Burns and Toxic Inhalation

1
Burns and Toxic Inhalation
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Assessment of Burns

• Depth
• Classified according the the skin layers that are
  affected
• First degree superficial
• Second degree partial thickness
• Third degree full thickness
• BSA affected
• Estimated by the rule of nines
• body is broken down into a total of 11 segments
  each 9 of the BSA

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Management of Major Burns

• Resuscitation
• Burns activate the inflammatory cascade causing
  increased vascular permeability
• Fluid shifts from intravascular to extravascular
  (leading to shock/relative hypovolemia) and
  exudates through injured skin
• Immediate fluid replacement is required for burns
  that cover gt20 of the BSA
• First 24 hours crystalloids only (NS or
  Ringers Lactate)fluid titrated against
  hemodynamic parameters and UOexpect tissue edema
• After 24 hours sodium requirements and vessel
  permeability decreaseuse low Na solutions or
  colloids to maintain volume and electrolyte
  balance
• Vasoactive agents may be required by dont use
  alpha adrenergics (like norepinephrine)it
  decreases blood flow to the injured skin

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Management of Major Burns

• Airway complications
• Upper airway damage likely with facial/neck burns
• Oropharyngeal swelling, cough, carbonaceous
  sputum, respiratory distress, stridor suggest
  upper airway damage
• Hyperventilation and hypercapnia from increased
  metabolism increase likelihood of respiratory
  failure

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Airway Obstruction

• Hot gases and toxic compounds in smoke cause
  rapid upper airway obstruction
• Early intubation is recommended with 2nd and 3rd
  degree facial burns
• If you dont intubate, monitor for signs of
  airway obstructionmay use bronchodilators or
  racemic epi
• Steroids dont seem to help

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Toxic Inhalation

• Highly soluble gases (like sulfur dioxide and
  chlorine gas) dissolve in upper airway secretions
  forming potent acids that cause mucosal
  inflammation, ulceration, and bronchospasm
• Low solubility gases (like nitrogen dioxide and
  phosgene) penetrate to the lower airway causing
  alveolar damage, pulmonary edema, and V/Q
  mismatch
• With severe toxic inhalations, the mucosa sloughs
  after 3 days and requires 7-14 days to
  regenerateinfection and pneumonitis are common
  during this time d/t secretion retention

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Toxic Inhalation

• Carbon monoxide
• Causes 75 of fire fatalities
• Hgb has 250 X the affinity for CO than for O2
• Low CO levels rapidly displace O2 producing
  non-functional carboxyhemoglobin
• Cant detect with pulse oximetry
• Must do cooximetry
• Treat with 100 O2 or HBO
• Cyanide
• Causes histotoxic hyopxia
• Treat with sodium thiosulphite or dicobalt
  edetate

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Metabolism and Nutrition

• Metabolic rate increases with burns (by up to
  100)the more surface burned, the higher the
  metabolic rate
• Fever and hypercapnia also increase metabolic
  rate
• High environmental temperature helps reduce heat
  and water loss and calorie requirements
• Early feeding recommendedpatients will have
  large calorie requirements b/c of the burn
• H2 antagonists are given to reduce stress ulcers

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Burn wound care/Skin grafts

• Early debridement and skin grafting improve
  outcome and decrease infection, pain, healing
  time, and mortality
• Scalds may heal without treatment
• Massive burns may require biosynthetic skin as
  graft sites may be inadequate
• Topical antibiotics (Silvadene) decrease
  bacterial infections (esp Staph and Pseudomonas)

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Infection

• Systemic antibiotics are not used unless there
  are documented wound infections
• Skin loss and decreased immunity make these
  patients at higher risk
• Pulmonary sepsis often causes death after severe
  burns, especially after smoke inhalation

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Analgesia

• IV opiates (morphine)
• Ketamine combined with a benzodiazepine
• Higher metabolic rate requires close attention to
  clearance

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Chemical/Electrical Burns

• Chemical burns
• Irrigate with water
• Treat like a thermal burn
• Avoid neutralizing solutions they could cause a
  reaction that increases thermal damage
• Electrical burns
• Produce extensive tissue damage and
  rhabdomyolysis
• Arrhythmias and myocardial injury may be an issue