Flame Burn

1. Block Z (Villafuerte, Waga, Yuga, Zuniega) Flame Burn

2. General Data • W. O. • 26/M • Single with partner • Furnace crew • Pasig City

3. Flame Burn Chief Complaint

4. History of Present Illness DOI: 12/05/13 TOI: 4am POI: Metal factory (Cainta, Rizal) MOI: flame burn

7. Was given Erythromycin eye ointment, Omeprazole 40mg IV, ATSandTeAna • Patient was transferred to PGH due to unavailability of room.

8. Primary Survey Airway Breathing Not in respiratory distress with RR 20 breaths/minute. Equal chest expansion, clear breath sounds, (-) rales/ wheezes Awake, able to speak in sentences. (-) stridor (-) singed nostril hairs (-) neck burn (-) sooty phlegm

9. Primary Survey Circulation Compartment Syndrome Cervical injury BP: 120/70 mmHg HR : 84 bpm FEP, PNB CRT <2secs (-) pain (-) pallor (-) paresthesia (-) pulselessness (-) Paralysis (-) poikilothermia (+) fall from standing height (-) head trauma (-) cervical tenderness

10. Primary Survey Deficits Exposure (-) motor deficits (-) sensory deficits Face – 0.25% Anterior trunk – 2% R hand – 0.25% L Hand – 0.5% R thigh – 5% L thigh – 7% R leg – 7% R foot – 7%

12. Primary Survey Fluids Weight: 60kg IVF Used: Plain Lactated Ringer Parkland formula: 4ml/kg/%TBSA Computation: 4mlx60kgx29% • 6,960 ml • 1st 8hrs: 3,480 ml (3480 cc/hr for 1hr since pt arrived 8 hrs post-injury) • Double line: IVF 1 – PLR Fast drip IVF 2 – PLR fast drip • Next 16hrs: 3,480 ml (220 cc/hr x 16 hrs) • Double line: IVF 1 – PLR @ 110 cc/hr IVF 2 – PLR @ 110cc/hr

13. Initial Assessment • Flame burn 29% TBSA • SPT: 27% ( face, B hands, B thighs, R leg, R foot) • DPT: 2% (anterior trunk)

14. Secondary Survey Past Medical History • Repair of facial fractures for vehicular crash (2007, hospital cannot be recalled) • (-) Bronchial asthma, allergy, DM, HPN, PTB Family Medical History • (-) DM, HPN, PTB, BA, goiter, cancer

15. Secondary Survey Personal and Social History • Occasional alcoholic beverage drinker • (-) smoking, illicit drug use • Has a partner with 2 children

16. Review of Systems (-) headache, nausea, vomiting (-) cough and colds (-) chest pain, palpitations (-) difficulty of breathing (-) abdominal pain (-) changes in bowel movement (-) urinary changes

17. Physical Examination

18. Course at the ER NPO for now IVF: (PLR 3.5L) R: fast drip 1L PLR then PLR 1L @ 110cc/hr L: fast drip 1L PLR then PLR 1L @ 110cc/hr Diagnostics: CBC, BT, PT/PTT, BUN, Crea, Na, K, Cl, Albumin, ABG, chest xray For SSD dressing Monitor VSQ1, UO Q1, I/O shift

19. Therapeutics • Omeprazole 40mg IV OD • Tramadol 50 mg IV q 8 • MV + Zinc 1 tab OD OD • Vitamin C 1 tab OD OD • Paracetamol 300mg IV q 4 prn for T>38.5

20. Discussion

21. The skin Largest organ in the body Prevents infection Protection from radiation Thermal regulation Prevents fluid and electrolyte loss

22. Pathological changes of thermal burn hypoperfusion • Denaturation of proteins and loss of plasma membrane integrity • Temperature + duration of contact = synergistic effect infection edema dessication

23. Burn Depth

24. Burn Classification Note: OPD if Minor; Admit if Moderate or Major

25. ER Management

26. Initial and Resuscitative Period • First 48 hours post burn • Includes: • Assessment of burn injury • Classification of burn injury • Criteria for admission • Initial ER management • Fluid resuscitation • Monitoring

