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Burn And Scald


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Burn And Scald

  1. 1. Burn and Scald
  2. 2. Burn & Scald <ul><li>Etiology </li></ul><ul><li>A burn injury occurs as a result of destruction of the skin from direct or indirect thermal force. </li></ul><ul><li>Burn are caused by exposure to heat, electric current, radiation or chemical. </li></ul><ul><li>Scald burn result from exposure to moist heat (steam or hot fluids) and involve superficial. </li></ul>
  3. 3. Types of burn injury <ul><li>Thermal burns. </li></ul><ul><li>Chemical burns </li></ul><ul><li>Electrical burns </li></ul><ul><li>Radiation burns. </li></ul>
  4. 4. Types of burn injury <ul><li>Thermal burns </li></ul><ul><li>-exposure to dry heat (flames) or moist heat (steam and hot liquids). </li></ul><ul><li>-Most common burn injuries </li></ul><ul><li>Chemical burns </li></ul><ul><li>-Direct skin contact with either acid or alkaline agents </li></ul><ul><li>-destroys tissue protein, leading to necrosis. </li></ul><ul><li>-Burn cause by alkalis are more difficult to neutralize than are burns caused by acid. </li></ul><ul><li>-Alkalis tends to have deeper penetration. </li></ul>
  5. 5. Chemical burns
  6. 6. Types of burn injury <ul><li>Electrical burns . </li></ul><ul><li>-severity depends on the type and duration of current, and amount of voltage. </li></ul><ul><li>-difficult to assess, due to electrical insulator. </li></ul><ul><li>Radiation burns. </li></ul><ul><li>-sunburn or radiation treatment of cancer. </li></ul><ul><li>-involve outermost layers tends to be superficial. </li></ul><ul><li>-all function skin is intact. </li></ul>
  7. 7. Electrical hand burn.
  8. 8. Burn & Scald:Epidemiology <ul><li>1 million people suffer thermal injury each year in U.S. </li></ul><ul><li>45,000 persons are admitted to hospital. </li></ul><ul><li>↑45,000 persons die as a result of burn injury. </li></ul><ul><li>The direct cost of treating a burn injury can be high. </li></ul><ul><li>Cost are higher for large burns. </li></ul>
  9. 9. Burn <ul><li>The depth of a burn is dependent on the temperature of the burning agent and the length of time. </li></ul><ul><li>Tissue damage may occur at temperatures of 48°c. </li></ul><ul><li>Irreversible damage to the dermis occurs at 70°. </li></ul><ul><li>Burn injuries are described as:- </li></ul><ul><li>1.Superficial (first-degree burns) </li></ul><ul><li>2.Superficial or deep partial thickness (second-degree burns). </li></ul><ul><li>3.Full thickness (third-degree burn) </li></ul>
  10. 13. Burn:Classification <ul><li>1. Superficial (first-degree burns) </li></ul><ul><li>Involve only the epidermal layer of the skin. </li></ul><ul><li>sunburns are commonly first-degree burns. </li></ul><ul><li>2. Superficial or deep partial thickness (second-degree burns). </li></ul><ul><li>Destruction of the epidermis and varying depths of the dermis. </li></ul><ul><li>Usually painful because nerve endings have been injured & exposed. </li></ul><ul><li>Ability to heal because epithelial cells is not destroyed. </li></ul>
  11. 14. 1° burn 2° burn
  12. 15. Superficial burn (1° burn)
  13. 16. Partial thickness (2°burn)
  14. 17. Burn:Classification <ul><li>Present of blisters indicates superficial partial-thickness injury. </li></ul><ul><li>Blister may ↑size because continuous exudation and collection of tissue fluid. </li></ul><ul><li>Healing phase of partial thickness, itching and dryness because ↑vascularization of sebaceous glands, ↓reduction of secretions and ↑perspiration. </li></ul>
  15. 18. Blister may ↑size because continuous exudation and collection of tissue fluid
