​Kembara Xtra - Medicine - Burn

​Kembara Xtra - Medicine - Burn 
Tissue damage brought on by the application of heat, chemicals, electricity, or radiation
The intensity and length of the exposure determine the extent of the damage (depth of the burn).
- The epidermis' outermost layers are affected in the first degree.
- The dermis and different portions of the epidermis (with blister formation) are involved in the second degree.
- Coagulation of the subdermal plexus and destruction of all skin components (full thickness) constitute the third degree.
Endocrine/metabolic, pulmonary, skin/exocrine, and other system(s) affected

Aspects of Geriatrics
Patients >60 years of age make about 11% of all burn patients, and the prognosis is worse for serious burns.
Child Safety Considerations
When dealing with hot water burns in children, keep in mind that abuse accounts for 15% of pediatric burns. Sharply delineated wounds, immersion injuries, and suspicious stories are particular causes for concern. early involvement of child welfare services.

Incidence and prevalence in Epidemiology 
30% of people are over 30 years old, 13% are newborns, and 11% are over 60. 70% of people are men.
Incidence
in the United States each year
Between 1.2 million and 2.0 million burns; 700,000 ER visits; 45,000 to 50,000 hospital stays; and 3,900 fatalities from burn-related complications
Burn care is estimated to cost $2 billion annually. House fires are the leading cause of burn deaths, accounting for 75% of all burn fatalities. Burn deaths nationwide are on the decline due to improved prevention and treatment. Burns from the illegal production of methamphetamines are on the rise. Combinations of chemical burn, thermal burn, and explosive injuries can manifest in patients.

Pathophysiology and Etiology 
The most frequent causes of burns (heat usually 45°C) are open flames and hot liquids; flame burns are more common in adults whereas scald burns are more common in youngsters.
Caustic substances or acids (may cause only minor first indications or symptoms)
Electricity (may cause serious injuries with very little skin damage on top)
 Too much solar exposure

Risk Elements
Overheated water heaters Chemical, electrical, or irradiation exposure at work Young children and elderly people with thin skin are particularly prone to harm.
18% of deadly fires in 2006 were attributed to cigarette carelessness.
Lack of smoke detectors: 63% of residential fires are attributed to a lack of or malfunctioning smoke alarms. Inadequate or faulty electrical wiring.
12.4% of fires in 2012 that resulted in fatalities were started intentionally.

Prevention 
Education about home safety should be a major component of injury prevention.
Families with knowledge of home safety are more likely to have hot water that is at a safe temperature.
As a result of safety education, more homes have working smoke alarms and employ fireguards more frequently.


Accompanying Conditions
Smoke inhalation syndrome: Occurs within 72 hours of burn; may entail thermal damage of respiratory mucosa (e.g., trachea, bronchi); may involve carbon monoxide inhalation; should be suspected in any burns that occur in enclosed spaces or exposure to explosions.


Check for congruence between the history and the physical characteristics of the burn when presenting the history and the source of the burn in children or the elderly.

clinical assessment 

First degree: erythema of the affected tissue, skin that blanches under pressure, and sometimes sensitive skin.
In the second degree, the skin is painful and reddened with blisters.
Third-degree burns result in brittle, leathery skin that is non-tender.
Rule of 9s: 9% for each upper and lower extremity for adults and 14% for children for each lower extremity
- Adult and kid trunk anterior: 18%
- Adult and kid trunks at the posterior: 18%
- Child: 18%; Head and Neck: 10%
Quick calculation: The patient's hand has 1% of the body surface area (BSA) (palmar surface plus fingers).

 Thorough documenting of burn extent and projected burn depth
Keep an eye out for any symptoms that could point to an affected airway, such as tachypnea, singed nose hair, face burns, carbonaceous sputum, developing hoarseness, an irritated oropharynx, and circumferential burns around the neck.


Diagnostic and Laboratory Tests
Children: glucose; smoke inhalation: arterial blood gas; carboxyhemoglobin; electrical burns: ECG; urine myoglobin; creatine kinase isoenzymes; hypoglycemia may arise in children due to insufficient glycogen store.
Initial Examinations (Laboratory and Imaging) Labs: Hematocrit; Type and Crossmatching; Electrolytes, including BUN and Creatinine; Urinalysis

 Chest radiographs and xenon scans are helpful in cases of possible smoke inhalation.
Other/Diagnostic Procedures
To assess the lower respiratory system after smoke inhalation, bronchoscopy may be required.


