1. Emergent phase
Goals
· Secure airway
· Support circulation by fluid replacement
· Keep the victim comfortable with analgesics
· Prevent infection through careful wound care
· Maintain body temperature
· Provide emotional support
· Prevent burn shock
Wound care
· Stop the burning process
· Remove tight clothing/ornaments
· Prevent tetanus
· Prevent tissue ischemia
· Transport the client to a burn specialty
Electrical burn
· Removal from current source by atrained person
· Assess and treat
· Ensure patent airway, check pulse distal to burns
· Stabilize cervical spine
· Most significant injury is within deep tissue
· Edema can compromise circulation
· Remove nonadherent clothing, shoes, watches, jewelry, glassess, or contact lenses if face was exposed.
Chemical burns
· A,B,C,D,E
· Stabilize cervical spine
· Remove all clothing
· Irrigate or flush chemical from wound and surrounding area with saline or 15-20 L of water
· Brush off any dry powder before irrigation
· Remove nonadherent clothing, shoes, waches, jewelry, glasses, or contact lenses if face was exposed.
· IV access
· Do not attempt to counteract acid bums using alkali or alkali bums using acid
· Triage: What is a serious burn?
· TBSA > 20 %
· Inhalation Injury
· Very Young or Old
· Concomitant Trauma
· These patients need airway assessment, IV resuscitation, foley, NG-tube, ICU care
Initial Assessment of Moderate and Major Burns
Primary Survey
· Assess for ABCDEF
A-Airway
B-Breathing
C-Circulation
· D-Disability(Neurologic Deficits)
· E-Expose and Examine
· F-Fluid Resuscitation
· Breathing (Breath sounds, chest rise)
· Circulation: get vitals (HR & BP)
· Place patient on continuous EKG / monitor
· Palpate or doppler extremity
· Disability (GCS less than eight -> intubate)
· Exposure: remove all clothing
· Fluid resuscitation
· Use 2 large bore IV line
· Start burn resuscitation
Secondary Survey
· Head-to-toe assessment to rule out any associated injuries
· Circumstances of Injury
· Cause of burn
· Did injury occur in a closed space
· Is there a possibility of smoke irthalation
· chemicals involved
· Was there related trauma
· Suspect airway injury if: Facial burns, singed nasal hairs, wheezing, carbonaceous sputum, tachypnea
· Give patient oxygen & put on pulse oximetry
· Progessive hoarseness is a sign of impending airway obstruction
· Intubate anyone with: Respiratory distress, inhalational injury, large burns.
AMPLE History
· a.Allergies
· b.Medications (also ask about last tetanus)
· c.Past medical history (CHF - careful fluids)
· d.Last meal
· e.Events regarding the injury (how did the fire start, how long was the exposure, what type of exposure - flame, grease)
· Prevent aspiration
· Insert ryles tube
· Minimize pain
· Airway management
· Early endotracheal intubation
· Oxygen concentration based on ABG values
· Mechanical ventilation
· High fowlers position- if no spinal injury
· Cough, deep breathing exercise, chest physiotherapy, suctioning
· Bronchodilators
Fluid management/ therapy
Table: Fluid and Electrolyte Changes in the Emergent/Resuscitative Phase
Fluid accumulation phase (shock phase) Plasma → interstitial fluid (edema at burn site)
OBSERVATION
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EXPLANATION
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Generalized dehydration
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Plasma leaks through damaged capillaries.
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Reduction of blood volume
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Secondary to plasma loss, fall of blood pressure, and diminished cardiac output
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Decreased urinary output
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Secondary to:
1.Fluid loss
2.Decreased renal blood flow
3.Sodium and water retention caused by increased adrenocortical activity
(Hemolysis of red blood cells, causing hemoglobinuria and myonecrosis or myoglobinuria)
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Potassium (K+) excess
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Massive cellular trauma causes release of K+ into extracellular fluid (ordinarily, most K+ is intracellular).
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Sodium (Na+) deficit
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Large amount of Na+ is lost in trapped edema fluid and exudate and by shift into cells as K+ is released from cells (ordinarily most Na+ is extracellular).
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Metabolic acidosis (base-bicarbonate deficit)
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Loss of bicarbonate ions accompanies sodium loss.
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Hemoconcentration(elevated hematocrit)
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Liquid blood component is lost into extravascular space.
