool the burnCool the burn Do not used ice water for cooling it Do not used ice water for cooling it

causes vasoconstriction and may result causes vasoconstriction and may result in further injury.in further injury.

Cover the wound to minimize bacteria Cover the wound to minimize bacteria contaminationcontamination

Cover victim to prevent hypothermia.Cover victim to prevent hypothermia.

60

Chemical burnsChemical burns Immediately remove the clothing and a hose Immediately remove the clothing and a hose

or shower to lavage the involved area for a or shower to lavage the involved area for a minimum 20 minutes.minimum 20 minutes.

Electrical burnsElectrical burns

-Serious harm to victim and rescuer.-Serious harm to victim and rescuer.

-Ensure source of electrical has been -Ensure source of electrical has been disconnected.disconnected.

-Use non conductive device to remove victim.-Use non conductive device to remove victim.

-If victim unresponsive, assess respiration and -If victim unresponsive, assess respiration and pulse.pulse.

-Commenced CPR (cardiopulmonary -Commenced CPR (cardiopulmonary resuscitation) if no pulse.resuscitation) if no pulse.

61

Radiation burnRadiation burn

Usually minor, involved epidermal Usually minor, involved epidermal layer of skin.layer of skin.

Helping the normal body mechanism Helping the normal body mechanism to promote wound healingto promote wound healing

Shielding, establishing distance.Shielding, establishing distance. Limit time of exposure to radioactive Limit time of exposure to radioactive

source.source.

6262

Phases of treatmentPhases of treatment

3 phases of treatment can be identified in 3 phases of treatment can be identified in the care of the severely burned patient.the care of the severely burned patient.

1.1. The emergent phase refers to the first 24 The emergent phase refers to the first 24 to 48 hours after a burn.to 48 hours after a burn.

2.2. Acute phaseAcute phase

3.3. Rehabilitation phase.Rehabilitation phase.

6363

Burn bedspaceBurn bedspace

1. Plastic sheet top2. bottom sterile Microdon sheeting3. Caps, masks, sterile gloves, gowns4. Intravenous fluids/equipment5. Intubation equipment6. Oxygen therapy7. Cardiac monitoring8. Catheter, syringes, needles

6464

IsolationIsolation

Reverse Isolation is designed to prevent Reverse Isolation is designed to prevent transmission of microorganisms to patient.transmission of microorganisms to patient.

Burn patient are protected from infection Burn patient are protected from infection from other patients, visitors, and health from other patients, visitors, and health care providers. care providers.

Universal precautions, apply to all burn Universal precautions, apply to all burn patients. patients.

The minimum requirements: Universal The minimum requirements: Universal Precautions are……………..Precautions are……………..

6565

Universal PrecautionsUniversal Precautions

1. All patients have a private room1. All patients have a private room

2. Handwashing is required before entering 2. Handwashing is required before entering and after leaving the patient's room.and after leaving the patient's room.

3. Gowns, gloves and masks, 3. Gowns, gloves and masks,

4. Health care provider having URTI are not 4. Health care provider having URTI are not allowed to enter roomallowed to enter room

6666

ER

AssessmentHistory

Physicalexamination

IntravenouslineNasogastric

tube

Indwellingcatheter

Neurologicalassessment

Vital signs

67

Emergency department Emergency department Management: Management:

Emergent/immediate phaseEmergent/immediate phase

1. Assessment1. Assessment-Health history, how, when, duration of contact, -Health history, how, when, duration of contact,

location, age, medical history.location, age, medical history.

2. Physical examination2. Physical examination Respiration, patent airway, sign of inhalation Respiration, patent airway, sign of inhalation

injury.injury. Listen for hoarsenes and crackle. Need Listen for hoarsenes and crackle. Need

intubation.intubation. Observe for upper body burned, erythema or Observe for upper body burned, erythema or

blistering of lips or buccal mucosa or pharynxblistering of lips or buccal mucosa or pharynx Area of body burned-face, hands, feet, perineum.Area of body burned-face, hands, feet, perineum.

