Transcript Advanced Burn Life Support Manual Review

Advanced Burn Life Support
Manual Review
Robyn Watts, M.D.
Nadia Afridi, M.D.
Division of Plastic Surgery
Dalhousie University, Halifax NS
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Skin Anatomy
Epidermis
Dermis
Hypodermis
Function of Normal Skin
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Protection from infection & injury
Prevention of loss of body fluid
Regulation of body temperature
Sensory contact with environment
What is a Burn?
• An injury to tissue from:
–Exposure to flames or hot liquids
–Contact with hot objects
–Exposure to caustic chemicals or
radiation
–Contact with an electrical current
Pathophysiology of Burn Injury
• Zone of Coagulation:
– Irreversible damage
• Zone of Stasis:
– Impairment of blood flow
– Recovery variable
• Zone of Hyperemia:
– Prominent vasodilation
– Usually recovers
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Severity of a Burn
Depends on:
• Depth of burn
• Extent of burn
• Location of injury
• Patient’s age
• Presence of associated
injury or diseases
Depth of a Burn
First Degree
Superficial Second
Deep Second
Third Degree
Depth of a Burn
• First Degree
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Epidermis only
Erythematous
Hypersensitive
Classic sunburn
Heals without scar
Depth of a Burn
• Second Degree
– Epidermis + part of
dermis
• Superficial
• Deep
– Blisters
– Edematous and red
– Very painful
– Scaring variable
Depth of a Burn
• Third Degree
– Full thickness burn
– Can involve
underlying muscle,
tendon, bone
– Waxy white,
leathery brown or
charred black
– Painless
– Heals with scar
Extent of a Burn
• “Rule of Nines”
– Most universal guide
for initial estimate
– Deviates in children
due to larger head
surface area
“Robyn’s Rule of 4s”
ABA Burn Referral Criteria
• 2nd & 3rd degree burns of greater than 10%
BSA in patients under 10 or over 50 yrs old
• 2nd & 3rd degree burns of greater than 20%
BSA in other age groups
• 2nd & 3rd degree burns with functional or
cosmetic implications
• 3rd degree burn of greater then 5% BSA
ABA Burn Referral Criteria
• Significant electrical burn
• Chemical injury with functional or cosmetic
impairment
• Inhalation injury
• Circumferential burn of chest or extremity
• Burn injury with pre-existing medical disorder
• Any burn with concomitant trauma
Primary Survey
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A – Airway
B – Breathing
C – Circulation / C-spine / Cardiac status
D – Disability / Neurologic Deficit
E – Exposure and Examination
F – Fluid Resuscitation
Secondary Survey
• Complete heat-to-toe examination
• Obtain as much information as possible
regarding injury:
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A – Allergies
M –Medications
P – Past medical history
L – Last meal or drink
E – Events preceding injury
Management Principles
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Stop the Burning Process
Universal Precautions
Airway Management
Circulatory Management
Insertion of a Nasogastric Tube
Insertion of a Foley Catheter
Management Principles
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Relieve Pain
Assess Extremity Pulses Regularly
Assess for Ventilatory Limitation
Provide Emotional Support
Suicide Management
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Inhalation Injury
• Important determinant of morbidity &
mortality
• Manifests within the first 5 days after injury
• Present in 20-50% of pts admitted to burn
centers
• Present in 60-70% of pts who die in burn
centers
Indicators of Inhalation Injury
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Burned in closed space
Facial or intra-oral burns
Singed nasal hairs
Soot in mouth, nostrils,
larynx
• Hoarseness or stridor
• Respiratory distress
• Signs of hypoxemia
History of Event
• Is there a history of unconsciousness?
• Were there noxious chemicals involved?
• Did injury occur in closed space?
