Department of Family & Community Medicine Perpetual Succour Hospital Presentor: LIZA D. MARIPOSQUE, M.D. 3 rd Year Famed Resident May 27, 2010
Department of Family & Community MedicinePerpetual Succour Hospital
Presentor:LIZA D. MARIPOSQUE, M.D.
3rd Year Famed ResidentMay 27, 2010
OBJECTIVES
GENERAL OBJECTIVES:
To discuss the family profile of Tim-tim & Martinez Family.
To present a case of thermal burn injury (kerosene).
SPECIFIC OBJECTIVES
To establish the family diagnosis of Tim-tim & Martinez Family using family assessment tools.
To briefly discuss the management, prevention and complications of thermal burn injury.
E. T.,44 y.o, female,Single, sari-sari store vendor owner, from Upper Laguerta, Lahug, Cebu City.
CC: oozing & infected burned skin of the L side of the face, neck & L arm
Past Medical History
(-) HPN, DM, BA
No known allergies
No Previous Hospitalization
History of Present Illness
2 wks PTC – while cooking food, sustained burn on the L side of the face, neck and L arm upon gas (kerosene) stove explosion.
– Spicy vinegar & water applied on the wound.
Hospitalized 1 week discharged w/ (VSMMC) home meds:
TT 0.5 ml IMTIG 250 IU IMCiprofloxacin 500mg 1tab BID x 10 days.Silver Sulfadiazine Cream (Flammazine)
apply to affected area OD.Tramadol 50mg 1tab q 8Hr prn for pain.
INTERVAL HISTORY
Ff-up check-up: 1 wk after discharged– Cont. Ciprofloxacin 500mg 1tab BID x 3 days more.– Cont. Flammazine cream OD.– Cont. Tramadol 50mg 1tab TID prn for pain.– Vit. C 500mg 1tab OD.– Vit. B-complex 1tab BID.
Physical Examination
Conscious, coherent, not in respiratory distress.
BP: 120/90-130/80 mmHg T: 37.20C
HR: 75 bpm
RR: 20 cpm Wt: 55 kg
Skin: dry, dark, warm
HEENT: Pinkish burn scar, wet & w/ purulent burn surface on the anterior neck. No lymphadenopathies
C/L: Equal chest expansion, No chest retractions, Clear breath sounds, No rales.
CVS: Distinct heart sounds, normal rate & regular rhythm, no murmur
Abd: Flabby, normoactive bowel sounds, soft, non-tender, no masses palpated, no hepatomegaly
Ext: No edema, (+) pinkish and wet burn on the medial side of the L arm, no limitation in movement, strong pulses
CNS: Within normal limits
Final Diagnosis
2nd Degree Burn,14.5% TBSA, on the L side of the Face, neck, & L arm
Estimating the size of the Burn as a % of the Total Body Surface (TBS)
A burn occurs when the skin, and often other bodily organs, come in contact with the ff:
HeatRadiationElectricityChemicals
TissueDamage
Kinds of Burns
Scald Burns - hot water Flame burns - thermal injury. Flash burns – explosion Contact burns - hot metals, plastic, glass, or hot
coals. Chemical Burns Electrical Burns Cold Injuries – hypothermia & Frosbites
Burn Severity is determined by:
Burn depth
Burn size
Burn location
Burn Depth – destruction of skin layers by the heat source.
Depth of injury -proportional to the temperature, duration of contact, and thickness of the skin.
http://www.burnsurgery.org/
Categories of Burns:
4th Degree: involves all layers
Estimating the size of the Burn as a % of the Total Body Surface (TBS)
High Risk areas for Burns
http://www.burnsurgery.org/
Airway
Breathing
Circulation
Disability
Expose & Examine
First Aid for Severe Burns: (2nd & 3rd Degree Burns)
DO NOT remove burnt clothing. Make sure the victim is breathing. Cover the burn with a cool moist sterile bandage or clean
cloth. If fingers or toes have been burned, separate them with
dry sterile, non-adhesive dressings. Elevate the burned area and protect it from pressure or
friction. Prevent shock Continue to monitor the victim's vital signs
RESTORING & MAINTAINING HEMODYNAMIC STABILITY
Loss of plasma volume is rapid after a burn injury as fluid collects in the burn tissue.
Early fluid resuscitation is required for burns exceeding 20% of body surface.
Estimate percent (%) of TBSA burned in order to estimate isotonic fluid requirements using "Rule of Nine".
Fluid Resuscitation Protocol
Burns >20% TBSA require initial fluid resuscitation
Start Lactated Ringer’s solution. Estimate initial rate according to the estimated
%TBS. Estimated body weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.)