68


Emergent/immediate phaseEmergent/immediate phase Cardiac monitoring, is indicated for cardiac Cardiac monitoring, is indicated for cardiac

history, electrical injury or respiratory history, electrical injury or respiratory problems.problems.

Vital signs-BP, PR. For severe burn an Vital signs-BP, PR. For severe burn an arterial catheter is used for blood pressure.arterial catheter is used for blood pressure.

Large bore intravenous lines and an Large bore intravenous lines and an indwelling urinary catheter are inserted to indwelling urinary catheter are inserted to assess and monitor fluid intake and output.assess and monitor fluid intake and output.

May assist in determining the extent of May assist in determining the extent of preburn renal function and fluids status.preburn renal function and fluids status.

69


Emergent/immediate phaseEmergent/immediate phase Nurse needs to know the maximal volume Nurse needs to know the maximal volume

of fluid the patient should receive.of fluid the patient should receive. Infusion pumps and rate controller are Infusion pumps and rate controller are

useful devices for correctly delivery.useful devices for correctly delivery. Insert nasogastric tube to remove gastric Insert nasogastric tube to remove gastric

juice, which can prevent aspiration and juice, which can prevent aspiration and vomiting.vomiting.

The neurologic assessment focuses on the The neurologic assessment focuses on the pateint`s levels of consciousness, pateint`s levels of consciousness, psychologic s status, pain, behavior and psychologic s status, pain, behavior and anxiety.anxiety.

7070

Support vital signSupport vital sign If the patient has no pulse and not If the patient has no pulse and not

breathing, begin CPR.breathing, begin CPR. Establish airway-nasotracheal suction and Establish airway-nasotracheal suction and

endotracheal intubation.-oxygen 100% via endotracheal intubation.-oxygen 100% via face mask.face mask.

Connect to cardiac monitor and observe Connect to cardiac monitor and observe for arrhytmia.for arrhytmia.

Pulse oximeter-assessment for patient oxygen

saturation.

7171

Pulse oximeterPulse oximeter

The pulse oximeter probe contains two The pulse oximeter probe contains two electrodes, which emit light of specific electrodes, which emit light of specific wavelength through a cutaneous vascular wavelength through a cutaneous vascular bed, such as that of the digits or the ear bed, such as that of the digits or the ear lobe. lobe.

7272

Pulse oximeterPulse oximeter

7373

Support vital sign; pulse rateSupport vital sign; pulse rate

1.1. Following a burn, tachycardia is inevitable,Following a burn, tachycardia is inevitable, due to hypovolemia as a result of tissue trauma and due to hypovolemia as a result of tissue trauma and

pain.pain.

2.2. A pulse rate lower than 120 beats/min A pulse rate lower than 120 beats/min usually indicates adequate volume.usually indicates adequate volume. Whereas a pulse rate higher than 130 beats/minWhereas a pulse rate higher than 130 beats/min usually suggests inadequate resuscitationusually suggests inadequate resuscitation 3.3. Beware that in the elderly or those with Beware that in the elderly or those with preexisting heart disease, the heart rate may not be able preexisting heart disease, the heart rate may not be able

to increase in proportion to the stimulus.to increase in proportion to the stimulus.

..

7474

Support vital signSupport vital sign

Continue assess heart output.Continue assess heart output. A minimal mean arterial pressure ofA minimal mean arterial pressure of-90mmHg should be maintained for adequate -90mmHg should be maintained for adequate

tissue perfusion.tissue perfusion. If the patient is hemodynamically unstable,If the patient is hemodynamically unstable,-the extremities are burned or if frequent -the extremities are burned or if frequent

measurement of arterial blood gases are measurement of arterial blood gases are required, insertion of an arterial catheter may be required, insertion of an arterial catheter may be necessary.necessary.

Obtain Arterial blood gases, Obtain Arterial blood gases, carboxyheamoglobin.carboxyheamoglobin.

