Acute Burn Management
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Transcript of Acute Burn Management
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ACUTE BURN MANAGEMENT
dr. Iqmal Perlianta, SpBP-RE
0821 799 13501
FK UNSRI MADANG
Palembang, 17 Sept 2014
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HIGH MORBIDITY AND MORTALITY RATE
U.S : 2 3 MILLION / YEAR
MORTALITY RATE : 5 6 THOUSAND / YEAR
CIPTO MANGUNKUSUMO HOSPITAL (1998)
ADMISSION NUMBER : 107MORTALITY RATE : 37,78%
DR. SOETOMO HOSPITAL (1999 - 2005)
ADMISSION NUMBER : 739MORTALITY RATE : 29,8%
ITSA CHALLENGE FOR US
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3
BURN PHASES
1. ACUTE / SHOCK / EARLY PHASE
- IMMEDIATE / EMERGENCY ROOM
- AIRWAY & FLUID PROBLEM
- WOUND
2. SUBACUTE PHASE
- DURING ADMISSION
- WOUND, INFECTION, SEPSIS PROBLEM
3. LATE PHASE
- AFTER DISCHARGED
- SCAR & CONTRACTURE PROBLEMS
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ACUTE PHASEMANAGEMENT
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ETIOLOGY
1. FIRE
2. SCALD
3. CHEMICAL SUBSTANCES
4. ELECTRIC & RADIATION
5. SUNBURN
6. STOVE / GAS EXPLOSION
7. BOMB EXPLOSION
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Burn
Capillary permeability and osmotic forcechange
Fluid and protein shift
Total blood volume have been lost
Burn shock
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DEPTH ASSESSMENT
1. 1stDEGREE
- EPIDERMIS
2. 2ndDEGREE
- SUPERFICIAL
- DEEP
3. 3rdDEGREE
- EXTENSION TO MUSCLE / BONE
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WOUND EXTENT
WALLACE
RULE OF NINE
Head & neck 9% --------> 9%
Upper extremities 9% --------> 18%
Anterior of the body --------------> 18%
Posterior of the body ------------> 18%
Lower extremities 18% -------> 36%
Genital / perineum -------------> 1 %
Total ----------------------------- 100%
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ADULT
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9
14
9 9
18 18
18 18
9 9
18 18
16 16
9
18 18
14
10 14 18
15 yrs 5 yrs 0 1 yr
JUVENILE - CHILDREN
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SEVERITY CRITERIA(AMERICAN BURN ASSOCIATION)
1. MILD- 2ndDEGREE < 15%- 2ndDEGREE < 10% IN JUVENILES- 3rdDEGREE < 1%
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2. MODERATE
- 2ndDEGREE 15-25% IN ADULTS
- 2ndDEGREE 10-20% IN JUVENILES
- 3rdDEGREE < 10%
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3. SEVERE
-2ndDEGREE >25% IN ADULTS
- 2ndDEGREE >20% IN JUVENILES
- 3rdDEGREE >10%
- AFFECTED HANDS, FACE, EARS, EYES, FEET, AND
GENITAL / PERINEUM
- INHALATION INJURY, ELECTRICAL INJURY, OR ASSOCIATED WITHOTHER TRAUMAS
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I. PRIMARY SURVEY
II. SECONDARY SURVEY
III.INITIAL CARE OF THE BURN WOUND
IV. INITIAL LABORATORY STUDIES
V. BURN CENTER REFERRAL
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I. PRIMARY SURVEY :LIKE ANY OTHER TRAUMA
A.AIRWAY & CERVICAL SPINE PROTECTION
B.BREATHING & VENTILATION
C.CIRCULATION & HEMORRHAGE CONTROL
D.DISABILITY NEUROLOGICAL EXAMINATION
E.EXPOSURE
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II. SECONDARY SURVEY :
A.HISTORY TAKINGB.PHYSICAL EXAMINATION /
HEAD TO TOE EXAMINATION
C.PRINCIPALS :
1. STOP THE PROCESS CAUSING BURN WOUNDS
2. UNIVERSAL PRECAUTION, HIV, HEPATITIS
3. FLUID RESUSCITATION : 2-4 CC RL X KG BW X
%WOUND SURFACE
4. VITAL SIGN
5. NASOGASTRIC TUBE / IF NECESSARY
6. URINARY CATHETER / IF NECESSARY
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7. PERFUSSION ASSESSMENT
8. CONTINUED VENTILATORY ASSESSMENT
9. PAIN MANAGEMENT
10.PSYCHOSOCIAL ASSESSMENT11.TETANUS TOXOID PROFILAXIS
12.MEASURING BODY WEIGHT
13.WOUND CLEANSING (OPERATING THEATRE, GENERAL
ANAESTHESIA)
14.ESCHAROTOMY & FASCIOTOMY
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FLUID RESUSCITATION
EVANS FORMULA
BROOKES FORMULA
PARKLANDS FORMULA
BROOKES MODIFICATION
MONAFOS FORMULA
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BAXTERSFORMULADR. SOETOMO GENERAL HOSPITAL
DAY 1 :
ADULT: RL 4 CC X KG BW X %WOUND SURFACE / 24 HRS
ANAK : RL : DEXTRAN = 17 : 3
2 CC X KG BW X %WOUND SURFACE +MAINTENANCE
MAINTENANCE :
< 1 YR : BW X 100 CC1-3 YRS : BW X 75 CC
3-5 YRS : BW X 50 CC
IN FIRST 8 HRS
NEXT 16 HRS
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DAY 2 :
ADULT : MAINTENANCEALBUMIN (IF NECESSARY)
JUVENILE : MAINTENANCE
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MONITORING FLUID RESUSCITATION
1. URINARY PRODUCTION PER HOUR
ADULT : 0,5 CC/BW/HR (30-50 CC/HR)
JUVENILE : 1 CC/BW/HR
2. OLIGURIAASSOCIATED WITH SYSTEMIC VASCULAR RESISTANCE &
CARDIAC OUTPUT RECUCTION
3. HAEMOCHROMOGENURIA (RED PIGMENTED URINE)
4. BLOOD PRESSURE
5. HEART RATE
6. HAEMATOCRITE & HAEMOGLOBIN
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CLOSED WOUND MANAGEMENT