Total Maintenance Fluid = (1500mL/m2)
+ Evaporative Water Loss [(25+%TBSA Burn) x m2 x 24]
m2 is square meters of TBSA
Schwartz's Surgery, Part I. Chapter 7. Burns
Copyright ©2007 The McGraw-Hill Companies.
Foley catheter Nasogastric tube Maintain: Systolic Blood Pressure >90
Urine output 0.5-1.0ml/kg/hr
Pulse <130
Temperature >37°C
Modify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients:
- Fluid requirements are greater to prevent burn shock
- Include colloid: either Hespan or Albumin in the patients from the beginning
Three major types of burn related scars
Keloid scars - overgrowth of scar tissue.
- The scar will grow beyond the site of the injury.
Hypertrophic scars - are red, thick and raise & do not develop beyond the site of injury or incision.
Contracture scar - is a permanent tightening of skin that may affect the underlying muscles and tendons.
http://www.burnsurgery.org/
Physical Therapy, pressure and exercise Surgery:
- Dermabrasion – smoothen skin
- Skin Grafts
Pressure Garments Nutrition Medications
http://www.burnsurgery.org/
MEDICATIONS
Tetanus prophylaxis Pain relievers Antibiotics
Silver Nitrate Mafenide Acetate Silver Sulfadiazine
Active component
0.5% in aqueous solution 11.1% in water-miscible base
1.0% in water-miscible base
Spectrum of antimicrobial activity
Gram-neg.—good Gram-neg.—good Gram-neg.—variable
Gram (+)—good Gram (+) —good Gram (+) —good
Yeast—good Yeast—poor Yeast—good
Topical Antimicrobial Agents for Burn Wound Care
Silver Nitrate Mafenide Acetate Silver Sulfadiazine
Method of Wound care
Occlusive dressings Exposure Exposure or single-layer dressings
Advantages
Painless
No hypersensitivity reaction
No gram-negative resistance
Dressings reduce evaporative heat loss
Greater effectiveness against yeasts
Penetrates eschar
Wound appearance
readily monitored
Joint motion unrestricted
No gram-negative resistance
Painless
Wound appearance
readily monitored
when exposure method used
Easily applied
Joint motion
unrestricted
when exposure
method used
Greater
effectiveness
against yeast
Silver Nitrate Mafenide Acetate Silver Sulfadiazine
DISADVANTAGES
Deficits of sodium, potassium, calcium, and chloride
Painful on partial-thickness burns
Neutropenia and thrombocytopenia
No eschar penetration Susceptibility to acidosis as a result of carbonic anhydrase inhibition
Hypersensitivity—infrequent
Limitation of joint motion by dressings
Hypersensitivity reactions in 7% of patients
Limited eschar penetration
Methemoglobinemia—rare
Argyria—rare
Staining of environment and equipment
FAMILY PROFILE
Eliza Tim-tim
44 yrs old, female, single Education: Primary Sari-sari store vendor owner Index patient
Walanita Martinez
59 yrs old, Female, widow Relative of Eliza,Significant Other Education: Primary Unemployed Living with her 2 children: JR & Nieves No known medical health problem
40 yrs. Old, female, single Education: Primary Laundry girl of Genee Laudryshop Family Head. No Known medical health problem.
Nieves Martinez
JR MARTINEZ
15 Yrs old, male, single
Son of Walanita 4th year High-
school student No known
medical health problem
•15 Yrs old, male, 4th year HS•Walanita’s Son •No known medical health problem
Jason Tim-tim
17 yrs old, male, single, 4th year HS Eliza’s nephew Unemployed No known medical health problem
Jian Hilardino
10 yrs old, male, Grade III student Eliza’s Nephew No known medical health problem
ELIZA
SIMA
MILANANGELINA
MARIO
LUISLEONA
ROGER
ELSIE JUNIEMERLYN
TIM-TIM & MARTINES FAMILYUpper Laguerta Lahug Cebu City
As of Nov. 2009
Index Patient
Sima 100+
Milan ?
