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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
Burns wound is classified into
1) First degree burns injury :
Injury confined to the epidermis. These burns are painful erythematous & blanch to touch with an intact epidermal barrier.
They are not life threatening and generally do not require intravenous fluid replacement because the epidermis remains intact.
2) Partial Thickness Burns (Second degree burns )
They are characterised by a red or mottled appearance with associated swelling and blister formation.
The surface have a weeping, wet appearance and is painfully hypersensitive, even to air current.
3) Full Thickness Burns (Third degree Burns )
Skin may also appear translucent or waxy white.
Surface is painless and generally dry; it may be red, but doesn't blanch with pressure.
There is little swelling of the full thickness burned tissue, although the surrounding tissue may swell a significant amount.
Estimating the Burns Size
Rule of 9
In infants or young child's head represents a larger proportion of the surface area and lower extremities represent a smaller proportion than an adult.
The percentage of total body surface area of an infant's head is twice that of the normal adult.
MANAGEMENT
Airway
Early protection of the airway is important.
Pharyngeal thermal injuries can produce marked upper airway edema and early protection of the airway is important.
Breathing
Breathing concern arises from
Hypoxia : Due to inhalation injury, inadequate ventilation due to circumferential chest burns or traumatic thoracic injury unrelated to the thermal injury.
Carbon monoxide poisoning : Suspected in burns in enclosed space
Smoke inhalation injury
Supplement oxygen .
Early management of inhalation injury may require endotracheal intubation and mechanical ventilation.
Signs of Inhalation Injury
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Circulation
Any patient with burns more than 20% of the body surface requires fluid resuscitation.
Secure two large bore IV cannula.
Upper extremities are preferred.
If the extent of the burns precludes placement of the catheter through unburned skin, the IV should be placed through through the burned skin into the accessible vein.
Fluid requirement
Parkland Formula : LR 4 ml * weight * %BSA over 24 hrs. Initial half over first 8 hrs and rest of the fluid over next 16 hrs.
Aim is to target a urine output of 1-2 ml/kg/hr. The rate of the fluid has to be adjusted based on urine output.
Documentation
Investigation
ECG, Chest X-ray
Electrolytes
ABG
HbCO levels
Gastric tube insertion
Insert a gastric tube and attach it to a suction setup if patient experience nausea, vomiting or abdominal distension or if burns involve more than 20% of total BSA.
Narcotics, Analgesics & Sedatives
Hypoxemia and fluid resuscitation should be carried before administering narcotics since they can mask signs of hypoxemia and hypovolemia.
Wound care
Partial thickness burns are painful when air current pass over the burned surface.
Gently cover the burns with clean sheet.
Do not break blisters or apply antiseptic agents.
Do not apply cold water to a patient with extensive burns >10% of BSA.
Tetanus Immunisation
Antibiotics
No indication for prophylactic antibiotics. Reserved only for treatment of infection.
Silver sulfadiazine 1% : Apply with a thin layer of silver sulfadiazine cream to the burn and then cover it with gauze dressing.
Alternatively triple antibiotic with neomycine, polymyxin-B and bacitran zinc can also be applied.
Dressings are changed twice daily as long as they continue to weep and then once daily.
Dressings with synthetic occlusive dressing heal better.
Monitor for compartment syndrome
AMERICAN BURN ASSOSCIATION BURN UNIT REFERRAL CRITERIA |
Third degree burns in any age group. Electrical burns Chemical burns Inhalation injury Burns injury in patients with preexisting medical disorders Burns injury in patients with concomitant trauma like fracture. Burns injury in patients who will require special social, emotional or long term rehabilitative intervention. Burns injury in children's < years and adults >50 years Burns injury in children in hospitals without qualified personnel or equipment to care for children. |
Updated on 15/12/14
Reference
Tintinalli
ATLS Students Manual
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor