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Copy2-BURNS slides.pptx
- 1. BURNS CENTRAL UNIVERSITY PASTUDENT’S TUTORIAL
- 2. OUTLINE CASE SCENARIO DEFINITION EPIDEMIOLOGY AETIOLOGY / RISK FACTORS ANATOMY PATHOPHYSIOLOGY/PATHOLOGY SIGNS AND SYMPTOMS CLASSIFICATION OF BURNS FACTORS THAT AFFECT THE DEGREE OF BURNS ESTIMATION OF EXTENT OF BURNS MANAGEMENT CRITERIA FOR REFERRAL COMPLICATION CAUSES OF DEATH IN BURNS
- 3. An 18 yearold female sustained burns from a gas explosion in the kitchen whilst cooking. The burns involved the entire chest up to the umbilicus and the anterior part of both upper limbs. There was presence of blisters and blanching of the areas of burns. The incidence happened around 4pm but she was able to report to the hospital at about 6pm. 1.What is inhalational injury? 2. What are the risk factors for inhalational injury? 3. What are your differential diagnoses? 4. Give one(1) reason each to support your differential diagnoses? 5. How will you manage the lady
- 4. DEFINITION Burns is definedas coagulative necrosis of the layers of the skin and other tissues. Or it can also be defined as damage to the tissue as a result of injury by various aetiological agents such as thermal (dry and moist heat), electrical, chemical ( acidic, alkaline, and organic chemical) and radiation. These agents causes coagulative necrosis of the tissues with the exception of alkaline chemicals which causes liquefactive necrosis with the ability for deeper injury.
- 5. EPIDEMIOLOGY Scalds whichrefers to injury resulting from moist heat has in the last few decades overtaken flame burns as the common type of burn injury in the west African sub region. These injuries occur commonly as domestic accidents with children and women constituting a majority of the casualties. Burns are the fifth most common cause of non-fetal childhood injuries. Commonest site of scald injury occur in the kitchen accounting to about 50% with the 2nd most common been the bathroom e.g water heaters.
- 6. Continuation. Outcomes forburn patients have improved dramatically over the past 20 years, yet burns still causes substantial morbidity and mortality. In the United States, approximately 1.25 million people with burns present to the emergency department each year. Among these 63,000 have minor injuries and an additional 6,000 sustain major burn injuries that require hospital admission.
- 7. AETIOLOGY / RISKFACTORS The causative agents of burns can be classified into the following: THERMAL BURNS o Dry heat (flame, gas explosion & flash burns) o Wet heat (hot water, hot soups & hot liquids) ELECTRICAL BURNS o Flash burns, flame burns and contact burns. o Low voltage < 1000Volts. o High Voltage > 1000 Volts o Type of current = AC/DC with AC being more dangerous
- 8. CHEMICAL BURNS oAcids (sulphuric acid, nitric acid) o Alkalis (caustic soda, industrial cleaners, cement) o Organic compounds (phenols, solvents, petroleum products) RADAITION BURNS o Thermal radiation o Radiofrequency energy o Ionizing radiation o Ultraviolet(UV) radiation- Sunburn
- 9. Risk factors Gender(Females). Higher risk for females is associated with open fire cooking, or inherently unsafe cookstoves, which can ignite loose clothing. Self-directed or interpersonal violence are also factors. Age. Children are more vulnerable to burns. This is due to improper adult supervision and child maltreatment.
- 10. continuation Socioeconomic factors.People living in low-and middle-income countries are at higher risk for burns than people living in higher income countries. Occupation that increases exposure to fire Alcohol abuse and smoking Use of kerosene as a fuel source for non-electric domestic appliances. Inadequate safety measures for LPG and electricity.
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- 12. Pathology The localconsequence of exposure to excessive temperature is a graded tissue injury radiating from the point of contact. The Jacksonian model of three-dimensional concentric histopathological zones apparently describes this. The zone of necrosis in the center is irreversibly damaged. Next to this is the zone of ischemia or stasis where vascular spasms and intravascular micro-thrombi result in compromised perfusion with potential to progressive conversion to tissue death. The outermost zone which is most remote from the inciting agent is the zone of inflammation or hyperemia manifesting with the classical signs of inflammation and expected to make complete recovery in 7-10 days
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- 14. PATHOPHYSIOLOGY Aside fromthe local effect of burn which results from heat transfer and ischemia, large surface area burns are associated with systemic physiologic derangements which are potentiated by mediators liberated by the damaged tissue as well as neuro-endocrine organs. These mediators activate inflammatory responses leading to increased capillary hydrostatic pressure, generalized leakage of intravenous fluid, electrolytes and proteins, decreased cardiac output and suppression of the immune system. Major burn injury is therefore a systemic disease affecting every system of the body irrespective of remoteness from site of injury.
