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INITIAL MANAGEMENT OF THERMAL INJURIES

INITIAL MANAGEMENT OF THERMAL INJURIES. DR L.N.KAHORO PLASTIC SURGEON KNH. INTRODUCTION. THERMAL INJURIES ARE A MAJOR CAUSE OF MORBIDITY AND MORTALITY

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INITIAL MANAGEMENT OF THERMAL INJURIES

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  1. INITIAL MANAGEMENT OF THERMAL INJURIES DR L.N.KAHORO PLASTIC SURGEON KNH

  2. INTRODUCTION THERMAL INJURIES ARE A MAJOR CAUSE OF MORBIDITY AND MORTALITY IN KNH TOTAL BURN ADMISSION PER YEAR AVERAGE 1000; OF THESE ABOUT 400 ARE SEVERE BURNS THAT REQUIRE ADMISSION TO BU; ≥30% IN ADULTS AND ≥20% IN CHILDREN BURNS OF ≥ 20% ARE CONSIDERED SEVERE BURNS

  3. CARE OF THE BURN PATIENT EARLY CARE WILL DICTATE CLINICAL COURSE AND OUTCOME AND THUS THOROUGH UNDERSTANDING OF PRINCIPLES IS ESSENTIAL MOST EARLY CARE OCCURS IN NON-BURN CENTERS EARLY CARE IS THE SAME AS FOR ALL TRAUMA PATIENTS FOLLOW ATLS PRINCIPLES

  4. PRIMARY SURVEY • A=AIRWAY AND CERVICAL CORD CONTROL • IDENTIFY INHALATON INJURY • LOOK FOR THE FOLLOWING S/S • HISTORY OF IMPAIRED MENTATION AND/OR CONFINEMENT IN AN ENCLOSED BURNING ENVIRONMENT • HISTORY OF EXPLOSION WITH BURNS TO TORSO AND HEAD • HEAD AND/OR NECK BURNS • SINGEING OF NASAL HAIRS AND EYEBROWS • PERIORAL AND ORAL BURNS • CARBONACEOUS SPUTUM • HOARSENESS OF VOICE • STRIDOR • PROPHYLACTIC INTUBATION IS VERY IMPORTANT • MUST RULE OUT CERVICAL CORD INJURY

  5. INITIAL ASSESSMENT AND MANAGEMENT OF THE AIRWAY • If Stridor Retraction or Respiratory Distress present or Deep Burns: Face, Neck *Intubate now! • *Use adequate size tube • *Humidified oxygen • *Elevate Head • *Transport to Burn Center • If Sridor retraction or respiratory Distress absent and no deep burns face and /or neck • *Provide 100% Oxygen • *Look for Signs of Airway Injury - Oropharyngeal erythema     - Hoarseness     -  Pulmonary status • * Can perform laryngoscopy • * If edema present, intubate now • * Transfer to Burn Center if history or findings are positive for smoke inhalation injury • REMEMBER: DETERIORATION IS OFTEN DELAYED IN ONSET.

  6. B=BREATHING MAKE SURE PT IS BREATHING RULE OUT ANY CONCOMITANT CHEST INJURY DO CHEST ESCHAROTOMIES IF 3ᵒ OR 4ᵒ BURNS THAT ARE TIGHT AND RESTRICTING CHEST MOVEMENT DO BASELINE ABGS INTUBATE AND MECHANICALLY VENTILATE IF NEEDED

