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  2. Diagnosis and Management of Acute Burns Initial/Resuscitative Period (first 48 hours) Definitive Management Period (after 48 hours) • Assessment of burn injury • Classification of burn injury • Criteria for admission • Initial ER management • Fluid resuscitation • Monitoring • Excision and grafting • Control of infection • Nutrition • Rehabilitation • Complication

  3. Initial Rescucitation

  4. Assessment of a burn injury • Complete history Eg: burn injury in an enclosed space – risk for inhalational injury • Classify as to type of burn • Scald burn: caused by hot liquids ( hot water, soups, sauces) which are thicker in consistency, remain in contact with the skin for a longer period of time • Flame burn: house fires, improper use of flammable liquids, kerosene lamps, careless smoking, vehicular accidents, clothing ignited from stove

  5. Flash burn (under flame burn): explosions of natural gas propane, gasoline and other flammable liquids causing intense heat for a very brief period of time. • Contact burn: results from hot metals, plastic, glass or hot coals; usually limited in extent but very deep

  6. Chemical burn: caused by strong alkali or acids; these cause progressive damage until chemical is deactivated with reaction with tissue or reaction with water • Acid burns: more self limiting than alkali burns; acid tend to tan the skin creating an impermeable barrier limiting further penetration of the acid • Alkali burns: combine with cutaneous lipids to create soap and thereby continue to dissolve the skin until they are neutralized • Electrical burns: injury from electrical current classified as high voltage or low voltage (high voltage 1000 V)

  7. 3. Estimate the Burn Size • Expressed as %BSA; count only areas with partial (2nd degree) or full thickness ( 3rd degree) burns • Accurately done using the Lund and Browder charts • Rule of Nines obtains a rough estimate of the areas involved but not accurate in children due to the large surface are of the child’s head and the relatively smaller are of lower extremities. • In electrical injuries, the %BSA does not correspond to the extent of injuries of the underlying soft tissues. • - may have normal looking skin over it

  8. 4. Assess the Burn Depth Important in estimating burn size and fluid requirement in determining the need for surgery and in evaluating the progress of the patient First Degree Burns – will heal in 7-10 d • Ex: sunburn

  9. Partial Thickness Burns • Second degree burns • Extends to the dermis but not through full thickness of the skin • Heals from epithelialization from surviving epidermal elements • (+) blanching when pressed Superficial partial thickness burns: with blisters;underlying skin is moist, pinkish, painful; will heal in 2-3 weeks Deep partial thickness burn: white to pale pink; moist to dry to waxy, slightly anesthetic, will heal in 3-5 weeks resulting in hypertrophic scarring and potential contracture Both types of partial thickness burns can convert to full thickness burns, signifying worsening of the patient’s condition

  10. Full Thickness Burns • Burns extending through full depth of the skin • May appear white, brown or gray with a waxy, leathery feel, skin is anesthetic • Presence of visible thrombosedveins [pathognomonic] • Heals by granulation and will require future skin coverage for wound coverage

  11. 5. Check for other injuries/medical problems • These problems play a role in the origin of burn and will have to be integrated in the management of burn • Eg: seizure disorders, diabetesdisorders, fractures, blunt abdominal injuries

  12. Classification of Burn Injury

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

  14. 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)

  15. Initial Labs • CBC • Blood typing • RBS, BUN, Crea, Na, K, Cl, Albumin • ABG (if inhalational injury is suspected) Other labs: • Chest X-ray • ECG (for electrical burns) • Urinalysis (for electrical burns, urine myoglobin& pH also included)

  16. Initial ER Management: MINOR Burns • Cool wound with tap water • Administer tetanus prophylaxis • TT booster if not received for the past 5 years • 0.5cc TeAna and 3000 u ATS (adults) • Clean wound with soap and water/betadinescrub • Debride dead tissue • Big blister unroof • Small blister aspirate

  17. Initial ER Management: MINOR Burns • Apply bland ointment (i.e., Bacitracin, Trimycin, Vaseline) and non-stick porous gauze and wrap with gauze • NO systemic prophylactic antibiotics are given • Oral/IM analgesics during wound cleaning • Send patients home with oral analgesics and instructions to clean the wound OD to BID and apply ointment and gauze.

