The Burning Pain

Department of Family & Community MedicinePerpetual Succour Hospital

Presentor:LIZA D. MARIPOSQUE, M.D.

3rd Year Famed ResidentMay 27, 2010

OBJECTIVES

GENERAL OBJECTIVES:

To discuss the family profile of Tim-tim & Martinez Family.

To present a case of thermal burn injury (kerosene).

SPECIFIC OBJECTIVES

To establish the family diagnosis of Tim-tim & Martinez Family using family assessment tools.

To briefly discuss the management, prevention and complications of thermal burn injury.

E. T.,44 y.o, female,Single, sari-sari store vendor owner, from Upper Laguerta, Lahug, Cebu City.

CC: oozing & infected burned skin of the L side of the face, neck & L arm

Past Medical History

(-) HPN, DM, BA

No known allergies

No Previous Hospitalization

History of Present Illness

2 wks PTC – while cooking food, sustained burn on the L side of the face, neck and L arm upon gas (kerosene) stove explosion.

– Spicy vinegar & water applied on the wound.

Hospitalized 1 week discharged w/ (VSMMC) home meds:

TT 0.5 ml IMTIG 250 IU IMCiprofloxacin 500mg 1tab BID x 10 days.Silver Sulfadiazine Cream (Flammazine)

apply to affected area OD.Tramadol 50mg 1tab q 8Hr prn for pain.

INTERVAL HISTORY

Ff-up check-up: 1 wk after discharged– Cont. Ciprofloxacin 500mg 1tab BID x 3 days more.– Cont. Flammazine cream OD.– Cont. Tramadol 50mg 1tab TID prn for pain.– Vit. C 500mg 1tab OD.– Vit. B-complex 1tab BID.

Physical Examination

Conscious, coherent, not in respiratory distress.

BP: 120/90-130/80 mmHg T: 37.20C

HR: 75 bpm

RR: 20 cpm Wt: 55 kg

Skin: dry, dark, warm

HEENT: Pinkish burn scar, wet & w/ purulent burn surface on the anterior neck. No lymphadenopathies

C/L: Equal chest expansion, No chest retractions, Clear breath sounds, No rales.

CVS: Distinct heart sounds, normal rate & regular rhythm, no murmur

Abd: Flabby, normoactive bowel sounds, soft, non-tender, no masses palpated, no hepatomegaly

Ext: No edema, (+) pinkish and wet burn on the medial side of the L arm, no limitation in movement, strong pulses

CNS: Within normal limits

Final Diagnosis

2nd Degree Burn,14.5% TBSA, on the L side of the Face, neck, & L arm

Estimating the size of the Burn as a % of the Total Body Surface (TBS)

A burn occurs when the skin, and often other bodily organs, come in contact with the ff:

HeatRadiationElectricityChemicals

TissueDamage

Kinds of Burns

Scald Burns - hot water Flame burns - thermal injury. Flash burns – explosion Contact burns - hot metals, plastic, glass, or hot

coals. Chemical Burns Electrical Burns Cold Injuries – hypothermia & Frosbites

Burn Severity is determined by:

Burn depth

Burn size

Burn location

Burn Depth – destruction of skin layers by the heat source.

Depth of injury -proportional to the temperature, duration of contact, and thickness of the skin.

http://www.burnsurgery.org/

Categories of Burns:

4th Degree: involves all layers

Estimating the size of the Burn as a % of the Total Body Surface (TBS)

High Risk areas for Burns


Airway

Breathing

Circulation

Disability

Expose & Examine

First Aid for Severe Burns: (2nd & 3rd Degree Burns)

DO NOT remove burnt clothing. Make sure the victim is breathing. Cover the burn with a cool moist sterile bandage or clean

cloth. If fingers or toes have been burned, separate them with

dry sterile, non-adhesive dressings. Elevate the burned area and protect it from pressure or

friction. Prevent shock Continue to monitor the victim's vital signs

RESTORING & MAINTAINING HEMODYNAMIC STABILITY

Loss of plasma volume is rapid after a burn injury as fluid collects in the burn tissue.

Early fluid resuscitation is required for burns exceeding 20% of body surface.

Estimate percent (%) of TBSA burned in order to estimate isotonic fluid requirements using "Rule of Nine".

Fluid Resuscitation Protocol

Burns >20% TBSA require initial fluid resuscitation

Start Lactated Ringer’s solution. Estimate initial rate according to the estimated

%TBS. Estimated body weight (4cc/kg/%TBS burn in 24 hours giving half of the estimate in 1-8 hours.)

