BURNS Part II - Early/Delayed Excision & Grafting

---------------------------------------------------------------------------------------------------------- Physical & Occupational Therapy in Burns

OUTPATIENT CARE - positioning, exercising, splints, & pressure garments help preserve
---------------------------------------------------------------------------------------------------------- function & appearance as Burn Wound heal.
- Body Surfaces with High Skin Tension & Movement = most
- Cool wound with Tap Water susceptible to formation of Scars & Contractures.
- Clean wound with Soap & Water o Face, Joints, Upper Legs, & Chest
- Debride dead tissue - With Extensive Burns, the Total Body Position is considered:
- Local Antibiotics may be used with Wound Dressings o Neck = Extended
- Tetanus Prophylaxis o Axilla = Flexed 30-60 & Abducted
- Follow-up Instructions/Change of Dressing o Elbow = Extension/slight Flexion
- Home Medications with Oral Analgesics o Wrist = slightly Extended 20-30
o MCP Joints = Flexed 90
---------------------------------------------------------------------------------------------------------- o Proximal & Distal IPJ = Extended completely
IN-HOSPITAL CARE o Thumb = slight Apposition to the Palm
---------------------------------------------------------------------------------------------------------- o Hips = Abducted & prevented from External Rotation
o Ankle = 90 Dorsiflexion
FLUID REPLACEMENT
- 1st 24 Hours (Leakage Day) TOPICAL ANTIMICROBIAL AGENTS FOR BURN WOUND CARE
o Parklands Formula = (4 mg/kg) / % TBSA Silver Mafenide Acetate Silver Sulfadiazine
o Modified Brook Formula = (2 ml/kg) / % TBSA Nitrate
o of Fluid is given in the 1st 8 hours Active 0.5% in Aqueous 11.1% in Water 1.0% in Water
- nd
2 Day = Colloid (0.5 ml/kg/TBSA) + D5W to maintain Urine Output Component Solution Miscible Base Miscible Base
of 1 cc/kg/BW (children) or 60 cc/hr (adults) Spectrum of Gram (-) = GOOD Gram (-) = GOOD Gram (-) = VAR
- Hypertonic Saline = (Hyperosmolar) may cause ICF shift into the ECF Antibacterial Gram (+) = GOOD Gram (+) = GOOD Gram (+) = GOOD
decreased tissue Edema Activity Yeast = GOOD Yeast = POOR Yeast = GOOD
o Extracellular Edema is increased as ICF is decreased Method of Occlusive Exposure Exposure or Single
less external Edema appearance Wound Care Dressings Layer Dressing
- Colloid Resuscitation = Plasma CHONs provide Oncotic Force Painless, No Penetrates Eschar,
o CHON Solutions NOT GIVEN in the 1st 24 hours (no more Hypersensitivity Wound Painless, Easily
effective than Salt-containing Crystalloids in maintaining Reaction, No Appearance Applied, Readily
intravascular volume) Advantages
Gram (-) Readily Monitored, Greater
o CHONs (Albumin) are given from the beginning of Resistance, Monitored, No Effectiveness
resuscitation with Crystalloids Reduced Gram (-) against Yeast
o CHONs should not be given between 8-12 hours post- Evaporative Heat Resistance
burn r/t massive fluid shift (start at the TIME OF BURN, no Loss
at the time of admission) Painful on Partial
o Plasmanate, Albumin, Fresh Frozen Plasma (FFP) Thickness Burns,
- Electrical Burns (4th Degree) = Urine Output is equal to 75-100 cc/hr Na, K, Ca, Cl Susceptibility to Neutropenia &
o Mannitol 12.5-25 g is given to promote diuresis (Wash- Disadvantages Deficits; No Acidosis due to Thrombocytopenia,
Out Medication to prevent Kidney Failure) Eschar Carbonic Limited Eschar
o Muscle Destruction increased Myoglobin/Hemoglobin Penetration Anhydrase Penetration
& deposits in the Kidney = NEED TO INCREASE UO Inbihition

WOUND MANAGEMENT ----------------------------------------------------------------------------------------------------------

- wear sterile gloves when examining!! RECENT BURN TREATMENT RESEARCH
- Check & Secure Airway (INTUBATE = Burn Injury >50% & Inhalation ----------------------------------------------------------------------------------------------------------
Injury); Inspect Inhalation Injury if:
o Face & Hair is Burned 1. A New Dressing Helps Treat Graft Donor Sites on Burn Patients
o Sooty Expectoration 2. Moist Exposed Burn Ointment may Reduce Hypertrophic Scarring
o Singed Nostril Hair 3. Full-Thickness Skin Grafts are Helpful in Treating Burn Wound on the
o Hoarseness & Stridor Face
o Hx of Burn in an Enclosed Space 4. A New Product Helps in the Healing of Burn Wounds on the Hand
o Circumferential Chest Burn 5. A New Dressing for Second Degree Wounds Helps Prevent Infection
- Perform Sterile Debridement in Sterile Area/Operating Room using 6. Tissue Expanders Helps in the Treatment of Some Pediatric Burn
Sterile Technique Patients
- Remove all of Patients Clothing; Cut Hair reaching the burn areas 7. Exercise in Important in Preventing Contractures
- Give Whole Body Bath with warm Water & Soap 8. Thymus Oil may be Helpful in Burn Wound Healing
- Debride all Burn Areas, Remove all dead skin, & unroof Blisters 9. Light Therapy may Help Diabetic Burn Survivors
o Make sure all areas are inspected 10. Why Dont Cultured Epithelial Autografts Always Take?
o If OPD, do not remove Blisters 11. Porcine Wound Models for Skin Substitution & Burn Treatment
- Decide the Type of Dressing
- If no Burn Unit, place patient in a Controlled Environment ~gwapo si JHERBEN.
- Tetanus Prophylaxis https://www.facebook.com/Lecitel.Candido
- Decide whether or not to use Systemic Antibiotics http://jherben.deviantart.com
https://twitter.com/JherBISHIE
SURGICAL http://dissociatedlobster.tumblr.com/
1. Conservative Management = unstable patients http://worldcosplay.net/member/jherBISHIE/
- Surgical Escharotomy (3-10 days) for Deep Lesions. http://en.curecos.com/profile/?ch=306581
- Split Thickness Skin Grafting (Meshed) when Granulation
Tissue is healthy.
2. Aggressive Management = stable patients & lesions in Primary Areas