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Marie Antoniette F.

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

3 Zones of Burn Injury

Zone of coagulation Zone of stasis Zone of hyperemia

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

Evaluation of Other Injuries


Constricting clothing and jewelry should be removed from burned parts, because local swelling begins almost immediately.

Estimation of Burn Size


Rule of Nines
Head Anterior trunk Posterior trunk Upper limbs Anterior Posterior Lower limbs Anterior Posterior 4.5 x 2 = 4.5 x 2 = 9 18 18 9 9

9x2= 9x2=

18 18 1
100%

Genitalia
Total

Estimation of Burn Size

Estimation of Burn Size

Carbon Monoxide Poisoning


Affinity of CO for hemoglobin is 200-250 times more than oxygen
Decreases levels of oxygenated hemoglobin

Anoxia and death

100% oxygen is the gold standard for CO poisoning

Hydrogen Cyanide Toxicity


20 times as toxic as CO and can cause immediate respiratory arrest Persistent lactic acidosis S-T elevation on ECG Cyanide inhibits cytochrome oxidase, in turn inhibits cell oxygenation Tx: Sodium thiosulfate, Hydroxocobalamin

Management of Burn patients


Should never receive prophylactic antibiotics Tetanus booster Narcotics Benzodiazepine Prevent hypothermia

Prognosis
Baux Score: mortality = age + percent TBSA Markers for burn mortality:
Age, burn size, inhalation injury

Comorbidities: preinjury HIV, metastatic cancer,

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

Treatment Aggressive pulmonary toilet Routine use of bronchodilators such as albuterol

Treatment of the Burn Wound


Silver sulfadiazine
Antimicrobial Inexpensive Easy to apply Destroys skin grafts

Treatment of the Burn Wound


Mafenide acetate
Antimicrobial Effective in eschar Excellent for fresh skin grafts Absorbed systemically Metabolic acidosis

Treatment of the Burn Wound


Silver nitrate
Antimicrobial Methemoglobinemia Causes black stains

Treatment of the Burn Wound


Bacitracin, Neomycin, Polymyxin B
Nearly healed useful for superficial partial-thickness facial burns as they can be applied and left open to air without dressing coverage Nephrotoxicity not for large burns

Mupirocin

Treatment of the Burn Wound


Only for methicillin resistant S. aureus

Silver impregnated dressings


Acticoat Aquacel Ag Used for donor sites and skin grafts

Treatment of the Burn Wound


Biologic membranes
Biobrane Prolonged barrier

Nutrition

Hypermetabolic response 200%

Catabolism

Decreased lean body mass

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

Harris Benedict equation Curreri formula


25kcal/kg per day + 40kcal/%TBSA per day Titration of caloric needs

Complications in Burn Care


Ventilator associated pneumonia / Post Injury Pneumonia
Elevate head of the bed Maintain excellent oral hygiene Pulmonary toilet

Abdominal compartment syndrome


Increased airway pressure Decreased urine output Hemodynamic compromise Decompressive laparotomy

Complications in Burn Care


Deep vein thrombosis
Rare Heparin prophylaxis

Catheter related bloodstream infections


Catheter cultured New site

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

Meshed autografted skin


Larger burns Allows drainage of blood and serous fluid

Nonmeshed sheet grafts


Areas of cosmetic appearance

Temporary Wound Coverage


Integra
Bilayer product with a porous collagenchondroitin 6-sulphate inner layer and silastic outer layer Silastic barrier prevents fluid loss and infection Inner layer becomes vascularized creating an artificial neodermis

Temporary Wound Coverage


Alloderm
Cryopreserved acellular human dermis Used in combination with split thickness grafts

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

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