  18. Initial Management: MAJOR & CRITICAL Burns • Wear sterile gloves • Remove all burnt clothing • Check & secure airway. 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

  19. Initial Management: MAJOR & CRITICAL Burns • Intubateif with: • Burns 50% BSA • Suspected inhalational injury • Smoke inhalation • Do complete PE, check for other injuries • Insert IV line for fluid resuscitation • Insert foleycatheter (to monitor UO). • Insert NGT (to decompress stomach). Start IV PPI (to avoid Curling’s ulcer).

  20. Initial Management: MAJOR & CRITICAL Burns • Weigh patient and record. If not possible, estimate: • For children: Wt (kg) = [2 x (age in years)] + 5 • For adults: Wt (kg) = 0.9 x [ht in cms – 100] • Administer ATSand TeAna • Check pulses, assess adequacy of chest expansion • Absent pulses or limited chest excursion is a surgicalemergencyand an indication for escharotomy

  21. Initial Management: MAJOR & CRITICAL Burns Escharotomy • Extremities • Prep with betadine soap • Cut through entire depth of skin along medial and lateral aspects of involved extremity. Avoid injuring the ulnar nerve and the peroneal nerve; facilitate separation of the skin by blunt dissection. • Chest • Cut along both anterior axillary lines and along the costalmargin producing a W-shaped incision

  22. Initial Management: MAJOR & CRITICAL Burns • Refer all pediatric patients to Pedia for co-management. Patients with other medical problems should also be referred accordingly. • No prophylactic antibiotics are given, unless there are concomitant medical conditions that indicate its’ early use.

  23. Fluid Resuscitation

  24. Fluid Resuscitation • Most common cause of mortality in the first 48 hours is inadequate fluid resuscitation • (Minor: inc OFI, Moderate to Major: IV route) • Start ASAP in the ER and even before other diagnostic exams

  25. Fluid Resuscitation: PARKLAND FORMULA Day 1 • Adults: Plain LR 4mL/kg BW per % BSA burned to be given: • ½ during the first 8 hours • ½ during the next 16 hours • Children: D5 LR 3mL/kg BW per % BSA burned to be given: • ½ during the first 8 hours • ½ during the next 16 hours • + maintenance • Cardiac, elderly patients: 2mL/kg BW per % BSA • Inhalational, electrical injury: 6mL/kg BW per % BSA

  26. In the presence of increased capillary permeability, colloid content of resuscitation fluid exerts little influence on intravascular retention during the initial hours post-burn, hence, crystalloid fluids are given.

  27. Fluid Resuscitation: PARKLAND FORMULA Day 2 • Adults / children: • D5NR(adults), half normal saline (children) and colloid sufficient to maintain good urine output

  28. Fluid Resuscitation • Colloid may be given in the form of plasma albumin or cryoprecipitate • Most protocols start colloid infusion after the first 24 hrs(capillary permeability thought to be restored by then) • For massive burns, colloid infusion can be started as early as 12 hours post-burn (to decrease total fluid requirements and lessen edema)

  29. Fluid Resuscitation • Regulate fluids to maintain adequate urine output • Adults: 0.5 mL/kg BW/hr • Children: 1.0 mL/kg BW/hr up to 30 kg BW Age influences relationship of body fluids to size: children have larger BSA per body volume • Fluid calculations – not absolute and should not be given by rate • Excessive urine volumes  overcorrectionand run the risk of fluid overload; • Smaller volumes  inadequate resuscitation • UO monitoring should be done strictly Q1

  30. Fluid Resuscitation • For electrical injuries: • Adjust fluid volume to maintain UO of 75-100 mL/hr (target UO: 1-2 cc/kg BW) • Mannitol 12.5-25g may be infused to promote diuresis • If UO and pigment clearing do not respond to fluid resuscitation, 12.5g osmotic diuretic mannitol may be added to each liter of resuscitation fluid • NaHCO3can be added to maintain a slightly alkaline urine (pH>5.5) to promote solubility of heme pigments

  31. Wound Dressing

  32. Wound 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

  33. Silver Sulfadiazine (Flammazine, Silvadene, Silversurf) • For full thickness burns, applied as sandwich dressing • May cause transient leucopenia • MOA: silver ion binds with the DNA of the organism and release sulphonamide which interferes with the metabolic pathway of the microbe • Effective against: Pseudomonas aerugenosa,Enterics, S. aureus, Klebsiellasp • Maximum of 2 weeksbec it retards wound healing • Leaves a yellow green pseudo-eschar which must be scraped off during dressing

