Describe the differences between partial and full-thickness burns. Describe the differences between partial and full-thickness burns


Download 457 b.
Sana22.05.2017
Hajmi457 b.



Describe the differences between partial and full-thickness burns.

  • Describe the differences between partial and full-thickness burns.

  • Describe how to estimate the size of a burn.

  • Describe initial care of burns.

  • Describe follow-up care of partial thickness burns.



Advanced Burn Life Support Course,

  • Advanced Burn Life Support Course,

  • American Burn Association, 1994

  • Textbook of Military Medicine, Part I, Vol 5

  • Conventional Warfare, OTSG, 1991

  • Textbook of Surgery, Sabiston, editor

  • W. B. Saunders, 1986

  • SESAP VI,

  • American College of Surgeons, 1988

  • Burn care product info



  • Partial thickness burn =

  • involves epidermis

  • Deep partial thickness =

  • involves dermis

  • Full thickness =

  • involves all of skin



Sunburn is a very superficial burn.

  • Sunburn is a very superficial burn.

  • Expect blistering and peeling in a few days.

  • Maintain hydration orally.

  • Heals in 3-6 days- generally no scaring

  • Topical creams provide relief.

  • No need for antibiotics



Blisters are typical of partial thickness burns.

  • Blisters are typical of partial thickness burns.

  • Don’t be in a hurry to break the blisters.

  • Heals in 14-21 days

  • Blisters provide biologic dressing and comfort.

  • Once blisters break, red raw surface will be very painful.



Yellow, “leathery” appearance; or charred

  • Yellow, “leathery” appearance; or charred

  • Often have no sensation (nerve endings destroyed)

  • Outer edges might be partial thickness.

  • Initial management same as partial thickness.

  • Later will need skin grafts.



Central yellow area might be full thickness.

  • Central yellow area might be full thickness.

  • Outer edges are probably partial thickness.

  • Initial management is the same.

  • Later will need skin grafts for the full thickness areas.



Zone of Coagulation

  • Zone of Coagulation

  • Zone of Stasis ‘circulation sluggish’

    • may covert to full thickness, mottled red
  • Zone of Hyperemia

    • outer rim, good blood flow, red




The patient’s own palm is about 1% of his body surface area.

  • The patient’s own palm is about 1% of his body surface area.

  • “Rule of Nines”





  • Partial thickness burns >10% BSA

  • Burns involving the face, hands, feet, genitalia, perineum, or major joints

  • full thickness/3 degree burn

  • Electrical, Chemical, and Inhalation burns

  • In combat, all but the most superficial burn should be evacuated



< 20% TBSA 2nd degree – Silvadene (SVC) Cream BID

  • < 20% TBSA 2nd degree – Silvadene (SVC) Cream BID

  • Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID

  • 3rd degree burn – SVC and SMC alt BID

  • *SMC only to the ears * Bacitracin Opth to face





Clean entire limb with

  • Clean entire limb with

  • soap and water (also under nails).

  • Apply antibiotic cream

  • (no PO or IV antibiotic).

  • Dress limb in position of function, and elevate it.

  • No hurry to remove blisters unless infection occurs.

  • Give pain meds as needed (PO, IM, or IV)

  • Rinse daily in clean water; in shower is very practical.

  • Gently wipe off with clean gauze.



In the pre-hospital setting, there is no hurry to remove blisters.

  • In the pre-hospital setting, there is no hurry to remove blisters.

  • Leaving the blister intact initially is less painful and requires fewer dressing changes.

  • The blister will either break on its own, or the fluid will be resorbed.



Upper arm burn day 1 day 2

  • Upper arm burn day 1 day 2



Blisters show probable partial thickness burn.

  • Blisters show probable partial thickness burn.

  • Area without blister might be deeper partial thickness.









Removing the blister leaves a weeping, very tender wound, that requires much care.

  • Removing the blister leaves a weeping, very tender wound, that requires much care.











Apply wet silver dressing

  • Apply wet silver dressing

  • directly on the burn.

  • Creams or dressings

  • under the silver dressing

  • impede the antimicrobial action.

  • Keep it moist!

  • Remove it, rinse it out, replace it on the burn.



Clean the burn and surrounding area.

  • Clean the burn and surrounding area.

  • Soak silver-impregnated dressing and gauze in

  • STERILE WATER or BOTTLED DRINKING WATER

  • Apply silver-impregnated dressing (over-lapping edges are best).

  • Wrap with the moist gauze.

  • Secure with mesh, gauze, or tape.

  • Keep it moist with WATER, every 12h or so More frequent in hot arid environments





Moisten dressing with WATER every 12h or so.

