Thermal Burn

Ronald Chrisbianto Gani405090223

Faculty of MedicineTarumanagara University

EMERGENCY MEDICINE BLOCK

THERMAL BURNS

THERMAL BURNS

THERMAL BURNS

• Injuries to the skin resulting from contact with heat, electrical current, radiation, or chemical agents

• Less than 44oC well tolerated• Above 60oC denaturation of protein

Rosen’s Emergency Medicine 7th Ed

EPIDEMIOLOGY

• American Burn Association– 500.000 burn injuries, 40.000 admissions– 4.000 deaths– Caused by : Fire (46%), scalds (32%), hot objects

(8%), electricity (4%), chemical agents (3%)– 38% >10% TBSA, 10% >30% TBSA– Age 19-44– Location : UE (41%), LE (26%), Head & Neck (17%)– <5% full thickness


PATHOPHYSIOLOGY

• Three concentric zone– Zone of irreversible coagulative necrosis– Zone of ischemia– Zone of hyperemia

• Regeneration comes from– Basal layer of cells– Dermal skin appendages (hair follicles and

sebaceous glands)


PATHOPHYSIOLOGY

• Clotting inflammatory cells recruitment (B2-

integrins, CD11b, CD18) cells marginate to vessel walls (ICAM-1) release of mediators and cytokines (cytotoxic reactive oxygen and nitrogen species) lipid peroxidation accumulation of leukocytes, RBC, platelet microthrombi reduce local perfusion


PATHOPHYSIOLOGY• Inhalation injury– Caused by steam, aldehydes, oxides of sulfur and

nitrogen, PVC, Hydrochloric Acid, CO– Airway edema & de-epithelization of injured

mucosa necrotic lining pseudomembranous cast airway obstruction

– Edema & congestion of pulmonary parenchyma bronchospasm, inflammation, destruction decreased lung compliance microatelectasis progressive hypoxemia ARDS


CLASSIFICATION

• 1st degree epidermis• 2nd degree superficial papilary dermis• 2nd degree deep reticular dermis• 3rd degree full thickness• 4rd degree subcutaneous or deeper


CLASSIFICATION• Percentage of TBSA involved– Rules of nine : 18% front trunk, 18% back trunk,

18% each LE, 9% each UE, 9% head & neck, 1% perineal


CLASSIFICATION

LUND-BROWDER CHART


1ST & 2ND DEGREE BURN INJURY

1st degree


Fitzpatrick’s Dermatology in General Medicine 7th Ed

3RDDEGREEBURN

INJURY



4TH DEGREE BURN INJURY


MANAGEMENT

• Prior to ED arrival– Stop burning process, extinguish flame, chemical

injury tap water wash– Protect from additional injury– Adequacy of airway and ventilation intubation– CO poisoning 100% oxygen – Extensive burns IV fluid LR, Parkland Formula– Morphine sulfate 2-4mg IV bolus– Cover burns with clean dressing– Prevent hypotermia


INPATIENT / OUTPATIENT


MANAGEMENT

• At Emergency Department (ABC!!)– Airway • Check for upper airway edema fiberoptic

laryngoscopy• Endotracheal intubation or crycothyrotomi if needed• Escharotomies if needed• Maintain PO2 >92%• Urethral catheter monitor urine output and eval for

rhabdomiolysis and myoglobinuria• NGT prevent gastric distention


MANAGEMENT

– Inhalation Injury• Fiberoptic laryngoscope & bronchoscopy soot,

charring, inflammation, edema, necrosis• Injury to parenchyma xenon ventilation (RARE)• Other : CO and cyanides• Treatment : mechanical ventilation, aleveolar lavage,

PO2 >92%, airway pressure <35cm H2O, pH >7,25• Bronchospasm bronchodilators + suctioning• N-acetylsistein with/without heparin aerosolized

breakdown thick mucous



MANAGEMENT

– Circulation and Fluid Resuscitation• Burn injury activate PG, Histamine, LT Intravascular

fluid extravasation fluid depletion + soft tissue edema• Small burns oral fluid, Large burns IV fluids• Volume Parkland Formula + adjustment as needed• Adjustment criteria : HR, BP, Conciousness, Capilarry

Refill, urine output.• Additional fluid : inhalation injury, electrical burn• Excessive fluid pneumonia, sepsis, ARDS, death


RESUSCITATION FORMULAS


MANAGEMENT

• Local Wound Care– Cleansing with soap + water, removal of debris

and necrotic tissue, TT booster– Cooling : tap water 10o-25o C up to 30mins after

injury, avoid hypothermia, ice/ice water contraindicated

– Burn Blisters : Fluid confined by necrotic skin heal faster less infection, 2nd degree debridement + intact less scaring, heal faster


MANAGEMENT

– Burn dressing• Open method : antimicrobial topical until skin is re-

epithelialized. Used on exudative burn. Mostly used silver sulfadiazine and mafenide acetate. Daily removed• Closed method : moist wound healing environment

heal faster. Mostly used : Nanocrystalline silver. • At home : washing, apply topicals. Occlusive should not

be opened unless saturated or malodorous go to ER. If swelling of fever go to ER


BURN DRESSINGS


MANAGEMENT

• Escharotomy– Releasing constriction of burn eschar with scalpel– Eschar constriction interrupts arterial outflow

pain, loss of sensation, delayed capilarry refill. – Indication: Doppler Signal & Pulse oximetry <90% – Avoid to cut underlying vessels and nerves


MANAGEMENT

• Pain Types and Management– 3 phases of burn recovery• Emergency / Resuscitative Phase• Healing Phase• Rehabilitative Phase

– In Emergency Phase, there are 3 kinds of pain• Background Pain• Breakthrough Pain• Procedural Pain


MANAGEMENT– Non pharmacologic• Cooling, tap water 10o-25oC• Moist occlusive dressing

– Pharmacologic• Morphine Sulfate (0,05-0,1mg/kg) titrated• Acetaminophen (1g adults, 15mg/kg child) /4-6h• Ibuprofen (400-800mg adults, 10mg/kg child) / 6-8h• Fentanyl 0,5-1mg/kg• Lidocaine• Anxyolytics : benzodiazepin (Lorazepam)• Others : gabapentin, stimulants, B-Blockers, antidepressants


COMPLICATION


COMPLICATIONStreptococcal Cellulitis


HYPERTROPHIC SCARBEFORE SURGERY AFTER SURGERY


BURN PREVENTION


REFERENCES

• Marx JA, Hockberger RS, Walls RM, Adams JG, editors. Rosen’s Emergency Medicine Concepts and Clinical Practice. 7th Ed. Philadelpia : Mosby Elsevier, 2010

• Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, editors. Fitzpatrick’s Dermatology in General Medicine. 7th Ed. New York : McGraw-Hill, 2008

Documents

Thermal Burn