BURNS - MANAGEMENT LOVYA GEORGE 2002 BATCH
PRE-HOSPITAL CARE • Remove from the source of injury • Ensure rescuer safety • Cool the burn wound, avoid hypothermia • All rings, jewelry,watches and belts should be removed
EMERGENCY CARE • Airway • Breathing • Circulation • Disability • Exposure
AIRWAY • Burned airway creates symptoms by swelling • Early intubation in suspected airway burn is safest • Clues of airway burn- blisters on hard palate, burned nasal mucosa, loss of hair in the nose and deep burns around the mouth and neck.
BREATHING • inhalational injury-due to smoke inhalation • Suspect in those trapped in fire, presence of soot in nose • Symptoms develop as late as 24 hrs to 5 days
Inhalational injury • Physiotherapy • Nebulisers • Warm humidified O2 • Blood gas measurements • IPPV if condition deteriorates • COHb of > 10% high inspired O2
Metabolic poisoning Suspect in those trapped in fire. • Mechanical block to breathing. Full thickness burns on chest wall. Do escharotomy.
OUTCOME • Percentage of surface area involved • Depth of burns • Presence of an inhalational injury • Age • Associated medical problem or other injuries
ASSESSMENT OF SIZE • In small burns patients hand can act as a guide.The area of hand is roughly 1% of TBSA. • Wallace’s rule of nine • LUND BROWDER CHART
Assessment of Depth • History- temperature, time and burning material. • Superficial burns have capillary filling. • Deep partial thickness burn do not blanch,and has some sensation. • FTB is hard and leathery and has no sensation.
FLUID THERAPY • First fluid resuscitation formula by Evans • The principle is to maintain Intravascular vol. at a state sufficient to perfuse not only all vital organs but also the peripheral tissues. • Fluid loss depends on BSA involved.
Cont… • IV fluid resuscitation appropriate : • CHILD > I0% TBSA ADULT >15% TBSA FLUIDS Ringer lactate human albumin FFP Hypertonic saline Max. fluid loss – first 8 hours
IV ACCESS • Upper limb preferred • LL more chance of septic thrombosis • <50%- peripheral venous cannula • >50% -central venous line
FORMULAS • Parkland • Evans • Staler • Brooke • Modified Brooke • Metrohealth
PARKLAND FORMULA • Dr.Charles Baxter of PARKLAND Hospital • Total vol. in first 24 hrs= 4 ml/kgBody Weight/% of burn TBSA • Half in first 8hrs • Next half in next 16 hrs
TIME DEPENDENT VARIABLES SHOULD BE CALCULATED FROM TIME OF BURNS • For next 24 hrs • 30-60% of plasma loss • CHILDREN – maintenance fluid DS • up to 10 kg-100ml/kg/24 hrs • 50ml/kg for next 10 kg • more than 20kg-20ml/kg/24 hrs
MONITORING • URINE OUTPUT • b/w 0.5-1 ml/Kg/Hr • if below this-increase infusion by 50% • below this+signs of hypoperfusion -10ml/Kg Bolus • Decrease if >2ml/kg/hr
Role of COLLOIDS • Usually in 2nd 24 hr • After capillary leak has subsided • Mostly in • Burns > 40% • heart diseases • inhalational injuries • geriatric age group
Muir and Barclay Formula • fluid -during the first 36 hours after a major burn… • 0.5ml/Kg body weight/5 TBSA • Each infusion volume is given as follows: • first 12 hours - 3 infusions at 4 hour intervals • second 12 hours - 2 infusions at 6 hour intervals • third 12 hours - 1 infusion • ALBUMIN is the resuscitation fluid.