  16. 19. Burn:Classification <ul><li>3.Full thickness (third-degree burn) </li></ul><ul><li>Destruction of the epidermis and the entire dermis, subcutaneous layer, muscle and bone. </li></ul><ul><li>Nerve ending are destroyed-painless wound. </li></ul><ul><li>Eschar may be formed due to surface dehydration. </li></ul><ul><li>Black networks of coagulate capillaries may be seen. </li></ul><ul><li>Need skin grafting because the destroyed tissue is unable to epithelialize. </li></ul><ul><li>Deep partial-thickness burn may convert to a full-thickness burn because of infection, trauma or ↓blood supply. </li></ul>
  17. 20. 3° burn
  18. 21. Eschar:composed of denatured protein
  19. 22. Full thickness (3°burn)
  20. 23. Burn and scald <ul><li>Function of the skin. </li></ul><ul><li>Protection </li></ul><ul><li>Body temperature regulation </li></ul><ul><li>Cutaneous sensation. </li></ul><ul><li>Metabolic functions (vit D) </li></ul><ul><li>Blood reservoir </li></ul><ul><li>Excretion. </li></ul><ul><li>As a result of burns & scald normal skin structure and function are impaired. </li></ul><ul><li>-sweat and sebaceous glands are destroyed. </li></ul><ul><li>-sensory receptors is ↓. </li></ul><ul><li>-body fluids escape, </li></ul><ul><li>-lack of temperature control. </li></ul>
  21. 24. Pathopysiology <ul><li>Local tissue response </li></ul><ul><li>Systemic response to burn injury. </li></ul><ul><li>Local tissue response </li></ul><ul><li>Damage to skin from thermal injury cause tissue changes know as zone of injury. </li></ul><ul><li>If the heat is severe, a zone of coagulation is formed, in this area protein has been coagulated and the damage is irresversible. </li></ul>
  22. 25. Local tissue response <ul><li>Therefore, blood vessels are damage, resulting in ↓perfusion. </li></ul><ul><li>Zon of statis </li></ul><ul><li>Poor blood flow and tissue edema will cause risk for death over a few hours or days. </li></ul><ul><li>Further necrosis can happen, because other factors e.g dehydration and infection. </li></ul><ul><li>Due to these wound have to be clean/care, hydration and prevention of infection are essential to limit further destruction. </li></ul>
  23. 26. Local tissue response <ul><li>Zone of hyperemia or inflammation is at the outer edge of the burn. </li></ul><ul><li>Here blood flow is ↑because of vasodilation. </li></ul><ul><li>Vasodilation because of the release of vasoactive substances. </li></ul><ul><li>↑ blood flow brings leukocytes and nutrients to promote wound healing. </li></ul>
  24. 27. Zon of injury
  25. 28. Thermal injury Inflammation Vasodilatation & ↑blood flow Leukocyctes & nutrient promote healing Vasoactive substance
  26. 29. Normal Vasodilatation
  27. 30. Systemic response to burn injury: severe burn <ul><li>Every organ system is affected by a major burn injury. </li></ul><ul><li>Systemic changes known as burn shock develop with a burn greater than 25% of the total body surface area (TBSA)-major burn injury. </li></ul><ul><li>Damaged tissue released cellular mediators and vasoactive substances. E.g, histamine, serotonin & prostaglandins </li></ul>
  28. 31. Systemic response to burn injury <ul><li>These substances induce a systemic inflammatory response and cause vasoconstriction & capillary permeability </li></ul><ul><li>Vasoconstriction occur for a short period due to vascular system attempts to compensate for fluids loss. </li></ul><ul><li>Vascular permeability, resulting in hypovolemia and edema. </li></ul><ul><li>This phase begins at injury, peaks in 12-24 hours, and last for 48 to 72 hours </li></ul>
  29. 32. Edema <ul><li>Osmotic pressure ↓, </li></ul><ul><li>Due to protein plasma </li></ul><ul><li>Escape out to interstitial </li></ul><ul><li>↓ blood flow & hypovolemia </li></ul>
  30. 33. Intravascular Normal
  31. 34. Burn Shock First 24 hours Burn Shock after 24 hours
  32. 35. Thermal injury Inflammation Histamine release Vasoconstriction ↑ blood pressure ↑ blood flow to injury ↑ capillary permeability Fluids leakage and Loss from injury Site (edema) ↓ intravascular fluid Hypovolemic shock ↑ Protein leakage Hypoproteinemia ↓ Plasma osmotic pressure