Types of Inhalation Injury
• Carbon Monoxide
Poisoning
• Inhalation Injury
Above the Glottis
• Inhalation Below the
Glottis
Carbon Monoxide Poisoning
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Colorless, odorless gas
Binds to hemoglobin 200 times more than oxygen
Most immediate threat to life in survivors with
severe inhalation injury
Toxicity related directly to percentage of
hemoglobin it saturates
Carbon Monoxide Poisoning
Signs & Symptoms of Carbon Monoxide Toxicity
Carboxyhemoglobin (%)
Signs/Symptoms
0-10
None
10-30
Headache
30-50
Headache, nausea,
dizziness, tachycardia
50-60
CNS dysfunction,
coma
60+
Death
Signs of CO Poisoning
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Cherry red coloration
Normal or pale skin with lip coloration
Hypoxic with no apparent cyanosis
PaO2 is unaffected
Essential to determine
carboxyhemoglobin levels !
CO Poisoning: Treatment
• 100% oxygen until carboxyhemoglobin
levels less than 15
– Increases rate of CO diffusion from 4 hours to
45 minutes
• Hyperbaric oxygen is of unproven value
– May be useful in isolated CO intoxication but
complicates wound care
Inhalation Injury Above the Glottis
• Most common inhalation
injury
• Results from heat
dissipation into tissues
• Commonly leads to
obstruction
• Edema lasts for 2-4 days
• Dx by visualization of
upper airways
Inhalation Injury Above the Glottis:
Treatment
Intubate!!!
Inhalation Injury Below the Glottis
• Chemical pneumonitis caused by toxic
products of combustion
– Ammonia, chlorine, hydrogen chloride,
phosgene, aldehydes, sulfur & nitrogen oxides
– Related to amount and type of volatile
substances inhaled
• Onset of symptoms is unpredictable
– Close monitoring for first 24 hours
Inhalation Injury Below the Glottis:
Treatment
Prior to transfer to burn center
• Intubation
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to clear secretions
relieve dyspnea
deliver PEEP
Improve oxygenation
• Steroids not indicated
• Prophylactic antibiotics unjustified
• Circumferential chest burns: escharotomies
Inhalation Injury in the Pediatric
Patient
• Small airways: rapid onset of obstruction
– Well secured, appropriately sized, uncuffed tube
• Rib cage is not ossified
– More pliable
– Pt exhausts rapidly due to decrease in compliance with
circumferential chest burns
– Escharotomies performed with first evidence of
ventilatory impairment
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Shock & Fluid Resuscitation
Goal:
• To maintain vital organ function while avoiding
the complications of inadequate or excessive
therapy
Systemic Effects of Burn Injury
• Magnitude & duration of response
proportional to extent of surface burned
• Hypovolemia
– Decreased perfusion & oxygen delivery
• Initial increase in PVR & decrease in CO
– Neurogenic & humoral effects
• Corrected with adequate fluid resuscitation
– Prevent shock & organ failure
Cellular Response to Burn Injury
• Severity dependant on
temperature exposed
and duration of
exposure
• “Zone of Stasis”:
recovery of injured
cells dependant on
prompt resuscitation
Resuscitation Fluid Needs
• Related to:
– extent of burn (rule of nines)
– body size (pre-injury weight estimate)
• Delivered through large bore peripheral IV
– Attempt to avoid overlying burned skin
– Can use venous cut down or central line
Resuscitation Fluid Needs:
First 24 Hours
• Parkland Formula:
– Adults: 2-4 ml RL x Kg body weight x % burn
– Children: 3-4 ml RL x Kg body weight x % burn
• First half of volume over first 8 hours, second
half over following 16 hours
– Hypovolemia, decreased CO
– Increased capillary permeability
– Crystalloid fluid is keystone, colloid not useful
Resuscitation Fluid Needs:
Second 24 Hours
• Capillary permeability gradually returns to
normal
• Colloid fluids started to minimize volume
– Only necessary in patients with large burns
(greater than 30% TBSA)
– 0.5 ml of 5% albumin x Kg body weight x % burn
Monitoring of Resuscitation
• Actual volume infused with vary from
calculates according to physiologic monitoring
• Optimal regimen:
– minimizes volume & salt loading
– prevents acute renal failure
– low incidence of pulmonary & cerebral edema
Monitoring of Resuscitation
• Urinary output is a reliable guide to end organ
