Supervised by: Dr' E' Kayyali

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Burn assessment and resuscitation

• Supervised by Dr. E. Kayyali
• Presented by
• Nahar Al-Selaim
• 423100455
• Ahmad Al-Hussain
• 423100773

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Outline

• Introduction
• Classification by etiology
• Pathophysiology
• Initial triage and management
• Referral criteria
• Resuscitation and management

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Introduction

• The history of modern burn resuscitation can be
  traced back to observation made after large urban
  fires at the rialto theatre in 1921
• At the time physicians noted that some patient
  with large burns survived the event but died from
  shock in the observation periods. underhill and
  moore identified the concept of thermal injury
  induced intravascular fluid deficits in the 1930s
  and 1940s and even soon followed with the
  earliest fluid resuscitation formulas in 1952
• Over the next 50 years, advanced in resuscitation
  further expaned and led to numerous strategies to
  treat burn shock.
• Epidemiology
• 2-3million thermal injury every year.
• 100 000 require hospital admission.
• 5-6 thousend people die as direct result of
  thermal injury every year.
• Patients require 1-1.5 hospital days/percent of
  TBSA burned.
• Demographic analysis shows four high risk groups
  for severe burn injuries
• The very young
• The very old
• The very unlucky
• The very careless

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Classification by etiology

• Thermal burns
• Scald burns
• 60degree centigrade-------gtfull thickness burn
• Boling water-------gtdeep burns
• Oil-------gtdeep dermal burns
• If burns is in contact with clothes-------gtdeeper
  burn due to the retention of clothes to heat
• Flame burns
• 2nd most common type
• If clothes have been involved-----gtusually full
  thickness burns
• Flash burns
• Caused by
• Explosion of natural gas,propane,gasoline and
  other flammable liquids.
• Electrical flash where electrical current does
  not pass through the body.
• Clothes protective of skin in this injury
• May heal without extensive need for skin grafting
• Contact burns
• Hot metals,plastics.coals.
• Occur mostly in industrial injuries.
• May be associated with crush injury.

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• Electrical burns
• Injury that can cause severe muscle ,cardiac and
  skin damage.
• Chemical burns
• Are burns caused by alkalis,acids or special
  chemicals.

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PathophysiologyThe underlying process involved
is both a local and systemic inflammatory
reaction.

• Systemic effects of burns
• Burn shock
• Hypermeability of capillaries
• Due to vasodilatation and release of inflammatory
  mediators.
• Heat induced (60c)denaturing of collagen fibers
• In the interstitium which cause extravasation of
  fluid.
• Immune response to burn
• Infiltration of tissue with WBC(neutrophils and
  granulocytes).
• Deficiency of neutrophils may cause death in
  burn due to fatal infections.

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Local effect of burns

• The burned wound comprised of three zones
• Zone of coagulation
• The central area.
• Composed of nonviable tissue.
• Zone of stasis
• Surrounding the central area.
• Initially blood flow is present here.
• But over the subsequent 24hr hypoperfusion and
  ischemia prevail and part of this area combines
  with the zone of coagulation.
• Zone of hyperemia
• Surrounding the zone of stasis.
• Contains viable tissue.

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Determinants of mortality

• Extent of burn.
• Age of the the patient.
• Depth of the burn wound.
• Wound depth is also a major determinant of a
  patients long term appearance and function after
  a burn.

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Initial triage and management

• Upon arrival of the patient to the ER, approach
  him/her with the ABC.
• HX
• General history
• History of the circumstances of the injury
• History suggestive of inhalation injury
• Burned in closed space and who inhaled smoke,loss
  of consciousness and a history of industrial
  injuries.
• Has strider,change in voice,erythema,carbonaceous
  material in the back of the throat or
  sputum,signed nasal hair and facial burn.

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Examination

• Systemic
• A B
• examine the patient for airway patency.
• Look for signs of inhalation injury and
  respiratory embarrassment,
• Patient completely undressed and all body
  surfaces examined.
• C
• Assess circulation by monitoring BP, pulse and
  signs of peripheral vascular insufficiency in the
  limbs.
• In cases of circumferential deep partial
  thickness or full thickness burns----gtsuspect
  compartment syndrome.

