Transcript Flame Burn

Block Z (Villafuerte, Waga, Yuga, Zuniega)
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W. O.
26/M
Single with partner
Furnace crew
Pasig City
Flame Burn
DOI: 12/05/13
TOI: 4am
POI: Metal factory (Cainta, Rizal)
MOI: flame burn
8 hrs PTC, While at work, the
furnace machine on which the
patient was attending to suddenly
exploded.
Patient was caught in flames –
face, abdomen, and bilateral legs.
(+) fall from standing height,
landed on his buttocks. (-) head
trauma, loss of consciousness,
headache, vomiting
He was immediately brought
to Amang Rodriguez
Hospital. No management
was done.
He was transferred to East Ave.
Medical Center. A> flash burn
67% (BLE, abdomen, BUE and
face)
IV fluids (PLR) was started.
Wound dressing was done
Was given Erythromycin eye
ointment, Omeprazole 40mg IV, ATS
and Te Ana
Patient was transferred to
PGH due to unavailability of
room.
AIRWAY
Awake, able to speak in
sentences.
(-) stridor
(-) singed nostril hairs
(-) neck burn
(-) sooty phlegm
BREATHING
Not in respiratory distress with
RR 20 breaths/minute.
Equal chest expansion, clear
breath sounds,
(-) rales/ wheezes
Primary Survey
Circulation
BP: 120/70 mmHg
HR : 84 bpm
FEP, PNB
CRT <2secs
Compartment
Syndrome
(-) pain
(-) pallor
(-) paresthesia
(-) pulselessness
(-) Paralysis
(-) poikilothermia
Cervical injury
(+) fall from
standing height
(-) head trauma
(-) cervical
tenderness
Primary Survey
Deficits
(-) motor deficits
(-) sensory deficits
Exposure
Face – 0.25%
Anterior trunk – 2%
R hand – 0.25%
L Hand – 0.5%
R thigh – 5%
L thigh – 7%
R leg – 7%
R foot – 7%
Fluids
Weight: 60kg
IVF Used: Plain Lactated Ringer
Parkland formula: 4ml/kg/%TBSA
Computation: 4mlx60kgx29%
 6,960 ml
 1st 8hrs: 3,480 ml (3480 cc/hr for 1hr since pt arrived 8 hrs post-injury)
▪ Double line: IVF 1 – PLR Fast drip
IVF 2 – PLR fast drip
 Next 16hrs: 3,480 ml (220 cc/hr x 16 hrs)
▪ Double line: IVF 1 – PLR @ 110 cc/hr
IVF 2 – PLR @ 110cc/hr
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Flame burn 29% TBSA
 SPT: 27% ( face, B hands, B thighs, R leg, R foot)
 DPT: 2% (anterior trunk)
Past Medical History
 Repair of facial fractures for vehicular crash
(2007, hospital cannot be recalled)
 (-) Bronchial asthma, allergy, DM, HPN, PTB
Family Medical History
 (-) DM, HPN, PTB, BA, goiter, cancer
Personal and Social History
 Occasional alcoholic beverage drinker
 (-) smoking, illicit drug use
 Has a partner with 2 children
(-) headache, nausea, vomiting
(-) cough and colds
(-) chest pain, palpitations
(-) difficulty of breathing
(-) abdominal pain
(-) changes in bowel movement
(-) urinary changes
General
Condition
Awake, alert, E4V5M6
Vital Signs
BP 120/70 HR 80 RR 20 O2S 99% T o 37.0
HEENT
Anicteric sclerae, pink conjunctivae, (-) singed eyebrows and
nostril hairs, (-) circumferential burns on neck
Chest and
Lungs
Equal chest expansion, clear breath sounds (rales/wheezes)
Heart
Adynamic precordium, normal rate, regular rhythm, distinct
heart sounds, (-) murmurs
Abdomen
Flat, NABS, soft, non-tender, (-) masses, organomegaly
Extremities
Pink nail beds, full equal pulses, (-) cyanosis
NPO for now
IVF: (PLR 3.5L)
R: fast drip 1L PLR then PLR 1L @ 110cc/hr
L: fast drip 1L PLR then PLR 1L @ 110cc/hr
Diagnostics:
CBC, BT, PT/PTT, BUN, Crea, Na, K, Cl,
Albumin, ABG, chest xray
For SSD dressing
Monitor VSQ1, UO Q1, I/O shift
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Omeprazole 40mg IV OD
Tramadol 50 mg IV q 8
MV + Zinc 1 tab OD OD
Vitamin C 1 tab OD OD
Paracetamol 300mg IV q 4 prn for T>38.5
Largest organ in the body
Prevents infection
Protection from
radiation
Thermal regulation
Prevents fluid and electrolyte loss
Denaturation of
proteins and loss
of plasma
membrane
integrity
 Temperature +
duration of contact
= synergistic effect
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hypoperfusion
infection
edema
dessication
CHILDREN
PTB
FTB
ADULTS
PTB
FTB
Age
Minor
Moderate
Major
<10%BSA
<2%BSA
10-20%BSA
2-10%BSA
>20%BSA
>10%BSA
<15%BSA
<2%BSA
15-25%BSA
>25%BSA
2-10%BSA
>10%BSA
<2 yrs with minor injury <10 yrs with major
injury
(-)
(+)
Involvement of hands,
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face, feet and perineum
Electrical injury
(-)
Chemical injury
(-)
Inhalational Injury
Not suspected
Major associated medical
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illnesses
Associated fractures,
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multiple trauma
Note:
OPD if Minor; Admit if Moderate or Major
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First 48 hours post burn
Includes:
 Assessment of burn injury
 Classification of burn injury
 Criteria for admission
 Initial ER management
 Fluid resuscitation
 Monitoring
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Airway
Breathing
Circulation
Cervical
Deficit
Exposure
Fluids
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Careful airway assessment
 especially in with face and neck involvement
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Intubation is generally only necessary in the
case of:
 with burns >50% BSA
 with suspected inhalational injury
 unconscious patients
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All patients with major burns must receive highflow oxygen for 24 hours.