perfusion
– Adults: 30-50 ml per hour
– Children (less than 30 Kg): 1 ml/Kg per hour
• Infusion rate should be increased or decreased
by 1/3 if u/o falls or exceeds limits by more than
1/3 for 2-3 hours
Management of Myoglobinuria &
Hemoglobinuria
• High voltage electrical injury and mechanical trauma
• Maintain urine output of 75-100 ml per hour
• Add 12.5 gm of Mannitol to each liter of fluid
– Urine output not sustained
– Urine pigment does not clear
• Sodium bicarbonate 1 amp (50 meq) per liter of fluid
– Heme pigments more soluble in alkaline urine
Monitoring Resuscitation
• Blood pressure:
– Can be misleading due to progressive edema &
vasoconstriction
• Heart Rate:
– Tachycardia commonly observed
• Hemaglobin & hematocrit:
– Not a reliable guide
– Transfusion not to be used for resuscitation
• Baseline serum chemistries & arterial blood gases
– Baseline to be obtained in burns of >30% BSA
Monitoring Resuscitation
• CXR: daily for first 5-7 days
– Normal study in first 24 hours does not r/o
inhalation injury
• ECG:
– All electrical injuries
– Pre-existing cardiovascular disease
Fluid Resuscitation in the
Pediatric Patient
• Require greater amounts of fluid
– Greater surface area per unit body mass
• More sensitive to fluid overload
– Lesser intravascular volume per unit surface
area burned
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Depth of Burn
• Partial Thickness
– First degree
– Superficial second
degree
– Deep second degree
• Full Thickness
– Third degree
Ack 361
Initial Management:
Chest Escharotomy
• Circumferential chest
wall burns
• Performed in the
anterior axillary line
• Extend to abdominal
wall if involved
• Divide eschar
completely
– Electric cautery
– Sharp division
Initial Management:
Extremity Escharotomy
• Circumferential burn of
the extremity
• Remove rings, watches
• Elevation of limb
• Hourly monitoring:
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Skin color, Temperature
Sensation, Pain
Capillary refill
Peripheral pulses
Ultrasonic flowmeter
Finger Escharotomy
• Seldom required
• Performed after
consultation with
burn center
physician
• Extend through full
thickness of skin
only
• Avoid tactile areas
Performing an Escharotomy
• Bedside procedure
• Sterile technique (sharp division or electrocautery)
• Local anesthesia not required
– Control anxiety
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Avoid major nerves & vessels
Extend incision into subcutaneous fat
Incision to be carried across involved joints
2nd incision on contralateral aspect of limb may be
required
Escharotomy Sites
Specific Anatomical Burns
• Facial Burns
– Require hospital care
– Possibility of
respiratory damage
– Elevate HOB 30
degrees
– Use water or NS to
clean to avoid chemical
conjunctivitis
Specific Anatomical Burns
• Burns of the Eyes
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Examine ASAP
Use fluorescein to identify corneal injury
Chemical burns to be rinsed with copious NS
Opthalmic antibiotic drops if corneal injury
present
– Solutions with steroids dangerous
– Tarsorrhaphy is never indicated in acute phase
Specific Anatomical Burns
• Burns of the Ears
– Examine external canal & drum early
– Determine if OM/OE present
– Avoid pressure dressings & additional trauma
Specific Anatomical Burns
• Burns of the Hands
– Determine vascular status
& need for escharatomy
– Presence of radial pulse
does not exclude
compartment syndrome
– Monitor with Doppler U/S
– Elevate hand above heart
– Dressings impair ability to
monitor
Specific Anatomical Burns
• Burns of the Feet
– Assess circulation
on scheduled basis
– Elevate limb
– Dressings to be
avoided to not
interfere with
monitoring
Specific Anatomical Burns
• Burns of the Genitalia & Perineum
– Burn to the penis requires immediate insertion
of Foley catheter
– With circumferential burns, a dorsal
escharotomy may be indicated
– Scrotal swelling does not require treatment
– Diverting colostomy not indicated in perineal
burns
Tar Burns
• Contact burns
• Bitumen is non-toxic
• Immediate cooling of
molten with cold H20
• Removal of tar not an
emergency
• Cover with petroleum
based product &
dressed to emulsify tar
Please Pass the Mayo!
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Electrical Injury
• Occurs when electricity is converted to heat
as it travels through tissue
• Divided into:
– High voltage – greater than 1000 V
– Low voltage – less than 1000
• Hands & wrists are common entrance
wounds
• Feet are common exit wounds
Electrical Injury
• Extremely difficult to evaluate clinically
• Greatest tissue damage occurs under and
adjacent to contact points
• Superficial tissues cool more rapidly than
the deeper tissue
– Accounts for non-viable tissue beneath viable,
more superficial muscle
Types of Tissue Injury
• Cutaneous Burn with no underlying
tissue damage
– No passage of current through patient
• Cutaneous Burn plus deep tissue damage
– Involving fat, fascia, muscle and/or bone
• Muscle damage associated with
myoglobin release
– Urine may be light red to “port wine” color
– Risk of kidney damage
Lightning Injury
• Direct current of >100 000 000 volts and up
to 200 000 amps
• Injury results from:
– Direct strike
– Side flash
• Flow of current between person & nearby object
• Often travels on surface of body
– Burns typically superficial
– “splashed on” spidery pattern
Management of Electrical Injury
• ABC’s
• Assess Injury
– History
• LOC, cardiac arrythmia, other trauma
– Physical Exam
• neuro exam, long bone #, dislocations, cervical spine
• Maintain Patency of Airway
• Cardiac Monitoring:
– Standard 12 lead EKG on admission
– Continuous cardiac monitoring for first 24 hours
Management of Electrical Injury:
Fluid Resuscitation
• Administer Ringer’s Lactate in amounts estimated
with Parkland Formula
– Will underestimate required volume due to underlying
tissue damage
– Increase fluids as per urine output
• Examine urine for pigment
– Maintain urine output 75-100 ml/hr until clear
– Add 1 amp (50 meq) per liter of RL to alkalize urine
– Mannitol 12.5 mg/liter to maintain urine output
Management of Electrical Injury:
Peripheral Circulation
• Hourly monitoring of skin color, sensation,
capillary refill and peripheral pulses
• Remove all rings, watches, jewelry
• Surgical correction of vascular compromise
– Decompression by escharotomy or fasciotomy
– Upper limb-volar & dorsal incisions with
protection of ulnar nerve
– Lower limb-medial & lateral incisions
Electrical Burns in the Pediatric
Patient
• Low voltage accidents
most common
– Generally household
(faulty insulation, frayed
cords, insertion of metal
object into wall socket)
– Cutaneous injury, no
muscle damage
• Oral commisure injury
– Look worse than they are
– No initial debridement
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Chemical Burns: Classification
• Alkalis
– Hydroxides, carbonates and caustic sodas of sodium,
ammonium, lithium, barium & calcium
– Oven & drain cleaners, fertilizers, industrial cleaners
• Acids
– HCl, oxalic, muriatic & sulfuric acids
– Common in household & swimming pool cleaners
• Organic Compounds
– Phenols, creosote, petroleum products
– Contact chemical burns & systemic effects
Chemical Burns
• Factors That
Determine Severity:
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Agent
Concentration
Volume
Duration of contact
(delay in treatment)
Treatment of Chemical Burns
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Wear gloves and protective clothing
Remove saturated clothing
Brush skin if agent is a powder
Irrigate, irrigate, irrigate!