  • Moisten dressing with WATER every 12h or so.

  • Remove outer gauze and silver dressing every day.

    • Inspect the burn.
    • Rinse exudate off burn.
  • Rinse exudate off silver dressing with WATER.

  • Return same silver dressing to the burn.

  • Apply new outer gauze moistened with WATER.





Replace silver dressing

  • Replace silver dressing

    • every 2 - 5 days
    • depending on amount of exudate, cellular debris
  • First wet the silver dressing before removing it.

  • Don’t pull on it if it’s stuck – moisten it more.

  • Apply new moist silver dressing and gauze.



SUMMARY

  • SUMMARY

  • Describe the differences between partial and full-thickness burns.

  • Describe how to estimate the size of a burn.

  • Describe initial care of small burns.

  • Describe follow-up and post-burn care.

  • NEXT TOPIC - BURNS OF SPECIAL AREAS





Be VERY concerned for the airway!!

  • Be VERY concerned for the airway!!

  • Eyelids, lips and ears often swell alarmingly.

  • In fact, they look even worse the next day.

  • But they will start to improve daily after that.

  • Cleanse eyes with warm water or saline.

  • Apply antibiotic ointment or liquid tears until lids are no longer swollen shut.

  • Bacitracin cream/ointment will serve



This is rather deep and might require grafting.

  • This is rather deep and might require grafting.

  • But initial management is basic.



Allow use of the hands in dressings by day.

  • Allow use of the hands in dressings by day.

  • Splint in functional position by night.

  • Keep elevated to reduce swelling.



Fingers might develop contractures if active measures are not taken to prevent them.

  • Fingers might develop contractures if active measures are not taken to prevent them.



Shower daily, rinse off old cream, apply new cream.

  • Shower daily, rinse off old cream, apply new cream.

  • Insert Foley catheter if unable to urinate due to swelling.





Airway

  • Airway

    • Facial edema, and/or airway edema
  • Breathing

    • Toxic inhalation (CO, +/- CN)
    • Respiratory failure due to smoke injury or ARDS


Amount of edema can be immense (even without facial burns)

  • Amount of edema can be immense (even without facial burns)

  • Depression of mental status can worsen problem

  • Edema peaks at 12 to 24 hours

  • Pediatric patients even more concerning



Circulation: “failure of resuscitation”

  • Circulation: “failure of resuscitation”

    • Cardiovascular collapse, or acute MI
    • Acute renal failure
    • Other end organ failure
  • Missed non-thermal injury



First assess

  • First assess

  • CBA’s

  • “Disability” (brief neuro exam)

  • Expose

  • Later

  • Examine rest of patient

  • Calculate IV fluids

  • Treat burn



“Flash” burns may refer to those that suddenly flare up, then die down quickly.

  • “Flash” burns may refer to those that suddenly flare up, then die down quickly.

  • Patients may have burnt facial hair and carbon on lips.

  • Patients with this kind of facial burn will probably NOT need an artificial airway.

  • Give humidified oxygen while under close observation.



Record vital signs.

  • Record vital signs.

  • Check distal pulses and nail beds.

    • Keep him warm!
    • Loss of skin impairs ability to retain heat and fluids.
    • Being cold will cause vasoconstriction.
  • Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr

  • Monitor at least HCT and urine specific gravity.

  • When available, monitor electrolytes.



The burn itself does not alter the level of consciousness.

  • The burn itself does not alter the level of consciousness.

  • If patient is not alert, think of other causes:

    • hypovolemia
    • carbon monoxide
    • head injury
  • Don’t allow swollen eyelids to prevent you from examining the pupils.

  • Test sensation and motion in burned extremities.



Undress the patient to examine the whole body.

  • Undress the patient to examine the whole body.

  • But burned patients lose body heat quickly, so keep them warm.

  • To keep warm, use whatever means available:

  • blankets

  • heating lamps

  • bed frame

  • large box covered with blankets



Obtain history and examine rest of body.

  • Obtain history and examine rest of body.

  • Ask about allergies, meds, medical conditions.

  • Look for other injuries.



wt in kg x % burn x 2 - 4cc / kg / %

  • wt in kg x % burn x 2 - 4cc / kg / %

  • 100 kg patient with 50% TBSA burn:

  • 100 x 50 x 2 = 10,000cc = 10 liters RL

  • This is calculated for the first 24 hours post-burn.

  • Give half of this in first 8 hours.

  • Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially



Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

  • Half of 10,000cc = 5000cc in 8 hrs = 400 cc / hr initially

  • How do we know if this is too much fluid, or too little?

