Advanced Burn Life Support Manual Review

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Skin Anatomy
Epidermis Dermis

Hypodermis

Function of Normal Skin

Protection from infection & injury Prevention of loss of body fluid Regulation of body temperature Sensory contact with environment

What is a Burn?
An injury to tissue from:
Exposure to flames or hot liquids Contact with hot objects Exposure to caustic chemicals or radiation Contact with an electrical current

Pathophysiology of Burn Injury

Zone of Coagulation:
Irreversible damage

Zone of Stasis:
Impairment of blood flow Recovery variable

Zone of Hyperemia:
Prominent vasodilation Usually recovers

Pathophysiology of Burns
Get edema in burned & non-burned skin Burns cause coagulative necrosis
Chemical/Electricity also cause direct injury to cell membranes, in addition to heat transfer

Depth of burn depends on:

1. Temperature 2. Time exposed 3. Specific heat (higher for grease)

Pathophysiology of Burns
Burns release of inflammatory mediators Increased capillary permeability
Leak proteins into interstitium

Large fluid loss due to fluid shifts & also losses from exposed burned skin Characteristic Ebb and Flow of burns
Ebb: Low metabolism/cardiac output, Temp Flow: hypermetabolism, high cardiac output, hyperglycemia, increased heat produx

Burn Pathophysiology: Systemic Response

Accelerated intravascular volume depletion Inadequate tissue perfusion Risk of multiorgan dysfunction

Burn Pathophysiology: Metabolic Response

Hypermetabolism: glucose metabolism, lipolysis, and proteolysis Neuroendocrine response: catecholamines, thyroid hormones, cortisol

Burn Pathophysiology: Tissue Repair

Initial hemostatic response = coagulation and microvascular constriction Resuscitative phase = vasodilatation and capillary leak Epithelialization = restoration of fluid maintenance, temperature regulation, and microbial barrier function Fibrogenesis = wound appearance and strength

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Initial Assessment (primary survey)

Initial burn treatment: remove burn source Always start with ABC
In trauma/burns, ABCDE (disability/exposure)

Airway can be an issue with severe burns or inhalational injury (esp. with indoor fire)
Direct injury from heated air/smoke -> edema Edema from inflammatory response to burns Edema from the resuscitation fluids

Initial Assessment (primary survey)

Suspect airway injury if:
Facial burns, singed nasal hairs, wheezing, carbonaceous sputum, tachypnea

Give pt oxygen & put on pulse oximetry Progressive hoarseness is a sign of impending airway obstruction Pre-emptively intubate anyone with:
Respiratory distress, inhalational injury, large burns (due to inevitable edema from resusc) Bronchoscopy to help dx inhalational injury

Initial Assessment (primary survey)

Breathing (Breath sounds, chest rise, ET CO2)
Chest escharotomies if constrictive eschar

Circulation: get vitals (HR & BP)

2 large bore IV (unburned before burned skin) Start burn resuscitation with Lactated Ringers Place patient on continuous EKG / monitor Palpate or doppler extremity signals with circumferential extremity burns

Disability (GCS less than eight -> intubate) Exposure: remove all clothing

Initial Assessment (secondary survey)

Complete heat-to-toe examination AMPLE history
Allergies Medications (also ask about last tetanus) Past medical history (CHF careful w fluids) Last meal Events regarding the injury (how did the fire start, how long was the exposure, what type of exposure flame, grease)

Initial Assessment
Burn Resuscitation with Lactated Ringers Figure out burn size by rule of nines or entire palmar surface of pts hand = 1% (palm rule) Parkland formula 4 x Wt(kg) x %TBSA = mL to give in 1 day Half over 1st 8hrs (subtract what was given) Give other Half over next 16 hours In reality, titrate to UOP of 0.5mL/kg/hr in adults and 1mL/kg/hr in children Do not give colloid in first 24 hrs

