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Burns.ppt
- 1. Burns • An injuryoccuring from destruction of the skin by thermal forces.
- 2. Classification • Burns areclassified by depth, type and extent of injury • Every aspect of burn treatment depends on assessment of the depth and extent
- 3. Classification by depth •1st degree(superficial)-affects the epidermis and is reddish eg a sun burn • 2nd degree(partial thickness)-affects dermis and epidermis, are pink or red, blistering or weeping and painful. • 3rd degree(full thickness)- affects epidermis, dermis,sq muscle or the bone. Eschar presents(leatherly,shiny) black or white, usually dry, have no sensation and do not blanch on pressure.
- 4. Burn extent • Burnextent is calculated only on individuals with second and third degree burns • Palmar method: the child’s palm is used to estimate the burnt area which represents approximately 1% of the total body surface area. • body surface area chart below according to age
- 5. LUND AND BROWDERMETHOD • Front and back of the head about 20% • Front and back of the head 2% • Upper limbs 10% each • Trunk 15% anterior 15% posterior • Buttocks 3% each • Lower limbs 15% each
- 6. Lab studies Severe burns: •Complete Blood Count • ABG with carboxyhemoglobin • Coagulation profile • U/A • Creatinine phosphokinase and urine myoglobin (with electrical injuries) • 12 Lead EKG
- 7. • HEAD =18% •ANTERIOR TRUNK-18% • POSTERIOR TRUNK-18% • UPPER LIMB-9%+9%=18% • LOWER LIMB-14%+14%=28% • PERINEUM-1%
- 8. Imaging studies • CXR •Plain Films / CT scan: Dependent upon history and physical findings
- 9. Treatment • Admit allchildren with burns covering > 10% of their body surface; those involving the face, hands, feet, perineum and joints; those that are circumferential and those that cannot be managed in an outpatient ward. • Initially, burns are sterile. Focus treatment on speedy healing and prevention of infection.
- 10. Cont’ • Consider whetherthe child has a respiratory injury due to smoke inhalation. – If there is evidence of respiratory distress, provide supplementary oxygen, and ensure the airway are safe and remain safe by regular observation. Inform the anaesthetist if there is potential airway obstruction – Severe facial burns and inhalation injuries may require early intubation or tracheostomy to prevent or treat airway obstruction
- 11. • Fluid resuscitationis required for burns covering > 10% total body surface. • Use Ringer’s lactate or normal saline with 5% glucose; for maintenance, use Ringer’s lactate with 5% glucose or half-normal saline with 5% glucose. • The total daily fluid requirement of a child is calculated with the following formula: 100 ml/kg for the first 10 kg, then 50 ml/kg for the next 10 kg, thereafter 25 ml/kg for each subsequent kg. • – First 24 h: Calculate fluid requirements by adding maintenance fluid requirements to the additional emergency fluid requirements (volume equal to 4 ml/kg for every 1% of surface burnt).
- 12. • 100ml×10=1000ml • 50ml×10=500ml •25ml×10=250ml • 4ml×30×30=3600ml Total fluids=5350mls in 24hours
- 13. Cont’ • Administer halfof total fluid in first 8 h, and remaining fluid in next 16 h. • Example: 20 kg child with a 25% burn: • Total fluid in first 24 h = (100×10+ 10*50) + 4 ml x 20 kg x 25% burn • = 1500 ml + 2000 ml • = 3500 ml (1750 ml over first 8 h) • – Second 24 h: give half to three quarters of fluid required during the first day.
- 14. Cont’ • Monitor thechild closely while giving emergency fluids (pulse, respiratory rate, blood pressure and urine output), taking care to avoid circulatory fluid overload. • – Blood may be given to correct anaemia or for deep burns to replace blood loss
- 15. Prevent infection: • –If skin is intact, clean with antiseptic solution, gently, without breaking the skin. • – If skin is not intact, carefully debride the burn. Except for very small burns, debride all bullae, and excise adherent necrotic (dead) tissue during the first few days. • – Give topical antibiotics or antiseptics (the options depend on resources;they include: silver nitrate, silver sulfadiazine, gentian violet, betadine and even mashed papaya). Clean and dress the wound daily. • – Small burns and those in areas that are difficult to cover can be managed by leaving them open to the air and keeping them clean and dry.
