Transcript Slide 1

Rania Hassan Abdel Hafiez
Case:
A 35 years old female weighing 100 kg with a 75% flame
burn was admitted at 4pm to the burn unit. Her burn
occurred at 2pm. On clinical examination she was
dyspnic (RR 32), with low reading on pulse oximetery
(SPO2 75%) and with change in her voice. she said that
she fall from the first floor.
 What is the first thing that you would like to do? And why?
 Calculate the fluid requirement for first 24 hours & their
distribution and type?
 What are the medications that you would like to prescribe
to her?
 What are the other investigations that should be done?
Definitions:
Burn wounds are coagulative lesions
of the surface layers of the skin
usually caused by contact with a
solid hot or cold object (contact
burn), flames (flame burn), heated
liquids (scald), chemicals or physical
agents (electricity, radiation,
lightening).
Definitions(con)
Burn injury is a complex traumatic
event with various local and
systemic effects, affecting several
organ systems beyond the skin.
Burn severity is related to:
 Burn surface area
 Burn depth
 Distribution
Burn Depth(con):
The depth of burn is not
static, wounds can
evolve over time =
becoming deeper if not
adequately managed
Burn Depth:
• First degree= epidermis
 Second degree =
 superficial partial thickness
=1+upper layers of dermis
 deep partial thickness
=1+2+deeper layers of dermis
 Third degree full-thickness
=1+2+3+subcutaneous tissue
 Fourth degree
=1+2+3+4+fascia,muscle,bone
Medline Plus (2009) www.nlm.nih.gov/.../ency/fullsize/1078.jpg
First degree burn
Second degree burn
Third degree burns
Burn surface area
Hand method
 A simple method of estimating burn
surface area
 used in triage
 uses the patient’s palmar surface area
being roughly equivalent to 1% of his/
her body surface area.
Burn surface area(con)
Wallace Rule of Nines
Burn surface area(con)
Lund and Browder
chart to assess burn
area
Patient categorization:
The American Burn Association
 Major burn injury
ICU
 Moderate burn injury
ward
outpatient
Minor burn injury
Major burn injury:
 Partial-thickness burns involving
more than 25% of TBSA in adults or
20% of TBSA in children younger
than 10 years or adults older than 50
years.
 Full-thickness burns involving
more than 10% of TBSA.
 Burns involving the face, eyes, ears,
hands, feet, or perineum.
Major burn injury (con)
 Burns caused by caustic chemical
agents;
 High-voltage electrical injury.
 Burns complicated by inhalation injury
or major trauma.
 Burns sustained by high-risk patients
(those with underlying debilitating
diseases).
Moderate burn injury:
 Partial-thickness burns of 15-25% of
TBSA in adults or 10-20% of TBSA in
children or older adults
 Full-thickness burns involving 2-10% of
TBSA that do not present serious threat
of functional or cosmetic impairment of
the eyes, ears, face, hands, feet, or
perineum.
Minor burn injury:
 Less than 15% of TBSA in adults or
10% of TBSA in children or older
persons,
 Full-thickness burns involving less
than 2% of TBSA
When burn wound area exceeds 20%
total body surface, the protective
inflammatory response becomes
counter productive, with proinflammatory mediators ‘flooding the
system’ and overwhelming the body.
systemic inflammatory response
syndrome (SIRS)
Systemic manifestations of
burn
Histamine, Serotonin,
Prostaglandins, platelet products,
.
complement, kinin
capillary
permeability
massive
loss of fluid
and
electrolytes
 This affects both local and systemic capillaries.
 It is now recognized that burn shock is a complex
process of circulatory and microcirculatory
dysfunction that is not easily or fully repaired by
fluid resuscitation.
 Hypoperfusion of burned tissue also may result
from direct damage to blood vessels or
vasoconstriction secondary to hypovolemia.
 In patients with major burns, release of
catecholamines, vasopressin, and angiotensin
causes peripheral and splanchnic bed
vasoconstriction that can compromise organ
perfusion.
 Myocardial contractility also may be
reduced by the release of inflammatory
cytokine tumor necrosis factor-alpha
 Cardiovascular system responds
immediately to thermal injury by a
reduction in cardiac output accompanied
by an elevation in peripheral vascular
resistance.
 In the absence of heart disease,
ventricular ejection fraction and
velocity of myocardial fiber
shortening are actually increased
during thermal injury.
 With replacement of plasma
volume, cardiac output increases to
levels that are above normal.
Pathophysiology of Burn Shock:
A) Hypovolemic etiology:
−
−
−
Decreased cardiac output
Increased extracellular fluids
Decreased plasma volume
 In burn shock, resuscitation is
complicated by obligatory burn edema
Q\Time for maximal edema formation?
B) Changes at cellular level:
>30% burn; cell transmembrane potential ----> NaK ATPase ( defective ATP metabolism(
Systemic manifestations of burn
B) Metabolic Response to Burn Injury
Hypercatabolism:
This response can last as long as a year
after injury and is associated with
impaired wound healing, increased
infection risk, erosion of lean body
mass, impaired rehabilitation, and
delayed integration of the burn
patient into society.
:
Catabolic hormones counteract the effect
of insulin; as a result, blood sugar levels
rise, and protein synthesis and
lipogenesis are inhibited. Growth
hormone is similarly antagonized and
less effective.
In this environment, skeletal muscle is
the major obligatory fuel. (compare to
starvation)
Growth hormone 
insulin; 
gluconeogenesis,
glyconeolysis,
muscle proteolysis
Systemic manifestations of burn (con)
C) Thermal effects
Hypothermia
 Increased evaporative water loss from
burned skin
obligatory concurrent
heat loss
 Large volumes of cool IV fluids
Exposure of body surfaces to a cool
emergency department environment.
Systemic manifestations of burn (con)
Hyperthermia
 The threshold set point of the
thermoregulatory centre is higher
and proportional to the size of burn.
The temperature set point increases 0.03
degree Celsius per % TBSA burn. (TNF, IL-1 and
IL-6)
Systemic manifestations of burn (con)
smoke
trauma
PVR
Systemic manifestations of burn (con)
RBF
GFR
Systemic manifestations of burn (con)
Care at the scene:
A)Airway (c):
 Cardiopulmonary Resuscitation
 Cervical spine immobilization
 100% O2 via a non rebreather mask if
there is any suspicion of smoke inhalation
 If unconscious or in respiratory distress ---> endotracheal intubation
Care at the scene:
B) Other injuries and transport:
 Assess other injuries; transport to nearest
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