- 15. CONTINUATION Systemic changes Oedemamaximum at 18-24hrs Hypovolaemia Inhalational injury. Inhalation injury is most deserving of immediate recognition and expeditious intervention. Renal changes Respiratory tract changes GI changes Central nervous system changes Haematological changes Metabolic changes
- 16. Inhalational injury Thehistory is usually indicative of exposure to fire or smoke in a closed space and the clinical features include facial burns, singed nasal vibrissae, hoarseness, wheezing and the production of carbonaceous sputum and probably loss of consciousness at the timeofinjury. Fibre-optic bronchoscopy with its potential for enormous therapeutic benefits is the gold standard for definitive diagnosis. Whereas heat is dispersed in the upper airways, the soot, carbon monoxide, hydrogen cyanide and other toxic products of smoke reach the bronchi and alveoli to evoke inflammatory changes. Increased vascular dilatation and permeability lead to erythema, exudation and airway oedema. This may cause patchy broncho-alveolar obstruction and impairment of oxygenation. The ciliated epithelial cells are separated from the basement membrane and there may be ulceration with consequent granulation tissue formation. Proteins in the exudates coalesce to form fibrin casts, which adhere to the bronchi and interfere with the function of the ciliated cuboidal cells. Destruction of the ciliated cells lead to replacement with squamous cells and scar tissue. There may thus be laryngeal obstruction, atelectasis, respiratory infections, acute lung injury, acute respiratory distress syndrome and respiratory failure.
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- 18. CLASSIFICATION OF BURNS Partial thickness burns o Superficial partial thickness burns May be difficult to diagnose initially, Involves the epidermis and superficial layers of dermis .Usually very painful . There are blisters (bullae) formation and blanching- suggests viable dermis , Appears red or pinkish , Heals by 1-2 weeks o Deep partial thickness burns o Involves the epidermis and dermis. Relatively less painful with mottling. Heals by 3-4 weeks
- 19. continuation Full thicknessburns o Involves epidermis, dermis, deep tissues, bones and nerves. Usually insensate (not painful) with charring. May also appear waxy and translucent/pale/white. Visible thrombosed veins beneath translucent skin is characteristic. Heals by 2-3 months
- 20. Can anyone identifythe degree of burns?
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- 24. FACTORS THAT AFFECTTHE DEGREE OF BURNS Temperature of heat source Duration of exposure Consequent inflammatory response Skin thickness
- 25. ESTIMATION OF EXTENTOF BURNS Estimation of percent body surface area can be done using: o Wallace’s rule of nine o Lund and Browder chart Wallace’s rule of nine Named after Dr Alexander Wallace, who first published the method The palm is 1% and may be used to estimate the extent of injury Usually a quick way of estimation although not accurate Wallace rule is preferred for adults
- 26. continuation Lund andBrowder’s chart o Created by Dr Charles Lund and Dr Newton Browder o More useful for children o Relatively accurate compared to Wallace rule o Takes into consideration the age of the patient, i.e. the %BSA decreases for the head region and increases for the extremities as the child ages
- 29. continuation Superficial burnsof 20% body surface area and above in adults or of 10% and above in children is considered major injury because the associated fluid exudation in the first 48h post-burns may be severe enough, to produce shock. Furthermore, burn wound infection easily supervenes in such large areas of acute skin loss with a high risk of septicemia. Major injuries of this nature should be admitted to hospital. Similarly, 10% deep burns or above in adults and 5 % deep burns and above in children also constitute major injury.