27. Primary Survey • Airway • Breathing • Circulation • Cervical • Deficit • Exposure • Fluids

28. Airway and Breathing • Careful airway assessment • especially in with face and neck involvement • Intubation is generally only necessary in the case of: • with burns >50% BSA • with suspected inhalational injury • unconscious patients

29. Airway and Breathing • All patients with major burns must receive high-flow oxygen for 24 hours. • Consider carbon monoxide poisoning • Suspect inhalational injury if with: • burn to face • sooty phlegm • singed nostril hairs • hoarseness or stridor • history of burn in enclosed space or unconscious at scene • circumferential chest burn

30. Circulation • Check the patient’s BP • Stop any external bleeding • Identify potential sources of internal bleeding • Secure a large-bore intravenous (IV) lines • Provide resuscitation bolus fluid

31. Cervical • Check for: • limitation of movement of the cervical spine • Tenderness over the neck area • May apply cervical collar when necessary

32. Compartment Syndrome • 6 Ps • pain • pallor • paresthesia • pulselessness • paralysis • poikilothermia

33. Deficit • Check for sensory and motor deficit

34. Exposure • Estimate burn size • Expressed as %BSA • Accurately done using the Lund and Browder charts

36. Fluids • Get the patient’s weight • Initiate fluids for ongoing resuscitation and fluid losses using the Parkland formula Plain LR must be given at 4mL/kg BW per % BSA burned To be given: • ½ during the first 8 hours after injury • ½ during the next 16 hours

37. Criteria for Admission to the Burn Unit • Acute burn patients • with moderateand majorinjuries • <2y/oregardless of % TBSA • with injuries to the hands, face, feet and perineum, major joints • with smoke inhalation injury, other associated medical illness, or multiple trauma • Acute electrical burn patients • Acute chemical burn patients

38. Criteria for Admission to the Burn Unit • Patients with massive exfoliative disease, such as: • Toxic Epidermal Necrosis (TENS) • Steven Johnson Syndrome (SJS) • Staphylococcal Scalded Skin Syndrome (SSSS)

39. Secondary Survey • Other Pertinent History • allergies, medications, prior illness, last meal, events surrounding the injury • Family History • Personal and social history • Review of systems • The rest of the PE • evaluation of other injuries

40. Diagnostics • CBC with PC • Blood Typing • RBS, BUN, Brea, Na, K, Cl, Albumin • ABG • Chest Xray

41. Insert foley catheter to monitor UO • Insert NGT to decompress the stomach

42. Medications • Start PPI to prevent stress ulcers • Give ATS and TeANA • Systemic antibiotics is not indicated. • Topical antimicrobials is applied over the affected areas.

43. Wound Care and Dressing Debridement/Initial Dressing: • Sterile technique • Cut hair or items that may reach any burned or dressing area • Full body bath with soap and water • Debride burned areas; visualize all affected areas. Reassess depth and %BSA of burn wounds • Wash with betadine soap, rinse with sterile water • Dress

44. Wound Care and Dressing • SSD (Silver sulfadiazine) • Silver sulfadiazine + Cerium nitrate • Dakin’s Solution

45. Monitoring • Check the following hourly: • vital signs • urine output • level of consciousness • pulmonary status Adequate urine output is defined as: Adults: 0.5 ml/kg BW/hr

46. Definitive management period • Excision and grafting • Control of infection • Nutrition • Rehabilitation • Complication

47. Surgical Management • Early surgical excision of the burn wound with immediate or delayed wound closure • For full-thickness or deep dermal burns unlikely to heal within 14-21 days • Common in flame and contact burns

48. Advantages of early excision • Improve survival • Decrease length of hospital stay • Faster return to work • Decrease expenditure • Limit duration of pain that burn patients must endure • Improve cosmetic and functional results

50. Nutrition • Burn patients - hypermetabolic response • Curreri’s Formula • Adult (25 x kg) + (40 x %BSA Burn) • Children (60 x kg) + (35 x %BSA Burn)