  34. Silver Sulfadiazine + Cerium nitrate (Flammacerium) • Topical antimicrobial • Applied in cases wherein early excision-grafting cannot be done (mass burn, extensive burns) • Reduces mortality by neutralizing toxin present in burned skin • Mechanism of action: • Cerium induces calcification of the dermal collagen remaining in the wound which produces the typical tanned, leathery crust

  35. Silver Nitrate (not used anymore) • Used as 0.5% solution • Gauze dressing must be wet, solution loses effectivity when dry • Creates a brownish black discoloration with anything it comes in contact with (will peel off with the burned skin) • Bacteriostatic for S. aureus, E. Coli, P. aeruginosa • Does not injure regenerating epithelium in the wound • Caution with children as it tends to leach out electrolytes (Na, Cl)

  36. Dakin’s Solution • Sodium hypochlorite 0.025% solution: 15 mL Sodium hypochlorite (Zonrox) + 985 mL NSS • Must be used within hours after it is prepared • Used in preparing granulation tissue for grafting • Bactericidal to S. aureus, P. aerugenosa, and other G(-) and G(+) bacteria

  37. Monitoring • Burn injury is a dynamic process. The initial exposure to the wounding agent starts a train of physiologic events that present to the physician a patient with complex and precarious physiologic state, which has to be optimized to maximize chances of a positive outcome.

  38. Monitoring At the ER: • Check VS, UO, consciousness, pulmonary status Q1 • Hgb, typing, Na, Cl, BUN, Crea, RBS • CXR and ABG (for inhalational injury) • ECG, urine myoglobin (for electrical burns)

  39. Monitoring During fluid resuscitation: • Check signs of adequate hydration • Weigh patient daily • Vital signs hourly • Monitor peripheral perfusion hourly (pulses, capillary refill) • Presence of Hgb and myoglobin in urine of electrical burn patient suggest delayed or inadequate fluid resuscitation

  40. Monitoring During fluid resuscitation: • Pulmonary status every 4-5 hours • Daily determination of Hgb, Hct, WBC, Na, K, BUN, crea • Status of wound daily during dressing change

  41. Monitoring Post resuscitative period: • Vital signs every 4 hours • Daily determination of weight, BUN, crea, Na, K • Assess burn status daily • Burn biopsies (not swabs) twice a week • Blood CS once a week if wound is infected or patient is septic • Weigh patient daily

  42. Definitive Management Priority in the 1st 48 hours—maintain intravascular volume Once addressed, definitive management ensues Classical Method: Allow eschar to spontaneously separate (3 weeks), wait until bed is ready for grafting, then place skin graft

  43. Definitive Management Present trend: Early excision (within 7d post burn) of burn wound, followed by skin grafting - improve survival and shorten hospital stay - adopted strategy by the PGH Burn Unit

  44. Excision and Grafting

  45. Excision and Grafting • To remove full thickness and deep partial burns until clean viable bleed is encountered and a skin graft is placed immediately to cover the wound • Early excision – done within 7 days • wound is not yet colonized by microorganisms, reducing the chances of infection and promoting good graft take

  46. Preparation for OR prerequisites • Stable vital signs • Not in septic shock • Afebrile • Blood available for OR use (200-400mL/%BSA) • Normal albumin • No contraindications for surgery

  47. Conduct for OR • OR table covered by sterile linen • Keep OR warm • Prep patient using betadine soap and paint for the donor site and betadine soap for the wound • Prep the donor site • Drape donor site separate from the burn wound

  48. Tangential Excision • Principle: to excise the wound in thin layers using a blade held at very acute angle with the skin surface • Goal: to remove non viable tissue leaving as much dermis as possible (excellent surface for grafting)

  49. Fascial Excision • Best used when excising large flat areas • When excision of the burn wounds has to be done with minimum blood loss • Less bloody than tangential excision, but with cosmetic effect defect • Limited use in extremities due to problems of edemadistal to the area of excision, presence of avascularfascia and presence of superficial nerves