Total Maintenance Fluid = (1500mL/m2)

+ Evaporative Water Loss [(25+%TBSA Burn) x m2 x 24]

m2 is square meters of TBSA

Schwartz's Surgery, Part I. Chapter 7. Burns

Copyright ©2007 The McGraw-Hill Companies.

Foley catheter Nasogastric tube Maintain: Systolic Blood Pressure >90

Urine output 0.5-1.0ml/kg/hr

Pulse <130

Temperature >37°C

Modify protocol in the presence of massive burns, inhalation injury, shock, and in elderly patients:

- Fluid requirements are greater to prevent burn shock

- Include colloid: either Hespan or Albumin in the patients from the beginning

Three major types of burn related scars

Keloid scars - overgrowth of scar tissue.

- The scar will grow beyond the site of the injury.

Hypertrophic scars - are red, thick and raise & do not develop beyond the site of injury or incision.

Contracture scar - is a permanent tightening of skin that may affect the underlying muscles and tendons.


Physical Therapy, pressure and exercise Surgery:

- Dermabrasion – smoothen skin

- Skin Grafts

Pressure Garments Nutrition Medications


MEDICATIONS

Tetanus prophylaxis Pain relievers Antibiotics

Silver Nitrate Mafenide Acetate Silver Sulfadiazine

Active component

0.5% in aqueous solution 11.1% in water-miscible base

1.0% in water-miscible base

Spectrum of antimicrobial activity

Gram-neg.—good Gram-neg.—good Gram-neg.—variable

Gram (+)—good Gram (+) —good Gram (+) —good

Yeast—good Yeast—poor Yeast—good

Topical Antimicrobial Agents for Burn Wound Care


Method of Wound care

Occlusive dressings Exposure Exposure or single-layer dressings

Advantages

Painless

No hypersensitivity reaction

No gram-negative resistance

Dressings reduce evaporative heat loss

Greater effectiveness against yeasts

Penetrates eschar

Wound appearance

readily monitored

Joint motion unrestricted

No gram-negative resistance

Painless

Wound appearance

readily monitored

when exposure method used

Easily applied

Joint motion

unrestricted

when exposure

method used

Greater

effectiveness

against yeast


DISADVANTAGES

Deficits of sodium, potassium, calcium, and chloride

Painful on partial-thickness burns

Neutropenia and thrombocytopenia

No eschar penetration Susceptibility to acidosis as a result of carbonic anhydrase inhibition

Hypersensitivity—infrequent

Limitation of joint motion by dressings

Hypersensitivity reactions in 7% of patients

Limited eschar penetration

Methemoglobinemia—rare

Argyria—rare

Staining of environment and equipment

FAMILY PROFILE

Eliza Tim-tim

44 yrs old, female, single Education: Primary Sari-sari store vendor owner Index patient

Walanita Martinez

59 yrs old, Female, widow Relative of Eliza,Significant Other Education: Primary Unemployed Living with her 2 children: JR & Nieves No known medical health problem

40 yrs. Old, female, single Education: Primary Laundry girl of Genee Laudryshop Family Head. No Known medical health problem.

Nieves Martinez

JR MARTINEZ

15 Yrs old, male, single

Son of Walanita 4th year High-

school student No known

medical health problem

•15 Yrs old, male, 4th year HS•Walanita’s Son •No known medical health problem

Jason Tim-tim

17 yrs old, male, single, 4th year HS Eliza’s nephew Unemployed No known medical health problem

Jian Hilardino

10 yrs old, male, Grade III student Eliza’s Nephew No known medical health problem

ELIZA

SIMA

MILANANGELINA

MARIO

LUISLEONA

ROGER

ELSIE JUNIEMERLYN

TIM-TIM & MARTINES FAMILYUpper Laguerta Lahug Cebu City

As of Nov. 2009

Index Patient

Sima 100+

Milan ?

Angelina 80

?80’s

I

III

II

Luis 70

Leona 60

Roger 47

Junie 42

Merlyn37

HPN

Eliza 44

Elsie48

FALL

Walanita59

Nieves40

Jian10

JR15

Jason17

Doling miyay EliongDolfin Amadeo 60’s

Maning Erineo Timoteo Candido Peling melanio

Rheumatoid arthritisThyroid CA

2 5

jc

ElizaNieves Jason JRJian

Walanita MerlynElsie

Roger

BETTYJunie

A P G A R ELIZA Almost always

(2)Some of the time (1)

Hardly ever (0)

ADAPTATION: I am satisfied that I can turn to my family for help when something is troubling me

PARTNERSHIP: I am satisfied with the way my family talks over things with me and shares problems with me

GROWTH: I am satisfied that my family accepts and supports my wishes to take on new activities and directions

AFFECTION: I am satisfied with the way my family expresses affection and responds to my emotions