hospital
Keep flat and warm and wrapped in clean
sheet and blanket.
NPO??????
IVF = isotonic crystalloid infusion ??????
Constricting clothing and jewelry should
be removed from burned parts due to
local swelling begins
Emergency Care
Primary rule: ignore the burn
and Search for life- threatening
injuries
ABCDEFGHI
Emergency Care
AIRWAY
Emergency Care
BREATHIG
Secure and protect airway
Cervical spine immobilization
Assess for inhalation injury
Circumferential chest burns can impair
ventilation
Inhalation Injuries
 Suspect inhalation injury when:









Burn in a closed space
Burns to face or neck
Singed nasal hair or eyebrows
Hoarseness of voice , wheezing or stridor
Sooty sputum
Brassy cough or drooling
Labored breathing or tachypnea
Erythema and blistering of oral or
pharyngeal mucousa
Routine use of fiberoptic bronchoscope
Inhalation Injuries Cont.,
Carbon Monoxide Poisoning
 Most common inhalation injury
 May occur with or without cutaneous burns
 Hemoglobin’s affinity for carbon monoxide
is 200x greater than that for oxygen; result =
hypoxia
 Diagnosis:
Serum COHb levels & ABG’s
Pulse Ox: false readings !!
 Management: 10
 100% O2
 Face mask or mechanical ventilation
Thermal Airway Injury:
What to do?
Thermal Airway Injury:
What to do?
Why to do?
When to do?
How to do?
Where to do?
intubation
Edema (max?)
Early
Nasal or oral?
ICU or ER.
narcotics
ketamine
Succinyl
choline
Thermal Airway Injury:
Treatment
Upper Airway:
Rapid endotracheal intubation .
Ability of adult pt to breathe around
the tube w/ the cuff deflated is an
indication for tube removal(leak
test).
.

Thermal Airway Injury:
Treatment
Lower Airway:
SUPPORTIVE TILL HEALING
PROTECTIVE LUNG
STRATEGY
.

Thermal Airway Injury:
Emergency Care
CIRCULATION
INITIATE RESTORATION OF
HEMODYNAMIC STABILITY
isotonic crystalloid infusion
 Large Bore Peripheral
Intravenous Lines
Remove any constricting items
Consider Escharotomy for
circumferential burns
Emergency Care
DISABILITY
Emergency Care
Enviroment
Escharotomy
Electrolytes
ESCHAROTOMY
Respiratory distress
due to deep
circumferential burn
wound of the thorax.
Peripheral
pulsations.
ESCHAROTOMY
Emergency Care
FLUIDS
Fluid Resuscitation:

Restore effective plasma volume
 Avoid microvascular ischemia
 Maintain vital organ function
The amount of fluid required varies
with patient's age, body weight,
and extent of burned TBS.
Fluid Therapy
Parkland Formula is used to calculate the
amount of fluid to use to resuscitate the
patient based on burn percentage.
4mL/kg/% burn in the first 24 hrs, half of which
is given in the first 8 hours (MAX?)
2mL/kg/% burn in the second 24 hrs, third of
which is given as colloid
Infuse at constant rate instead of by bolus
Vitamin C and Vasopressin help reduce fluid
requirements
Emergency Care
GET VITAL SIGNS
 Blood pressure - only reliable as volume indicator
if low
 Pulse: young patient - pulse less than 120,
reasonable perfusion; pulse > 130, increase fluid
 Elderly or with heart disease - pulse not accurate
reflection of perfusion
 Urine output - 0.5 to 1 cc/kg/hr is adequate in
absence of diuretic such as alcohol
 Exception: Myoglobin or hemoglobinuria where
over 1cc/kg/hr is indicated
Base deficit > 5 meq / liter reflects decreased
tissue oxygenation. Look for progressive decrease
in base deficit as marker of adequacy of
resuscitation.
Electrocardiogram - particularly important for
patient more than 45 years old
Temperature - Avoid hypothermia
Peripheral perfusion: for circumferential arm,
leg burns
Emergency Care
Head To Toe
History
Emergency Care
INSPECT
Burn wound
Emergency Care:





Antibiotics
Anticoagulants
Antistress
Antioedema
Analgesics
Case:
A 35 years old female weighing 100 kg with a 75% flame
burn was admitted at 4pm to the burn unit. Her burn
occurred at 2pm. On clinical examination she was
dyspnic (RR 32), with low reading on pulse oximetery
(SPO2 75%) and with change in her voice. she said that
she fall from the first floor.
 What is the first thing that you would like to do? And why?
 Calculate the fluid requirement for first 24 hours & their
distribution and type?
 What are the medications that you would like to prescribe
to her?
 What are the other investigations that should be done?
Thank you