Burns presentation ms 4 kzn.ppt

MANAGEMENT OF A BURN – ASSESSMENT, RESUSCITATION & REHABILITATION Dr T N Shangase (acknowledgement: Prof Hardcastle)  Burns: Causes  Thermal energy  Electrical energy  Chemical –Acid or alkaline  Initial Assessment of a Major Bu...

MANAGEMENT OF A BURN – ASSESSMENT, RESUSCITATION & REHABILITATION Dr T N Shangase (acknowledgement: Prof Hardcastle)  Burns: Causes  Thermal energy  Electrical energy  Chemical –Acid or alkaline  Initial Assessment of a Major Burn Primary survey Initial management is similar to that of any trauma pt A modified ATLS primary survey is performed Particular emphasis on assessment of the airway and breathing Burn injury must not distract from this sequential assessment, as serious associated injuries may be missed Initial Assessment of a Major Burn Primary Survey – A :Airway with C Spine Control ? Compromised or at risk of compromise Signs of Inhalational Injury: Hx of flame burns or burns in an enclosed space Deep dermal or full thickness burns to face, neck or upper torso Singed nasal hair Carbonaceous sputum or carbon particles in oropharynx  Initial Assessment Indications for Intubation – Erythema or swelling of oropharynx on direct visualisation – Change in voice, with hoarseness or harsh cough – Stridor, tachypnoea, or dyspnoea If there is any concern about the patency of the airway then intubation is the safest policy  Initial assessment B – Breathing All burn patients should receive humidified oxygen via a non- rebreathing mask Compromise can occur via several ways : Mechanical Restriction of Breathing – Deep dermal or full thickness circumferential burns of the chest can limit chest excursion and prevent adequate ventilation – May require escharotomies  Initial Assessment Blast Injury – Blast lung can complicate ventilation – Lung contusions and alveolar trauma can lead to ARDS – Penetrating injuries can cause pneumothoraces Smoke Inhalation – Products of combustion act as direct irritants – Resultant bronchospasm, inflammation, bronchorrhoea, and impaired ciliary action  Initial Assessment Carboxyhaemoglobin – CO binds preferentially to Hb and intracellular proteins – Leads to intra- and extracellular hypoxia – The signs of CO intoxication vary with COHb levels – Pt’s with an altered LOC after burns have CO intoxication unless proven otherwise – Rx with 100% oxygen – Pt’s with COHb levels greater than 25 – 30% should be ventilated  Indications for ventilation CXR shows “ARDS-like” picture pH < 7,2 pO2 < 8 kPa pCO2 > 6,5 kPa Sats 30 or < 10 / minute  Initial Assessment C –Circulation – Establish IV access with 2 large bore cannulas, preferably through unburnt skin – Profound hypovolaemia is not the normal initial response to a burn – If pt hypotensive may be due to delayed presentation, cardiogenic dysfxn, or occult blood loss (chest, abdo, pelvis)  Initial Assessment D- Neurological Disability – Assess GCS – Confusion ? Hypoxia or hypovolaemia E – Exposure with Environmental Control – Fully assess burn area and depth – Check for concomittant injuries – Keep warm – burn pt’s easily become hypothermic; leads to hypoperfusion and deepening of burn wounds  Initial Assessment F – Fluid Resuscitation – Using guidelines – Urinary catheter mandatory in burns >20% TBSA Analgesia – All pt’s with large burns should receive IV morphine at a dose appropriate to body wt – titrate against pain and respiratory depression  Secondary survey At the end of the primary survey and emergency management, a secondary survey should be performed This is a head to toe examination to look for any concomitant injuries Assessment and Resuscitation Assessment of Burn Area  Assessment of Burn Area 3 commonly used methods of estimating burn area, and each has a role in different scenarios When calculating burn area, erythema should not be included Palmar surface – the surface area of a pt’s palm (including fingers) is roughly 1% TBSA – Can be used to estimate relatively small burns (85%, when unburnt skin is counted) – Less accurate for medium sized burns  Assessment of Burn Area Wallace rules of nines Quick way of estimating large burns in adults Body is divided into areas of 9% and the total burn area calculated Not accurate in children  Assessment of Burn Area Lund and Browder Chart If used correctly is the most accurate method Compensates for variation in body shape with age, and gives an accurate assessment in children  Assessment of Burn Area Important that all of the burn is exposed and assessed – touch the wounds!! During assessment, the environment should be kept warm, and small segments of skin exposed sequentially to reduce heat loss Pigmented skin can be difficult to assess, and it may be neccesary to remove all loose epidermal layers to calculate burn size  Assessment of Burn Area The two important determinants of the seriousness of the burn injury are the area and depth of the burn The likelihood of mortality is a function of the Age of the patient and the % TBSA The greater the surface area involved, the greater the mortality rate  Minor Burn TBSA 15% in adults and >10% in children warrant formal resuscitation The most commonly used used formula is the Parkland’s formula, a pure crystalloid formula Easy to calculate and the rate is titrated against urine output The starting point is the time of injury, not time of admission  Fluid Resuscitation Regimens The following pt groups routinely require extra fluid requirements : – Children – Inhalational Injury – Electrical Injury – Delayed Resuscitation – Dehydration – intoxicated pt’s Fluid Resuscitation Regimens Are guidelines to the probable amount of fluid required Continuously adjust according to urine output, pulse, BP, and RR Regular investigations are mandatory for monitoring the pt’s resus status. These include plasma sodium, base excess ,lactate and packed cell volume  Who to Transfer ADULTS CHILDREN >10% FT (Red Cross Hospital) > 20 Deep partial >5% FT Flexors >10% Deep Partial Perineum Rest as for adults Inhalation Head and neck  When is care “futile” >60% FT with inhalation >70% FT without inhalation >80% DP What to do: – Secure airway (don’t ventilate) – Adequate analgesia (IVI) – Catheter – Counsel family and call spiritual leader  Transfer wound coverage Burnshield Cling-wrap  In-hospital care Prevent sepsis Cover with silver containing cream Debride blisters Resuscitate Early enteral feeding Early excision and biological wound coverage  Skin cover options Autologous split skin grafts Living related donors Cadaver skin Synthetic analogues - expensive Xenografts – pig and frog 20 % BSA per sitting Tissue biopsy for MCS  Rehabilitation: a Team Effort Early chest physio Early mobilisation Post graft splinting ADL adaptation Compression garments and dynamic hand splints – OT later phase  Rehabilitation: a Team Effort Social Worker Psychologist Dietician Pastor / Imam / Rabbi Family and community Reconstructive (plastic) surgeon