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1. burn

2. Improvement of survival
 Advances in fluid resuscitation
 Early excision of burn wound
 Specialized burn centers

3. Risk factors
 Children <5 yr
 In adult
Alcoholism
Senility
Psychiatric disorders
Neurological disease(epilepsy)

4. Mechanisms of thermal injury
 Body has very few specific protective &repair
mechanisms for
thermal,electrical,radiation&chemical burn
 Heat changes molecular structure of tissue and
denaturation of proteins is a common effect of all
types of burns

5. Severity of injury
 Temperature of agent
 Concentration of heat
 Duration of contact

6. Classification
 Thermal
 Electrical
 chemical

7. thermal
 Flash and flame
most common cause of adult admissions
Flash burn:
Reach progressive layers of dermis in proportion to amount
and kind of fuel that explodes
Flame burn:
Invariably deep dermal if not full thickness
More prolonged exposure
Often with inhalational injury &other concomitant
trauma

8. scalds
 Most common cause of pediatric burn admissions
 Depth of scald injury:
Temprature
Skin thickness
Duration of contact

9.  Hot water scalds:
60* & 3s deep dermal burn
69* & 1s deep dermal burn

10. Contact burn
 Hot metals,plastic,glass&coals
Small size
deep dermal or full thickness

11. Tar
 Boiling point of paving tar 140*,roof tiling tar 232*
 Hot tar contact skin: cools,solidified & sticks
At scene for cooling & solidification apply cold
water
Often deep second degree or third degree

12.  Difficult to remove tar,no pressing medical need to
removr rapidly
 Remove of tar improves patient comfort & allow
assesment of underlying damage
 Remove of tar carries risk of infection &conversion
of a partial thickness injury to a full thickness

13. Remove of tar
 Silversulfadiazin
 Neosporin
 Mayonnaise
 Butter
 Sunflower seed oil

14. Electrical burn
 Cardiac arrhythmia
 Compartment syndrom
 rhabdomyolysis

15. Chemical burn
 Most important initial therapy :
removal of toxic substance
Irrigation with water 30 minutes
 Exception to irrigation
Powdered lye
Concrete powder
 Formic acid
Hemolysis&hemoglobinuria
 Hydrofluoric acid
Hypocalcemia
Treatment: topical calcium gluconate&subcutaneous or iv
infiltration of calcium gluconate

16. Initial evaluation
1.Airway management
2.Evaluation of other injury
3.Estimation of burn size
4.Diagnosis of co and cyanid poisoning

17.  Direct thermal injury to upper airway or smoke
inhalation rapid &sever airway edema
 Anticipating need for intubation & establishing an
early airway is critical

18.  Inhalation injury
Facial burn
Perioral burn &signed nasal hairs
Erythema of mucous membranes
Soot in airway
 Hoarse voice
 Wheezing
 Stridor
 Subjective dyspnea
trigger prompt elective intubation

19. Burn patient considered trauma
patient
 Primary survey as A,B.C.D,..
 Burn >40% TBSA: two large_bore IV catheters
 IV through burn skin is safe
 In severly burned patient central venous access used
as to volum status

20. Comprehensive secondary survey
 History
 Examination
 Radiology & lab tests

21. In prehospital care
 Prevent hypothermia
 Hypothermia >>> resuscitation failure
 Patient wrapped with clean blankets in transport

22. Estimation of burn size
 Rule of nines:
 In adult:
Anterior trunk 18%
Posterior trunk 18%
Each upper extremity 9%
Each lower extremity 18%
Head&neck 9%
Genitalia/perineum 1%

23. In children <3 yr
 head&neck 20%
 Ant.trunk 18%
 Pos.trunk 18%
 Each upper extremity 9%
 Each lower extremity 13%

24. -
 Superficial or first degree burns not included in
percent of TBSA burned
 Clean ing of soot &debris mandatory to avoid
confusing area of soiling with burns

25. Co poisoning
 Affinity of co 200-250 times more than o2 for hb
 Decrease oxyhemoglobin>>anoxia,death
Diagnosis:
 Unexpected neurologic symptpms>>>co poisoning
 Arterial carboxyhemoglobin
 Puls oximetry not used ,is falsely elevated.