Severity of a Burn
Depends on: Depth of burn Extent of burn Location of injury Patients age Presence of associated injury or diseases

Depth of a burn
Superficial (1): epidermis (sunburn) Partial-thickness (2): Superficial partial-thickness: papillary dermis Blisters with fluid collection at the interface of the epidermis and dermis. Tissue pink & wet. Deep partial-thickness: reticular dermis Blisters. Tissue molted, dry, decreased sensation. Full-thickness (3): dermis Leathery, firm, insensate. 4th degree: skin, subcutaneous fat, muscle, bone

Classification of Burn Depth

Third degree

Depth of a Burn
First Degree
Epidermis only Erythematous Hypersensitive Classic sunburn Heals without scar

Depth of a Burn
Second Degree Epidermis + part of dermis Superficial Deep Blisters Edematous and red Very painful Scaring variable

Depth of a Burn
Third Degree Full thickness burn Can involve underlying muscle, tendon, bone Waxy white, leathery brown or charred black Painless Heals with scar

Extent of a Burn
Rule of Nines
Most universal guide for initial estimate Deviates in children due to larger head surface area Palm rule

The Rule of Nines and LundBrowder Charts

Orgill D. N Engl J Med 2009;360:893-901

Robyns Rule of 4s

Criteria for Referral to a Burn Center

(Orgill D. NEJM 2009;360:893-901)

ABA Burn Referral Criteria (addition)

2nd & 3rd degree burns of greater than 10% BSA in patients under 10 or over 50 yrs old 2nd & 3rd degree burns of greater than 20% BSA in other age groups 2nd & 3rd degree burns with functional or cosmetic implications 3rd degree burn of greater then 5% BSA Circumferential burn of chest or extremity

Management Principles
Stop the Burning Process Universal Precautions Airway Management Breathing Management Circulatory Management Insertion of a Nasogastric Tube Insertion of a Foley Catheter

Management Principles
Relieve Pain Assess Extremity Pulses Regularly Assess for Ventilatory Limitation Provide Emotional Support Suicide Management

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Airway Management

Inhalation Injury
Important determinant of morbidity & mortality Manifests within the first 5 days after injury Present in 20-50% of pts admitted to burn centers Present in 60-70% of pts who die in burn centers

Indicators of Inhalation Injury

Burned in closed space Facial or intra-oral burns Singed nasal hairs Soot in mouth, nostrils, larynx Hoarseness or stridor Respiratory distress Signs of hypoxemia

History of Event
Is there a history of unconsciousness? Were there noxious chemicals involved? Did injury occur in closed space?

Types of Inhalation Injury

Carbon Monoxide Poisoning Inhalation Injury Above the Glottis Inhalation Below the Glottis

Carbon Monoxide Poisoning

Colorless, odorless gas Binds to hemoglobin 200 times more than oxygen Most immediate threat to life in survivors with severe inhalation injury Toxicity related directly to percentage of hemoglobin it saturates

Carbon Monoxide Poisoning

Signs & Symptoms of Carbon Monoxide Toxicity

Carboxyhemoglobin (%)
0-10 10-30 30-50 50-60 60+

Signs/Symptoms
None Headache Headache, nausea, dizziness, tachycardia CNS dysfunction, coma Death

Signs of CO Poisoning
Cherry red coloration Normal or pale skin with lip coloration Hypoxic with no apparent cyanosis PaO2 is unaffected Essential to determine carboxyhemoglobin levels !

CO Poisoning: Treatment
100% oxygen until carboxyhemoglobin levels less than 15
Increases rate of CO diffusion from 4 hours to 45 minutes

Hyperbaric oxygen is of unproven value

May be useful in isolated CO intoxication but complicates wound care

Inhalation Injury Above the Glottis

Most common inhalation injury Results from heat dissipation into tissues Commonly leads to obstruction Edema lasts for 2-4 days Dx by visualization of upper airways

Inhalation Injury Above the Glottis: Treatment

Intubate!!!

