Burn injury. A : patent airway with smoking inhalation, stridor. D: E4V5M6,pupil 2mm RTLBE

Transcription

1 Burn injury Pinyong Uthaitas Emergency Department Faculty of Medicine, Ramathibodi Hospital A Thai man 52 year old came to the hospital due to flam burn ½ hr ago at his house. He gain conscious but hoarseness speaking and has 2 nd degree burn at face, back, both palm and foot. Physical examination at ED : primary surway A : patent airway with smoking inhalation, stridor B: tachypnea, C: BP stable D: E4V5M6,pupil 2mm RTLBE Seconedary surway vital sign : T 37.2 c BP 110 /70 mmhg RR 26 /min PR 120 bpm Ext : 2 nd degree burn at face, back, both palm and foot above 15 % of BSA Management at ER in this case Flame Burn with Inhalation injury Intubation to protect airway, monitor v/s, fluid resuscitation,w/u lab, retain foley cath, Debride and Dressing wound with silver sulfadiazine and admit due to major burns

2 DISCUSSION In the patient who came to the hotpital due to burn injury, we should evaluate primary surway ABCD at first : - Airway assessment and protection, while maintaining cervical spine stabilization - Breathing and ventilation assessment (maintain adequate oxygenation) - Circulation assessment (control hemorrhage and maintain adequate end-organ perfusion) - Disability assessment (perform basic neurologic evaluation) - Exposure, with environmental control (undress patient and search everywhere for possible injury, while preventing hypotherm Airway Patients with upper airway burns should be intubated early, before airway anatomy becomes distorted by edema. Soot in the mouth, facial burns, and body burns may be more useful predictors of inhalation injury than symptoms of stridor, hoarseness, drooling, and dysphagia During the initial resuscitation, burn care should be limited to preventing further injury by removing clothing that is hot, burned, or exposed to chemicals. Jewelry that may become constricting should also be removed. After that, should evaluate 2 nd surway (complete physical examination and evaluate surface and degree of burn use Modified Lund and Browder or Rule of nine )

3 Physical examination A complete physical examination, including vital signs with pulse oximetry, should be performed. An accurate weight is essential for determining fluid requirements and should be obtained whenever possible. Capnography may be helpful for assessing ventilation and detecting metabolic acidosis Modified Lund-Browder chart Numbers refer to the percent body surface area burned

4 Modified Lund and Browder chart Area Birth to 1 year 1 to 4 years 5 to 9 years 10 to 14 years 15 years Head Neck Anterior trunk Posterior trunk R buttock L buttock Genitalia R upper arm L upper arm R lower arm L lower arm R hand L hand R thigh L thigh R leg L leg R foot L foot Numbers refer to % total body surface area involved. Adapted from Lund, CC, Browder, NC, Surg Gynecol Obstet 1944; 79:352.

5 Burn classification Burn Severity In order to determine the need for referral to a specialised burn unit, the American Burn Association devised a classification system to aid in the decision-making process. Under this system, burns can be classified as major, moderate and minor. This is assessed based on a number of factors, including total body surface area (TBSA) burnt, the involvement of specific anatomical zones, age of the person and associated injuries. Major burns are defined as: Age 10-50yrs: partial thickness burns >25% of total body surface area Age <10 or >50: partial thickness burns >20% of total body surface area Full thickness burns >10% Burns involving the hands, face, feet or perineum

6 Burns that cross major joints Circumferential burns to any extremity Any burn associated with inhalational injury Electrical burns Burns associated with fractures or other trauma Burns in infants and the elderly Burns in persons at high-risk of developing complications These burns typically require referral to a specialised burn treatment center. Moderate burns are defined as: Age 10-50yrs: partial thickness burns involving 15-25% of total body surface area Age <10 or >50: partial thickness burns involving 10-20% of total body surface area Full thickness burns involving 2-10% of total body surface area Persons suffering these burns often need to be hospitalised for burn care. Minor burns are: Age 10-50yrs: partial thickness burns <15% of total body surface area Age <10 or >50: partial thickness burns involving <10% of total body surface area Full thickness burns <2% of total body surface area, without associated injuries These burns usually do not require hospitalization. Diagnostic studies Portable x-rays Plain radiographs play an important role in the primary evaluation of the unstable trauma patient. For hemodynamically compromised patients proceeding directly to the operating room after the primary survey, plain x-rays of the lateral cervical spine, chest,