  7. C=CIRCULATION • FLUID RESUSCITATION IS VITAL IN BURNS • NO FLUIDS IN 50% BURNS PT IN 4 HRS EQUALS ARF • PARKLANDS FORMULA STILL BEST • 4MLS X %TBSA X KG BODY WEIGHT • GIVE HALF THIS AMOUNT IN IST 8 HRS AND THE REST IN THE NEXT 16HRS • USE CRYSTALLOIDS USUALLY RINGERS LACTATE IN FIRST 24HRS AND CONSIDER ALBUMIN OR FFP AFTER THIS PERIOD • INSERT URINARY CATHETER AND MONITOR HRLY URINE OUTPUT TO MAINTAIN AT 1ML/KG/HR FOR CHILDREN WITH WEIHGT ≤30KG AND 0.5ML/KG/HR FOR ADULTS • ADD MAINTAINANCE FLUID AS 5%DEXTROSE FOR CHIDREN DUE TO THEIR REDUCED GLYCOGEN STORES • ADJUST FLUID BASED ON PATIENT RESPONSE • MUST GET IV ACESS • WIDE BORE PERIPHERAL ACESS G16 AND BIGGER • CVP • VENOUS ACESS CAN BE DONE THROUGH BURNED SKIN IF NO OTHER ALTERNATIVE • MUST RESTORE CIRCULATION IN AT RISK EXTREMETIES DUE TO A TIGHT ESCHAR. DO ESCAROTOMIES TO RELIEVE THE TISSUE PRESSURE

  8. Resuscitation Fine Points • MORE IS NOT BETTER!!! • CRYSTALLOID … NOT COLLOID & ONLY LR • GOAL IS NORMOTENSIVE, PERFUSED, URINATING PT. • < 4 CC OF LR /KG/%TBSA •  CENTRAL MONITORING • ESCHAROTOMIES • ACS IS UNACCEPTABLE!!!

  9. RESUSCITATION EXAMPLE • 50 % BURN IN A 70 KG ADULT • 4 X 50 = 200 X 70 = 14000 / 2 = 7000 / 8 = 875 ML/HR • START LACTATED RINGERS SOLUTION • GOAL IS 30 - 50 CC OF URINE / HOUR • URINE OUTPUT GREATER THAN GOAL • DECREASE FLUID RATE BY 10% • URINE OUTPUT LESS THAN GOAL • INCREASE FLUID RATE BY 10% • AVOID FLUID BOLUSES • THEY ONLY INCREASE EDEMA

  10. C=CIRCULATION Example of escharotomy of an upper limb with deep burns

  11. D=DISABILITY • CHECK FOR ANYOTHER DISABILITY • ASSOCIATED INJURIES THAT MAY TAKE PRECEDENCE IN MANAGEMENT SUCH AS HEAD, ABD ,CHEST OF MUSCULOSKELETAL TRAUMA ESPECIALLY IN BURNS WHERE EXPLOSION OCCURRED OR IN MOB JUSTICE PTS • LOSS OF CONSCIOUSNESS OR DEPRESSED MENTATION RULE OUT CO POISONING

  12. E=EXPOSURE/ENVIRONMENT CONTROL EXPOSE THE BURNS PT IN ORDER TO EXAMINE FURTHER. REMOVE ALL CLOTHES AND JEWERELY CAREFULLY REMOVE CLOTHES THAT WERE BURNED BY CHEMICAL; BRUSH OFF POWDER CHEMICAL BEFORE REMOVAL; AVOID DIRECT CONTACT WITH CHEMICAL RINSE AREAS AFFECTED BY CHEMICAL BURNS WITH COPIOUS AMOUNTS OF WATER CONTROL THE ENVIRONMENT BY HEATING THE ROOM OR ADEQUATELY COVERING PT WITH CLEAN LINEN TO PREVENT HYPOTHERMIA

  13. SECONDARY SURVEY THOROUGH HISTORY HEAD TO TOE EXAM DOCUMENTATION BASELINE INVESTIGATIONS WOUND CARE TREATMENT

  14. HISTORY • DETAILED ACCOUNT OF INCIDENT • MECHANISM OF BURN SHOULD CORELATE WITH CLINICAL PRESENTATION • AMPLE • TIME OF INCIDENT • IMP. FLUID RESUSCITATION PERIOD BEGINS AT TIME 0 OF BURNS

  15. HEAD TO TOE EXAM • DETERMINE BURN WOUND DEPTH • 1ᵒ • 2ᵒ SUPERFICIAL • 2ᵒ DEEP • 3ᵒ • 4ᵒ

  16. HEAD TO TOE EXAM • DETERMINE %TBSA • RULES OF 9’S IN ADULTS • RULES OF 7’S IN OLDER CHILDREN • LUND AND BROWDER CHARTS • PT’S PALM AND FINGERS = 1%