– Copious amounts of water
– Continued until pain or burning has decreased
• Neutralization of agent contraindicated
– Generation of heat may lead to further injury
Specific Chemical Burns:
Treatment
• Alkali Injury to the Eye
– Bond to tissue proteins leading to liquefaction
necrosis
– Require prolonged irrigation
• Water or saline
– Likely to present with swelling & lid spasm
– Place catheter in lateral sulcus to irrigate
Specific Chemical Burns:
Treatment
• Petroleum Injuries
– Contact with gasoline or diesel fuel
– Delipidation: causes an initial partial thickness
burn become a full-thickness burn
– Systemic toxicity evident within 6 to 24 hours
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Pulmonary insufficiency
Hepatic failure
Renal failure
CNS narcosis
– No specific antidote
Specific Chemical Burns:
Treatment
• Hydrofluric Acid
– Most tissue reactive inorganic acid
– Fluoride ion penetrates & binds tissue
• Ceases when it combines with Ca or Mg
• Burns greater than 5%TBSA – can be life threatening
– Acute Tx: copious irrigation with H2O or
Zephiran (benzalkonium chloride)
– Topical calcium gluconate gel or Epsom salts
– If pain persists, inject 10% Ca gluconate into site
– Intraarterial and IV infusions with Bier block
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Pediatric Burns
• Scald burns most
common burn in < 3
years
• Flame burns most
common in children
> 3 years
• Always consider
child abuse
Pediatric Burns:
Pathophysiology
• Greater surface area per pound of body
weight
– Greater fluid needs
– Greater evaporative water loss
– Greater heat loss
• Disproportionately thin skin
– Burns may be deeper than initially assessed
– Requires less exposure time to result in burn
Pediatric Burns:
Airway
• Intubation performed by someone experienced
• Larynx more cephalad
– More acute angulation of the glottis
• Incuffed tube always used
• Cricothyroidotomy is never indicated
• Large bore needle placed through cricothyroid
membrane may be used in emergency cases
Pediatric Burns:
Circulatory Status
• Burn > 10% BSA should be hospitalized
• IV Ringer’s Lactate is administered as per formula
– Must also add maintenance fluid (4-2-1 rule)
• NG tube
• Urinary catheter to monitor urine output:
– <30 Kg: 1ml/Kg per hour
– >30 Kg: 30-50 ml per hour
• If hypoglycemic, add 5% glucose to RL solution
Pediatric Patient:
Wound Care
• Stop burning process
• Remove all clothing
• Topical antibiotics not indicated before
transfer
• Conserve heat with thermal blankets
• Escharotomy
– Chest: ventilatory impairment
– Limb: vascular compromise
Overview
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Burn Pathophysiology
Initial Assessment & Management
Airway Management & Inhalation Injury
Shock & Fluid Resuscitation
Burn Wound Management
Electrical Injuries
Chemical Burns
Pediatric Burns
Other Topics
Radiation Injury
• Effects reproductive mechanism of certain
tissue cells
• Mature cells suffer less damage
• Stem cells are more vulnerable to injury
• Large doses of radiation (> 2000 RAD) may
lead to acute mortality
Outcomes Associated with
Ranges of Whole Body Radiation
Whole Body Dose(RAD)
Response
20-100
Change in # of leukocytes
200-400
Severe reduction in leuks, N/V, hair loss, death due
to infection
600- 1 000
Destruction of mone marrow, diarrhea, 50%
mortality within 1 month
1 000-2 000
GI ulceration, death within 2 weeks
2 000+
Death within hours due to severe damage to CNS
Types of Ionizing Radiation
• Alpha particles
– Large, highly charged particles
– Associated with decay of natural radioactive
elements
– Penetrate only a few microns of tissue
• Beta particles
– Positive electrons or negatively charged particles
– Penetrate approximately 1 cm of tissue
Types of Ionizing Radiation
• Gamma and X-rays
– Radioactive decay or x-ray machines
– Penetrate deeply
– Once removed from source, no further radiation
injury occurs
– Poses no threat to attendants
• Protons, Deuterons, Neutrons, Mesons and
Heavy Nuclei
– Produced by equipment for medical and
industrial use
Radiation Burns