BROOKE FORMULA • FIRST 24 HOURS • RL 1.5ml/kg/%burn • COLLOID – 0.5ml/kg/% • GLUCOSE IN WATER – 2000ml • SECOND 24 HOURS • RL - Half to three fourth of first 24 hour requirement • COLLOIDS – • 2000 ml
EVANS FORMULA FIRST 24 HOURS N.S. – 1ml/kg/%burns COLLOID – 1ml/kg/%burns GLUCOSE IN WATER – 2000ml SECOND 24 HOURS HALF OF FIRST REQUIREMENT
SLATER FORMULA • RL – 2L/24 HOUR • FFP – 75ml/kg/24hour MONAFO FORMULA • Hypertonic saline • VOLUME – to maintain urine output at 30ml/L
DEMLING FORMULA • FFP & DEXTRAN • Dextran 40 in saline - 2ml/kg/h • RL – To maintain output at 30ml/hr • FFP – 0.5ml/kg/h for 18hrs
Fluid reqd will be more than indicated in • Electric burns • Burned while drunk • Delayed resuscitation • Gross soft tissue involvement
Volume sensitive pts will be • Those above 50 yrs • Less than 2 yrs • With cardio-pulmonary disease
Tetanus prophylaxis • Escharotomy- in circumferential FTB
ESCHAROTOMY • Are releases of burn eschar performed at bedside with a scalpel or electrocautery unit. • Need arises in second and third degree burns. • wounds encompassing the circumference of an extremity interfering with peripheral circulation to the limb by a tourniquet effect.
Oedema beneath eschar impedes venous outflow and affects arterial inflow to limbs. • Truncal eschar decrease ventilation by limiting chest expansion. • In the neck oedema may obstruct trachea
Indications • Clinicalsigns • absence of pulse • pain in the limb • cyanosis,impaired capillary refilling • Doppler signals indicating decreased or absent flow • Compartment pressure > 40mm Hg • Oxygen saturation <95%
AIM • To release pressure over involved deeper tissues and restore circulation. • TECHNIQUE • Ward procedure • No need of anaesthesia
Escharotomies • In a circumferentially burned limb - along the mid lateral or mid medial line. • should extend from proximal to distal margin of burn area. • should extend through the entire depth of eschar.
IN chest • bilaterally in the anterior axillary line extending from clavicles to coastal margins. • if chest expansion not adequate join with transverse incision along costal margin.
Bleeding must be controlled • Elevation of limb to prevent oedema • Complications • blood loss • release of anaerobic metabolites causing transient hypotension • If escharotomy does not restore blood flow fasciotomy is required
Wound dressing • Superficial PTB heal irrespective of the dressing • Borderline deep dermal burns may heal without scar if properly dressed with suitable dressing
Topical antimicrobial dressing • Simplest method of treating superficial wound is by exposure • Permeable wound dressing eg: fixamol or Mefix. • Vaseline impregnated gauze or a fenestrated silicone sheet.
Hydrocolloid dressings especially useful in mixed depth burns. • Moist environment good for epithelialisation. • Eg: Duoderm
Biological dressings Synthetic and natural • Biobrane,Trancyte,integra, amniotic membrane, allograft xenograft etc. • Good healing environment • No need to change • Useful in superficial burns.
Biobrane • Consist of collagen coated silicone manufactured into a sheet • Provides a barrier to moistureloss,does not require dressing changes • Epithelium is complete under biobrane sheet it is easily peeled off the wound
TRANSCYTE • Similar to biobrane with addition of growth factors from lysed fibroblast grown in culture • INTEGRA • A product that combines a collagen matrix (dermal sustitute) with silicone sheath outside layer (epidermal substitute) • BIOLOGICAL DRESSINGS • xenografts from swine • allografts from cadaver donor
FTB and obvious deep dermal burn – require operative treatment for excision and skin grafting • Early excision is preferred rather than wait for eschar to separate.
advantages Decrease • Hospital stay • Need for painful debridements • Infectious complications • Hypermetabolism • Scarring
Till then managed by antibacterial dressing to prevent bacterial colonisation • Agents : earlier staphylococci and streptococci • Now pseudomonas
Topical treatment • 1% Silver sulphadiazene • Method : exposure or single layer dressing • Broad coverage, also to pseudomonas and MRSA. • Painless,easy • Limited eschar penetration
.5% Silver nitrate solution • Occlusive dressing • Change in 2 – 4 hrs • Black staining • Mafenide acetate 5% • Exposure • Painful
Serum nitrate • Bacitracin • Neomycin, • Polymyxin B • Mupirocin etc
Escharectomy • Excision of whole or part of an eschar • Burn eschar is a necrotic tissue • Can lead on to systemic infections and intoxication
Early excision and grafting is done in full thickness and deep dermal burns.(except <4 cm square). • Can be done in first week when the patient is heamodynamically stable. • Can be done serially or in a single operation