1. Rania Hassan Abdel Hafiez

2. :Case A 35 years old female weighing 100 kg with a 75% flame burn was admitted at 4pm to the burn unit. Her burn occurred at 2pm. On clinical examination she was dyspnic (RR 32), with low reading on pulse oximetery (SPO­ 2 75%) and with change in her voice. she said that she fall from the first floor.  What is the first thing that you would like to do? And why?  Calculate the fluid requirement for first 24 hours & their distribution and type?  What are the medications that you would like to prescribe to her?  What are the other investigations that should be done?

4. Definitions: Burn wounds are coagulative lesions of the surface layers of the skin usually caused by contact with a solid hot or cold object (contact burn), flames (flame burn), heated liquids (scald), chemicals or physical agents (electricity, radiation, lightening).

5. Definitions(con) Burn injury is a complex traumatic event with various local and systemic effects, affecting several organ systems beyond the skin.

6. Burn severity is related to:  Burn surface area  Burn depth  Distribution

7. Burn Depth(con):  The depth of burn is not static, wounds can evolve over time = becoming deeper if not adequately managed

8. Burn Depth: First degree= epidermis Second degree = superficial partial thickness =1+upper layers of dermis deep partial thickness =1+2+deeper layers of dermis Third degree full-thickness =1+2+3+subcutaneous tissue Fourth degree =1+2+3+4+fascia,muscle,bone

9. Medline Plus (2009) www.nlm.nih.gov/.../ency/fullsize/1078.jpg

10. First degree burn

11. Second degree burn

12. Third degree burns

13. Burn surface area Hand method A simple method of estimating burn surface area used in triage uses the patient’s palmar surface area being roughly equivalent to 1% of his/ her body surface area.

14. Burn surface area(con) Wallace Rule of Nines

15. Burn surface area(con) Lund and Browder chart to assess burn area

16. Patient categorization: The American Burn Association  Major burn injury ICU  Moderate burn injury ward  Minor burn injury outpatient

17. Major burn injury: Partial-thickness burns involving more than 25% of TBSA in adults or 20% of TBSA in children younger than 10 years or adults older than 50 years. Full-thickness burns involving more than 10% of TBSA. Burns involving the face, eyes, ears, hands, feet, or perineum.

18. Major burn injury (con) Burns caused by caustic chemical agents; High-voltage electrical injury. Burns complicated by inhalation injury or major trauma. Burns sustained by high-risk patients (those with underlying debilitating diseases).

19. Moderate burn injury: Partial-thickness burns of 15-25% of TBSA in adults or 10-20% of TBSA in children or older adults Full-thickness burns involving 2-10% of TBSA that do not present serious threat of functional or cosmetic impairment of the eyes, ears, face, hands, feet, or perineum.

20. Minor burn injury:  Less than 15% of TBSA in adults or 10% of TBSA in children or older persons,  Full-thickness burns involving less than 2% of TBSA

21. systemic inflammatory response syndrome (SIRS) When burn wound area exceeds 20% total body surface, the protective inflammatory response becomes counter productive, with pro- inflammatory mediators ‘flooding the system’ and overwhelming the body.

22. Systemic manifestations of burn

23. Histamine, Serotonin, Prostaglandins, platelet products, complement, kinin. capillary permeability massive loss of fluid and electrolytes

24. This affects both local and systemic capillaries. It is now recognized that burn shock is a complex process of circulatory and microcirculatory dysfunction that is not easily or fully repaired by fluid resuscitation. Hypoperfusion of burned tissue also may result from direct damage to blood vessels or vasoconstriction secondary to hypovolemia. In patients with major burns, release of catecholamines, vasopressin, and angiotensin causes peripheral and splanchnic bed vasoconstriction that can compromise organ perfusion.

25. Myocardial contractility also may be reduced by the release of inflammatory cytokine tumor necrosis factor-alpha Cardiovascular system responds immediately to thermal injury by a reduction in cardiac output accompanied by an elevation in peripheral vascular resistance.

26. In the absence of heart disease, ventricular ejection fraction and velocity of myocardial fiber shortening are actually increased during thermal injury. With replacement of plasma volume, cardiac output increases to levels that are above normal.

27. Pathophysiology of Burn Shock : A) Hypovolemic etiology: − Decreased cardiac output − Increased extracellular fluids − Decreased plasma volume  In burn shock, resuscitation is complicated by obligatory burn edema Q\Time for maximal edema formation? B) Changes at cellular level: >30% burn; cell transmembrane potential ----> Na- (K ATPase ( defective ATP metabolism

28. Systemic manifestations of burn B) Metabolic Response to Burn Injury Hypercatabolism: This response can last as long as a year after injury and is associated with impaired wound healing, increased infection risk, erosion of lean body mass, impaired rehabilitation, and delayed integration of the burn patient into society. :

29. Catabolic hormones counteract the effect of insulin; as a result, blood sugar levels rise, and protein synthesis and lipogenesis are inhibited. Growth hormone is similarly antagonized and less effective.  In this environment, skeletal muscle is the major obligatory fuel. (compare to starvation)

30. gluconeogenesis, glyconeolysis, muscle proteolysis

31. Systemic manifestations of burn (con) C) Thermal effects Hypothermia  Increased evaporative water loss from burned skin obligatory concurrent heat loss  Large volumes of cool IV fluids  Exposure of body surfaces to a cool emergency department environment.