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 Local

• Estimation of TBSA
• Only partial and full thickness burn(not
  superficial or 1st degree burns) should be
  included in quantitating the extent of burns.
• The rule of nines
• Is a rough estimate of the extent of burn injury.
• The lund and browder charts
• Easy to use.
• Corrected for age.
• More accurate than the rule of nines.
• Provides a permanent medical record of the
  initial injury.

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The lund and browder charts
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Burn depth

• Most accurate way to determine burn depth is
  clinical assessment.
• The changing perfusion in the zone of stasis and
  the fact that burn depth is not uniform
  everywhere make it difficult for the physician to
  accurately determine the depth of burn for the
  first 24 to 48 hr after injury.
• Immersion scalds in very young children are
  particularly difficult to assess for depth.
• A number of techniques such as burn biopsy, vital
  dyes,fluorescein and laser Doppler flowmeter have
  been tried in attempt to aid clinical observation
  but none has been completely successful.

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• First degree(superficial)
• Superficial burn
• Erythema
• Sensate painful burn
• Usually due to sun burn
• Second degree
• Superficial partial thickness
• Blistered
• Appers pink
• Blanches with pressure
• Sensate painful burn
• Hair does not pull out
• Has intact dermal appendages
• Reepithelialization over 10 -14 days
• Deep partial thickness
• Reddish to mottled
• Can have blistered areas
• Sensate
• Hair does not pull out

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• Third degree(full thickness burns)
• No blisters
• Leathery with thrombosed veins
• Insensate
• Hair pulls out
• Fourth degree(charcoaling)
• involve deep layers of the skin, muscles, tendons
  and bones.
• Carbonating burn of all structures.
• Due to prolong contact with flame burn Or due to
  electrical burns.

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Investigations

• CBC
• U E
• Hypernatremia
• Result from inaduequate replacement of water
  losses.
• Estimated water loss 1ml/kg/TBSA/24hr
• Hyponatremia
• Topical SILVER NITRATE
• Use of BROOKE FORMULA IN CHILDERN
• Over estimation of evaporative water losses e.g.
  use of BIOLOGIC DRESSINGS which will diminish
  water losses.
• Hyperkalemia
• Due to TISSUE and RBC destruction
• POTASSIUM should not be routinely administered
  during the 1st 24 hr. 
• Hypokalemia
• Urinary potassium losses.
• Topical SULFAMYLON or topical SILVER NITRATE.
• Urine analysis for myoglobinurea
• ABG(for hypoxemia)
• Carboxyhemoglobin levels(gt15)
• X-ray of C-spine,CXR,Abs X-ray to rule out blunt
  trauma,closed head injury,pnemuothorax and other
  thorasic trauma,spinal injuries,intraabdominal
  injuries and pelvic and long bone fracture.

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REFERAL CRITERIA

• The American burn association has identified
  burns that should be treated in a specialized
  center.
• This category includes the following injuries
• 2nd and 3rd degree burns gt 10 TBSA in pts under
  10 or over 50 years of age.
• 2nd and 3rd degree burns gt 20 TBSA in other age
  groups
• 3rd degree burns gt5 TBSA in any age group
• 2nd and 3rd degree burns involving
  face,hands,feet,genitalia,perineum or major
  joints
• Electric burns, including lighting injury
• Chemical burns with serious threat of functional
  or cosmotic impairment
• Inhalation injuries
• Lesser burns in patients with preexisting medical
  problems that could complicate management
• Combined mechanical and thermal injury in which
  the burn wound poses the grater risk.

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RESUSCITATION AND MANAGEMENT

• The 1st priority must be
• Maintenance of a patent airway
• Effective ventilation
• Support of the systemic circulation

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AIRWAY BREATHING/
CIRCULATION

• AIRWAY BREATHING
• Indications for intubation
• Unconscious ptn
• Ptns in respiratory distress
• Ptns who have suffered severe burns
• Ptns who are hemodynamically unstable despite
  fluid resuscitation
• Where there is any Q of an inhalation injury
• Upper airway burn
• CIRCULATION
• Two large bore IV canulas
• Avoid inserting IV lines in burn areas esp. limbs
  due to tourniquet effect of eschar
• Patients with burns alone are often hypertensive
• signs of systemic hypovolmia in a burn patient
  should raise suspicion of another occult injury

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FLUID MANAGEMENT

• The goal of IVF
• Restore and maintain adequate tissue perfusion
  and oxygenation
• Avoid organ ischemia
• Preserve heat-injured but viable soft tissue
• Minimize exogenous contribution to edema