- 30. MANAGEMENT The principle ofmanagement are to revive, restore, repair and to rehabilitate the patient. First aid Resuscitation History Examination Investigations Treatment
- 31. FIRST AID Thisis the first and foremost care that must be given at the site/venue where the burns took place The following principles can be used as a guide FLAME BURNS o stop the burning process, Call the National Fire Service on 192 and national ambulance on 193. Take patient away from the source of flames. Extinguish flames by rolling the patient on the bare ground i.e STOP, DROP, ROLL. Remove all hot charred clotting/jewellery as quickly as possible. If clothing is stuck, cut around the area. Lay the casualty down, protecting the burned areas from contact with the ground if possible to prevent contamination. Reassure and transport to hospital
- 32. Cooling the burnsurface Cool with cold running water for at least 20mins Check for ABC while cooling and be ready to resuscitate. DO NOT use ice block or iced water. Extreme cold causes vasoconstriction, it also deepens injury, risk of hypothermia. Cooling the surface of wound is an extremely effective analgesia Cover the injury with a clean gauze or non fluffy material to prevent contamination A clean plastic bag or kitchen film may be used DO NOT put oil, shear butter or any creams on the wound
- 33. ACID BURNS Protectyour hands and body Move the patient away from the source Prompt irrigation with copious water. Should be started within 10mins of contact with the substance Trim finger nails (some may hide in there)
- 34. ALKALI BURNS Lessimmediate damage than acid More long-term damage as they liquefy tissue and penetrate more deeply Irrigate for longer period- at least 1 hour
- 35. ELECTRIC BURNS Don’tpanic First switch off the power source (make sure you’re safe) Remove victim from power source with a non conductor (dry board or wood/plastic) Clear airway Protect the cervical spine (usually for those who fell and hit the ground) Start CPR if needed Check for injuries Always call for help
- 36. COAL TAR/BITUMEN Rapidcooling Use of cooking oil DO NOT use any petroleum product e.g.- kerosene, petrol, etc. which can cause tissue damage and systemic toxic effects
- 37. RESUSCITATION Before managementof the burn wound can begin, the patient should be properly and completely evaluated. Often, this is brief effort, particularly in patients with small,uncomplicated wounds. In those with larger burns evaluation of the wound is often of secondary importance. As described by the American College of Surgeon Committee on Trauma,evaluation of burn patient is organized into a primary survey and secondary survey.
- 38. continuation Primary surveywhich involves the following systematic methodology. o Timely resuscitation is important every burns patient o This can followed as ABCDEF o A - Airway maintenance and C- spine control o B - Breathing and ventilation o C - Circulation with bleeding control o D - Disability and neurological status o E - Exposure and environmental control o F - Fluid resuscitation
- 39. FLUID RESUSCITATION Adultswith more than 20% TBSA superficial burns and children with more than 10% TBSA superficial burns or half the values when the burns are deep require intravenous fluid replacement to correct the plasma loss and prevent hypovolaemic shock. Various formulae used in administering fluids are only estimates, the amount of fluid given should be guided by the patient's response to treatment as determined by his general condition (fluid overload, heart failure, kidney failure) and the hourly urine output. (1-2ml/kg/hr for children).
- 40. continuation There aretwo formulas for the estimation of the amount of fluid intake for the first 24hrs that is modified Brooke and the Parkland formula, but the most commonly used formula is the Parkland formula. The fluid of choice is ringers lactate, but normal saline, human plasma protein fraction (albumin 4.5%) and dextran 110 may also be used. Modified Brooke formula is 2mls x TBSA x weight. Parkland formula is 4mls x TBSA x weight. 50% is the maximal TBSA used even if the TBSA is more than 50% Half the calculated volume is given within the 1 st 8-hours from the time of burns. The 2nd half of the calculated volume is given over the remaining 16- hours.
- 41. continuation The normaldaily fluid maintenance is added for children On the 2nd day (the 2nd 24hrs), half the total volume calculated for the first 24hrs is given + the daily maintenance fluid for children. In patients in whom depth of burns is deep with loss of red cells, blood may be used as part of the requirement if necesary
- 42. Secondary survey History oCause of burns- rule out domestic violence in children. How??? o Time of burns , Place of burns (whether in an enclosed space) due to inhalational injury and carbon monoxide intoxication. o Ask of any complications if patient is conscious e.g.- cough, difficulty breathing, chest pains, etc. o Ask of any other injuries sustained (whilst trying to escape or falling from a height). Helpful if patient is conscious o Any chronic medical condition o Current medications/drug history and allergies
- 43. Examination Head totoe examination- examine all systems This should not be limited to only the area of burns Look out for other injuries including fractures, abrasions Look out for possible signs of inhalational – singeing of hair in nostril, soot around the nasal region and mouth, etc. Persons with facial burns should undergo a careful examination of the cornea prior to the development of lid swelling that can compromise examination.