7 and pelvis, obtained in the ED or immediately upon arrival to the OR, can detect life threatening injuries that might otherwise be missed. Treatments Supplemental oxygen and airway protection are the cornerstones of treatment for inhalation injury. Patients with severe burns often require tracheal intubation. Fluid resuscitation Burn shock during the initial 24 to 48 hours following major burns is characterized by myocardial depression and increased capillary permeability resulting in large fluid shifts and depletion of intravascular volume. Rapid, aggressive fluid resuscitation to reconstitute intravascular volume and thereby maintain end-organ perfusion is crucial. Delays in fluid resuscitation and inadequate resuscitation are associated with increased mortality. Arterial lines are often used to monitor blood pressure; urine output is used to determine the adequacy of fluid resuscitation. Fluid resuscitation of the patient with moderate or severe burns consists of an IV crystalloid solution. The ideal solution has not been determined, but lactated Ringer's solution (LR) is typically given Estimating initial fluid requirements factors as patient age, severity of burn, associated injury, and comorbidities can substantially alter the actual fluid requirements of individual patients. As an example, patients with inhalation injury require greater resuscitation volumes than those without. The Parkland (also known as Baxter) formula is the most widely used guide to initial resuscitation fluid needs in the burn patient, e fluid requirement during the initial 24 hours of treatment is 4 ml/kg of body weight for each percent of TBSA burned, given IV. Superficial burns are excluded from this calculation. One-half of the calculated fluid need is given in the first eight hours, and the remaining half is given over the subsequent 16 hours. The rate of

8 infusion for intravenous resuscitation fluid should be as constant as possible; sharp decreases in infusion rates can lead to vascular collapse and an increase in edema Monitoring fluid status Confirming the adequacy of resuscitation is more important than strict adherence to Parkland or any fluid resuscitation formula. Monitoring urine output using an indwelling bladder catheter (eg, Foley catheter) is a readily available means of assessing fluid resuscitation. Hourly urine output should be maintained at 0.5 ml/kg in adults. Urine output should be maintained at 1 to 2 ml/kg per hour for children Immediate burn care and cooling Burned areas should be cooled immediately using cool water or saline soaked gauze. cooling can minimize the zone of injury Pain and anxiety management Partial-thickness burns in particular can be excruciatingly painful. Intravenous (IV) morphine has been the mainstay of pain management for patients with significant burns. These patients may require extremely large doses of IV morphine or other opioids. It is reasonable to give patients with significant burns benzodiazepines given the anxiety associated with these injuries. Tetanus Tetanus immunization should be updated if necessary for any burns deeper than superficialthickness. Tetanus immune globulin should be given to patients who have not received a complete primary immunization

9 Antibiotics Topical antibiotics are applied to all nonsuperficial burns. If the patient is immediately transferred to a burn center, burns are covered with clean, dry dressings and antibiotics are applied at the burn center. Treatment can be started in the ED if, for example, delays in transferring the patient to a burn center are anticipated. The best treatment of blistered burns is unclear. We apply topical antibiotics to partial thickness burns with intact blisters. Topical chemoprophylaxis is typically continued until wound epithelialization is complete. There is no role for prophylactic IV antibiotics. Wound dressing For patients who are being rapidly transferred to a burn unit, burns should be covered with dry sterile dressings. Ointments or creams should not be applied because they can hinder initial wound assessment at the burn center. Partial and full-thickness burns should be dressed for all other patients. Factors to consider when choosing a dressing include the following: A moist wound environment should be maintained for optimal healing. The dressing should provide a barrier that reduces the risk of infection. For optimum pain relief, the dressing should maintain maximum contact with the wound without adhering to it.

10 Concusion Algorithm Burn Management

11 REFERENCES 1. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil 1996; 17: Mertens DM, Jenkins ME, Warden GD. Outpatient burn management. Nurs Clin North Am 1997; 32: Wasiak J, Spinks A, Ashby K, et al. The epidemiology of burn injuries in an Australian setting, Burns 2009; 35: Gomez R, Murray CK, Hospenthal DR, et al. Causes of mortality by autopsy findings of combat casualties and civilian patients admitted to a burn unit. J Am Coll Surg 2009; 208: Evers LH, Bhavsar D, Mailänder P. The biology of burn injury. Exp Dermatol 2010; 19: Ramzy PI, Barret JP, Herndon DN. Thermal injury. Crit Care Clin 1999; 15:333.