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Moderator:Prof.Anjan Trikha Presentors:Dr.Balachandran.S

Burns and Anaesthesiologist Resususcitative phase:0-36 hrs Post rescue phase-2 nd to 6 th day Rehabilitative phase-7 th day onwards. Moderator:Prof.Anjan Trikha Presentors:Dr.Balachandran.S Dr.Chittaranjan Joshi. www.anaesthesia.co.in anaesthesia.co.in@gmail.com.

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Moderator:Prof.Anjan Trikha Presentors:Dr.Balachandran.S

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  1. Burns and Anaesthesiologist Resususcitative phase:0-36 hrsPost rescue phase-2nd to 6th dayRehabilitative phase-7th day onwards Moderator:Prof.Anjan Trikha Presentors:Dr.Balachandran.S Dr.Chittaranjan Joshi www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Classification of Burns • Based on cause Flames Explosion Contact Scald Chemical Electrical

  3. Classification of Burns

  4. Superficial burns on the trunk and right arm of a young child. Typically, these are red burns that blanch with pressure.

  5. Superficial partial-thickness burn on a man's right knee. Blistering wounds that blanch with pressure are characteristic of superficial partial-thickness burns. These wounds are are typically moist and weeping

  6. Deep partial-thickness burns on the trunk and extremities of a young child. These burns are typified by easily unroofed blisters that have waxy appearance and do not blanch on touch

  7. Full-thickness burn on a woman's left flank. Burn areas of this type are characteristically insensate and waxy white or leathery grey in colour

  8. Definition of Major Burns • Full thickness burn >10%TBSA • Partial thickness burn >25%TBSA in adults or >20% in extreme of age • Burn involving face, hand, feet, perineum • Inhalation, electrical, chemical burn • Burns in patients with serious preexisting medical disorder

  9. American Burn Association's Grading System for Burn Severity and Disposition of Patients

  10. Pathophysiology • Skin • zones of local response • zone of coagulation • zone of stasis • zone of hyperaemia

  11. Pathophysiology • Local and systemic mediators • Minor burn inflammatory response restricted locally • Major burn systemic inflammatory response

  12. Pathophysiology • Cardiovascular system • First 24-48 hours Burn shock (hypovolumic shock) Depressed myocardial contractility Increased blood viscosity • Impaired distal perfusion in circumferential extremity burn

  13. Pathophysiology • Cardiovascular system • After 48 hours • Increased cardiac output • Decreased peripheral resistance

  14. Pathophysiology • Respiratory system In first 24 – 72 hr( acute pulmonary insufficiency ) • Asphyxia • CO poisoning • Bronchospasm due to irritants • Upper airway obstruction due to edema No parenchymal injury

  15. Pathophysiology • Respiratory system • Next 3 – 5 days • Diffuse parenchymal injury with infiltrates mimicking ARDS • Later stage(complications) • Bronchopneumonia • Pulmonary emboli • Pulmonary atelectasis

  16. Pathophysiology • Renal system • Decreased renal blood flow • Decreased glomerular filtration • ATN secondary to myoglobinuria and haemoglobinuria • ARF secondary to hypovolumia

  17. Pathophysiology • Metabolism and nutrition Hypermetabolism: • Inflammatory mediators • Heat loss • Bacterial translocation • Excessive catabolic/stress hormones

  18. Pathophysiology • Varying degree of hepatic dysfunction • Hematological system • Anaemia • Platelet dysfunction • Consumption coagulopathy • Immune suppression

  19. Prehospital • Remove from source • 100% O2 in any suspected inhalational injury • Remove any burning, clothes, ring, belt etc • Cooling with water at room temperature

  20. Initial assessment • Type of burn Flame , Scald , Electric , Explosion , Chemical • CVS • BP , PR • Any circumferential extremity burn • Vascular access

  21. Initial assessment Pulmonary • Facial burn • Inhalational injury • Deep chest wall injury • Closed space smoke injury • Carbonaceous sputum • Wheeze, progressive hoarseness, tachypnea

  22. Initial assessment • Skin • % of burn surface area • degree of burns • areas affected in burn • Look for associated trauma • H/O or signs of any comorbid illness • Assess burn injury severity

  23. Estimating the size of the Burn as a % of the Total Body Surface (TBS)

  24. Monitoring • Pulse rate • ECG • Blood pressure if required IBP • Urine output - 0.5 - 1.0 ml/kg/hr • Peripheral perfusion – pulse pressure

  25. Monitoring • ABG • Electrolytes • Temperature • PT , aPTT – especially >50%TBSA

  26. Initial Management: Airway & Pulmonary ProblemsManagement of Carbon Monoxide Exposure

  27. Management of the Upper AirwayStridor Retraction or Respiratory Distress present or deep burns :face or neck

  28. Management of Lower Airway Injury

  29. Fluid resuscitation Crystalloids or colloids Formula based or clinical assessment Role of albumin

  30. Formula for fluid resuscitation For all formula based regimen give half the volume in first 8 hrs and remaining in next 16 hrs Crystalloid regimen: Parkland formula - 4ml/kg/%TBSA/day Modified Brooke formula -2ml/kg/%TBSA/day

  31. Formula for fluid resuscitation Colloid regimen Evans - NS 1ml/kg/%TBSA + 5%D 2000ml/24hrs + Colloid 1ml/kg/%TBSA Brooke - RL 1.5 ml/kg/%TBSA + 5%D 2000ml/24hrs Colloid 0.5ml/kg/%TBSA

  32. Steps for the Prevention and Treatment of Impaired Distal Perfusion • Remove constricting objects, such as jewellery • Immediate elevation of burned extremities Escharotomies in circumferential third or fourth degree burns, if perfusion is impaired (preferably done in Burn Center) • Monitor using pulse palpation and Doppler

  33. Circumferential burn

  34. wound care • Superficial burns • Painful, Erythematous, Blanch to touch • eg: Sunburn, Minor scald injury • Heals spontaneously within 1 week without scar • Skin moisturizers

  35. wound care Superficial dermal burn • Most painful, Erythematous, Blanch to touch, Often blisters • eg: Overheated scald injurY, Flash flame injury • Heals within 1-2 week usually without scar • Cleansing and debridement of wound with dilute chlorhexidine • Bacitracin ointment to keep wound moisture • Petroleum impregnated gauze covered with dry dressing • Temporary skin substitutes

  36. wound care • Deep dermal burn • Painless with preserved sensation to touch, Pale and mottled, Covered with eschar, Do not blanch to touch • eg Direct contact with flame • Heals within 4- 10 weeks with scar • Remove eschar, Topical silver containing ointment covered with dry gauze • Early excision and grafting

  37. wound care • Deep burn • Painless with loss of touch sensation, • Covered with hard leathery black or white eschar • eg direct exposure to flame, Hot liquid like grease, tar, caustic material • Requires early excision with skin grafting or permanent skin substitutes

  38. Tetanus prophylaxis

  39. Nutrition • Nutrition requirements may be as high as 200% due to hypermetabolism • Curreri formula to calculate caloric requirement: 256kcal/kg/day + 40kcal/%TBSA/day • Protein content should be 1 – 2 g/kg/day

  40. Role of anaesthesiologist • Fluid management • Airway management Decision making and intubation mechanical ventilatory support • Monitoring • Anaesthesia for associated severe trauma • Pain management www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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