• Identical in appearance to thermal burns
– Treat as you would a non-contaminated burn
• Differ from thermal burns from time
between exposure and clinical manifestation
SKIN RESPONSE TO RADIATION
200-300 (RADS)
Epilation
300
Erythema
1000-2000
Transdermal Injury
2000
Radionecrosis
Toxic Epidermal Necrolysis
(TEN)
• Exfoliative deramatitis
– Begins with target lesions, develop into papules & bullae
– Injury identical to partial thickness burn
– Mucosal involvement of conjunctiva & GI tract
• Multiple eitiologies
– Drugs (penicillins, sulfas, anti-inflammatories)
– Infection: (staph toxin, HSV, menigococcus, septicemia)
– Often unknown
Toxic Epidermal Necrolysis
• TEN Type I
– (Staph scalded skin
syndrome)
– Only stratum corneum
denuded
– Frequently in children
– Excellent prognosis
– 5% mortality
• TEN Type II
– ( Stevens-Johnson
syndrome)
– Separation is at the
dermal/epidermal
junction
– Adult population
– High mortality (2550%)
Initial Management of TEN
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Steroids not indicated
Systemic antibiotics limited to specific infection
Fluid replacement
Biologic dressing
Maintain nutrition
Prevent complications
Cold Injuries:
Frostbite
• Formation of ice crystals in the tissue fluids
• Occurs in areas that lose heat rapidly
• Three degrees of frostbite:
– First degree: painful white or yellow firm plaque
– Second degree: painful superficial clear or milky blisters
– Third degree: deep red or purple blisters or skin color
that is markedly changed
• Severity influenced by both patient & environment
factors
Cold Injuries:
Treatment of Frostbite
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Rapid re-warming in 4O degree water bath
Avoid mechanical trauma - No massaging!
Tetanus prophylaxis
Escharotomy if vascularity compromised
Tissue injury is often underestimated
Cold Injuries:
Hypothermia
• Defined as a core temperature < 34 degrees C
• Signs are vague & non-specific
– May mimic other disease states
• Treatment:
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Limit stimulation of patient –V.Fib easily induced
Rapid re-warming i9n warm water bath
Intubation to administer warm air
Central administration of warm Ringer’s solution
Cold Injuries:
Hypothermia
– Monitor for systemic acidosis with serial ABGs
• Treat with sodium bicarbonate
– Cardiopulmonary bypass
– Cardiac monitoring
• Ventricular dysrhythmia
– Patients not to be declared dead until rewarmed
• Continue CPR until core temperature> 36 degrees C.
– Secondary assessment for contributing diseases
Hyperthermia:
Clinical Syndromes
• Heat Cramps
– Result from excessive loss of salt by evaporation
– Experiences severe pain & cramping in muscles
– Tx: oral replacement of salt & water
Hyperthermia:
Clinical Syndromes
• Heat Exhaustion
– Consequence of inappropriate cardiovascular
response to stress of heat
– Diversion of blood to skin is not accompanied by
vasoconstriction to other areas or by volume
expansion
– Present with postural hypotension, profuse
sweating, pallor, nausea, light-headedness
– Tx: oral replacement or IV normal saline if severe
Hyperthermia:
Clinical Syndromes
• Heat Stroke
– Failure of body cooling mechanism
• severe hyperpyrexia
– Setting of physical exercise w/o acclimatization
– Present with temperature>103, no sweating,
decreased LOC
– Tx: rapid cooling until temperature <102 deg
– If shivering develops, slowly give IV Thorazine
– DIC frequently reported
Tetanus Immunization
CLINICAL
FEATURES
Age of wound
Configuration
Mechanism
TETANUS-PRONE
WOUNDS
> 6 Hours
Stellate, avulsion
Missile, crush, heat,
cold
Signs of Infection Present
Devitalized Tissue Present
Contaminants
Present
CLEAN
WOUNDS
<6 Hours
Linear,
abrasion
Sharp surface
Absent
Absent
Absent
Tetanus Immunization
History Of Tetanus
Clean Wounds
TD1 TIG
Uncertain
0-1
2
3 or more
yes
yes
yes
no
Tetanus-Prone Wounds
TD1 TIG
no
no
no
no
yes
yes
yes
no
yes
yes
no
no
Consider patient partially immunized if:
**For a clean wound, if last Td given > 1O years ago
**For a dirty wound, if last Td given > 5 years ago
The End!