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Parkland/Baxter Formula
· Lactated Ringer's solution: 4mL x kg body weight x % TBSA burned = total fluid requirement for first 24 hr after burn
· Day 1: Half to be given in first 8 hours; half to be given over next 16 hours
· Day 2: Varies. Colloid is added.
· Example:
· For a 70 kg patient with a 50% TBSA burn:
· 4ml x 70 kg x TBSA burn= 14000ml= 14L in 24hr
· ½ of total in first 8 hr= 7000 ml
· ¼ of total in second 8 hr= 3500ml
· ¼ of total in of total in-third 8 hr
Brooke Army Formula (modified)
1.Colloids: 0.5 ml x kg body weight x % TBSA burned
2.Electrolytes (lactated Ringer's solution): 1.5 mL x kg body weight x % TBSA burned
3.Glucose (5% in water): 2,000 mL for insensible loss
· Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
· Day 2:Half of colloids; half of electrolytes; all of insensible fluid replacement.
· ie; 2ml (RL) x kg body weight x % of TBSA given in 1st 8 hrs. Remaining fluid to be given in next 16 hrs.
· Second- and third-degree (partial- and full-thickness) burns exceeding 50% TBSA are calculated on the basis of 50% TBSA.
Evans Formula
· l. Colloids: 1 ml x kg body weight x % TBSA bumed
· 2.Electrolytes (saline): 1 ml x body weight x % TBSA burned
· 3.Glucose (5% in water): 2,000 rnL for insensible loss
· Day 1: Half to be given in first 8 hours; remaining half over next 16 hours
· Day 2: Half of previous day's colloids and electrolytes; all of insensible fluid replacement Maximum of 10,000 rnL over 24 hours. Second- and third-degree (partial- and full-thickness) bums exceeding 50% TBSA are calculated on the basis of 50% TBSA
Consensus Formula
· Lactated Ringer's solution (or other balanced saline solution): 2-4 rnLx kg body weight x % TBSA burned.
· Half to be given in first 8 hours
· Remaining half to be given over next 16 hours
Burn wound management
· Deep 2nd or 3rd degree extremity burn can compromise circulation
· Assess for the 6 P's
· Pain, pallor, pulselessness (check Doppler), paresthesias, paralysis, poikilothermia
· Watch for Compartment syndrome
· Initially clean/debride & cover with topical antimicrobial- open method (no dressing over the wound)
· Superficial - 2nd: can use temporary pigskin/ cadaver skin
· Multiple dressing change method: sterile gauze dressings are impregnated with or laid over a topical antimicrobial
· 3rd & (most) deep 2nd need early excision & grafting, except palm/soles/face/genitals
· Perform at -3-7 days post-burn
Treatment:
· Debridement
· Escharotomy- surgical procedure used to treat full thickness (third-degree) circumferential burns. Since full thickness burns are characterized by tough, leathery eschar, an escharotomy is used primarily to combat,compartment syndrome.
· Give tetanus toxoid if not up to date
· An escharotomy is performed by making an incisiõn through the eschar to eipose the fatty tissue below. Due to the residual pressure, the incision will often widen substantially
Other care measures
· Facial care
· Eye care for corneal burns or edema
· Splints- applied to burned hands and feet to maintain in functional position
· Hands and arms - extended and elevated on pillows or slings to minimize edema
· Ears should be kept free from pressure because of their poor vascularization and predisposition to infection
· Ear and neck burns- should not use pillows
· Head can be elevated using a rolled towel placed under the shoulders Perineum- kept clean and dry
· Indwelling catheter, perineal and catheter care
· Routine laboratory test
· Physical therapy ; ROM
Drug therapy
Name of the drug
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Purpose
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· Vitamin A,C, E and multivitamines, Minerals: zinc, iron Okandrolone (Oxandrin) | · Promotes cell integrity and hemoglobin formation · Promotes Weight gain and preservation of lean body mass |
Analgesia
Morphine, Sustained relaease morphin, Fentanyl, Methadone, NSAlDs | |
· Haloperidol · Lorazepam · Midazolam |
Produces antipsychotic and sedative effects, promotes sleep Diminishes anxiety
Has short acting amnestic properties |
· Ranitidine · Nystatin · Mylanta, Maalox | · Prevents overgrowth of candida albicans in oral mucosa · Neutralizes stomach acid |
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