Inhalation Injury Below the Glottis

Chemical pneumonitis caused by toxic products of combustion
Ammonia, chlorine, hydrogen chloride, phosgene, aldehydes, sulfur & nitrogen oxides Related to amount and type of volatile substances inhaled

Onset of symptoms is unpredictable

Close monitoring for first 24 hours

Prior to transfer to burn center Intubation

to clear secretions relieve dyspnea deliver PEEP Improve oxygenation

Inhalation Injury Below the Glottis: Treatment

Steroids not indicated Prophylactic antibiotics unjustified Circumferential chest burns: escharotomies

Inhalation Injury in the Pediatric Patient

Small airways: rapid onset of obstruction
Well secured, appropriately sized, uncuffed tube

Rib cage is not ossified

More pliable Pt exhausts rapidly due to decrease in compliance with circumferential chest burns Escharotomies performed with first evidence of ventilatory impairment

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Shock & Fluid Resuscitation

Goal:
To maintain vital organ function while avoiding the complications of inadequate or excessive therapy

Systemic Effects of Burn Injury

Magnitude & duration of response proportional to extent of surface burned Hypovolemia
Decreased perfusion & oxygen delivery

Initial increase in PVR & decrease in CO

Neurogenic & humoral effects

Corrected with adequate fluid resuscitation

Prevent shock & organ failure

Cellular Response to Burn Injury

Severity dependant on temperature exposed and duration of exposure
Zone of Stasis: recovery of injured cells dependant on prompt resuscitation

Resuscitation Fluid Needs

Related to:
extent of burn (rule of nines) body size (pre-injury weight estimate)

Delivered through large bore peripheral IV

Attempt to avoid overlying burned skin Can use venous cut down or central line

Resuscitation Fluid Needs: First 24 Hours

Parkland Formula:
Adults: 2-4 ml RL x Kg body weight x % burn Children: 3-4 ml RL x Kg body weight x % burn

First half of volume over first 8 hours, second half over following 16 hours
Hypovolemia, decreased CO Increased capillary permeability Crystalloid fluid is keystone, colloid not useful

Resuscitation Fluid Needs: Second 24 Hours

Capillary permeability gradually returns to normal Colloid fluids started to minimize volume
Only necessary in patients with large burns (greater than 30% TBSA) 0.5 ml of 5% albumin x Kg body weight x % burn

Monitoring of Resuscitation
Actual volume infused with vary from calculates according to physiologic monitoring Optimal regimen:
minimizes volume & salt loading prevents acute renal failure low incidence of pulmonary & cerebral edema

Monitoring of Resuscitation
Urinary output is a reliable guide to end organ perfusion
Adults: 30-50 ml per hour Children (less than 30 Kg): 1 ml/Kg per hour

Infusion rate should be increased or decreased by 1/3 if u/o falls or exceeds limits by more than 1/3 for 2-3 hours

Fluid Resuscitation Complications

Overresuscitation complications: Poor tissue perfusion Compartment syndrome Pulmonary edema Pleural effusion Electrolyte abnormalities

Management of Myoglobinuria & Hemoglobinuria

High voltage electrical injury and mechanical trauma Maintain urine output of 75-100 ml per hour Add 12.5 gm of Mannitol to each liter of fluid
Urine output not sustained Urine pigment does not clear

Sodium bicarbonate 1 amp (50 meq) per liter of fluid

Heme pigments more soluble in alkaline urine

Monitoring Resuscitation
Blood pressure:
Can be misleading due to progressive edema & vasoconstriction

Heart Rate:
Tachycardia commonly observed

Hemaglobin & hematocrit:

Not a reliable guide Transfusion not to be used for resuscitation

Baseline serum chemistries & arterial blood gases

Baseline to be obtained in burns of >30% BSA

Monitoring Resuscitation
CXR: daily for first 5-7 days
Normal study in first 24 hours does not r/o inhalation injury