26. Treatment of co poisoning
 Gold standard>>> 100% o2
 Hyperbaric o2 (mixed data)

27. Refer to burn center
 Partial thickness burns>10%TBSA
 Burn that involve face,hands,feet,genitalia,perineum,major
joints
 Third –degree burn in any age group
 Circumferencial burns in any age group
 Electrical burns including litghtning injury
 Chemical burns
 Burns with a suspicion of inhalation injury
 Burn of any size with concomitant trauma or disease
which might complicate treatment or prolong recovery
or affect mortality

28. Refer to burn center
 Toxic epidermal necrolysis,Necrotizing
fasciitis,staphylococcal scalded child syndrom,ets
if involved skin area is 10% for children &elderly
and 15% for adults
 Any patient with burn& concomitant trauma in
which burn poses greatest risk of morbidity or
mortality
If trauma poses greater immediate risk patient initially
stabilized in trauma center befor transferred to
burn center

29. Refer to burn center
 Any type of burn if any doubt about treatment
 Burned children in hospitals without qualified
personnel or equipment for care of children
 Burn injury in patients who will require special
social ,emotional,or longterm rehabilitative
intervention
 Suspected nonaccidental injury

30. Burn depth
 Superficial (first degree)
 Partial thickness(second degree)
 Full thickness(third degree)
 Fourth_degree

31. First degree
 Eidermis involvement
 Sunburn
 dry,red,blanches with pressure,no blisters
 May be painful
 Shoud be left to heal by itself whitin 7 days
 No scarring

32. Superficial partial thickness burn
 Epidermis and part of papillary dermis involvement
 Pale pink,fine blistering,blanches with pressure
 Extremly painful
 Should be left to heal by itself within 14 days
 Can have color match defect
 Low to moderate risk of hyoertrophic scarring

33. Deep partial thickness
 Down to reticular dermis involvement
 Dark pink to red,large blisters,no capillary refill,
 May be painful or reduced/absent sensation
 Should not be left to heal by itself,but instead
should probably be submitted to surgery
 Healing 14_over 21 days
 Moderate to high risk of hypertrophic scarring

34. Full thickness
 Entire thickness of skin(flame,chemical,high voltage
electricity
 White,waxy or charred,no blisters,no capillary refill
 No sensation
 No healing capacity,should be always be submitted
to surgery
 Will scar

35. .
 Prediction for healing of partial thickness burn is a
problem
>>>>burn wound evolve over 48_72 hr
 techniques:
Full thickness biopsy(most effective)
Laser doppler
Ultrasound
Serial examination by burn surgeon(most practical
&reliable)

36. Prognostic factors
 Age
 Percent TBSA burned
 Inhalation injury
 Coexistent trauma
 pneumonia

37. resuscitation
 Parkland formula:
3_4ml * kg (w)*percent TBSA burned
 Lactated ringer
 ½ first 8 hr , ½ subsequent 16 hr

38. children
 Children under 20 kg do not have sufficient
glycogen stores to maintain an adequete glucose
level in response to inflammatory response
 Add maintenance IV fluid with glucose
supplementation in addition to resuscitation fluid

39. Adequacy of resuscitation
 Blood pressure
 Urin output(30 ml/hr in adult)(1_1.5ml/kg/hr in
pediatric)
 Serum lactate
 Base deficit

40. .
 Usually actual administered fluid volumes exceed
volumes predicted by standard formulas:
1.Opioid analgesic use>>>vasodilation,hypotention
2.Inhalation injury
 Complication s in patients receiving higher fluid
volumes:
Abdominal compartment syndrome
Extremity compartment syndrome
Itraocular cmpartment syn
Pleural effusions

41. Inhalation injury
 In 35% hospitalized burn patients
 Increase mortality in burn patients
 Increase hospital stay
 >>>ARDS(recruitment of alveolar
leukocytes,activated cytokine response)
 60%TBSA+inhalation injury+ARDS>>>100%
mortality

42. Mechanism of inhalation injury
 1.Direct heat injury to upper airways:
Maximal edema in 24_48 hr
Will require endotracheal intubation for airway
protection

43. .
 2.inhalation of combustion products into lower
airways:
Mucosal injury>>>mucosal sloughing,edema,reactive
bronchoconstriction,obstraction of lower airway
Injury to epithelium&alveolar macrophages>>>release
of prostaglandins,chemokines>>>increase capillary
permeability>>>ARDS

44. Effects of inhalation injury
 Decrease lung compliance
 Increase airway resistance
 Increase metabolic demands
 Increase fluid requirements

