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Absalon
Epidemiology
More than 1.2 million people/year most cases are minor approximately 50,000 burns/year are moderate to severe more than 3900 people die of complications related to burns Burn deaths: immediately after the injury or weeks later as a result of multiorgan failure 2/3 of all burns occur at home 75% of burn-related deaths occur in house fires A significant percentage of burns in children are due to child abuse. Other risk factors include low socioeconomic class and unsafe environments.
Pathophysiology of Burns
Local changes
Burn causes coagulative necrosis of the epidermis and underlying tissues, with the depth depending on the temperature to which the skin is exposed and the duration of exposure.
Systemic Changes
Classification of Burns
Thermal
Flame
Most common cause of hospital admission
Contact Scald
Classification of Burns
Electrical
potential for cardiac arrhythmias and compartment syndromes with concurrent rhabdomyolysis
Chemical
Initial therapy: removal of the toxic substance and irrigation of the affected area with water for a minimum of 30 minutes
Burn Depth
Burn Depth
First degree burn / Superficial
confined to the epidermis painful and erythematous, blanch to the touch, and have an intact epidermal barrier do not result in scarring
Burn Depth
Second degree burns / Partial thickness
Superficial
Upper layer of dermis erythematous and painful, blanch to touch, and often blister May result to slight discoloration
Deep
Reticular dermis More pale and mottled, do not blanch to touch, but remain painful to pinprick May result to severe scarring
Burn Depth
Third degree burn / Full thickness
through the epidermis and dermis hard, leathery eschar that is painless and black, white, or cherry red no epidermal or dermal appendages remain
Burn Depth
Fourth degree burn
involve other organs beneath the skin, such as muscle, bone, and brain
Initial Evaluation
Airway management Evaluation of other injuries Estimation of burn size Diagnosis of carbon monoxide and cyanide poisoning
Airway Management
100% oxygen given in cases of smoke inhalation Evaluate oral cavity and pharynx for mucosal injury Endotracheal intubation Impending resp compromise
Hoarse voice Wheezing Stridor
Initial Evaluation
Primary Survey Airway Management Breathing Circulation
large-bore peripheral IV catheters and fluid resuscitation should be initiated > 40% TBSA - two large-bore Ivs CVP insertion
Initial Evaluation
Secondary survey
radiology studies Tetanus booster Dont give antibiotics Pain management
9x2= 9x2=
18 18 1
100%
Genitalia
Total
Prognosis
Baux Score: mortality = age + percent TBSA Markers for burn mortality:
Age, burn size, inhalation injury
Resuscitation
Parkland or Baxter formula 3 to 4 ml/kg per percent burned Lactated Ringers solution Half given during the first 8 hours Other half during the next 16 hours Target MAP of 60 mmHg Target Urine Output of 30ml/hr or 1 to 1.5ml/kg per hour in pedia
Inhalation injury
Seen in 35% of burn patients Causes direct injury to the upper airways Maximal edema in the first 24 to 48 hours Requires endotracheal intubation Causes injury to lower airways Combustion particles irritants Direct mucosal injury Bronchoconstriction Obstruction
Inhalation injury
Decreases lung compliance Increases airway resistance Increase overall metabolc demands
Mupirocin
Nutrition
Catabolism
Nutrition
Early enteral feeding for patients with >20%TBSA
Safe Prevents lean body mass loss Slows the hypermetabolic response More efficient protein metabolism Gastric ileus can be avoided
Surgery
Escharotomies
release of the burn eschar at the bedside by incising the lateral and medial aspects of the extremity with a scalpel or electrocautery unit Prevent compartment syndromes
Surgery
Early excision and grafting
Within 3-7 days Reduced burn mortality more than any other intervention Early wound closure also reduces hospital stay, duration of illness, septic complications Scarring is less severe
Wound Coverage
Split thickness grafts
Durable Cosmetic
Donor Sites
Thighs
Easily harvested Hidden
Buttocks
Infants and toddlers
Back
Thicker Older patients
Scalp
Thick, heals quickly Completely hidden
Rehabilitation
Initiated on admission Physical and occupational therapy Passive ROM twice a day Prevent extremity swelling Desensitize burn areas Prevent disuse atrophy Psychological rehab