ECG:
All electrical injuries Pre-existing cardiovascular disease

Fluid Resuscitation in the Pediatric Patient

Require greater amounts of fluid
Greater surface area per unit body mass

More sensitive to fluid overload

Lesser intravascular volume per unit surface area burned

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Wound Management: General

Clean & debride wound Prophylactic systemic abx unnecessary (no data for oral or IV abx) Topical abx delay wound colonization and infection Give tetanus toxoid if not up to date Escharotomy/fasciotomy may be required (circumferential burns, deep burns, compartment syndrome)

Initial Burn Wound Management

Circumferential deep 2nd or 3rd degree extremity burn can compromise circulation Assess for the 6 Ps
Pain, pallor, pulselessness (check Doppler), paresthesias, paralysis, poikilothermia

Initial Burn Wound Management

Extremity Escharotomy Chest Escharotomy Circumferential burn of Circumferential chest the extremity wall burns Remove rings, watches Performed in the anterior Elevation of limb axillary line Hourly monitoring: Extend to abdominal wall Skin color, Temperature if involved Sensation, Pain Capillary refill Divide eschar completely
Electric cautery Sharp division Peripheral pulses Ultrasonic flowmeter

Initial Burn Wound Management

Finger Escharotomy Seldom required Performed after consultation with burn center physician Extend through full thickness of skin only Avoid tactile areas

Performing an Escharotomy
Bedside procedure Sterile technique (sharp division or electrocautery) Local anesthesia not required
Control anxiety

Avoid major nerves & vessels Extend incision into subcutaneous fat Incision to be carried across involved joints 2nd incision on contralateral aspect of limb may be required

Wound Management: Topical Antibiotics

Mafenide acetate (Sulfamylon) for ears
Good at penetrating eschar & is painful Broad spectrum Side effect: metabolic acidosis via carbonic anhydrase inhibition

Bacitracin for face

Gram-positive bacteria

Silver sulfadiazine (Silvadene) for trunk & extremities

Broad spectrum, esp. Pseudomonas Does not penetrate eschar very well Side effects: neutropenia/thrombocytopenia

Excision and Grafting

3rd & (most) deep 2nd need early excision & grafting, Except
palm, soles, face, Genitals Perform 3-7 days post-burn

Orgill D. N Engl J Med 2009;360:893-901

Wound Management: Burn Excision & Grafting

Early excision & grafting improved burn patient mortality & functional outcome Initial excision should occur soon after resuscitation Full-thickness skin grafts (FTSG) Split-thickness skin grafts (STSG) Human allograft Porcine xenograft Dermal substitutes: Integra

Specific Anatomical Burns

Facial Burns

Require hospital care

Possibility of respiratory damage

Elevate HOB 30 degrees

Use water or NS to clean to avoid

chemical conjunctivitis

Specific Anatomical Burns

Burns of the Eyes
Examine ASAP Use fluorescein to identify corneal injury Chemical burns to be rinsed with copious NS Opthalmic antibiotic drops if corneal injury present Solutions with steroids dangerous Tarsorrhaphy is never indicated in acute phase

Specific Anatomical Burns

Burns of the Ears
Examine external canal & drum early Determine if OM/OE present Avoid pressure dressings & additional trauma

Specific Anatomical Burns

Burns of the Hands
Determine vascular status & need for escharatomy Presence of radial pulse does not exclude compartment syndrome Monitor with Doppler U/S Elevate hand above heart Dressings impair ability to monitor

Burns of the Feet

Assess circulation on scheduled basis Elevate limb Dressings to be avoided to not interfere with monitoring

Specific Anatomical Burns

Burns of the Genitalia & Perineum
Burn to the penis requires immediate insertion of Foley catheter With circumferential burns, a dorsal escharotomy may be indicated Scrotal swelling does not require treatment Diverting colostomy not indicated in perineal burns

Tar Burns
Contact burns Bitumen is non-toxic Immediate cooling of molten with cold H20 Removal of tar not an emergency Cover with petroleum based product & dressed to emulsify tar

Please Pass the Mayo!