Consider carbon monoxide poisoning
Suspect inhalational injury if with:
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burn to face
sooty phlegm
singed nostril hairs
hoarseness or stridor
history of burn in enclosed space or unconscious at
scene
 circumferential chest burn
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Check the patient’s BP
Stop any external bleeding
Identify potential sources of internal bleeding
Secure a large-bore intravenous (IV) lines
Provide resuscitation bolus fluid
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Check for:
 limitation of movement of the cervical spine
 Tenderness over the neck area
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May apply cervical collar when necessary
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6 Ps
 pain
 pallor
 paresthesia
 pulselessness
 paralysis
 poikilothermia
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Check for sensory and motor deficit
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Estimate burn size
Expressed as %BSA
Accurately done using the Lund and Browder
charts
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Get the patient’s weight
Initiate fluids for ongoing resuscitation and
fluid losses using the Parkland formula
Plain LR must be given at
4mL/kg BW per % BSA burned
To be given:
 ½ during the first 8 hours after injury
 ½ during the next 16 hours
 Acute burn patients
 with moderate and major injuries
 <2y/o regardless of % TBSA
 with injuries to the hands, face, feet and
perineum, major joints
 with smoke inhalation injury, other associated
medical illness, or multiple trauma
 Acute electrical burn patients
 Acute chemical burn patients
 Patients with massive exfoliative disease, such as:
 Toxic Epidermal Necrosis (TENS)
 Steven Johnson Syndrome (SJS)
 Staphylococcal Scalded Skin Syndrome (SSSS)
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Other Pertinent History
 allergies, medications, prior illness, last meal,
events surrounding the injury
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Family History
Personal and social history
Review of systems
The rest of the PE
 evaluation of other injuries
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CBC with PC
Blood Typing
RBS, BUN, Brea, Na, K, Cl, Albumin
ABG
Chest Xray
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Insert foley catheter to monitor UO
Insert NGT to decompress the stomach
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Start PPI to prevent stress ulcers
Give ATS and TeANA
Systemic antibiotics is not indicated.
Topical antimicrobials is applied over the
affected areas.
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
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SSD (Silver sulfadiazine)
Silver sulfadiazine + Cerium nitrate
Dakin’s Solution
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Check the following hourly:
 vital signs
 urine output
 level of consciousness
 pulmonary status
Adequate urine output is defined as:
Adults: 0.5 ml/kg BW/hr
 Excision and grafting
 Control of infection
 Nutrition
 Rehabilitation
 Complication
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Early surgical excision of the burn wound with
immediate or delayed wound closure
For full-thickness or deep dermal burns
unlikely to heal within 14-21 days
Common in flame and contact burns
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Improve survival
Decrease length of hospital stay
Faster return to work
Decrease expenditure
Limit duration of pain that burn patients
must endure
Improve cosmetic and functional results
 Burn patients - hypermetabolic response
 Curreri’s Formula
 Adult
 Children
(25 x kg) + (40 x %BSA Burn)
(60 x kg) + (35 x %BSA Burn)
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Early mobilization
Prevent contracture
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Sepsis
ARDS
contractures
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Examine the impact of chronic glucose
control on outcomes in the acute period after
burn
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Retrospective analysis comparing outcomes
in patients with chronic hyperglycemia
(HbA1c ≥6.5%) and euglycemia (HbA1c
<6.5%)
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Patients aged 18 to 89 years, admitted for
initial burn care between January 1,2009, and
June 30, 2010, with an HbA1c measurement
at admission were included
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The primary endpoint was unplanned
readmissions, with secondary endpoints of
length of stay and mortality
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258 burn injury patients were included
 32 with chronic hyperglycemia
 226 with euglycemia
Burn characteristics
were similar
between the two
groups
 Primary cause of
burn injury was
thermal, followed
by scald, for both
groups.
 Patients with
chronic
hyperglycemia were
significantly older
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Patients with chronic
hyperglycemia were more
likely to have glucose greater
than 150 mg/dl at admission
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Patients with chronic
hyperglycemia experienced
significantly more glucose
variability, as well as an
increased incidence of both
moderate and severe
hypoglycemia during
admission
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There was a significant
difference in the primary
endpoint of unplanned
readmissions, with an
increased rate of unplanned
readmissions in patients with
chronic hyperglycemia
compared with patients with
chronic euglycemia
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Of the 14 unplanned
readmissions, eight were for
uncontrolled pain and wound
care, four for infection/sepsis,
and two for other reasons.
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This study confirmed that patients admitted for initial
management of burn injury with elevated HbA1c
levels at admission have higher glucose
measurements at admission and throughout their
hospital stay, as well as increased glucose variability.
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Regardless of preexisting diabetic status, patients
with chronic hyperglycemia are more likely to have an
unplanned readmission after their initial admission for
burn management
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There is a significant need to further evaluate
interventions to improve burn-related outcomes in
patients with chronic hyperglycemia
Burn Center Service Manual
Stander, M. and Wallis, L. (2011). The Emergency Management
and Treatment of Severe Burns. Emergency Medicine
International.