7575

Arterial blood gasesArterial blood gases

PH ↓PH ↓ 7.35-7.457.35-7.45

PCO2 ↑PCO2 ↑ 35-45 mmHg35-45 mmHg

PO PO 75-100mmHg75-100mmHg

*To assess acid-base balance due to a respiratory disorder, respiratory acidosis.

7676

Support vital signSupport vital sign

Cover patient to maintain body Cover patient to maintain body temperature and to prevent wound temperature and to prevent wound contaminationcontamination

Initiate fluids replacement Initiate fluids replacement Urine output, this is the single best monitor Urine output, this is the single best monitor

of fluid replacement.of fluid replacement. Weight should be measured daily, as Weight should be measured daily, as

changes in weight from admission allow changes in weight from admission allow an assessment of fluid balance an assessment of fluid balance

7777

Insert Foley catheterInsert Foley catheter

1.Foley catheter should be placed in all patients 1.Foley catheter should be placed in all patients undergoing resuscitation for severe burns and in undergoing resuscitation for severe burns and in patients with smaller burns with a history of patients with smaller burns with a history of difficulty voiding. difficulty voiding.

2. A loose-fitting catheter should be placed to 2. A loose-fitting catheter should be placed to prevent urethral stricture. prevent urethral stricture.

3.The catheter should remain in place throughout 3.The catheter should remain in place throughout resuscitation. resuscitation.

4. Acceptable values are 0.5ml/kg/hr in an adult 4. Acceptable values are 0.5ml/kg/hr in an adult and at least 1ml/kg/hr in a childand at least 1ml/kg/hr in a child

7878

Summary; Emergent Summary; Emergent phasephase

7979

Emergency ManagementEmergency Management

SiteSite

-Maintain clear airway -Maintain clear airway

-Remove from source of injury -Remove from source of injury

-Prevent ongoing thermal injury -Prevent ongoing thermal injury

-Keep others safe -Keep others safe

-Arrange prompt transfer to Burns Unit -Arrange prompt transfer to Burns Unit

8080


HospitalHospital PrioritiesPriorities -Airway -Airway -IV access – large bore peripheral line -IV access – large bore peripheral line -Analgesia – diluted opioids,-Analgesia – diluted opioids,

--intravenously, large bore.intravenously, large bore.Catheterise bladder Catheterise bladder Investigations [ see box below] Investigations [ see box below]

8181

Diagnostic testDiagnostic test

InitialInitial

EssentialEssential OptionalOptional

Full Blood CountFull Blood Count CXRCXR

Urea & electrolytesUrea & electrolytes ECGECG

Blood sugarBlood sugar CarboxyhemoglobinCarboxyhemoglobin

Grouping & typingGrouping & typing ABGsABGs

UrinalysisUrinalysis

LaterLater

PCV until stablePCV until stable ABGsABGs

Daily FBCDaily FBC

Daily urea , electrolytesDaily urea , electrolytes

Swabs for culture Swabs for culture &sensitivity&sensitivity

8282


History of accident History of accident General Examination General Examination Estimate the Estimate the AreaArea and the and the depthdepth of the burn. of the burn.

Look for signs of inhalational burns Look for signs of inhalational burns • Stridor Stridor • Respiratory distress Respiratory distress • Cough Cough • Sooty sputum Sooty sputum • Singed nasal hair Singed nasal hair • Nasolabial burns Nasolabial burns • Airway swelling Airway swelling • Document all findings Document all findings

8383

Estimation of Total Body Surface Estimation of Total Body Surface Area Burned [ TBSA]Area Burned [ TBSA]

Major BurnsMajor Burns : >10 % BSA deep burn in a : >10 % BSA deep burn in a child child >25% BSA deep burn in an >25% BSA deep burn in an adult adult All major burns WILL need parenteral fluid All major burns WILL need parenteral fluid resuscitation , since the main cause of resuscitation , since the main cause of early mortality is early mortality is Burns Shock.Burns Shock.

