Burns and Anaesthesiologist Resususcitative phase:0-36 hrs Post rescue phase-2nd to 6th day Rehabilitative phase-7th day onwards

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Burns and Anaesthesiologist Resususcitative
phase0-36 hrsPost rescue phase-2nd to 6th
dayRehabilitative phase-7th day onwards

• ModeratorProf.Anjan Trikha
• PresentorsDr.Balachandran.S
• Dr.Chittaranjan Joshi

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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Classification of Burns

• Based on cause
• Flames
• Explosion
• Contact
• Scald
• Chemical
• Electrical

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

• Full thickness burn gt10TBSA
• Partial thickness burn gt25TBSA in adults or gt20
  in extreme of age
• Burn involving face, hand, feet, perineum
• Inhalation, electrical, chemical burn
• Burns in patients with serious preexisting
• medical disorder

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American Burn Association's Grading System for
Burn Severity and Disposition of Patients
Minor Moderate major
Criteria lt10 percent TBSA burn in adultlt5 percent TBSA burn in young or oldlt2 percent full-thickness burn 10 to 20 percent TBSA burn in adult5 to 10 percent TBSA burn in young or old2 to 5 percent full-thickness burnHigh-voltage injurySuspected inhalation injuryCircumferential burnConcomitant medical problem predisposing the patient to infection (e.g., diabetes, sickle cell disease) gt20 percent TBSA burn in adultgt10 percent TBSA burn in young or oldgt5 percent full-thickness burnHigh-voltage burn Known inhalation injuryAny significant burn to face, eyes, ears, genitalia or jointsSignificant associated injuries
Disposition OPDmanagement Hospital admission Burn referal unit
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Pathophysiology

• Skin
• zones of local response
• zone of coagulation
• zone of stasis
• zone of hyperaemia

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Pathophysiology

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

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Pathophysiology

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

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Pathophysiology

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

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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

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Pathophysiology

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

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Pathophysiology

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

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Pathophysiology

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

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Pathophysiology

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

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Prehospital

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

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Initial assessment

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

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Initial assessment

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

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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

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Estimating the size of the Burn as a of the
Total Body Surface (TBS)
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Monitoring

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

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Monitoring

• ABG
• Electrolytes
• Temperature
• PT , aPTT especially gt50TBSA

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Initial Management Airway Pulmonary Problems
Management of Carbon Monoxide Exposure
Awake Obtunded
High flow by mask oxygen (Fi02 100) until COHgblt5) Intubate and provide 100 oxygen via a ventilator
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Management of the Upper AirwayStridor Retraction
or Respiratory Distress present or deep burns
face or neck
If Present If Absent
Intubate now! Use adequate size tube Humidified oxygen Elevate Head Transport to Burn Center Provide 100 Oxygen Look for Signs of Airway Injury       - Oropharyngeal erythema       - Hoarseness       - Pulmonary status Can perform laryngoscopy If edema present, intubate now
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Management of Lower Airway Injury
Asymptomatic Symptomatic Symptomatic
Cough, Wheezing, Bronchorrhea, Good gas exchange Shortness of breath, Impaired gas exchange, progressive symptom
Continued reassessment and Oximetry Provide 100 oxygen by mask, Aggressive pulmonary toilet, Bronchodilators, Monitor oximetry and blood gases Intubate and 100O2, Assess lower airway function clinically,Baseline CXR , Bronchodilators, Consider chest wall escharotomy
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• Fluid resuscitation
• Crystalloids or colloids
• Formula based or clinical assessment
• Role of albumin

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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

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Formula for fluid resuscitation

• Colloid regimen
• Evans - NS 1ml/kg/TBSA
• 5D 2000ml/24hrs
• Colloid 1ml/kg/TBSA
• Brooke - RL 1.5 ml/kg/TBSA
• 5D 2000ml/24hrs
• Colloid 0.5ml/kg/TBSA

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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

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Circumferential burn
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wound care

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

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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

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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

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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

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Tetanus prophylaxis
Immunisation status Action
gt10 yr since last booster or doubtful about immunisation status or never had immunisation Burn lt24 hrs TIG 250 IU IM gt24hrs TIG 500 IU IM ADT/DPT/DT in other arm
gt5and lt10 yr of last booster dose and have completed all 3 doses ADT/DPT/DT
lt5 yr of last booster dose and completed all 3 doses No action required
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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

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Role of anaesthesiologist

• Fluid management
• Airway management
• Decision making and intubation
• mechanical ventilatory support
• Monitoring
• Anaesthesia for associated severe trauma
• Pain management

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