RESOLVE: I am satisfied with the way my family and I share time together

A P G A R

9

SOCIAL

CULTURAL

RELIGIOUS

EDUCATIONAL

ECONOMICS

MEDICAL

Weakness &

Strength

WEAKNESS &

STRENGTH

WEAKNESS &

STRENGTH

Strength

STRENGTH

STRENGTH

WEAKNESS &

STRENGTH

WEAKNESS &

STRENGTH

ECONOMIC PROFILE

Total Monthly Income Php > 10,000 PERCENT ALLOCATION

Total MonthlyExpenses: Food: Electricity: Water: Medicine: Miscellaneous:

6,2001,200560< 1,000< 500

62%12%5.6%10%5%

Savings 540-1000

WEAKNESS &

STRENGTH

WEAKNESS &

STRENGTH

SOCIAL

CULTURAL

RELIGIOUS

EDUCATIONAL

ECONOMIC

MEDICAL

RESOURCE

(STRENGTH)

PATHOLOGY

(WEAKNESS)S C R E E MS C R E E M

Impact of Illness

Stage I – Onset of Illness

Stage II – Reaction to Diagnosis

(Impact phase)

Stage III – Major Therapeutic efforts

Stage IV – Early Adjustment to Outcome (Recovery)

Stage V – Adjustment to the Permanency of the Outcome

Smilkstein’s Cycle of Family Smilkstein’s Cycle of Family FunctionFunction

STREESFUL LIFE EVENTS:

CRISIS:Inadequate family income

EXTRA-FAMILIAL RESOURCES:•Financial Assistance from the siblings, relatives & Franciscan Sisters•Help from Famed residents

work

BURNS

FAMILY IN EQUILIBRIUM

DISEQUILIBRIUM

SARI-SARI STORE

Family diagnosis

Tim-tim & MARTINEZ family

– Blended type of family with low income.– Stage of Family Cycle : Family with adolescents– Stage in Family illness:

Stage IV – Early Adjustment to Outcome (Recovery)

– APGAR Assessment : Highly Functional

Smilkstein’s Family Cycle : – Adaptation

Evaluation by SCREEM– Strength:

Religion, Education and Economic

– Weakness: Social, cultural, Economic & Medical

RECOMMENDATIONS

To the patient:– Teach and demonstrate and encourage

range of motion (ROM) exercises daily.– Visit Wellness Clinic for regular BP

monitoring at least once a week.– Advised diet modification: low salt &low

fat.– Advised to cover her burned skin with

clothes if exposed to sunlight.

Prescribe Gabapentin and use of Sunblock lotion.

Advised to seek help in Franciscan Sisters for free supply of medications during operation.

Networking with PCSO and Gov’t health card. Refer and accompany patients for evaluation, release

of contractures and possible skin grafting.

To Nieves & Walanita

Continue supporting Eliza. Visit Wellness Clinic also for regular BP

monitoring. Advised for FBS & lipid screening as well as

ECG.

To JR, Jason & Jian:

To continue their support. Stays to be good. Advised to continue their study. Advised to help household chores. Advised to help in tending sari-sari store.

To the community

Give lectures about safety and fire preventions.

Give lectures about first AID for burns and poisoning.

Advise to have presence of mind and don’t panic in case of accident.

Encourage to visit the Wellness Clinic every Tuesday, Wednesday and Friday.

Family Family membermember

ProblemsProblems primary primary preventiopreventio

nn

2ndry 2ndry

preventionpreventionTertiary Tertiary

preventiopreventionn

EliizaEliiza

44 y.o44 y.ocontracturecontracture Lectures

about Safety & fire prevention, & first aid for burns

Surgical referral for release of contrature & graftingUse of Sunblock

ROM exercise,

low salt, low fat diet

Regular monitoring of BP; blood sugar & lipid screening; ECGFLU Vaccine, cervical vaccine; Breast Exam’n, pap smear

Networking with VSMMC, Franciscan’s Sister & PCSO



nn

2ndry 2ndry



WalahitWalahita , 59 a , 59 y.oy.o

& & Neives, Neives, 40 y.o40 y.o

nonenone Lectures about safety & fire prevention , & first aid for burns

blood sugar & lipid monitoring

Regular monitoring of BP, FLU Vaccine, cervical vaccine; Breast Exam’n, pap smear



nn

2ndry 2ndry



Jason, Jason, 17 y.o, 17 y.o, JR, 15 JR, 15 y.o & y.o & Jian, 5 Jian, 5 y.oy.o

nonenone Lectures about fire prevention & first aid for burns

Sexual educ. & teen-age pregnancy, lectures about drug addiction, smoking & alcoholism

FLU & hepa Vaccine,

Health & Medicine

The Burning Pain