8484

PathophysiologyPathophysiology: Fluids : Fluids replacementreplacement

A. Four major processes are thought to contribute to the A. Four major processes are thought to contribute to the major loss of intravascular fluid.major loss of intravascular fluid.

1. 1. change in microvascular membrane integritychange in microvascular membrane integrity

2. 2. change in tissue forceschange in tissue forces

3. 3. cellular shockcellular shock

4. 4. evaporative lossesevaporative losses

8585

B.ChangesB.Changes in microvascular integrity in microvascular integrity

1. 1. Following a burn there is a massive release of Following a burn there is a massive release of inflammatorinflammator

mediators.mediators.

2. Histamine is released early,which increase 2. Histamine is released early,which increase capillary permeabilitycapillary permeability

3. 3. Polymorphonuclear leukocytes adhere to the Polymorphonuclear leukocytes adhere to the endothelium.endothelium.

8686

C. Changes in tissue forcesC. Changes in tissue forces

1.1.The capillary leak causes fluid and plasma The capillary leak causes fluid and plasma proteins to shift from the intravascularproteins to shift from the intravascular

to the interstitial space. to the interstitial space. 2. This causes hypoproteinemia, decreased 2. This causes hypoproteinemia, decreased

intravascular osmotic pressure and intravascular osmotic pressure and increased interstitial osmotic pressure. increased interstitial osmotic pressure.

3.Edema results when the volume of 3.Edema results when the volume of interstitial fluid exceeds the capacity of interstitial fluid exceeds the capacity of the lymphatics to remove it. the lymphatics to remove it.

8787

E. Evaporative lossesE. Evaporative losses

Additional evaporative losses through the Additional evaporative losses through the burn wound can be between 4 and 20 burn wound can be between 4 and 20 times greater than normal and persist until times greater than normal and persist until complete wound closure is obtained.complete wound closure is obtained.

8888

Fluids resuscitationFluids resuscitation

Lactated Ringer’s (LR) solution is the most Lactated Ringer’s (LR) solution is the most popular resuscitation fluid used. popular resuscitation fluid used.

There are numerous formula that can be There are numerous formula that can be used for fluid resuscitation. used for fluid resuscitation.

No fluid resuscitation formula has proven No fluid resuscitation formula has proven to be superior. to be superior.

All formulas are only a starting point.All formulas are only a starting point. Administered fluids through 2 large bore Administered fluids through 2 large bore

needle.needle.

8989


Fluid prescription for adults commonly uses the Fluid prescription for adults commonly uses the Parkland Formula which is:Parkland Formula which is:

4cc X weight (kg) X %TBSA burn = cc’s for 1st 4cc X weight (kg) X %TBSA burn = cc’s for 1st 24 hours (Ringer's Lactated)24 hours (Ringer's Lactated)

First half of this total is administered over the First half of this total is administered over the first 8 hours,first 8 hours,

And the second half over the next 16 hours.And the second half over the next 16 hours. Over 24 hours, >30% burn, provide 5% dextroseOver 24 hours, >30% burn, provide 5% dextrose

9090

Exampel: ParklandExampel: Parkland

4cc X weight (kg) X %TBSA burn4cc X weight (kg) X %TBSA burn 4cc x 50kg x25% = 5000cc4cc x 50kg x25% = 5000cc

5000 ÷ 500mls = 10 bottles.5000 ÷ 500mls = 10 bottles. 50% to be administer = 2500 cc x 8 Per 50% to be administer = 2500 cc x 8 Per

hours ~ 312.5cc.hours ~ 312.5cc. Second half to be administer = 2500cc x Second half to be administer = 2500cc x

16 hours.16 hours. Per hour~156.25ccPer hour~156.25cc

9191

Fluids resuscitation; Over 24 hoursFluids resuscitation; Over 24 hours

4cc X weight (kg) X %TBSA burn4cc X weight (kg) X %TBSA burn 4cc x 50kg x25% = 5000cc4cc x 50kg x25% = 5000cc 5000cc of Ringer's Lactated + 2000cc 5% 5000cc of Ringer's Lactated + 2000cc 5%

Dextrose water.Dextrose water.