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MONITORING

• 1 HR
• Pulse rate is a better indicator than BP
• lt120 per minute ? adequate volume status in young
  ptns
• Elderly ? less cardiac reserve ?can not increase
  their pulse in response to volume defict? pulse
  rate is less reliable indicator of resuscitation.
• 2 BP
• Blood pressure is relatively insensitive monitor
  of resuscitation ( the release of catecholamines
  maintain blood pressure in the severly burned
  ptns)

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MONITORING

• 3 urine output
• With crystalloid resuscitation regimens such as
  the parkland formula , urine output remains an
  excellent guidelines for the adequacy of
  resuscitation.
• Target
• 0.5 to 1 cc/kg/hr in the adult
• 1 cc/kg/hr in the child.
• Invasive monitoring ( CVP Pulmonary artery CATH
  )
• Target
• Cardiac index gt 4.5L/min/m2
• DO2gt 600 ml/min/m2
• VO2 170ml/min/m2
• Pulm artery occlusion pressure 12-15 mm hg
• Few ptns will benefit from invasive hemodynamic
  monitoring , they include
• Elderly ptns with preexisting cardiac or
  repiratory Dis.
• Massively burned ptns with significant inhalation
  injury
• Use should be reserved for the complicated or
  difficult resuscitations

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MONITORING

• ABG
• Persistent metabolic acidosis ? inadequate
  perfusion ? an indication for increasing fluid
  administration.
• Except in CO poisioning when the ptn may be
  acidotic secondary to CO inhalation
• HEMATOCRIT
• Serial hematocrit determinations ? determine the
  adequacy of resuscitation
• Initial hemo concentration is followed by a later
  decease in hematocrit that mainly reflects
  reexpansion of the intravascular compartment with
  fluid resuscitation

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RESUSCITATION FORMULA/TYPES OF FLUIDS

• RESUSCITATION FORMULA
• The most commonly used here is the PARKLAND
  formula
• 4 ml/kg/1 in 1st 24 hrs
• ½ in 1st 8 hrs
• ½ in 16 hrs
• TYPES OF FLUIDS
• There are many resuscitation fluids
• The most popular resuscitation fluid is RLs in Na
  conc. 130 meq/L
• It is a crystalloid type of resuscitation
• Less expensive compared to colloids
• Quantity of crystalloid is dependent upon the
  parameters used to monitor resuscitation
• Normal urinary output is optional
• Approximately 2ml/kg/40 burn will be needed for
  adequate perfusion in 24 hrs

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CARE OF THE BURNED WOUND

• Assess
• Size of burn
• Depth
• Pulses distal to circulation

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ESCHAROTOMY and FASCIOTOMY

• Chest escharotomy
• In case of early respiratory distress may be due
  to compromises of the ventilator function .In
  deep circumferential burn wound of the chest
• Performed in an anterior auxiliary bilateral.
  With contact by transverse incision along the
  costal margin
• Escharotomy of extremities
• Remove rings ,watches,jewelry.
• Skin color, sensation, capillary refill and
  prepheral pulses should be assessed.
• Doppler U/S can be of use pre and post
  escharotomy
• Direct monitoring of IM compartment pressure
• Bedside in sedation no need for L.A

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• PAIN CONTROL
• During shock phase of burn care ,medication
  should be IV.
• SC and IM will be absorbed variably depending on
  perfusion and should be avoided
• Best managed with IV morphine 2-5 mg. Usually
• PSYCHOLOGICAL CARE
• Realistic assessment regarding the prognosis of
  the burn. Should be related to the family.
• GASTRIC DECOMPRESSION
• To prevent gastric ulceration
• To prevent aspiration

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• TETANUS
• Tetanus burn wounds
• Previos immunization within 5 years requires no
  treatment
• Immunization within 10 years tetanus toxic
  booster to be given
• Unknown immunization status requires booster
• PE PREVENTION
• Preventive efforts should be directed at patients
  with classical risk factors for PE
• History of prior thromboembolic Dis.
• Obesity
• Burns of the lower exteremities
• NUTRITION
• Hypermatabolic state
• Lasts until the wound is closed
• The gut of the the burn patients should be used
  for nutrition if it is available
• Adequate nutrition is imp. To maximaize patient
  survival and minimize complications.

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• Thank you