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Electrical Injury
Occurs when electricity is converted to heat as it travels through tissue Divided into:
High voltage greater than 1000 V
Local injury, deep injury, fractures, blunt injuries Risk of rhabdomyolysis, compartment syndrome, cardiac injury

Low voltage less than 1000

Local injury

Hands & wrists are common entrance wounds Feet are common exit wounds

Electrical Burns
Extremely difficult to evaluate clinically Greatest tissue damage occurs under and adjacent to contact points, Most significant injury is within deep tissue Edema can compromise circulation Explore & debride necrotic tissue May have to re-explore questionable areas Late complications: cataracts, progressive demyelinating neurologic loss

Types of Tissue Injury

Cutaneous Burn with no underlying tissue damage
No passage of current through patient

Cutaneous Burn plus deep tissue damage

Involving fat, fascia, muscle and/or bone

Muscle damage associated with myoglobin release

Urine may be light red to port wine color Risk of kidney damage

Lightning Injury
Direct current of >100 000 000 volts and up to 200 000 amps Injury results from:
Direct strike Side flash
Flow of current between person & nearby object

Often travels on surface of body

Burns typically superficial splashed on spidery pattern

Management of Electrical Injury

ABCs Assess Injury
History LOC, cardiac arrythmia, other trauma Physical Exam neuro exam, long bone #, dislocations, cervical spine

Maintain Patency of Airway Cardiac Monitoring:

Standard 12 lead EKG on admission Continuous cardiac monitoring for first 24 hours

Management of Electrical Injury: Fluid Resuscitation

Administer Ringers Lactate in amounts estimated with Parkland Formula
Will underestimate required volume due to underlying tissue damage Increase fluids as per urine output

Examine urine for pigment

Maintain urine output 75-100 ml/hr until clear Add 1 amp (50 meq) per liter of RL to alkalize urine Mannitol 12.5 mg/liter to maintain urine output

Follow serial CPK & urine myoglobin due to possibility of rhabdomyolysis

Management of Electrical Injury: Peripheral Circulation

Hourly monitoring of skin color, sensation, capillary refill and peripheral pulses Remember 6Ps Remove all rings, watches, jewelry Surgical correction of vascular compromise
Decompression by escharotomy or fasciotomy Upper limb-volar & dorsal incisions with protection of ulnar nerve Lower limb-medial & lateral incisions

Electrical Burns in the Pediatric Patient

Low voltage accidents most common
Generally household (faulty insulation, frayed
cords, insertion of metal object into wall socket) Cutaneous injury, no muscle damage

Oral commisure injury

Look worse than they are

No initial debridement

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Chemical Burns: Classification

Alkalis
Hydroxides, carbonates and caustic sodas of sodium, ammonium, lithium, barium & calcium Oven & drain cleaners, fertilizers, industrial cleaners

Acids
HCl, oxalic, muriatic & sulfuric acids Common in household & swimming pool cleaners

Organic Compounds
Phenols, creosote, petroleum products Contact chemical burns & systemic effects

Chemical Burns
Factors That Determine Severity:
Agent Concentration Volume Duration of contact (delay in treatment) Alkalis generally cause worse damage

Treatment of Chemical Burns

Speed is essential, ABCDE, Eremove clothing The clinical signs of severe chemical injury : altered mental status, respiratory insufficiency, cardiovascular instability, and a period of unconsciousness or convulsions. Initial supportive therapy should be focused on airway patency, ventilation, and circulation, at the same time that patients are examined for burns, trauma, and other injuries.

