Burns: Management of Burns- The Emergent or Resuscitative phase

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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
EXPLANATION
Generalized dehydration
Plasma leaks through damaged capillaries.
Reduction of blood volume
Secondary to plasma loss, fall of blood pressure, and diminished cardiac output
Decreased urinary output
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)
Potassium (K+) excess
Massive cellular trauma causes release of K+ into extracellular fluid (ordinarily, most K+ is intracellular).
Sodium (Na+) deficit
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).
Metabolic acidosis (base-bicarbonate deficit)
Loss of bicarbonate ions accompanies sodium loss.
Hemoconcentration(elevated hematocrit)
Liquid blood component is lost into extravascular space.


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
Purpose
Nutritional support:
·         Vitamin A,C, E and multivitamines, Minerals: zinc, iron

Okandrolone (Oxandrin)
·         Promotes wound healing
·         Promotes cell integrity and hemoglobin formation
·         Promotes Weight gain and preservation of lean body mass

Analgesia
Morphine, Sustained relaease morphin, Fentanyl, Methadone, NSAlDs
·         All analgesic drugs
Sedation
·         Haloperidol    
·         Lorazepam    
·         Midazolam

Produces antipsychotic and sedative effects, promotes sleep Diminishes anxiety
Has short acting amnestic properties
Gastrointestinal support
·         Ranitidine
·         Nystatin
·         Mylanta, Maalox

·         Decreases incidence of curling's ulcer
·         Prevents overgrowth of candida albicans in oral mucosa
·         Neutralizes stomach acid



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notes.nursium.com: Burns: Management of Burns- The Emergent or Resuscitative phase
Burns: Management of Burns- The Emergent or Resuscitative phase
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https://notes.nursium.com/2017/06/burns-management-of-burns-emergent-or.html
https://notes.nursium.com/
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