32. Systemic manifestations of burn (con) Hyperthermia  The threshold set point of the thermoregulatory centre is higher and proportional to the size of burn. The temperature set point increases 0.03 degree Celsius per % TBSA burn. ( TNF, IL-1 and IL-6 )

33. Systemic manifestations of burn (con) smoke PVRtrauma

34. Systemic manifestations of burn (con) RBFGFR

35. Systemic manifestations of burn (con)

37. Care at the scene: A)Airway (c):  Cardiopulmonary Resuscitation  Cervical spine immobilization  100% O2 via a non rebreather mask if there is any suspicion of smoke inhalation  If unconscious or in respiratory distress -- --> endotracheal intubation

38. Care at the scene: B) Other injuries and transport:  Assess other injuries; transport to nearest hospital  Keep flat and warm and wrapped in clean sheet and blanket.  NPO??????  IVF = isotonic crystalloid infusion ??????  Constricting clothing and jewelry should be removed from burned parts due to local swelling begins

39. Emergency Care Primary rule: ignore the burn and Search for life- threatening injuries ABCDEFGHI

40. Emergency Care AIRWAY

41. Emergency Care BREATHIG

42.  Secure and protect airway  Cervical spine immobilization  Assess for inhalation injury  Circumferential chest burns can impair ventilation

43. Inhalation Injuries Suspect inhalation injury when: Burn in a closed space Burns to face or neck Singed nasal hair or eyebrows Hoarseness of voice, wheezing or stridor Sooty sputum Brassy cough or drooling Labored breathing or tachypnea Erythema and blistering of oral or pharyngeal mucousa Routine use of fiberoptic bronchoscope

44. Inhalation Injuries Cont., Carbon Monoxide Poisoning  Most common inhalation injury  May occur with or without cutaneous burns  Hemoglobin’s affinity for carbon monoxide is 200x greater than that for oxygen; result = hypoxia  Diagnosis:  Serum COHb levels & ABG’s  Pulse Ox: false readings !!  Management: 10 100% O2 Face mask or mechanical ventilation

45. Thermal Airway Injury: What to do?

46. Thermal Airway Injury: intubation What to do? Why to do? Edema (max?) When to do? Early How to do? Nasal or oral? Where to do? ICU or ER.

47. ketamine narcotics Succinyl choline

48. Thermal Airway Injury: Treatment Upper Airway: Rapid endotracheal intubation. Ability of adult pt to breathe around the tube w/ the cuff deflated is an indication for tube removal(leak test)..

49. Thermal Airway Injury: Treatment Lower Airway: SUPPORTIVE TILL HEALING PROTECTIVE LUNG STRATEGY.

50. Thermal Airway Injury:

51. Emergency Care CIRCULATION

52. INITIATE RESTORATION OF HEMODYNAMIC STABILITY  isotonic crystalloid infusion  Large Bore Peripheral Intravenous Lines  Remove any constricting items  Consider Escharotomy for circumferential burns

53. Emergency Care DISABILITY

54. Emergency Care Enviroment Escharotomy Electrolytes

55. ESCHAROTOMY  Respiratory distress due to deep circumferential burn wound of the thorax.  Peripheral pulsations.

56. ESCHAROTOMY

57. Emergency Care FLUIDS

58. Fluid Resuscitation:  Restore effective plasma volume  Avoid microvascular ischemia  Maintain vital organ function The amount of fluid required varies with patient's age, body weight, and extent of burned TBS.

59. Fluid Therapy  Parkland Formula is used to calculate the amount of fluid to use to resuscitate the patient based on burn percentage.  4mL/kg/% burn in the first 24 hrs, half of which is given in the first 8 hours (MAX?)  2mL/kg/% burn in the second 24 hrs, third of which is given as colloid  Infuse at constant rate instead of by bolus  Vitamin C and Vasopressin help reduce fluid requirements

60. Emergency Care GET VITAL SIGNS

61. Blood pressure - only reliable as volume indicator if low Pulse: young patient - pulse less than 120, reasonable perfusion; pulse > 130, increase fluid Elderly or with heart disease - pulse not accurate reflection of perfusion Urine output - 0.5 to 1 cc/kg/hr is adequate in absence of diuretic such as alcohol Exception: Myoglobin or hemoglobinuria where over 1cc/kg/hr is indicated

62.  Base deficit > 5 meq / liter reflects decreased tissue oxygenation. Look for progressive decrease in base deficit as marker of adequacy of resuscitation.  Electrocardiogram - particularly important for patient more than 45 years old  Temperature - Avoid hypothermia  Peripheral perfusion: for circumferential arm, leg burns

63. Emergency Care Head To Toe History

64. Emergency Care INSPECT Burn wound

65. Emergency Care:  Antibiotics  Anticoagulants  Antistress  Antioedema  Analgesics

66. :Case A 35 years old female weighing 100 kg with a 75% flame burn was admitted at 4pm to the burn unit. Her burn occurred at 2pm. On clinical examination she was dyspnic (RR 32), with low reading on pulse oximetery (SPO­ 2 75%) and with change in her voice. she said that she fall from the first floor.  What is the first thing that you would like to do? And why?  Calculate the fluid requirement for first 24 hours & their distribution and type?  What are the medications that you would like to prescribe to her?  What are the other investigations that should be done?

68. Thank you