  33. 36. Factors determining severity of burns <ul><li>Size of burn </li></ul><ul><li>Depth of burn </li></ul><ul><li>Age of victim </li></ul><ul><li>Body part involved </li></ul><ul><li>Mechanism of injury </li></ul><ul><li>History of cardiac, pulmonary, renal, or hepatic disease </li></ul><ul><li>Injuries sustained at time of burn. </li></ul>
  34. 37. Effects of a severe burn <ul><li>Cardiovascular </li></ul><ul><li>Respiratory </li></ul><ul><li>Immune </li></ul><ul><li>Integumentary </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Urinary </li></ul>
  35. 38. Cardiovascular system <ul><li>Blood pressure falls-fluid leaks from intravascular to interstitial (sodium and protein) </li></ul><ul><li>When blood pressure is low, pulse rate ↑. </li></ul><ul><li>Blood flow in intravascular is concentrated and cause static. </li></ul><ul><li>Cardiac output ↓, </li></ul><ul><li>Due to that tissue perfusion ↓, </li></ul>
  36. 39. Hematologic changes <ul><li>Some RBC is destroys to the burn injury.-anemia </li></ul><ul><li>Thrombocytopenia, abnormal platelet function, depressed fibrinogen levels, deficit plasma clotting factors. </li></ul><ul><li>Life span ↓RBC. </li></ul><ul><li>Blood loss during diagnostic and therapeutic procedure. </li></ul>
  37. 40. Respiration system <ul><li>Majority of deaths from fire are due to smoke inhalation. </li></ul><ul><li>Pulmonary damage can be from direct inhalation injury or systemic respond to the injury. </li></ul><ul><li>Damage to cilia and cell in the airway-inflammation. </li></ul><ul><li>Mucociliary transport mechanism not functioning-bronchial congestion and infection. </li></ul><ul><li>Pulmonary edema, fluids escape to interstitial. </li></ul><ul><li>Airway obstruction. </li></ul>
  38. 41. Factors determining inhalation injury or potential airway obstruction <ul><li>Burns to face and neck </li></ul><ul><li>Singed hairs, nasal hair, beard, eyelids or eyelashes </li></ul><ul><li>Intraoral charcoal, especially on teeth and gums </li></ul><ul><li>Hoarseness </li></ul><ul><li>Smell of smoke on victims clothes or on victim. </li></ul><ul><li>Respiratory distress. </li></ul><ul><li>Copious sputum production. </li></ul>
  39. 44. Features of respiratory failure <ul><ul><li>Inability to speak due to dyspnea </li></ul></ul><ul><ul><li>Sweating </li></ul></ul><ul><ul><li>Apparent exhaustion/tired </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Tachypnea [R. Rate > 40 /min in adults ] </li></ul></ul>
  40. 45. Management <ul><li>Anaesthetic consultation </li></ul><ul><li>High flow oxygen </li></ul><ul><li>Tracheobronchial [ bronchoscopy] </li></ul><ul><li>Physiotherapy </li></ul><ul><li>Close monitoring [preferably ICU ] </li></ul><ul><li>Ventilatory support </li></ul><ul><li>Hemodynamic support, when required </li></ul>
  41. 46. Gastrointestinal <ul><li>Burn >20% experience ↓peristalsis, gastric distention and ↑risk of aspiration. </li></ul><ul><li>Paralytic ileus due to secondary to burn trauma. </li></ul><ul><li>Stress ulcer (stomach/duodenum) due to burn injury. </li></ul><ul><li>Indication of stress ulcer-malena stool or hematemesis. </li></ul><ul><li>These signs suggest gastric or duodenal erosion (Curling`s ulcer) </li></ul><ul><li>Gastric distention and nausea may lead to vomiting. </li></ul>
  42. 47. Urinary system <ul><li>Hypovolemic state, blood flow to kidney ↓, causing renal ischemia. </li></ul><ul><li>If this continues, acute renal failure may develop. </li></ul><ul><li>Full thickness and electrical burns, myoglobin (from muscle breakdown) and heamoglobin (from RBC breakdown) are released into the bloodstream and occlude renal tubules. </li></ul><ul><li>Adequate fluid replacement and diuretics can counteract this obstruction. </li></ul>
  43. 48. Myoglobinuria