Treatment of Chemical Burns

Wear gloves and protective clothing Remove saturated clothing Brush skin if agent is a powder End the exposure, Irrigate, irrigate, irrigate!
Copious amounts of water Continued until pain or burning has decreased

Neutralization of agent contraindicated

Generation of heat may lead to further injury

Specific Chemical Burns: Treatment

Alkali Injury to the Eye
Bond to tissue proteins leading to liquefaction necrosis Require prolonged irrigation
Water or saline

Likely to present with swelling & lid spasm Place catheter in lateral sulcus to irrigate

Specific Chemical Burns: Treatment

Petroleum Injuries
Contact with gasoline or diesel fuel Delipidation: causes an initial partial thickness burn become a full-thickness burn Systemic toxicity evident within 6 to 24 hours
Pulmonary insufficiency Hepatic failure Renal failure CNS narcosis

No specific antidote

Specific Chemical Burns: Treatment

Hydrofluric Acid
Most tissue reactive inorganic acid Fluoride ion penetrates & binds tissue
Ceases when it combines with Ca or Mg Burns greater than 5%TBSA can be life threatening

Acute Tx: copious irrigation with H2O or Zephiran (benzalkonium chloride) Topical calcium gluconate gel or Epsom salts If pain persists, inject 10% Ca gluconate into site Intraarterial and IV infusions with Bier block Hydrofluoric acid: can cause severe hypoCa

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Pediatric Burns
Scald burns most common burn in < 3 years Flame burns most common in children > 3 years Always consider child abuse

Pediatric Burns: Pathophysiology

Greater surface area per pound of body weight
Greater fluid needs Greater evaporative water loss Greater heat loss

Disproportionately thin skin

Burns may be deeper than initially assessed Requires less exposure time to result in burn

Pediatric Burns: Airway

Intubation performed by someone experienced Larynx more cephalad
More acute angulation of the glottis

Incuffed tube always used Cricothyroidotomy is never indicated Large bore needle placed through cricothyroid membrane may be used in emergency cases

Pediatric Burns: Circulatory Status

Burn > 10% BSA should be hospitalized IV Ringers Lactate is administered as per formula
Must also add maintenance fluid (4-2-1 rule)

NG tube Urinary catheter to monitor urine output:

<30 Kg: 1ml/Kg per hour >30 Kg: 30-50 ml per hour

If hypoglycemic, add 5% glucose to RL solution

Pediatric Patient: Wound Care

Stop burning process Remove all clothing Topical antibiotics not indicated before transfer Conserve heat with thermal blankets Escharotomy
Chest: ventilatory impairment Limb: vascular compromise

Overview
Burn Pathophysiology Initial Assessment & Management Airway Management & Inhalation Injury Shock & Fluid Resuscitation Burn Wound Management Electrical Injuries Chemical Burns Pediatric Burns Other Topics

Radiation Injury
Effects reproductive mechanism of certain tissue cells Mature cells suffer less damage Stem cells are more vulnerable to injury Large doses of radiation (> 2000 RAD) may lead to acute mortality

Outcomes Associated with Ranges of Whole Body Radiation

Whole Body Dose(RAD)
20-100 200-400

Response

Change in # of leukocytes Severe reduction in leuks, N/V, hair loss, death due to infection

600- 1 000 Destruction of mone marrow, diarrhea, 50% mortality within 1 month

1 000-2 000
2 000+

GI ulceration, death within 2 weeks

Death within hours due to severe damage to CNS

Types of Ionizing Radiation

Alpha particles
Large, highly charged particles Associated with decay of natural radioactive elements Penetrate only a few microns of tissue

Beta particles
Positive electrons or negatively charged particles Penetrate approximately 1 cm of tissue

Types of Ionizing Radiation

Gamma and X-rays
Radioactive decay or x-ray machines Penetrate deeply Once removed from source, no further radiation injury occurs Poses no threat to attendants

Protons, Deuterons, Neutrons, Mesons and Heavy Nuclei

Produced by equipment for medical and industrial use

Radiation Burns
Identical in appearance to thermal burns
Treat as you would a non-contaminated burn

