Possible Pathophysiology changes in really ill patients: Hemodynamic changes Impaired thermoregulatory control Metabolic abnormalities Fluid and electrolyte imbalance Loss of nutrients
These pathophysiological changes may lead to: Peripheral edema Pulmonary complications Altered immune functions Infections Persistent inflammation Vasodilation Increase blood flow Erythema & Edema High output cardiac failure
These pathophysiological changes may lead to: Increased cutaneous blood flow RadiationHeat loss HYPOTHERMIA Compensatory mechanisms against hypothermia Make up for heat loss Raised BMRShivering Attempt to raise core body temperature Failure to compensate POIKILOTHERMIA Convection
Fluid and Electrolyte Imbalance: Normal TEWL= 400 ml/day(600-1000 ml) In ASF, increase 3-4 times In TEN, 3-4 lit/day Dehydration and decrease urine Low Na+ and high K+ Prerenal uraemia Hypophosphatemia Hypocalcemia
Loss of Nutrients: Protein – Causes: exfoliation,increase BMR,decrease hepatic synthesis,dermatogenic enteropathy,decrease oral intake due to oral lesions. – Normal exfoliation= 500-1000 mg/ day – Increase several folds (9 gm/sq.m./day) – Diffuse scaling- protein loss (20-30 g/sq.m/day) – Psoriasis > Drug Reaction > Eczema – In exudative,150 -200 gm/ day Iron,Vit. B12 and Folate deficiency.
Peripheral Edema: Increase capillary leakage due to increase levels of circulating VPF and VEGF. Hypoalbuminemia Cardiac failure Inflammation
Pulmonary Complications: Severe pulmonary edema ARDS Aspiration Pneumonia In TEN,dreaded complication
Altered Immune Functions: Impaired chemotaxis and phagocytosis Low serum gamma globulin level In TEN,lymphopenia,neutropenia and thrombocytopenia
Infections: Colonization and systemic entry Septic complications Colonization and systemic entry Septic complications
NoOrgan Involved Complications 1. Eye Ectropion, Entropian, Corneal Scarring, Symblepharon 2. Mucosal InvolvementMucosal Involvement Esophagus Esophagus Dysphagia resulting from stricture Urethra UrethraStricture and phimosisStricture and phimosis Vagina VaginaSynechiae 3. Skin Pigmentary changes, hypohirosis, contracture 4. HairScarring alopeciaScarring alopecia 5. NailBeau’s lines, splinter hemorrhage, distal onycholysis, dystrophy and total shedding of nails Long-term Complications:
General Supportive Treatment: Assessment and Monitoring Fluid and Electrolyte balance Control of infections Temperature control Nutrition
Clinical Biochemica l Hematolo gical Microbiological Pulse rate Respiratory Rate Level of consciousness Urine Output Gastric emptying Blood and Urine Sugar Urea/ creatinin e Serum Elecrolyt es Albumin Phospho rus Total and differe ntial WBC and Platele t count Bacteriology of skin lesions. Urine Culture Assessment and Monitoring :
Fluid and Electrolyte Balance: Fluid of choice = Colloids( Human albumin or FFP), NS Daily Fluid Reqd= Expected TEWL +Urine output. In TEN,Fluid Reqd= 2/3 rd to 3/4 th of burns.
Control of Infections: Local Removal of dead skin Regular bathing Open dressing Silver sulphadiazine Silver nitrate Oil based emollients Control of Infections: Systemic: Indications of Antibiotics High bacterial count Sudden Hypothermia Confused Mental Status Infection Temperature Control: Maintain the Env. Temp at 30 -32.C Antipyretic
Nutrition: In ASF, body can not compensate the energy loss due to reduced appetite, oropharyngeal lesions and malabsorption. Aggressive approach 1500-2000 calories in first 3-4 days followed by 3000-4000 calories. High protein diet= 2-3 gm/kg body wt/day 3-4 gm/kg body wt/day Vitamins and trace elements
No Underlying Condition Important Causes of Mortality 1. Erythroderma High output cardiac failure Adult respiratory distress syndrome Capillary leak syndrome Sepsis 2. SJS/TEN Massive fluid and electrolyte loss Prerenal uremia Septicemia Pulmonary embolism Adult respiratory distress syndrome Gastrointestinal hemorrhage 3. Acute generalized pustular psoriasis Hypocalcemia Oligemia Acute tubular necrosis of kidney 4. Pemphigus Septicemia Fluid and electrolyte imbalance 5. Staphylococcal scalded Skin syndrome Septicemia Causes of Mortality:
Specific Treatment: Specific measures depends on the etiology of the ASF. Conclusion: An entity just as mortal as failure of heart, lungs or kidneys. A dermatological emergency Multi-disciplinary and intensive care approach The earlier it is recognized and treated, the more satisfactory is its outcome. Based on the above facts the Nursing responsibility is highly important in saving the life of the patients specially in following ways: –Care in electrolytes balance –Care in avoiding infections –Care in temperature balance Compulsory part of the curriculum are highlighted in purple.