  44. 49. Immunologic changes <ul><li>Skin barrier to invading organisms s destroyed, circulating levels of immunoglobulins are ↓ </li></ul><ul><li>Changes in WBC both quantitative and qualitative. </li></ul><ul><li>Depression of neutrophil, phagocytic and bactericidal activity is found after burn injury. </li></ul><ul><li>All this changes in the immune system can make the burn patient more susceptible to infection. </li></ul>
  45. 50. Complications <ul><li>Early </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Fluid overload </li></ul><ul><li>Renal dysfunction </li></ul><ul><li>Hemoglobinuria </li></ul><ul><li>Stress gastroduodenal ulcers </li></ul><ul><li>Pulmonary dysfunction </li></ul><ul><li>Local / systemic sepsis </li></ul>
  46. 51. Complications <ul><li>Late </li></ul><ul><li>Scarring –hypertrophic, keloid </li></ul><ul><li>Contractures – limbs, neck </li></ul><ul><li>Disfigurement </li></ul><ul><li>Functional disability </li></ul><ul><li>Posttraumatic stress </li></ul>
  47. 52. Extent of surface area burned <ul><li>Rule of nines - An estimated of the TBSA involved as a result of a burn. </li></ul><ul><li>The rule of nines measures the percentage of the body burned by dividing the body into multiples of nine. </li></ul><ul><li>The initial evaluation is made upon arrival at the hospital. </li></ul>
  48. 53. Rule of nines
  49. 54. Lund and Browder <ul><li>More precise method of estimating </li></ul><ul><li>Recognizes that the percentage of BSA of various anatomic parts. </li></ul><ul><li>By dividing the body into very small areas and providing an estimate of proportion of BSA accounted for by such body parts </li></ul><ul><li>Includes, a table indicating the adjustment for different ages </li></ul><ul><li>Head and trunk represent larger proportions of body surface in children. </li></ul>
  50. 56. Lund and Browder chart 3½ 3¼ 3 2¾ 2½ 2½ C-1 leg (back or front) 4¾ 4½ 4¼ 4 3¼ 2¾ B-1 thigh (back or front) 3½ 4½ 5½ 6½ 8½ 9½ A-head (back or front) Adult 15 10 5 1 0 Age in years
  51. 57. Review <ul><li>Types of burn injury </li></ul><ul><li>Burn: Classification </li></ul><ul><li>Pathophysiology:- </li></ul><ul><li>local tissue respond (zon of injury) </li></ul><ul><li>systemic respond to burn injury. </li></ul><ul><li>surface area burned:- </li></ul><ul><li>Rule of nines and Lund & Bruder Browder </li></ul>
  52. 58. Prehospital patient management <ul><li>Rescuers must ensure their own safety, ones safety is establish:- </li></ul><ul><li>Eliminate the heat source. </li></ul><ul><li>Stabilizing the victim condition. </li></ul><ul><li>Identify the type of burn. </li></ul><ul><li>Preventing heat loss. </li></ul><ul><li>Reducing wound contamination. </li></ul><ul><li>Restrict jewelry and clothing is removed </li></ul><ul><li>Preparing for emergency transport. </li></ul>
  53. 59. Stop the burning process:Thermal burns. <ul><li>Stop the flame: extinguish the flame/lavage with water. </li></ul><ul><li>Cool the burn </li></ul><ul><li>Do not used ice water for cooling it causes vasoconstriction and may result in further injury. </li></ul><ul><li>Cover the wound to minimize bacteria contamination </li></ul><ul><li>Cover victim to prevent hypothermia. </li></ul>
  54. 60. Chemical burns <ul><li>Immediately remove the clothing and a hose or shower to lavage the involved area for a minimum 20 minutes. </li></ul><ul><li>Electrical burns </li></ul><ul><li>-Serious harm to victim and rescuer. </li></ul><ul><li>-Ensure source of electrical has been disconnected. </li></ul><ul><li>-Use non conductive device to remove victim. </li></ul><ul><li>-If victim unresponsive, assess respiration and pulse. </li></ul><ul><li>-Commenced CPR (cardiopulmonary resuscitation) if no pulse. </li></ul>
  55. 61. Radiation burn <ul><li>Usually minor, involved epidermal layer of skin. </li></ul><ul><li>Helping the normal body mechanism to promote wound healing </li></ul><ul><li>Shielding, establishing distance. </li></ul><ul><li>Limit time of exposure to radioactive source. </li></ul>
