MANAGEMENT OF A SEVERELY BURNT PATIENT Dr Sunil Keswani NATIONAL BURNS CENTRE Navi Mumbai Dr. Sunil Keswani, National Burns Centre, www.burns- india.com, [email protected]
May 07, 2015
MANAGEMENT OF A SEVERELY BURNT PATIENT
Dr Sunil KeswaniNATIONAL BURNS CENTRE
Navi Mumbai
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Aim of burn care
• Rescue• Resuscitate• Refer• Resurface
• Rehabilitate• Reconstruct• Review
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
INTENSIVE BURN CARE UNIT(IBCU)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
INTENSIVE BURNS CARE UNIT(IBCU)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
History
• Type of burn:– Flame (open flame, closed space)
– Chemical (type of chemical)
– Scald (type of liquid)
– Electrical (voltage, arcing/flame, contact time)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
FIRST-AID FOR BURNS
• Pour Water on Burns till the burning sensation subsides
A: AirwayHistory & Physical: Inhalational injury
• Fire in a closed space.• Full-thickness/ deep
chemical burns to face, neck.
• Singed nasal hair.• Carbonaceous sputum.• Carbonaceous particles in
oropharynx.
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
A: Airway
• Burned airways swell rapidly.
• Intubate patient as early as possible before airway swelling.
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
A: Airway
• Indications for intubation:– Oropharyngeal erythema/ swelling on direct
visualization.
– Change in voice, harsh cough.
– Stridor.
– Dyspnea, tachypnea.
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
B: Breathing
• Circumferential full-thickness burns may impair ventilation.
• Blast injuries can cause pneumothorax, lung contusions.
• Noxious chemical (plastic) can cause a chemical pneumonitis.
• Carbon monoxide poisoning (if COHb > 15-40% ventilate).
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
C: Circulation
• BP, HR, color of unburnt skin• 2 large bore I.V.s in unburnt skin• Draw bloodwork.• Insert urinary catheter.• Insert nasogastric tube. • Doppler exam of circumferentially burnt
extremities
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ASSESSMENT OF BURNS
• TBSA(Total body surface area)• Decides fluid requirements and nutritional needs• Wallace’s rule of nines• Lund and Browder chart
• DEPTH• Dictates local and surgical wound management
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ASSESSMENT OF BURN WOUND DEPTH• Clinical-wound appearance,blanching,capillary return,degree of
fixed capillary staining,evaluation of retained light touch and sensation
• Wound biopsy• Measurement of tissue perfusion-Laser Doppler
Flowmetry,Indocyanine Green Video Angiography,Fluroscein Fluoresecence
• Photooptical measurements—Reflection-optical Multispectral Imaging,Fibreoptic Confocal Imaging,Polarisation Sensitive Optical Coherence Tomography
• Thermography• Radioisotopes and Nuclear Magnetic Resonance
Fluid resuscitation
• Need to replace losses to maintain homeostasis.• Formulas are ONLY GUIDELINES.• Monitor physiologic parameters.• Maintain adequate tissue perfusion to prevent
increase in depth of burn.• Too little fluid Hypotension renal failure, etc.► ►• Too much fluid Edema Tissue hypoxia► ►
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Fluid resuscitation
• Fluid resuscitation should be started when– >15% TBSA burns in an adult– >10% TBSA in children and elderly
• First 8-12 hrs: intravascular volume shifts to interstitial space.
• Fast fluid boluses are of no benefit.• Colloids: Questionable in first 24 hrs (capillary
leakage)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Fluid resuscitation
Parkland Formula
• Total fluid requirement in first 24 hrs =4ml x TBSA burn (%) x body weight (kg)
50% given in first 8 hours from time of injury
50% given over next 16 hours.
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Pediatric Fluid resuscitation
• Use Parkland formula + MAINTENANCE fluid• For maintenance fluid, hourly rate of
4 mL/kg for first 10 kg of body weight plus2 mL/kg for second 10 kg of body weight plus1 mL/kg for >20 kg of body weight
• End point: urine output of 1.0-1.5 mL/kg/hr• Maintenance fluid given is D5W/E45 (child’s liver not
fully matured- limited glycogen stores).
