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KGD 2

Alexandro Ivan
405 09 0227
FK UnTar
2012
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

Rosens 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
Rosens Emergency Medicine 7th Ed
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)

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


CLASSIFICATION

1st degree epidermis


2nd degree superficial papilary dermis
2nd degree deep reticular dermis
3rd degree full thickness
4rd degree subcutaneous or deeper
Rosens Emergency Medicine 7th Ed
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

Rosens Emergency Medicine 7th Ed


CLASSIFICATION
LUND-BROWDER CHART

Rosens Emergency Medicine 7th Ed


1ST & 2ND DEGREE BURN INJURY

Rosens Emergency Medicine 7th Ed

1st degree

Fitzpatricks Dermatology in General Medicine 7th Ed


3RD
DEGREE
BURN
INJURY
Rosens Emergency Medicine 7th Ed

Fitzpatricks Dermatology in General Medicine 7th Ed


4TH DEGREE BURN INJURY

Fitzpatricks Dermatology in General Medicine 7th Ed


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
Rosens Emergency Medicine 7th Ed
INPATIENT / OUTPATIENT

Fitzpatricks Dermatology in General Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


Rosens Emergency Medicine 7th Ed
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

Rosens Emergency Medicine 7th Ed


RESUSCITATION FORMULAS

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


BURN DRESSINGS

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


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

Rosens Emergency Medicine 7th Ed


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
Rosens Emergency Medicine 7th Ed
COMPLICATION

Fitzpatricks Dermatology in General Medicine 7th Ed


Complication
Inhalation injury ARDS
Larynx edema
Tracheostomy
Endotracheal intubation
Curling ulcer / stress ulcer
Keloid, hypertropic scar - contarcture
Schizophrenia postburn
HYPERTROPHIC SCAR
BEFORE SURGERY AFTER SURGERY
INHALATION INJURY
As treatment of burn shock and sepsis has
improved, inhalation injury has emerged as
the main cause of mortality in burn patients.
associated with closed-space fires
Exposure to smoke includes exposure to
heat, particulate matter, and toxic gases.
Half of all fire-related deaths are due to smoke
inhalation.
Smoke inhalation causes injury in two ways:
by direct heat injury to the upper airways
by inhalation of combustion products into the
lower airways.
Direct injury to the upper airway causes
airway swelling that typically leads to
maximal edema in the first 24 to 48 hours
after injury.
Lower airway injury is caused by combustion
products found in smoke, most commonly
from synthetic substances burned in structural
fires.
These irritants cause direct mucosal injury,
which in turn leads to mucosal sloughing,
edema, reactive bronchoconstriction, and
finally obstruction of the lower airways.
Injury to both the epithelium and to
pulmonary alveolar macrophages causes
release of prostaglandins and chemokines,
migration of neutrophils and other
inflammatory mediators, a rise in
tracheobronchial blood flow, and finally
increased capillary permeability, leading to
ARDS.
Bronchoscopic findings, including carbon
deposits, erythema, edema, bronchorrhea,
and a hemorrhagic appearance, can be useful
for confirmation of inhalation injury
A decreased partial pressure of arterial
oxygen:fraction of inspired oxygen ratio <200:
predict inhalation injury
The initial diagnosis of smoke inhalation is
made from the history of exposure to a fire in
an enclosed space and physical signs that
include facial burns, singed nasal hair, soot in
the mouth or nose, hoarseness, carbonaceous
sputum, and expiratory wheezing.
Treatment of inhalation injury
Aggressive pulmonary toilet and routine use
of nebulized bronchodilators (albuterol)
Intrabronchial surfactant - salvage therapy in
patients with severe burns and inhalation
injury
Inhaled nitric oxide - last effort in burn
patients with severe lung injury
The use of steroids has been avoided
PROGNOSIS
The Baux score (mortality = age + percent TBSA)
predict mortality in burns.
Age, burn size, inhalation injury the most
robust markers for burn mortality.
Preinjury HIV, metastatic cancer, and kidney or
liver disease may influence mortality and length
of stay.
The highest predictive value for mortality were
age, percent TBSA, inhalation injury, coexistent
trauma, and pneumonia.
BURN PREVENTION

Rosens Emergency Medicine 7th Ed


SEPSIS SYNDROMES
DEFINITIONS
Activated Inflammatory cascade cause the
bodyd defenses and regulatory system
become overwhelmed leading to disruption of
hemeostasis
Systemic Inflammatory Response Syndrome
(SIRS) 2 or more : tachycardia, tachypnea,
hyperthermia or hypothermia, high or low
WBC count, bandemia.

Rosens Emergency Medicine 7th Ed


DEFINITIONS
Sepsis : SIRS + infection
Severe Sepsis : Sepsis + Organ Dysfunction
Septic Shock : Severe Sepsis + hypotension
which is not responsive to fluid challange
Approach : PIRO (predisposition, infection
source, response of host, organ dysfuntion)
Bacteremia is not obligatory in diagnosis of
sepsis

Rosens Emergency Medicine 7th Ed


EPIDEMIOLOGY
In United States :
10th most common
cause of death
571.000 cases of severe
sepsis
Mortality rate 20-50%
Incidence

Rosens Emergency Medicine 7th Ed


PATHOPHYSIOLOGY
Infection host response neutrophil and
macrophage mobilization to injury site
release cytokines inflammatory cascade
synthesis is not well regulated sepsis
Ongoing toxin persistent inflammatory
response mediator activation cellular
hypoxia, tissue injury, shock, Multi-Organ
Failure, death

