Management of acute burns
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Transcript of Management of acute burns
Presentation Outline
IntroductionTypes of burnsClassificationEstimation of extentABCs, incl. DEFFurther managementCommon PitfallsFurther Rx and PrognosisChemical and Electrical Burns
Introduction
2/3 of all burns happen at homeThe skin: Largest organ 15% of total body weight 1.7 m2
USA Statistics 1.2mil cases per year require attention 50 000 admitted 10 000 fatal
Types of Burns
Thermal burns Vast majority >80%
Chemical burns About 10-15%
Electrical burns About 1%
Classification
•Degrees vs Thickness
•1st, 2nd, 3rd degree
•Partial and full-thickness
•Moved away from Degree Classification
Classification
•Superficial Partial Thickness
•old 1st degree
•Epidermis only
•Resembles Sunburn
•No blistering
•Capacity to heal completely
Classification
•Deep Partial Thickness
•old 2nd degree
•Through epidermis, into dermis
•Pink, moist, blisters, very painful
•Some capacity to heal
Classification
•Full thickness burn
•old 3rd degree (and 4th)
•Through epidermis, dermis and connective tissue
•Appears leathery and dry and is not painful
•Has various colours
Estimation of Extent
• Adults
•Rule of Nines
•Head and Neck - 9%
•Thorax – 2x9% + 2x9%
•Arms – 9% + 9%
•Legs – 2x9% + 2x9%
•Perineum – 1%
•Children
•Palm surface = 1%
A is for Airway
Make sure the patient has an open airwayLook out for signs of inhalation injury Singed nasal hairs Hoarse voice Burns to lips and nose Soot in mouth/nose
May need early intubation/surgical airway due to airway oedemaPoor prognosis
B is for Breathing
Ensure adequate ventilationCircumferential burns may need escharotomyWatch for Carbon Monoxide poisoning Classic cherry-red but often not Ventilate with 100% O2
Pulse oximeter is not reliable (drop in 3% for up to 40% carboxyhaemoglobin)
C is for Circulation
Vast amounts of fluid loss from skinMonitor BP If shocked or >15% BSA partial thickness burns, or
>5% full thickness burns then give IV fluid boluses of Ringer’s Lactate (1litre over first hour minimum)
For children, >10% partial thickness burns require IV
Can get IV access through burnsPut 2 large bore IVsSecure Secure Secure the lines
D is for Dressings
Cover all burns with clean dry cloth initially Stops air drafts which are painful and increase fluid loss If possible, remove all dead tissue, incl burst blisters Don’t burst blisters Don’t apply cold water or cold gel burn-shield to extensive
burns
Flamazine is excellent with absorbent dressings Only needs changing every 1-2 days Can use cling-wrap over the dressings
…and D is for Drugs
Analgesia Morphine 1-2mg shots on as required IVI
Tetanus ToxoidMay require Ranitidine/OmeprazoleNO prophylactic topical or systemic antibiotics
E is for Exposure
Prevent Hypothermia Warm IV Fluids Use thermal blanket
Prevent Infection Regular handwashing with
hibitane/alcohol Don’t fiddle with dressings Insert NG tube due to gastro-colic stasis
(especially if over 20% BSA burns)
F is for Fluids
Calculate fluid resuscitation requirements Many formulas out there
Parkland formula 4ml x weight (kg) x %burn = ml of Ringer’s over 24 hr Half over first 8hrs (after burn, not arrival). Remainder
over next 16hrs Day 2 requires half the amount over 24hrs If NPO then must add normal daily requirements on
top (2-3 litres for an adult, calculate for children’s weight)
Only a guideline – must monitor response
Monitor response by urine output Pass catheter if necessary
Adults must pass >30ml / hour Paeds must pass >1ml / kg / hour
Further Management
Admit if: any burn over 10% in area, IV fluids for burns over 15% burns in special areas face, neck, hands, feet, perineum (need
referral to specialist ASAP) electrical burns any burn with history of smoke inhalation chemical burns full thickness burns where grafting is indicated (needs referral)
Laboratory investigations (where available) Electrolytes Blood gases Glucose Protein Haemoglobin (must be kept >12 g%)
Common Pitfalls
Pulmonary injury Needs early intubation
and ventilation
HypothermiaInadequate fluid resuscitationCircumferential burns
Compartment syndrome requires emergency fasciotomy
Further Rx and Prognosis
Wound debridementSkin graftingNeed nutritional supportRehabilitation
Prevent contractures Physiotherapy Psychological support
Bad prognosis Mortality rises exponentially above 30% burns If Age + Burn % >100 then survival unlikely ARDS Other injuries such as head injury Secondary infection
Chemical and Electrical Burns
Chemical Burns Copius irrigation >10 minutes Hydrofluoric acid – wet dressing with magnesium sulphate
paste and injection of calcium gluconate limits pain and damage
Phenol – Polyethyl alcohol to remove traces Phosphorous – Cover with petroleum jelly to exclude air, then
excise under GA ASAP
Electrical Burns Cause deep necrosis of muscle and thrombosis of vessels Can cause arrhythmias Watch for compartment syndrome Remove dead tissue as appropriate