  17. ESTIMATING THE TBSA OF A BURN

  18. DOCUMENTATION DETAILS AND TIME OF INJURY AMOUNT OF FLUIDS INFUSED INTERVENTIONS DONE TREATMENTS GIVEN RESULTS OF BASELINE INVESTIGATIONS AND VITAL SIGNS DOCUMENTATION

  19. BASELINE INVESTIGATIONS ABGS HGRAM U/E/CREAT SERUM GLUCOSE CHEST XRAY/CERVICAL XRAY IF NECESSARY

  20. WOUND CARE COVER WITH CLEAN LINEN KEEP WARM DEFINITIVE WOUND CARE TO BE DECIDED IN THE RECEIVING WARD NON ADHESIVE DRESSING ,GAUZE AND CREPE BANDAGE FOR 2ᵒBURNS SILVER SULPHADIAZINE CREAM,GAUZE AND CREPE BANDAGE FOR 3ᵒ AND DEEPER BURNS EARLY EXCISION AND GRAFTING ≤ 7 DAYS POST BURN HAS REDUCED MORTALITY

  21. TREATMENT AND OTHER INTERVENTIONS • TUBES-NGT, URINARY CATHETER,INTRAVENOUS CATHETER, ETT, • EARLY ENTERAL NUTRITION IS VERY IMPORTANT • PHYSIOTHERAPY AND SPLINTING FROM DAY 1 • DRUGS • T. T INJ • ANALGESICS- NO IM ROUTE; IV OR ORAL IF TOLERATED • NO PROPHYLACTIC ANTIBIOTICS

  22. CHEMICAL BURNS SEVERITY DEPENDS ON : TYPE OF CHEMICAL,CONCENTRATION,QUANTITY AND CONTACT TIME WATER LAVAGE FOR BURN WOUNDS IS THE MOST IMP IMMEDIATE INTERVENTION IRRIGATION LONGER IN ALKALI BURNS AND BURNS TO THE EYES EVEN UPTO 8 HRS

  23. ELECRICAL BURNS • DEPTH DEPENDS ON VOLTAGE AND RESISTANCE OF TISSUE.BONE› FAT ›TENDON › SKIN › MUSCLE › BLOOD ›NERVE • DIVIDED INTO HIGH VOLTAGE ˃ 1000V AND LOW VOLTAGE ˂1000V • INJURY MAY BE HIDDEN. RELATIVELY NORMAL SKIN MAY HIDE MUSCLE NECROSIS • IV FLUID RESUSCITATION VOLUMES SHOULD BE INCREASED TO MAINTAIN URINE OUTPUT OF AT LEAST 100MLS /HR IN ADULT • WATCH OUT FOR MUOGLOBINURIA AND MAY NEED INTERVENTION WITH MANNITOL • MAY AFFECT OTHER SYSTEMS • NERVOUS SYSTEM • CARDIAC- DO CARDIAC MONOTORING • MUSCULOSKELETAL- FRACTURES AND DISLOCATIONS • IF HIGH VOLTAGE INJURY IN EXTEREMITIES PT WILL NEED FASCIOTOMYURGENTLY

  24. ELECTRICAL INJURIES EXAMPLE OF HIGH VOLTAGE BURN IN AN UPPER EXTREMITY THAT WILL NEED FASCIOTOMY

  25. EXAMPLE OF LOWER LIMB FASCIOTOMY FOR ELECTRICAL BURN

  26. RESUSCITATION CONTROL OF INFECTION SUPPORT OF THE HYPERMETABOLIC RESPONSE TO TRAUMA EARLY CLOSURE OF THE BURN WOUND MANAGEMENT OF INHALATION INJURY DECREASED MORTALITY FROM MAJOR THERMAL INJURY HAS BEEN DUE TO ADVANCES IN:

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