Rosens Emergency Medicine 7th Ed


PATHOPHYSIOLOGY
Mediators of Sepsis
Proinflammatory : IL-1, IL8, TNF
Anti-inflammatory IL-10, IL-6 TGF B, IL-1ra
Growth promoting
Arachidonat acid pathway peripheral
dilation, vasocontriction, leukocyte and
platelet aggregation
PG fever

Rosens Emergency Medicine 7th Ed


PATHOPHYSIOLOGY
Vasopressin release in stress condition,
cause vasoconstriction, osmoregulation,
maintenance of normovolemia
NO Regulating vascular tone, platelet
adhesion, insulin secretion,
neurotransmission, tissue injurt, inflammation
and cytotoxicity

Rosens Emergency Medicine 7th Ed


ORGAN SYSTEM DYSFUNCTION
AND DEATH

Rosens Emergency Medicine 7th Ed


ORGAN SYSTEM DYSFUNCTION
Neurologic
Altered mental status and lethargy septic
encephalopathy
Cardiovascular
Myocardial depression : killed organism / bacteria
Distributive shock : toxic mediators
Early sepsis : Cardiac output , vascular
resistance
Reversible cardiac function usually in 10 days

Rosens Emergency Medicine 7th Ed


ORGAN SYSTEM DYSFUNCTION
Pulmonary
Right-to-left shunting, arterial hypoxemia,
intractable hypoxemia
Sepsis : High catabolic state + airway resistance
ARDS
Gastrointestinal
Ileus hypoperfusion. splanchnic blood flow.
Aminotransferase + bilirubin hepatic
failure (rare)

Rosens Emergency Medicine 7th Ed


ORGAN SYSTEM DYSFUNCTION
Endocrine
Adrenal insufficiency
IL-1 & IL-6 activate hypothalamic-pituitary axis
TNF-A & corticostatin, depressed bloow flow,
depress pituitary function and secretion
Hematologic
DIC, fibrin deposition, microvascular thrombi
Associated with Protein C

Rosens Emergency Medicine 7th Ed


CLINICAL SIGNS & SYMPTOMS
Identify systemic infection and the source
Altered conciousness intubation
Systemic Infection : tachycardia, tachypnea,
hypo/hyperthermia, hypotension (severe)
Flushed/warm skin while in vasodilation state
Hypoperfused mottled and cyanotic
Shock exclude other shock etiologies
Use MEDS score for risk stratification
Rosens Emergency Medicine 7th Ed
MEDS
SCORE

Rosens Emergency Medicine 7th Ed


SOURCE OF INFECTIONS
Respiratory (most common) : cough, fever, chills,
throat and ear pain, pneumonia, etc
GI (2nd most common) : abdominal pain, Murphy
sign, McBurney Sign, etc
Neurologic : meningitis
Genitourinary :Flank pain,dysuria,polyuria, etc
Musculoskeletal
IV drug abuse, artificial heart valve, endocarditis

Rosens Emergency Medicine 7th Ed


DIAGNOSTIC FEATURES
Hematology
Leukocytosis
Febrile neutropenic admission, isolation,
empirical IV antimicrobial
Bandemiarelease of immature cell from marrow
Ht >30%, Hb >10g/dL
Acute phase platelet
Low platelet shock
Thrombocytopenia, pTT & aPTT , fibrinogen ,
DIC & severe sepsis syndrome

Rosens Emergency Medicine 7th Ed


DIAGNOSTIC FEATURES
Chemistry
bicarbonate acidosis & inadequate perfusion
serum creatinine ARF
Lactate inadequate perfusion, shock
Arterial blood gas detect acid base disturbance
Metabolic acidosis inadequate perfusion
Bilirubin source from gallbladder
Amilase & Lipase pancreatitis

Rosens Emergency Medicine 7th Ed


DIAGNOSTIC FEATURES
Microbiology
Culture from blood, sputum, urine, CSF, tissue
Obtained before/soon after AB administration
Start with empirical therapy
Radiology
Chest pneumonia, ARDS
Bowel perforation free air aunder diaphragm
Pneumomediastinum esophageal perforation,
mediastinitis
Rosens Emergency Medicine 7th Ed
DIAGNOSTIC FEATURES
Ct-Scan diverticulitis, appendicitis, necrotizing
pancreatitis, microperforation, intra-abdominal
abscess
Head CT septic emboli
Abdominal USG Cholycystitis
Pelvic USG endometritis
Transesophageal USG --> endocaditis
MRI soft tissue

Rosens Emergency Medicine 7th Ed


DIFFERENTIAL DIAGNOSIS

Rosens Emergency Medicine 7th Ed


MANAGEMENT
Principles
AB therapy
Maintenance of adequate tissue perfusion

Rosens Emergency Medicine 7th Ed


MANAGEMENT
Respiratory Support
Airway protection, intubation, mechanical
ventilatory support if needed
Cardiovascular support
Initial therapy 2L of isotonic crystalloid
Normal Saline/ LR.
Maintain MAP >65mmHg, but 75mmHg in patient
ith history of severe hypertensive patient

Rosens Emergency Medicine 7th Ed


MANAGEMENT
Drugs : Vasopresin, Norepinephrine, Dopamine,
Phenylephrine, Epinephrine.
Inotropic agents : Dobutamine, Bicarbonate, AB
Novel Therapies
Activated Protein C
Steroid Therapy

Rosens Emergency Medicine 7th Ed


MANAGEMENT

Rosens Emergency Medicine 7th Ed


Rosens Emergency Medicine 7th Ed