  56. 62. Phases of treatment <ul><li>3 phases of treatment can be identified in the care of the severely burned patient. </li></ul><ul><li>The emergent phase refers to the first 24 to 48 hours after a burn. </li></ul><ul><li>Acute phase </li></ul><ul><li>Rehabilitation phase. </li></ul>
  57. 63. Burn bedspace <ul><li>Plastic sheet top </li></ul><ul><li>bottom sterile Microdon sheeting </li></ul><ul><li>Caps, masks, sterile gloves, gowns </li></ul><ul><li>Intravenous fluids/equipment </li></ul><ul><li>Intubation equipment </li></ul><ul><li>Oxygen therapy </li></ul><ul><li>Cardiac monitoring </li></ul><ul><li>Catheter, syringes, needles </li></ul>
  58. 64. Isolation <ul><li>Reverse Isolation is designed to prevent transmission of microorganisms to patient. </li></ul><ul><li>Burn patient are protected from infection from other patients, visitors, and health care providers. </li></ul><ul><li>Universal precautions, apply to all burn patients. </li></ul><ul><li>The minimum requirements: Universal Precautions are…………….. </li></ul>
  59. 65. Universal Precautions <ul><li>1. All patients have a private room </li></ul><ul><li>2. Handwashing is required before entering and after leaving the patient's room. </li></ul><ul><li>3. Gowns, gloves and masks, </li></ul><ul><li>4. Health care provider having URTI are not allowed to enter room </li></ul>
  60. 66. ER Assessment History Physical examination Intravenous line Nasogastric tube Indwelling catheter Neurological assessment Vital signs
  61. 67. Emergency department Management: Emergent/immediate phase <ul><li>1. Assessment </li></ul><ul><li>-Health history, how, when, duration of contact, location, age, medical history. </li></ul><ul><li>2. Physical examination </li></ul><ul><li>Respiration, patent airway, sign of inhalation injury. </li></ul><ul><li>Listen for hoarsenes and crackle. Need intubation. </li></ul><ul><li>Observe for upper body burned, erythema or blistering of lips or buccal mucosa or pharynx </li></ul><ul><li>Area of body burned-face, hands, feet, perineum. </li></ul>
  62. 68. Emergency department Management: Emergent/immediate phase <ul><li>Cardiac monitoring, is indicated for cardiac history, electrical injury or respiratory problems. </li></ul><ul><li>Vital signs-BP, PR. For severe burn an arterial catheter is used for blood pressure. </li></ul><ul><li>Large bore intravenous lines and an indwelling urinary catheter are inserted to assess and monitor fluid intake and output. </li></ul><ul><li>May assist in determining the extent of preburn renal function and fluids status. </li></ul>
  63. 69. Emergency department Management: Emergent/immediate phase <ul><li>Nurse needs to know the maximal volume of fluid the patient should receive. </li></ul><ul><li>Infusion pumps and rate controller are useful devices for correctly delivery. </li></ul><ul><li>Insert nasogastric tube to remove gastric juice, which can prevent aspiration and vomiting. </li></ul><ul><li>The neurologic assessment focuses on the pateint`s levels of consciousness, psychologic s status, pain, behavior and anxiety. </li></ul>
  64. 70. Support vital sign <ul><li>If the patient has no pulse and not breathing, begin CPR. </li></ul><ul><li>Establish airway-nasotracheal suction and endotracheal intubation.-oxygen 100% via face mask. </li></ul><ul><li>Connect to cardiac monitor and observe for arrhytmia. </li></ul><ul><li>Pulse oximeter-assessment for patient oxygen </li></ul><ul><li>saturation. </li></ul>
  65. 71. Pulse oximeter <ul><li>The pulse oximeter probe contains two electrodes, which emit light of specific wavelength through a cutaneous vascular bed, such as that of the digits or the ear lobe. </li></ul>
  66. 72. Pulse oximeter