- 16. Cont’ • closed treatmentfor burns of the hand and feet with a vaseline gauze and bandage Treat secondary infection if present. • – If there is evidence of local infection (pus, foul odour or presence of cellulitis), treat with amoxicillin (15 mg/kg orally three times a day) plus cloxacillin (25 mg/kg orally four times a day). If septicaemia is suspected,use gentamicin (7.5 mg/kg IM or IV once a day) plus cloxacillin (25– 50mg/kg IM or IV four times a day). If infection is suspected beneath an eschar, remove the eschar
- 17. Cont’ Pain control • Makesure that pain control is adequate, including before procedures such as changing dressings. • – Give paracetamol (10–15 mg/kg every 6 h) by mouth, or give IV narcotic analgesics (IM injections are painful), such as morphine sulfate(0.05–0.1 mg/kg IV every 4 h or prn)or pethidine 1mg/kg prn if pain is severe. Check tetanus vaccination status. • In all cases, administer tetanus prophylaxis • – If not immunized, give tetanus immune globulin. • – If immunized, give tetanus toxoid booster, 0.5ml stat if this is due.
- 18. Nutrition • – Beginfeeding as soon as practical in the first 24 h. • – Children should receive a high-calorie diet containing adequate protein, and vitamin and iron supplements. (Omit the iron initially in severe malnutrition.) • – Children with extensive burns require about 1.5 times the normal calorie and two to three times the normal protein requirements.
- 19. anaemia • Check thehb and if less than 7g/dl transfuse .give ferrous sulphate for less severe anemia.
- 20. • Burn contractures:burn scars across fl exor surfaces contract. This happens even with the best treatment (and nearly always happens with poor treatment). • – Prevent contractures by passive mobilization of the involved areas and • by splinting fl exor surfaces to keep them extended. Splints can be made of plaster of Paris. Splints should be worn only at night.
- 21. Physiotherapy and rehabilitation •Should begin early and continue throughout the course of burn care • If the child is admitted for a prolonged period, ensure that she or he has access to toys and is encouraged to play.
- 22. Complications of burns Hypothermia Renalfailure Infection Anemia Contractures
- 23. Exercise • Master Xone and a half years old and 11kgs has been admitted in your ward with 30% burns. – Calculate the total amount of ringers lactate you will administer in the first 2 days (4mks) – Other than the surface area burnt, explain two (2) other factors of determining the Severity of burnt wounds. (2 marks) – State three acute complications of burns.(3mks) – Discuss the specific nursing management of Master X. In the first 24hrs (11mks)
- 24. GASTROENTERITIS : Acute Gastroenteritis(AGE): diarrheal disease of rapid onset, with or without accompanying symptoms, signs, such as nausea, vomiting, fever, or abdominal pain Diarrhea: the frequent passage of unformed liquid stools (3 or more loose, watery stool per day) Dysentery: blood or mucus in stools
- 25. Diarrhea Acute diarrhea: Short induration (less than 2 weeks). Chronic diarrhea: 6 weeks or more
- 26. Etiologies: Viral 70-85% of AGEin developed countries • Rotavirus-50% • Caliciviruses, astroviruses, and enteric adenoviruses,Norwalk virus Presentaion: • Low-grade fever • Vomiting followed by copious watery diarrhea (up to 10- 20 bowel movements per day) • Symptoms persisting for 3-8 days
- 27. Etiologies: Bacterial Salmonella, Shigella, E.coli, Campylobacter, Yersinia, Clostridium difficile Presentation: High fevers Shaking chills Bloody bowel movements (dysentery) Abdominal cramping & fecal leukocytes
- 28. Etiologies: Parasitic Giardia and Cryptosporidium <10%of cases Presentation: • Watery stools • Low-grade fever • differentiated from viral gastroenteritis by a protracted course or history of travel to endemic areas
- 29. Other causes • Emotionalstress- increases motility • Intenstinal infection- inflamaation of mucosa, increased mucus secretion in colon • Food sensitivity- decreased digestion of food • Food intolerance(lactose or introduction of new foods, overffeding) • Medications(iron, antibiotics)-irritation • Colon disease-(colitis, enterocolitis, necrotizing enterocolitis)-inflammation
- 30. • Inflammation andulceration of intenstinal walls, reduced absorption of fluids, increased intenstinal motilitity • Surgical alterations- short bowel syndrome- reduced size of colon, decreased absorption surface)
- 31. Pathophysiology The primary mechanisms (1)Osmotic diarrhea; Osmotic diarrhea results from the presence of osmotically active, poorly absorbed solutes in the bowel lumen that inhibit normal water and electrolyte absorption. Certain laxatives such as lactulose and citrate of magnesia or maldigestion of certain food substances such as milk are common causes of osmotic diarrhea eg Mg So4 and Na So4 (2) Secretory diarrhea: occurs when the small and large intestines secrete rather than absorb electrolytes and water ie there is reduced absorption and increased secretion. (3) Increased bowel motility diarrhea;due to reduced transit time when food passes the bowel too quickly could be due to infection.