- 44. Signs of inhalationalinjury
- 45. INVESTIGATIONS FBC- tobe repeated weekly if patient on admission. Blood grouping and cross matching- if patient needs transfusion Sickling- routine if status not known BUE/CR – to assess renal function and electrolytes. Can be repeated on as needed basis LFT- to assess protein and albumen levels. Can be repeated every 2 weeks or as needed. May also indicate liver damage as a complication Random blood sugars CXR- if complications such as inhalational injury or pneumonia is suspected ECG- crucial in electrical burns
- 46. TREATMENT Analgesia Woundcare Antibiotic therapy Prophylaxis for Curling’s ulcers DVT prophylaxis Tetanus prophylaxis Nutritional support Physiotherapy
- 47. Analgesia Paracetamol –available as oral, IV and suppository. Adults 500 mg – 1g 6-8hourly. Children 6-12 years 250-500 mg 6-8 hourly. Ibuprofen Adults 200 – 800 mg 6-8 hourly. Children 10-15 mg/kg 6-8 hourly /Diclofenac oral Adults 50mg 8 hourly or 100 mg 12 hourly. Children more than 12 years 50 mg 12 hourly. Not recommended for children less than 12 years./Naproxen EC oral Adults 250-500 mg 12 hourly. Children- not indicated.- not recommended in severe burns due to Curling’s ulcers but can be used in minor burns Tramadol- available as IV, IM and oral Morphine- available as IV, IM and oral Pethidine – available as IM or IV NB: the choice of analgesia will depend on individual patient factors
- 48. Wound care Thisis often done after resuscitation The wound is cleaned with water and antiseptic under sedation or adequate analgesia Blisters can be left alone if patient will be transferred to a high centre Blisters can also be de-roofed to help estimate percentage body surface area All debris and devitalized tissue are debrided/removed Topical antibacterial creams can be used • Silver sulfadiazine (dermazin, silver derma, flamazine) • Mupirocin (supirocin, bactroban) • Povidone iodine Wound is preferably covered with Vaseline gauze to prevent material from sticking into the wound- exclude facial wounds Dressing- typical dressing for burns - Vaseline gauze -Soff ban -Crepe bandage -Occasionally – POP application if indicated
- 49. Antibiotic therapy Antibioticsare not routinely recommended in most adult burns where contamination is not suspected All children with burns should however be placed on antibiotics All burns managed outside a burns unit may also consider antibiotics since those environments are often not sterile The choice of antibiotics should be individualised Commonly used: Cefuroxime, metronidazole, flucloxacillin, clindamycin, ceftriaxone, etc. When available, wound culture can be done to guide antibiotic choice
- 50. Prophylaxis for Curling’sulcer Proton pump inhibitors are often used o Omeprazole o Esomeprazole Antacids may be added for symptomatic relief o Magnesium tricilicate /Aluminium hydroxide mixtures (e.g.- Nugel suspension)
- 51. DVT Prophylaxis Formajor burns with prolonged hospitalization Any of the following can be used if indicated and available o Heparin o Enoxaparin (Clexane) o Dalteparin (Fragmin) They are usually given subcutaneous (SC)
- 52. Tetanus Prophylaxis Tetanusvaccine – can be given to those without previous tetanus immunization history Human tetanus immunoglobulin- anti-tetanus serum(ATS)- if available. NB-Give only after resuscitation Both are given IM
- 53. Nutritional support Highprotein diets recommended- eggs, beans, fish, etc. Parenteral amino acids if available – Astymin-3 Dietician or nutritionist should be involved if available Add haematinics if no active infection ongoing- , Iron III polymaltose, Ferrous sulphate, Folic acid, etc. Add Vitamin C to improve wound healing
- 54. Physiotherapy Starts rightfrom the beginning of the burn injury Exercises to the underlying joints before each dressing Splinting when necessary Encouraging the patient to use affected limbs in every day activities Mobilize out of bed as early as possible
- 55. CRITERIA FOR REFERRAL Burns more than 10% TBSA Burns involving the face, hands, feet, genitalia, perineum and major joints 3rd degree (full thickness) burns in any age group Electrical burns including lightening injury Chemical burns Inhalational injury Burns in patients with co-morbid medical conditions that could complicate management, prolong recovery or affect mortality Burned children without qualified personnel or equipment for their care Burn injury in patients who will require special social, emotional and rehabilitative interventions.
- 56. COMPLICATIONS Early complicationsof burns are the pathophysiological changes that would affect every system of the body when the appropriate resuscitation is inadequate or delayed. Hypovolaemic Shock Infections Gastrointestinal problems Acute gastric dilatation, Paralytic ileus, Curling's ulcers, Liver damage Cardio-respiration problems Respiratory obstruction Tracheo-bronchitis Pneumonia, atelectasis Genito-urinary problems Renal failure Cystitis, pyelonephritis, Calculi Vascularproblems Thrombophlebitis, Deep venous thrombosis Pulmonary embolism Anemia Disseminated intravascular coagulation (DIC)
- 57. continuation Late complicationsof burns are usually related to consequences of poor healing of the burn wound and include Unstable scars and chronic burn wounds. Burn scar hypertrophy and Keloids Burn scar contractures and deformities Dyschromic scars (hypo-, hyper-, & de-pigmentation) Burn Scar metaplasia and Marjolin's ulcers Loss of body parts. Psychiatric problems including PTSD
- 58. CAUSES OF DEATHIN BURNS Hypovolemic shock Renal failure Sepsis Laryngeal oedema/inhalational injury Curling’s ulcers --- upper GI bleeding/perforation