  67. 73. Support vital sign; pulse rate <ul><li>1.   Following a burn, tachycardia is inevitable, </li></ul><ul><li>due to hypovolemia as a result of tissue trauma and pain. </li></ul><ul><li>2.  A pulse rate lower than 120 beats/min </li></ul><ul><li>usually indicates adequate volume. </li></ul><ul><li>Whereas a pulse rate higher than 130 beats/min </li></ul><ul><li>usually suggests inadequate resuscitation </li></ul><ul><li>3.  Beware that in the elderly or those with </li></ul><ul><li>preexisting heart disease, the heart rate may not be able to increase in proportion to the stimulus. </li></ul><ul><li>. </li></ul>
  68. 74. Support vital sign <ul><li>Continue assess heart output. </li></ul><ul><li>A minimal mean arterial pressure of </li></ul><ul><li>-90mmHg should be maintained for adequate tissue perfusion. </li></ul><ul><li>If the patient is hemodynamically unstable, </li></ul><ul><li>-the extremities are burned or if frequent measurement of arterial blood gases are required, insertion of an arterial catheter may be necessary. </li></ul><ul><li>Obtain Arterial blood gases, carboxyheamoglobin. </li></ul>
  69. 75. Arterial blood gases *To assess acid-base balance due to a respiratory disorder, respiratory acidosis . 75-100mmHg PO 35-45 mmHg PCO2 ↑ 7.35-7.45 PH ↓
  70. 76. Support vital sign <ul><li>Cover patient to maintain body temperature and to prevent wound contamination </li></ul><ul><li>Initiate fluids replacement </li></ul><ul><li>Urine output, this is the single best monitor of fluid replacement. </li></ul><ul><li>Weight should be measured daily, as changes in weight from admission allow an assessment of fluid balance </li></ul>
  71. 77. Insert Foley catheter <ul><li>1.Foley catheter should be placed in all patients undergoing resuscitation for severe burns and in patients with smaller burns with a history of difficulty voiding. </li></ul><ul><li>2. A loose-fitting catheter should be placed to prevent urethral stricture. </li></ul><ul><li>3.The catheter should remain in place throughout resuscitation. </li></ul><ul><li>4. Acceptable values are 0.5ml/kg/hr in an adult and at least 1ml/kg/hr in a child </li></ul>
  72. 78. Summary; Emergent phase
  73. 79. Emergency Management <ul><li>Site </li></ul><ul><li>-Maintain clear airway </li></ul><ul><li>-Remove from source of injury </li></ul><ul><li>-Prevent ongoing thermal injury </li></ul><ul><li>-Keep others safe </li></ul><ul><li>-Arrange prompt transfer to Burns Unit </li></ul>
  74. 80. Emergency Management <ul><li>Hospital Priorities -Airway -IV access – large bore peripheral line -Analgesia – diluted opioids, </li></ul><ul><li>- intravenously, large bore. Catheterise bladder Investigations [ see box below] </li></ul>
  75. 81. Diagnostic test   Swabs for culture &sensitivity   Daily urea , electrolytes   Daily FBC ABGs PCV until stable   Later   Urinalysis ABGs Grouping & typing Carboxyhemoglobin Blood sugar ECG Urea & electrolytes CXR Full Blood Count Optional Essential   Initial
  76. 82. Emergency Management <ul><li>History of accident </li></ul><ul><li>General Examination </li></ul><ul><li>Estimate the Area and the depth of the burn. Look for signs of inhalational burns </li></ul><ul><ul><ul><li>Stridor </li></ul></ul></ul><ul><ul><ul><li>Respiratory distress </li></ul></ul></ul><ul><ul><ul><li>Cough </li></ul></ul></ul><ul><ul><ul><li>Sooty sputum </li></ul></ul></ul><ul><ul><ul><li>Singed nasal hair </li></ul></ul></ul><ul><ul><ul><li>Nasolabial burns </li></ul></ul></ul><ul><ul><ul><li>Airway swelling </li></ul></ul></ul><ul><ul><ul><li>Document all findings </li></ul></ul></ul>
  77. 83.   Estimation of Total Body Surface Area Burned [ TBSA] <ul><li>Major Burns : >10 % BSA deep burn in a child                         >25% BSA deep burn in an adult All major burns WILL need parenteral fluid resuscitation , since the main cause of early mortality is Burns Shock. </li></ul>