Angelina 80
?80’s
I
III
II
Luis 70
Leona 60
Roger 47
Junie 42
Merlyn37
HPN
Eliza 44
Elsie48
FALL
Walanita59
Nieves40
Jian10
JR15
Jason17
Doling miyay EliongDolfin Amadeo 60’s
Maning Erineo Timoteo Candido Peling melanio
Rheumatoid arthritisThyroid CA
2 5
jc
ElizaNieves Jason JRJian
Walanita MerlynElsie
Roger
BETTYJunie
A P G A R ELIZA Almost always
(2)Some of the time (1)
Hardly ever (0)
ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me
PARTNERSHIP: I am satisfied with the way my family talks over things with me and shares problems with me
GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities and directions
AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotions
RESOLVE: I am satisfied with the way my family and I share time together
A P G A R
9
SOCIAL
CULTURAL
RELIGIOUS
EDUCATIONAL
ECONOMICS
MEDICAL
Weakness &
Strength
WEAKNESS &
STRENGTH
WEAKNESS &
STRENGTH
Strength
STRENGTH
STRENGTH
WEAKNESS &
STRENGTH
WEAKNESS &
STRENGTH
ECONOMIC PROFILE
Total Monthly Income Php > 10,000 PERCENT ALLOCATION
Total MonthlyExpenses: Food: Electricity: Water: Medicine: Miscellaneous:
6,2001,200560< 1,000< 500
62%12%5.6%10%5%
Savings 540-1000
WEAKNESS &
STRENGTH
WEAKNESS &
STRENGTH
SOCIAL
CULTURAL
RELIGIOUS
EDUCATIONAL
ECONOMIC
MEDICAL
RESOURCE
(STRENGTH)
PATHOLOGY
(WEAKNESS)S C R E E MS C R E E M
Impact of Illness
Stage I – Onset of Illness
Stage II – Reaction to Diagnosis
(Impact phase)
Stage III – Major Therapeutic efforts
Stage IV – Early Adjustment to Outcome (Recovery)
Stage V – Adjustment to the Permanency of the Outcome
Smilkstein’s Cycle of Family Smilkstein’s Cycle of Family FunctionFunction
STREESFUL LIFE EVENTS:
CRISIS:Inadequate family income
EXTRA-FAMILIAL RESOURCES:•Financial Assistance from the siblings, relatives & Franciscan Sisters•Help from Famed residents
work
BURNS
FAMILY IN EQUILIBRIUM
DISEQUILIBRIUM
SARI-SARI STORE
Family diagnosis
Tim-tim & MARTINEZ family
– Blended type of family with low income.– Stage of Family Cycle : Family with adolescents– Stage in Family illness:
Stage IV – Early Adjustment to Outcome (Recovery)
– APGAR Assessment : Highly Functional
Smilkstein’s Family Cycle : – Adaptation
Evaluation by SCREEM– Strength:
Religion, Education and Economic
– Weakness: Social, cultural, Economic & Medical
RECOMMENDATIONS
To the patient:– Teach and demonstrate and encourage
range of motion (ROM) exercises daily.– Visit Wellness Clinic for regular BP
monitoring at least once a week.– Advised diet modification: low salt &low
fat.– Advised to cover her burned skin with
clothes if exposed to sunlight.
Prescribe Gabapentin and use of Sunblock lotion.
Advised to seek help in Franciscan Sisters for free supply of medications during operation.
Networking with PCSO and Gov’t health card. Refer and accompany patients for evaluation, release
of contractures and possible skin grafting.
To Nieves & Walanita
Continue supporting Eliza. Visit Wellness Clinic also for regular BP
monitoring. Advised for FBS & lipid screening as well as
ECG.
To JR, Jason & Jian:
To continue their support. Stays to be good. Advised to continue their study. Advised to help household chores. Advised to help in tending sari-sari store.
To the community
Give lectures about safety and fire preventions.
Give lectures about first AID for burns and poisoning.
Advise to have presence of mind and don’t panic in case of accident.
Encourage to visit the Wellness Clinic every Tuesday, Wednesday and Friday.
Family Family membermember
ProblemsProblems primary primary preventiopreventio
nn
2ndry 2ndry
preventionpreventionTertiary Tertiary
preventiopreventionn
EliizaEliiza
44 y.o44 y.ocontracturecontracture Lectures
about Safety & fire prevention, & first aid for burns
Surgical referral for release of contrature & graftingUse of Sunblock
ROM exercise,
low salt, low fat diet
Regular monitoring of BP; blood sugar & lipid screening; ECGFLU Vaccine, cervical vaccine; Breast Exam’n, pap smear
Networking with VSMMC, Franciscan’s Sister & PCSO
Family Family membermember
ProblemsProblems primary primary preventiopreventio
nn
2ndry 2ndry
preventionpreventionTertiary Tertiary
preventiopreventionn
WalahitWalahita , 59 a , 59 y.oy.o
& & Neives, Neives, 40 y.o40 y.o
nonenone Lectures about safety & fire prevention , & first aid for burns
blood sugar & lipid monitoring
Regular monitoring of BP, FLU Vaccine, cervical vaccine; Breast Exam’n, pap smear
Family Family membermember
ProblemsProblems primary primary preventiopreventio
nn
2ndry 2ndry
preventionpreventionTertiary Tertiary
preventiopreventionn
Jason, Jason, 17 y.o, 17 y.o, JR, 15 JR, 15 y.o & y.o & Jian, 5 Jian, 5 y.oy.o
nonenone Lectures about fire prevention & first aid for burns
Sexual educ. & teen-age pregnancy, lectures about drug addiction, smoking & alcoholism
FLU & hepa Vaccine,