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in first 24 hrs
• If myoglobinuria, may require bicarbonate infusion to alkalinize urine to pH > 8
• End point: urine output of 1.5-2 mL/kg/hrDr. Sunil Keswani, National Burns Centre,
www.burns-india.com, [email protected]
Antibiotic Protocol
• FRESH BURN• Start with a 3rd gen Cephalosporin with an
aminoglycoside
• INFECTED OLD BURN• Start with a semisynthetic Penecillin like Pipra
and Tazobactum or a Carbapenem
• LATER go by wound swabs culture and sensitivityDr. Sunil Keswani, National Burns Centre,
www.burns-india.com, [email protected]
Pain Management
• Continuous infusion round the clock of Tramadol 100mg Ketamine 100mg Midazolam 10mg• In a 50cc syringe in a syringe pump• Resting Pain-At 4-6cc per hour to start and then
titrate with pain response• Procedural Pain-During dressing 30-40cc per hour
and titrate
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Nutritional support
• Burns patient is hypercatabolic – up to 150- 200% above baseline.
• Nutrition needed for burns >20% TBSA.• Curreri formula
– Adult: 25kcal/kg/day + 40kcal/ % TBSA burn– Child: 60kcal/kg/day + 35kcal/ % TBSA burn
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Nutritional support
• Calorie : Nitrogen = 100 : 1 • Protein requirement
– Adult: 2g/ kg/ day– Child: 3g/ kg/ day
• Fat emulsion– 4g/ kg/ day max.
• Carbohydrate (glucose)– 6.2mg/ kg/ min. max.
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
NUTRITION• Burn patient caloric requirement 3000-
5000calories per day
• Early feeding• Nasogastric tube No 10• Hourly tube feeding
Butter milk diet 1cal/cc Eggs 4 Bananas 4 Sugar 4Tbs Curd 1 litreDr. Sunil Keswani, National Burns Centre,
www.burns-india.com, [email protected]
Initial burn wound management
• Early transfer to burn centre (within first 24 hours):– Remove smoldering, non-adherent clothes.– No debridement or topical agents needed.– Clean, dry sheets, – Wet dressing cause heat loss.
• If transfer is delayed > 24 hours:– Unroof blisters >2 cm, cleanse with chlorhexidine– Silver sulfadiazine cream OD or Povidone Iodine solution
and Vaseline gauzeDr. Sunil Keswani, National Burns Centre,
www.burns-india.com, [email protected]
Burn wound management
• Circumferential extremity burns:– Edema under eschar– Remove all rings, jewelry– Elevate, active motion– Check skin color,
sensation, capillary refill, Doppler pulses q1h
– Rule out hypotension, arterial injury
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Burn wound management
• Bedside escharotomy• 3rd degree burns
insensate• Use electrocautery• Mid-medial or mid-
lateral, across joints• Recheck pulses - may
have to do opposite side of limb
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Fasciotomy In Burns
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Burn wound managementSpecific anatomical areas:
Face - watch for airway compromise
Eyes - fluorescein exam, copious irrigation, antibiotic ointment,mydriatics
Ears - external canal, TM (children, perf in blast injury)
Genitalia, perineum - insert Foley to stent urethra treat scrotal edema conservatively diverting colostomy NOT automatically indicated in perineal
burnsDr. Sunil Keswani, National Burns Centre, www.burns-
india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
SURGICAL TECHNIQUES-ACUTE BURNS
EARLY EXCISION
Tangential excision and grafting-within first 72 hrs
Cadaveric skin from SKIN BANK
DELAYED EXCISION
Fascial excision and grafting-after 72hrsCadaveric skin from SKIN BANK
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
Dermatome with blade
DERMATOME-HARVESTING GRAFT
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Fascial excision
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Integra and ACTICOAT
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Skin grafting of extensive Burns
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Case -2 skin grafting
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com,
NATIONAL BURNS CENTREBurns Helpline:
+91 22 2779 3333
www.burns-india.com [email protected]