  78. 84. Pathophysiology : Fluids replacement <ul><li>A. Four major processes are thought to contribute to the major loss of intravascular fluid. </li></ul><ul><li>1.       change in microvascular membrane integrity </li></ul><ul><li>2.       change in tissue forces </li></ul><ul><li>3.       cellular shock </li></ul><ul><li>4.       evaporative losses </li></ul><ul><li>  </li></ul>
  79. 85. B.Changes in microvascular integrity <ul><li>1. Following a burn there is a massive release of inflammator </li></ul><ul><li>mediators. </li></ul><ul><li>2. Histamine is released early,which increase capillary permeability </li></ul><ul><li>3. Polymorphonuclear leukocytes adhere to the endothelium. </li></ul>
  80. 86.   C. Changes in tissue forces <ul><li>1. The capillary leak causes fluid and plasma proteins to shift from the intravascular </li></ul><ul><li>to the interstitial space. </li></ul><ul><li>2. This causes hypoproteinemia, decreased intravascular osmotic pressure and increased interstitial osmotic pressure. </li></ul><ul><li>3.Edema results when the volume of interstitial fluid exceeds the capacity of the lymphatics to remove it. </li></ul>
  81. 87. E. Evaporative losses <ul><li>Additional evaporative losses through the burn wound can be between 4 and 20 times greater than normal and persist until complete wound closure is obtained. </li></ul>
  82. 88. Fluids resuscitation <ul><li>Lactated Ringer’s (LR) solution is the most popular resuscitation fluid used. </li></ul><ul><li>There are numerous formula that can be used for fluid resuscitation. </li></ul><ul><li>No fluid resuscitation formula has proven to be superior. </li></ul><ul><li>All formulas are only a starting point. </li></ul><ul><li>Administered fluids through 2 large bore needle. </li></ul>
  83. 89. Fluids resuscitation <ul><li>Fluid prescription for adults commonly uses the Parkland Formula which is: </li></ul><ul><li>4cc X weight (kg) X %TBSA burn = cc’s for 1st 24 hours (Ringer's Lactated) </li></ul><ul><li>First half of this total is administered over the first 8 hours, </li></ul><ul><li>And the second half over the next 16 hours. </li></ul><ul><li>Over 24 hours, >30% burn, provide 5% dextrose </li></ul>
  84. 90. Exampel: Parkland <ul><li>4cc X weight (kg) X %TBSA burn </li></ul><ul><li>4cc x 50kg x25% = 5000cc </li></ul><ul><li>5000 ÷ 500mls = 10 bottles. </li></ul><ul><li>50% to be administer = 2500 cc x 8 Per hours ~ 312.5cc. </li></ul><ul><li>Second half to be administer = 2500cc x 16 hours. </li></ul><ul><li>Per hour~156.25cc </li></ul>
  85. 91. Fluids resuscitation; Over 24 hours <ul><li>4cc X weight (kg) X %TBSA burn </li></ul><ul><li>4cc x 50kg x25% = 5000cc </li></ul><ul><li>5000cc of Ringer's Lactated + 2000cc 5% </li></ul><ul><li>Dextrose water. </li></ul>
  86. 92. Fluids resuscitation <ul><li>Calculate fluid deficit and decide fluid requirement </li></ul><ul><li>2 types of fluids – Crystalloids and Colloids </li></ul><ul><li>Crystalloids [e.g. –Ringer’s Lactate] </li></ul><ul><li>-Several formulas: Evans, Brookland etc. 3 – 4 ml / Kg. bodyweight / % Burn during the first 24 hours, </li></ul><ul><li>-half of which is to be given in the first 8 hrs [ from the time of injury ] </li></ul>
  87. 93. Crystalloid Solutions   273 308 289 Osmolality (mosm/kg)   6.7 5.7 7.4 pH mEq/L Lactate (28) -- Bicarb. (26) Buffer mEq/L 3/0 -- 5/2 Ca/Mg mEq/L 4 -- 4-5 K mEq/L 109 154 103 Cl mEq/L 130 154 141 Na   Ringer’s lactate 0.9% Saline Plasma  
  88. 94. Colloids [e.g. Human Albumin Solution ] <ul><li>1.Proteins in plasma generate osmotic pressure </li></ul><ul><li>and serve to maintain the intravascular volume. </li></ul><ul><li>-The administration of colloid compensates for this protein lost. </li></ul><ul><li>2 .  Much debate exists as to when capillary integrity is established and when or if colloid should be given </li></ul><ul><li>3. Early infusion of colloid solutions may decrease overall fluid requirements and reduce edema. However, excessive use of colloid risks iatrogenic pulmonary complications. </li></ul>