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Calculate fluid deficit and decide fluid Calculate fluid deficit and decide fluid requirement requirement

2 types of fluids –2 types of fluids –CrystalloidsCrystalloids and and ColloidsColloids

CrystalloidsCrystalloids [e.g. –Ringer’s Lactate] [e.g. –Ringer’s Lactate] -Several formulas: Evans, Brookland etc. -Several formulas: Evans, Brookland etc.

3 – 4 ml / Kg. bodyweight / % Burn3 – 4 ml / Kg. bodyweight / % Burn during the during the first 24 hours,first 24 hours,

-half of which is to be given in the first 8 hrs [-half of which is to be given in the first 8 hrs [from from the time of injurythe time of injury] ]

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Plasma Plasma 0.9% 0.9% Saline Saline

Ringer’s Ringer’s lactate lactate

NaNa 141141 154154 130130 mEq/LmEq/L

ClCl 103103 154154 109109 mEq/LmEq/L

KK 4-54-5 ---- 44 mEq/LmEq/L

Ca/MgCa/Mg 5/25/2 ---- 3/03/0 mEq/LmEq/L

BufferBuffer Bicarb. Bicarb. (26)(26)

---- Lactate Lactate (28)(28)

mEq/LmEq/L

pHpH 7.47.4 5.75.7 6.76.7

Osmolality Osmolality (mosm/k(mosm/kg)g)

289289 308308 273273

Crystalloid SolutionsCrystalloid Solutions

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Colloids Colloids [e.g. Human Albumin Solution ][e.g. Human Albumin Solution ]

1.Proteins in plasma generate osmotic pressure1.Proteins in plasma generate osmotic pressureand serve to maintain the intravascular volume. and serve to maintain the intravascular volume. -The administration of colloid compensates for this -The administration of colloid compensates for this

protein lost.protein lost.

22. . Much debate exists as to when capillary integrity Much debate exists as to when capillary integrity is established and when or if colloid should be is established and when or if colloid should be givengiven

3.3. Early infusion of colloid solutions may decrease Early infusion of colloid solutions may decrease overall fluid requirements and reduce edema. overall fluid requirements and reduce edema. However, excessive use of colloid risks However, excessive use of colloid risks iatrogenic pulmonary complications. iatrogenic pulmonary complications.

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ColloidsColloids

4.4.Guidelines for adding colloid to crystalloid Guidelines for adding colloid to crystalloid regimen:regimen:

a.a.patients with burns less than 30% TBSA patients with burns less than 30% TBSA do not usually require colloiddo not usually require colloid

b.b.patients with burns greater than 30% patients with burns greater than 30% TBSA should receive colloid eight hours TBSA should receive colloid eight hours after injuryafter injury

c.c.patients with inadequate urine outputpatients with inadequate urine outputd.d.colloid is administered by adding 50g of colloid is administered by adding 50g of

albumin to each liter of crystalloidalbumin to each liter of crystalloid

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Rate of infusionRate of infusion

Adult formulaAdult formula: Fluid : Fluid first 24 hours = 4cc x first 24 hours = 4cc x % total body surface x % total body surface x body weight (one half body weight (one half in first 8 hours)in first 8 hours)

if shock present give if shock present give bolus of fluid until bolus of fluid until perfusion restored perfusion restored

then use constant rate, then use constant rate, adjusting as needed adjusting as needed

after 10 to 12 hrs. after 10 to 12 hrs.

gradually decrease gradually decrease infusion rate to avoid infusion rate to avoid excess edema while excess edema while maintaining perfusionmaintaining perfusion

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Intravenous AccessIntravenous Access

A peripheral vein catheter through nonburn A peripheral vein catheter through nonburn tissue is the route preferred for fluid tissue is the route preferred for fluid administration. administration.