45. Diagnosis
 clinical finding(most important)
 Bronchoscopy
 Ct scan
 Ventilation_perfusion scan
 Partial pressure of arterial o2/fraction of inspired
o2<200

46. Treatment of inhalation injury
 Supportive care
 Aggressive pulmonary toilet
 Nebulized bronchodilators,n_acetylcysteine,heparin
 Surfactant
 New ventilator strategies
 Extracorporeal membrane oxygenation

47. Treatment of burn wound
Silver sulfadiazin
 Most widely use d
 Wide range of antimicrobial activity
 Soothing qualities
 Not significantly absorbed systemically
 Neutropenia
 Destroy skin grafts
 Contraindicated on burns in proximity to newly
grafted areas

48. Mafenid acetate
 Antimicrobial
 Effective in presence of eschar
 Excellent for fresh skin grafts
 Pain
 Metabolic acidosis

49. Silver nitrate
 Broad_spectrum antimicrobial
 Hyponatremia
 Methemoglobinemia
 Black stains

50. Silver_impregnated dressings
acticoat
For donor site&skin grafts
Recduce number of dressing changes

51. Nutrition
 Hypermetabolic response in burn injury raise
BMR by 200%
 Catabolism of muscle proteins &reduce lean body
mass
 Early enteral feeding:
Prevent loss of lean body mass
Slow hypermetabolic response
Prevent gastric ileus

52. .
 Reduction of hypermetabolic state:
Beta blocker
Anabolic steroid oxandrolone
Insulin
oral hypoglycemic agents(metformin)

53. surgery
 Early excision and grafting:
Improve mortality
Decrease reconstruction surgery
Improve hospital length of stay
Reduce costs of care

54. escharotomy
 Full thickness burns with rigid eschar >>>
tourniquet effect(as edema progress) >>>
compartment syndrome
Exteremity comp.syn
Abdominal comp.syn.
Thoracic comp.syn.
escharotomy

55. Complications of burn
infection
 Burned patient is immunosuppressed
 Infection in wounds,iv line,lungs
 Prophylactic antibiotics eliminares normal flora
and allows resistant organisms to grow
 Contamination and then overgrowth of burned
wound typically occure 2_3 weeks after injury
 Waiting until there is good clinical evidence of
infection delay infection by resistant organisms

56. Gastrointestinal ulcers
 Mucosal ischemia from burns >>>> ulcer
 As early as 12 hr after injury
 Prophylaxy by anacids,h2 blockers,early enteral
feeding decreased GI ulcers

57. Heterotopic ossification
 Typically in joints under the burn injury
 Calcium deposition in soft tissue around the joints
leads to restriction of motion,pain,skin breakdown
 Elbow is common
 Treatment:surgery ,radiotherapy

58. Hypertrophic scar
 when Deep wounds allowed to heal without
grafting hypertrophic scar,unstable epithelium
,poor skin elasticity occur
 Early skin grafting of deep wounds shortens period
of healing and inflammation and avoids some of
later problems of hypertrophic scar

59. DVT
 6_25% burned patients
 Heparin prophylaxis prevent DVT in burn

60. Electrical burns
 High voltage(>1000 V)
 Low voltage (<1000V)
 Flash burn

61. .
 Low voltage injury Rarely cause significant damage beyond a
small deep partial thickness burn at contact points
 High voltage injury cause extensive skin injury with
necrosis at contact point and deeper structures
 Electricity flows through tissue and generates heat
 Injury is multiorgan
 Degree of tissue injury is more extensive than perceived
on initial examination

62. .
 In high voltage victim usually thrown away from electric
circuit and lead to traumatic injury
 Contact wounds usually present at entry and exit
points & injuries more sever these points
 Vascular damage >>> progressive tissue necrosis
 Damage to tissue is three_dimentional with extensive
necrosis of the tissue at different levels from skin to
bone

63. Wound management
 Primary debridment
 Suitable decompression(fasciotomy)
 Serial & multiple debridment
 Early skin cover

64. Myonecrosis
 Massive muscular destruction >>>
myoglobinuria>>> acute renal failure
 Treatment by early aggressive fluid
replacement+osmotic diuretics(manitol)+alkalinizing
agents(bicarbonat)

65. Cardiac dysfunction
 Arrhythmia in 1/3 patients
 EKG monitoring for first 24 hr

66. Abdominal visceral complications
 Intestinal necrosis &perforation

67. Late complications
 Peripheral nerve injury (sensory
deficits,paraesthesia)
 Cataract