Emergency Management of Burn

Dr Budhi Nath Adhikari

What causes Burn?

Heat How hot?

What does the burn cause?

Local tissue death. How? Systemic Effects.

Stratification
Major/Intermediate/Minor Burns Flame/Scald/Electrical/Chemical

Prognosis

Dangers of Burn
Death Sepsis/Renal Failure/Pulmonary Complications Contracture Scars Emotional problems

Management
Surgical Emergency PainPain..Pain Field Management -- Stop the burning process (wet or dry) and cool the burned part (never ice) ABCDEFG.one action for each assessment

A
Airway control + Cervical Spine Stabilization Chin lift/jaw thrust Beware head tilt (In line traction) Suctioning Guedels Airway ETT

B
Breathing and ventilation Adequate chest excursions Oxygen 12 L/min Beware RR >20/min Circumferential chest burn prepare for escharotomy Saturation

C
Circulation with hemorrhage control Pulse volume/rate Delayed capillary blanch (inadequate resuscitation, compartment syndrome) Direct Pressure 2 large bore cannulas and send blood investigations

D
Disability: neurological Status AVPU Pupils Altered consciousness hypovolemia(<50%), hypoxia, intoxication, CO/CN poisoning, associated injuries (EDH/SDH), electrolyte imbalances

E
Exposure with Environmental control Assessment of the Body Surface Area involved Wallace rule of 9 Proper coverage Heater Jewelry

Depth Assessment
FIRST DEGREE Sunlight exposure or burn by hot tea cup Heals in 3-6 days without scarring/discoloration Not included while calculating fluid requirement for burns Red and dry Very painful

SECOND DEGREE SUPERFICIAL Hot liquid or flash flame Pink or mottled red in appearance Blisters or bulla, soft and moist Painful 7-10 days to heal Hypo or hyper pigmented areas

SECOND DEGREE DEEP Chalky white Soft and moist Sensation is obtunded More than 21 days to heal Heals with lot of scarring and contractures

THIRD DEGREE BURN Prolonged exposure or electric burn Dry and parchment like Translucent, can see fat and thrombosed veins No sensation Needs debridement of eschar and skin grafting

F
Fluid RL 4 ml/kg/% burn starting from the time of burn Maintenance for children Replace blood with blood Monitor adequacy of resuscitation urine output

G
Get X rays (CXR, Pelvis, Cervical spine lateral view) Get tubes ( Foley catheter, Ryles tube) Get reports, Urine RE/ME, ECG Give morphine, TT

 Reassess

AMPLE
Allergies Medications anti-diabetics, steroids, antihypertensives, anti-epileptics Previous illness Last meal Events leading to the burn Mechanism of injury, seizure, recreational drugs, alcohol

Secondary Survey
Detailed head to toe examination Need for fasciotomy Inhalation injury Associated injuries

 Consent Documentation (pro-forma) Dressing clean and closed CSS dressing, Neosporin ointment for the face Positioning and Physiotherapy

Finally

Specific Problems Electric Injuries

Cardiac arrythmias Prevent renal failure 2 ampoules of Sodium bicarbonate, 100 ml of Mannitol and Urilizer if urine dark. Exit wounds - not always at foot High urine output >1ml/kg/hour Low threshold for fasciotomy Frequent reassessments needed

Chemical Injuries
Remove cloths Prolonged irrigation Remove the irritating substance Special care for eyes Dont search for antidotes

Nutrition
NPO and Ryles tube for > 25% Burn High protein high calorie diet later 6 egg whites Only restrict tobacco/alcohol Curerri formula 25 kcal/Kg + 40 Kcal/% burn

Infection
No role of prophylactic antibiotics Conversion/sepsis Pseudomonas aeruginosa, Staph aureus, Staph epidermidis, Streptococcus pyogenes, Enterococcus faecalis, Enterobacter species, Escherachia coli

Focal dark brown or black discoloration Degeneration of wound with neoeschar Rapid separation of eschar ( 2 weeks ) Hemorrhagic discoloration of subeschar fat Erythematous wound margin Metastatic septic lesion in unburned tissue

Infection (histological)
Organism in unburned tissue Hemorrhage in unburned tissue inflammatory reaction in adjacent tissue Small vessel thrombosis or ischaemic necrosis of unburned tissue Perineural and intralymphatic migration of organism Vasculitis and perivascular cuffing of organisms

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Gram-positive sepsis
Burn wound biopsy >105 organisms/g tissue and/or histologic evidence of viable tissue invasion Symptoms develop gradually Increased temperature to 105F or higher (>40C) WBC 20 000 50 000 Decreased hematocrit Wound macerated in appearance, ropy and tenacious exudate Anorexic and irrational Ileus/intolerance of tube feed Decreased BP and urinary output

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Gram - negative sepsis

Burn wound biopsy >105 organisms/gm tissue and/or histologic evidence of viable tissue invasion Rapid onset well to ill in 812 hours Increased temperature to 100103F (3839C) or may remain within normal limits (37C) WBC may be increased Followed by hypothermia 94F (34 35C) plus a decrease in WBC Ileus/intolerance of tube feed Decreased BP and urinary output Wounds develop focal gangrene Satellite lesions away from burn wound Mental obtundation

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 Ceftazidime + Amikacin, Meropenem, Imipenem, Ciprofloxacin, Clox, Fluclox, Vancomycin Treat other sources of infection Ceftriaxone, Metron, Cefixime

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 Questions?