  89. 95. Colloids <ul><li>4. Guidelines for adding colloid to crystalloid regimen: </li></ul><ul><li>a. patients with burns less than 30% TBSA do not usually require colloid </li></ul><ul><li>b. patients with burns greater than 30% TBSA should receive colloid eight hours after injury </li></ul><ul><li>c. patients with inadequate urine output </li></ul><ul><li>d. colloid is administered by adding 50g of albumin to each liter of crystalloid </li></ul>
  90. 96. Rate of infusion <ul><li>Adult formula : Fluid first 24 hours = 4cc x % total body surface x body weight (one half in first 8 hours) </li></ul><ul><li>if shock present give bolus of fluid until perfusion restored </li></ul><ul><li>  then use constant rate, adjusting as needed </li></ul><ul><li>after 10 to 12 hrs. </li></ul><ul><li>gradually decrease infusion rate to avoid excess edema while maintaining perfusion </li></ul>
  91. 97. Intravenous Access <ul><li>A peripheral vein catheter through nonburn tissue is the route preferred for fluid administration. </li></ul><ul><li>A central line or pulmonary artery line is only occasionally needed to monitor the patient during the initial resuscitation period and is removed as soon as it is no longer needed. </li></ul><ul><li>The possibilities for intravenous access are: </li></ul>
  92. 98. Choices For Access <ul><li>First choice: Peripheral vein; nonburn area </li></ul><ul><li>Second choice: Central vein; nonburn area </li></ul><ul><li>Third choice: Peripheral vein; burn area </li></ul><ul><li>Worst choice: Central vein; burn area </li></ul>
  93. 99. Choices For Access <ul><li>Central venous access </li></ul><ul><li>1. subclavian vein- most desirable site due to lowest infection rate </li></ul><ul><li>2. internal jugular vein </li></ul><ul><li>3. femoral vein </li></ul>
  94. 100. Interventions: Ineffective airway clearance <ul><li>Baseline assessments respiratory status. </li></ul><ul><li>Chest x-ray, ABG, vital signs. </li></ul><ul><li>Intubation for burns of chest, face or neck. </li></ul><ul><li>Maintain the head of the bed at 30°. </li></ul><ul><li>Turn patient side to side every 2 hours to prevent hypostatic pneumonia. </li></ul>
  95. 101. Ineffective airway clearance <ul><li>Encourage coughing and deep breathing exercise promote airway clearance of mucus and fibrin. </li></ul><ul><li>Chest physiotherapy - via percussion and vibrations, assists with bronchial drainage </li></ul><ul><li>Positioning - patients are shaken and turned side to side every two hours to aid in secretion mobilization </li></ul><ul><li>Early ambulation - allows adequate air exchange in lung regions that are normally hyperventilated while the patient is recumbent </li></ul>
  96. 102. Ineffective airway clearance <ul><li>To keep airway clear, suction the client frequently, removes accumulated secretions that cannot be removed by spontaneous cough. </li></ul><ul><li>Caring of patient with nasotracheal tube placement and orotracheal-more than 3 week tracheostomy performed. </li></ul><ul><li>Aseptic procedure for suctioning. </li></ul><ul><li>Patients should be hyperoxygenated with 100% oxygen prior to suctioning. This should not be continued for more than 15 seconds without further oxygenation. </li></ul><ul><li>Vagal stimulation and bradycardia are possible complications. </li></ul>
  97. 103. Ineffective airway clearance <ul><li>Medication to dilate constricted bronchial passages.-via intravenous/inhalants to control bronchospasms and wheezing. </li></ul><ul><li>Proper positioning to ↓the work of breathing and promote chest expansion. </li></ul><ul><li>Ensure adequate tissue oxygenation-pulse oxymeter. </li></ul><ul><li>Oxygenation therapy, ↓oxygenation saturation. </li></ul>
  98. 104. Burn victim
  99. 105. Endotracheal tube
  100. 106. Tracheostomy