A central line or pulmonary artery line is A central line or pulmonary artery line is only occasionally needed to monitor the only occasionally needed to monitor the patient during the initial resuscitation patient during the initial resuscitation period and is removed as soon as it is no period and is removed as soon as it is no longer needed. longer needed.

The possibilities for intravenous access The possibilities for intravenous access are:are:

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First choice: Peripheral vein; nonburn First choice: Peripheral vein; nonburn areaarea

Second choice: Central vein; nonburn Second choice: Central vein; nonburn areaarea

Third choice: Peripheral vein; burn Third choice: Peripheral vein; burn areaarea

Worst choice: Central vein; burn areaWorst choice: Central vein; burn area

Choices For AccessChoices For Access

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Choices For AccessChoices For Access

Central venous accessCentral venous access

1. 1. subclavian vein- most desirable site due subclavian vein- most desirable site due to lowest infection rateto lowest infection rate

2. 2. internal jugular veininternal jugular vein

3. 3. femoral veinfemoral vein

100100

Interventions:Interventions:Ineffective airway Ineffective airway clearanceclearance

Baseline assessments respiratory status.Baseline assessments respiratory status. Chest x-ray, ABG, vital signs.Chest x-ray, ABG, vital signs. Intubation for burns of chest, face or Intubation for burns of chest, face or

neck.neck.

1.1. Maintain the head of the bed at 30°.Maintain the head of the bed at 30°.

2.2. Turn patient side to side every 2 hours to Turn patient side to side every 2 hours to prevent hypostatic pneumonia.prevent hypostatic pneumonia.

101101

Ineffective airway clearanceIneffective airway clearance

Encourage coughing and deep breathing Encourage coughing and deep breathing exercise promote airway clearance of mucus exercise promote airway clearance of mucus and fibrin.and fibrin.

Chest physiotherapy - via percussion and Chest physiotherapy - via percussion and vibrations, assists with bronchial drainagevibrations, assists with bronchial drainage

Positioning - patients are shaken and turned Positioning - patients are shaken and turned side to side every two hours to aid in secretion side to side every two hours to aid in secretion mobilizationmobilization

Early ambulation - allows adequate air exchange Early ambulation - allows adequate air exchange in lung regions that are normally hyperventilated in lung regions that are normally hyperventilated while the patient is recumbentwhile the patient is recumbent

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To keep airway clear, suction the client To keep airway clear, suction the client frequently, removes accumulated secretions that frequently, removes accumulated secretions that cannot be removed by spontaneous cough. cannot be removed by spontaneous cough.

Caring of patient with nasotracheal tube Caring of patient with nasotracheal tube placement and orotracheal-more than 3 week placement and orotracheal-more than 3 week tracheostomy performed.tracheostomy performed.

Aseptic procedure for suctioning.Aseptic procedure for suctioning. Patients should be hyperoxygenated with 100% Patients should be hyperoxygenated with 100%

oxygen prior to suctioning. This should not be oxygen prior to suctioning. This should not be continued for more than 15 seconds without continued for more than 15 seconds without further oxygenation. further oxygenation.

Vagal stimulation and bradycardia are possible Vagal stimulation and bradycardia are possible complications.complications.

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Medication to dilate constricted bronchial Medication to dilate constricted bronchial passages.-via intravenous/inhalants to passages.-via intravenous/inhalants to control bronchospasms and wheezing.control bronchospasms and wheezing.

Proper positioning to ↓the work of Proper positioning to ↓the work of breathing and promote chest expansion.breathing and promote chest expansion.

Ensure adequate tissue oxygenation-pulse Ensure adequate tissue oxygenation-pulse oxymeter.oxymeter.

Oxygenation therapy, ↓oxygenation Oxygenation therapy, ↓oxygenation saturation.saturation.

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Burn victimBurn victim

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Endotracheal tubeEndotracheal tube

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TracheostomyTracheostomy

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burn and scald

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