Data Interpretation Venkatesh adults = fire



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Burns

14/12/10


FANZCA Part II Notes

OHOA


Data Interpretation - Venkatesh

- adults = fire

- children = scalding

- maybe associated with ET-OH, abuse, epilepsy or psychiatric problem

- mortality is related to age (>50yrs), TBSA (40%) burnt and burn depth

CLASSIFICATION


Superficial – epidermis only

Partial – superficial (epidermis and upper layer of dermis), deep (extends to deeper layer of dermis)

Full – all layers of dermis and may involve underlying tissue

METHODS OF ASSESSING EXTENT


Rules of 9’s

Palm of patient = 1% TBSA burn

Lund-Browder Chart

OTHER IMPORTANT ASPECTS

Resuscitation – airway patency, breathing, circulation, LOC

Adequacy of resuscitation to date – HR, BP, urine output, fluid received

Associated trauma

Airway burn or inhalational injury – stridor, burns to face, nose and mouth, carbonaceous sputum

Facial and/or corneal burns, perineal burns

Circumferential burns – extremities -> compartment syndrome, ventilator inadequacy -> escharotomy

Rhabdomyolysis

Inhalation of toxic gases – CO

Temperature

Adequacy of analgesia

Problems with vascular access

Evidence of drug/alcohol ingestion

Co-morbid conditions

MANAGEMENT


EMST/ATLS protocol – primary and secondary survey

Burn assessment and management – debridement by 48 hours

Transfer to definitive care facility

Primary Survey
Airway with C-spine control
- may need ETT quickly (use an uncut tube + wire to maxilla)

- warning signs include = singed nasal hairs, horse voice, productive brassy cough, soot in sputum, stridor, facial burns, breathed fire, voice change.

- maximum wound oedema takes place @ 12-36hrs after injury

- FOB or nasoendoscopy

- Bronchoscopy - soot, charring, mucosal erythema, necrosis, airway oedema

- RSI


- sux ok for 24-48hrs then none for 2 days -> 2 yrs

- may need AFOI or surgical airway



Breathing with O2
- 15L/min + resevior bag

- may require ETT + IPPV because of other injuries, major resusication, sedation, ARDS & analgesia, decreased pulmonary compliance

- protective lung injury

- NAC & heparin nebs

- suction

Circulation with haemorrhage control
- >25% -> SIRS with oedema

- IV access through intact skin where possible

- IVF for >15% in adults & >10% in children

- Hartmans is preferred

- x-match units

- may have to stop surgery to catch up

- aim for PCV 0.3

Disability with assessment of neurological function
- CHI

- CO poisoning

- ET-OH poisioning

- analgesia



Exposure with temperature control
- remove all clothes

- if stuck to patient, cut around adherent areas

- keep warm

- assess %TBSA

- 1% = patients palm and fingers

- assess burn depth -> superficial = red and painful

deep = no capillary refill and not painful

- warm theatre (32 C)

- humidify (70-80%)

Secondary Survey
- cool with running cold water (20min)

- bronchoscopy for evidence of an inhalational injury (nebulized heparin and NAC)

- watch for hypothermia

- cover with clingfilm (limits evaporation, heats loss & pain)

- IV morphine

- escharotomy - limbs & chest wall

- have lots of blood ready

- watch for COHb -> will need 100% O2 or hyperbaric O2

ICU MANAGEMENT

Fluid replacement
- required in adult > 15%, children >10%

- Modified Parklands Formulae


-> Adults - 4mL/kg/%

-> Children - 3-4mL/kg/%


- give 1/2 in first 8hrs since injury

- give 1/2 in next 16hrs

+ normal maintenance!!!
- aim for urine output of 0.5mL/kg/hr and normal cardiovascular parameters

- then albumin after first 24 hours (keep albumin > 20)

- test for myoglobinuria -> if +ve then
(1) aim 1-2mL/kg/hr

(2) alkalinise urine with 25mmol of HCO3- for each litre of Hartmans

(3) promote diuresis with 12.5g mannitol to each litre of Hartmans

Dressings
- biobrane: superficial

- acticoat: partial

- subcut infusions: hypertonic saline + acetic acid (anti-pseudomonal)

Other issues
- N\J tube -> feed

- strict asepsis

- vigilance for nosocomial infections: line changes every 7 days

- tetanus

- antibiotics in initial period if dirty (frequently cooled at scene with dirty water)

- family discussion

- prognosis: age + TBSA burn should be less than 100.

- monitor for post burn leukopenia (cease silver sulfadiazine and use mafenide acetate, stop cimetidine, consider G-CSF if doesn’t improve in 3 days)




Chemical Burns
- protect self with gloves, apron & facemask

- remove contaminated clothing

- neutralize or dilute with H2O (1hr)
Hyrdroflouric acid - topical calcuim gluconate burn gel + Biers block with 10-15mL of 10% calcium gluconate + 5000U of heparin in 40mL 5 % dextrose
Phosphorus - copper sulphate solution
Bitumen - cool with H2O, remove with vegetable or parafil oil

Electrical Burns
- low voltage (<1000V) -> local contact burn

- high voltage (>1000V) -> entrance & exit wound -> may require fasciotomy

-> side flash = nearby lightening strike -> superficial burns, entry & exit burns +/- respiratory arrest

- direct lightening strike -> often fatal





Jeremy Fernando (2011)



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