Differ from thermal burns from time between exposure and clinical manifestation
SKIN RESPONSE TO RADIATION 200-300 (RADS) 300 1000-2000 2000 Epilation Erythema Transdermal Injury Radionecrosis

Toxic Epidermal Necrolysis (TEN)

Exfoliative deramatitis
Begins with target lesions, develop into papules & bullae Injury identical to partial thickness burn Mucosal involvement of conjunctiva & GI tract

Multiple eitiologies
Drugs (penicillins, sulfas, anti-inflammatories) Infection: (staph toxin, HSV, menigococcus, septicemia) Often unknown

Toxic Epidermal Necrolysis

TEN Type I
(Staph scalded skin syndrome) Only stratum corneum denuded Frequently in children Excellent prognosis 5% mortality

TEN Type II
( Stevens-Johnson syndrome) Separation is at the dermal/epidermal junction Adult population High mortality (25-50%)

Initial Management of TEN

Steroids not indicated Systemic antibiotics limited to specific infection Fluid replacement Biologic dressing Maintain nutrition Prevent complications

Cold Injuries: Frostbite

Formation of ice crystals in the tissue fluids Occurs in areas that lose heat rapidly Three degrees of frostbite:
First degree: painful white or yellow firm plaque Second degree: painful superficial clear or milky blisters Third degree: deep red or purple blisters or skin color that is markedly changed

Severity influenced by both patient & environment factors

Cold Injuries: Treatment of Frostbite

Rapid re-warming in 4O degree water bath Avoid mechanical trauma - No massaging! Tetanus prophylaxis Escharotomy if vascularity compromised Tissue injury is often underestimated

Cold Injuries: Hypothermia

Defined as a core temperature < 34 degrees C Signs are vague & non-specific
May mimic other disease states

Treatment:
Limit stimulation of patient V.Fib easily induced Rapid re-warming i9n warm water bath Intubation to administer warm air Central administration of warm Ringers solution

Cold Injuries: Hypothermia

Monitor for systemic acidosis with serial ABGs
Treat with sodium bicarbonate

Cardiopulmonary bypass Cardiac monitoring

Ventricular dysrhythmia

Patients not to be declared dead until rewarmed

Continue CPR until core temperature> 36 degrees C.

Secondary assessment for contributing diseases

Hyperthermia: Clinical Syndromes

Heat Cramps
Result from excessive loss of salt by evaporation Experiences severe pain & cramping in muscles Tx: oral replacement of salt & water

Hyperthermia: Clinical Syndromes

Heat Exhaustion
Consequence of inappropriate cardiovascular response to stress of heat Diversion of blood to skin is not accompanied by vasoconstriction to other areas or by volume expansion Present with postural hypotension, profuse sweating, pallor, nausea, light-headedness Tx: oral replacement or IV normal saline if severe

Hyperthermia: Clinical Syndromes

Heat Stroke
Failure of body cooling mechanism
severe hyperpyrexia

Setting of physical exercise w/o acclimatization Present with temperature>103, no sweating, decreased LOC Tx: rapid cooling until temperature <102 deg If shivering develops, slowly give IV Thorazine DIC frequently reported

Tetanus Immunization
CLINICAL TETANUS-PRONE CLEAN FEATURES WOUNDS WOUNDS Age of wound > 6 Hours <6 Hours Configuration Stellate, avulsion Linear, abrasion Mechanism Missile,crush,heat, Sharp surface cold Signs of Infection Present Absent Devitalized Tissue Present Absent Contaminants Present Absent

Tetanus Immunization
History Of Tetanus Clean Wounds TD1 TIG yes yes yes no no no no no Tetanus-Prone Wounds TD1 TIG yes yes yes no yes yes no no

Uncertain 0-1 2 3 or more

Consider patient partially immunized if:

**For a clean wound, if last Td given > 1O years ago **For a dirty wound, if last Td given > 5 years ago

The End!