  • Monitor at least:

  • urine output - in adults, around 50 cc / hr

  • Decreasing urine output = need for more fluids.



The head accounts for about 18% (instead of 9%).

  • The head accounts for about 18% (instead of 9%).

  • The legs account for about 13% (instead of 18%).



Use same formula for fluids to replace loss from burns.

  • Use same formula for fluids to replace loss from burns.

  • In children, add this amount to normal maintenance rate:

  • 10 kg - about 40 cc / hr maintenance fluids

  • 20 kg - about 60 cc / hr

  • 30 kg - about 70 cc / hr

  • Expected urine output for child: 1 cc / kg /hr

  • for infant: 2 cc/ kg / hr



20 kg child with 30% burn:

  • 20 kg child with 30% burn:

  • 20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hr

  • Half of this in first 8 hr = 600 cc in 8 hr = 75 cc / hr initially

  • 75 cc / hr for burn loss + normal 60 cc / hr maintenance =

  • 135 cc / hr initially

  • How do you know if the patient is getting too much fluid,

  • or too little?

  • Check urine output, urine specific gravity, HCT



Be sure the patient’s airway, breathing and circulation are secure.

  • Be sure the patient’s airway, breathing and circulation are secure.

  • Then treat the burn wound itself.

  • In patients with large burns, do not initially spend much time carefully calculating fluids.

  • Instead, start an IV and start giving fluids rather rapidly while exam is being performed. DO NOT BOLUS! 500cc/hr is a good rule.

  • Later do the calculations.





  • Limb is burned all the way around.

  • Soft tissues under the skin always swell with burns

  • (due to capillary leak of fluids in first day or so).

  • There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue

  • Pressure inside limb gradually increases.

  • Eventually, pressure inside limb exceeds arterial pressure.

  • This requires escharotomy to relieve the pressure.



Circulation to distal limb is in danger due to swelling.

  • Circulation to distal limb is in danger due to swelling.

    • Progressive loss of sensation / motion in hand / foot.
    • Progressive loss of pulses in the distal extremity by palpation or doppler.
  • In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest.



COMPLICATIONS

  • COMPLICATIONS

  • Bleeding: might require ligation of superficial veins

  • Injury to other structures: arteries, nerves, tendons

  • NOT every circumferential burn requires escharotomy.

  • In fact, most DO NOT need escharotomy.

  • Repeatedly assess neuro-vascular status of the limb.

  • Those that lose circulation and sensation need escharotomy.



Eschar = burned skin

  • Eschar = burned skin

  • Escharotomy = cut burned skin to relieve underlying pressure

  • Similar to bivalving a tight cast.

  • Cut along inside and outside of limb from good skin to good skin

  • Knife can be used, or cautery.

  • Use local or no anesthesia.

  • (Full-thickness burn should have no sensation, but underlying tissues do!)



Incise along medial and/or lateral surfaces.

  • Incise along medial and/or lateral surfaces.

  • Avoid bony prominences.

  • Avoid tendons, nerves, major vessels.



Patient had escharotomy of

  • Patient had escharotomy of

  • both legs.

  • Incisions will heal.

  • They will not be closed by DPC.

  • These large burns are often

  • treated by the “open” technique,

  • that is, without dressings.



Outer skin might

  • Outer skin might

  • not appear too bad.

  • But heat was conducted

  • along the bone.

  • Causes the most damage.

  • Burns from inside out.

  • Usually requires fasciotomy



Fascia = thick white covering of muscles.

  • Fascia = thick white covering of muscles.

  • Fasciotomy = fascia is incised (and often overlying skin)

  • Skin and fascia split open due to underlying swelling.

  • Blood flow to distal limb is improved.

  • Muscle can be inspected for viability.



Particles of phosphorus must be removed from under the skin.

  • Particles of phosphorus must be removed from under the skin.

  • Pick them off with forceps.

  • Must apply wet dressing to prevent re-igniting.



Describe how to estimate the body surface area of burn.

  • Describe how to estimate the body surface area of burn.

  • Describe how to calculate initial fluid requirements in a patient with a large burn.

  • Describe intial management of a patient with a large burn.

  • Discuss indications and complications of escharotomy.



Educate your Task Force!

  • Educate your Task Force!

  • proper technique for burning waste, wear of clothing

  • Do not hesitate to evacuate.

  • Burns other than inhalation generally don’t kill at point of injury- Bleeding and breathing injuries do!

  • Oral Abx if managing burn at BAS ?




Do'stlaringiz bilan baham:


Ma'lumotlar bazasi mualliflik huquqi bilan himoyalangan ©fayllar.org 2017
ma'muriyatiga murojaat qiling