WOUND CLEANSING, DEBRIDEMENT, & DESINFECTION WITH
SAVLON 1 : 30
TULLE
TOPICAL SILVER SULFADIAZINE (SSD)
THICK STERILE GAUZE / ELASTIC BANDAGE
OPEN THE WOUND DRESSINGS AT DAY 5 UNLESS THERE IS
ANY SIGN OF INFECTION
PERFORM UNDER GENERAL ANAESTHESIA (IN THE OPERATING
THEATRE)
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III. LABORATORY EXAMINATIONBURNS IMPAIR ORGAN FUNCTIONS
BASELINE LABORATORY TESTS
1. HAEMATOCRITE
2. COMPLETE BLOOD COUNT (Hb)
3. ALBUMIN
4. RFT & LFT
5. ELECTROLITE, Na, K, Cl, HCO3
6. BLOOD UREA NITROGEN
7. URINALYSIS
8. CHEST X-RAY9. ARTERIAL BLOOD GAS (INHALATION INJURY)
10.CARBOXY HAEMOGLOBIN
11.ECG (ELECTRIC INJURY)
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Functions of the skin
Protection
intact skin is the first line of defense against
bacterial and foreign-substance invasion
Heat regulation Sensory preception
Excretion
Vitamin D production Expression
important with body image - fear of disfigurement
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STAGES OF BURNS
Hypovolemic statebegins at the onset of burn and lasts for the first 48hours - 72 hours
Rapid fluid shifts - from the vascular compartmentsinto the interstitial spaces
Capillary permeability with burns increases withvasodilation
Fluid loss deep in wounds Initially Sodium and H2O Protein loss - hypoproteninemia
Hemoconcentration - Hct increases
Low blood volume, oliguria Hyponatremia - loss of sodium with fluid Hyperkalemia - damaged cells release K, oliguria Metabolic acidosis
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STAGES OF BURNS
Diuretic Stage
begins 48 - 72 hours after burn injury: Capillary membrane integrity returns
Edema fluid shifts back into vessels - blood volume
increases Increase in renal blood flow - result in diuresis
(unless renal damage)
Hemodilution - low Hct, decreased potassium as itmoves back into the cell or is excreted in urine withthe diuresis
Fluid overload can occur due to increasedintravascular volume
Metabolic acidosis - HCO3loss in urine, increase infat metabolism
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SIGNS OF ADEQUATEFLUID RESUSCITATION :
Clear sensorium
Pulse < 120 beats per minute
Urine output for adults 30 - 50cc/hour
Systolic blood pressure > 100 mm Hg
Blood pH within normal range 7.35 -7.45
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Organisms that usuallyinfect burns are:
a. Staphylococcus aureus
b. Pseudomonas Infection is usuallythe cause of any deterioration
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Signs of Sepsis:
a. Change in sensorium
b. Fever
c. Tachyapnead. Paralytic ileus
e. Abdominal distention
f. Oliguria
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Ways to prevent infection:
a. Gowns, masks, gloves
b. Sterile linen
c. Persons with URI should not come incontact with patient
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WOUND CARE PRINCIPLES
1. GOALS1. close wound as soon as possible2. prevent infection3. reduce scarring and contractures4. provide for comfort
2. Wound cleaning + closed technique3. Debridement, mechanical, surgical, enzymatic4. Topical antibacterial therapy mafenide (sulfonamide)
sulfadiazine5. Biological dressing
- Homograft (cadaver skin )- Heterograft- Autograft
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IV. BURN CENTER REFERRAL
REFERRAL CRITERIA
1. 2nd degree >10%
2. Affecting face, hands, genital, perineum, & main
joints3. 3rddegree
4. Electric injury
5. Chemical injury
6. Inhalation injury7. Juveniles
8. Associated with other traumas
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ACUTE BURN
A. Airway : inhalation injury
B. Breathing : fullthickness
circumferntial burn
C. Circulation : syok
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Carbon monoxide poisoning
Inhalation injury above the glottis
Inhalation below the glottis
Any victim, burned in a closed area, like a
house fire, should be presumed to have an
inhalation injury until proven otherwise
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INHALATION INJURY
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INHALATION INJURY
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INHALATIONINJURY
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http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/171924292429burn_images7.jpg&template=izoom2 -
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Fullthickness
circumferentialburns
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/171924292429burn_images7.jpg&template=izoom2http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/med/images/Large/171924292429burn_images7.jpg&template=izoom2 -
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65CLINITRON BED
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