- 32. Sign & Symptoms •Nausea & Vomiting • Diarrhea • Loss of appetite • Fever • Headaches • Abdominal pain • Abdominal cramps • Bloody stools • Fainting and Weakness • Heartburn • Dehydration • Lethargy
- 33. • Goals: • Preventdehydration • Replacement of electrolytes maintaenance of hydration • Proper feeding • Treat the cause if identified
- 34. plan A-Diarrhea withno dehydration • Done according to severity of dehydration • Give extra fluid ie breastfeed more,ors and clean water • Children up to 2 years give 50mls-100 after each loose stool • >2yrs 100-200mls after each loose stool given as small frequent sips if vomits wait for 10 min then continue slowly.
- 35. Plan B-some dehydration •Give ors 75ml/kg plus 100-200mls of clean water during the first 4 hours then reassess and classify for dehydration. Then treat appropriately • Give extra fluid • Continue feeding • Give ors to use at home
- 36. Plan c-severe dehydration •Give iv ringers Lactate 100ml/kg if unavailable give nomal saline if the child can drink give ors 5ml/kg/hr. reassess every 1-2hrsif hydration status not improving give fluids more rapidly. Reassess the child after 3 hrs and an infant after 6 hours. Then give appropriate plan ie A B or C • Can use ngt if iv access not possible with ORS 120ml/kg for 6hrs reassess after 1-2 hrs if hydration status not improving refer for iv therapy. After 6hrs and choose appropriate
- 37. Dehydration with severe malnutrition •Use rehydration solution for malnutrition(resomal) contain40mmol Na, 40mmol K and 3mmol/litre. Give orally or by ngt 5ml/kg q 30 min for the first 2 hours then 5-10ml/kg for the next 10 hrs. if rehydration is still occuring at 6 and 10 hrs give starter F- 75 instead of resomol the same volume. • *do not use iv route except in cases of shock don’t use ors as it has high levels of sodium and low of K
- 38. management • Give acombination of ORS and Znso4 • Vitamin A • intravenous therapy ringers lactate if not available use normal saline • Dehydration with severe malnutrition use rehydration solution for malnutrtion(resomal)
- 39. cont • Breastfeeding • Orsif not available give uji or rice water,yoghurt • High caloric diet eg with cereals .dairy products and eggs, fresh fruit juices and bananas • Thick soup • Avoid a lot of sugar
- 40. • Drugs shouldbe given ONLY when absolutely necessary. Do not use antidiarrheal and anti emetic. • Use antibiotics for proven dysentry with ciprofloxacin and cholera cases with erythromycin 15mg/kg orally or iv 6hrly as 1 st line and chloramphenical 50mg/kg as 2nd line • Antiprotozoal ie metronidazole 15-50mg/kg od in case of amoebiasis
- 41. Complication • Dehydration Excessive lossof fluids and minerals (electrolytes) from the body Common in infants and young children with viral gastroenteritis or bacterial infection Kidney failure, eg in infection by E.coli • Electrolyte deficiency
- 42. prevention .Early and exclusivebreast feeding • Rota virus and measles vaccination • Vit A supplimentation • Hand washing with running soapy water(5 instances) • Proper disposal of feaces • Improved water supply quantity and quality
Editor's Notes
- #4 Eschar –due to denatured proteins
- #5 age modified Rule of nine: deduct 1% from the head and add 0.5% to each leg for each year after 2 years
- #28 Clostridium difficile has emerged as an important cause of antibiotic-associated diarrhea in children. Any antibiotic can trigger infection with C difficile, though penicillins, cephalosporins, and clindamycin are the most likely causes.3 Since 50% of neonates and young infants are colonized with C difficile, symptomatic disease is unlikely in children younger than 12 months.3