Management 

Prehospital treatment
- Take the patient away from the burn's origin.
- Put out the fire and take off any burning garments.
- Water at room temperature may be applied to burns, but only for the first 15 minutes after exposure.
- Wrap the sufferer to keep them warm.
- All patients will be given face masks with 100% oxygen.
Admission to a hospital for any severe burns
- Any 3rd-degree burn - 2nd-degree burns exceeding 10% of BSA
- Hand, foot, face, or perineum burns
- Lightning or electrical burns
- Chemical burns - Circumferential burn - Inhalation injury
For (2)[C], transfer to the burn center
- 2nd- and 3rd-degree burns over 10% of BSA in patients between the ages of 10 and 50 - 2nd-degree burns exceeding 20% of BSA and full-thickness burns exceeding 5% of BSA in patients of any age.
Burns of the third degree in any age group
- Hand, foot, face, or perineum burns
- Lightning or electrical burns
- Burns from chemical substances
Burning circumferentially
- Burns in patients who also have secondary trauma (fractures, etc.), when the burn is the more serious damage; if not, transfer the patient to a trauma hospital for stabilization.
- Burn injuries in patients with underlying illnesses that can compromise care, survival, or recovery


Prevention 
Based on the rule of 9s and an accurate estimation of the total BSA involved, the depth of the burns
Tetanus vaccination (if not already had)
To prevent a tourniquet effect, take off all rings, watches, and other jewelry from the wounded extremities.

 Take off your clothes, and place dry blankets over all burned skin.

 Rinse the chemical burn area (for about two hours).
Use 100% oxygen delivery for any severe burns; think about intubating early.
Don't put ice on the burn spot.
(High risk of paralytic ileus) Nasogastric tube
Analgesia, Foley catheter

In the first 24 hours after an electrical burn, ECG monitoring is recommended. In the case of severe burns, whirlpool hydrotherapy is followed by silver sulfadiazine (Silvadene) occlusive dressings.
Daily or bi-daily cleaning and dressing
Burn fluid resuscitation: The time of the burn should be used to calculate fluid resuscitation, not the start of treatment.
In children, this is given in addition to maintenance fluids and is regulated in accordance with urine output and vital signs. - 2 to 4 mL lactated Ringer body weight (kg) % BSA burn (1/2 given in first 8 hours, in second 8 hours, and in third 8 hours). The results of protocol-based resuscitation are superior.
- Colloid solutions should not be administered during the first 12 to 24 hours after CPR.
- Other: For burn covering, the use of biologic membranes or skin replacements may be advised.

Injury from inhalation - breathing assisted by positive end-expiratory pressure. Utilize breathing techniques that protect the lungs.
– Patients with carbon monoxide levels above 25%, those with comas, localized neurological deficits, ischemic ECG abnormalities, and pregnant patients may benefit from hyperbaric oxygen therapy. Steroids and antibiotics for prevention are not recommended.

First Line of Medicine
For extreme pain, IV morphine or hydromorphone (Dilaudid).
Oral analgesics for moderate pain, such as acetaminophen with codeine (Tylenol), acetaminophen and oxycodone (Percocet), or acetaminophen and hydrocodone (Lortab).
Apply topically to the burn site with silver sulfadiazine (Silvadene) (may cause leukopenia). Use with caution in sulfa-allergic patients, pregnant or nursing women, and young children (under two months old).
Apply bacitracin or neosporin ointment to facial burns.
Acticoat A.B., a dressing made of two sheets of high-density polyethylene mesh coated with nanocrystalline silver, has a more controlled, prolonged release of silver, allowing for less frequent dressing changes. Mupirocin: has potent inhibitory activity against methicillin-resistant Staphylococcus aureus (MRSA).
Myoglobinuria and electrical burn call for urine and mannitol alkalinization.
Consider using H2 blockers (such as famotidine) or proton pump inhibitors (such as lansoprazole, pantoprazole) to prevent stress ulcers in individuals who have suffered severe burns.
Tetanus immunoglobulin/tetanus toxoid
There isn't a certain reason to take systemic antibiotics as a preventative measure.
When compared to a conventional hydrocolloid dressing, the use of negative pressure wound therapy may produce a low-protease environment with higher levels of angiogenic factor (vascular endothelial growth factor [VEGF]), resulting in a more disorderly, hyperkeratinized, thickened epidermis.

Next Line

Mafenide (Sulfamylon) is better for full-thickness burns and is most effective against Pseudomonas (caution: painful metabolic acidosis).
0.5% silver nitrate (messy, drains electrolytes from burns, harmful to water)
Povidone-iodine (Betadine) may cause iodine absorption from the burn and "tan eschar," which makes débridement more challenging.

Surgical Technique 
Escharotomy may be required to treat compartment syndrome-related circumferential burns to the chest or extremities.
Various dressings (e.g., biosynthetic, biologic) are available to help reduce the number of dressing changes and promote healing. Tangential excision with split-thickness skin grafts: Early excision of burns results in a significant reduction in mortality (excluding patients with inhalational injury) and a significant decrease in hospital length of stay.


Take Action 
The aim is early mobilization.


Nutrition 
When bowel movement returns, a high-protein, high-calorie meal is recommended. In the early postburn period, nasogastric tube feedings may be necessary.
Total parenteral feeding if NPO is anticipated to last more than 5 days.
Shorter stays in the intensive care unit (ICU) and lower rates of wound infection are the effects of early enteral feeding initiation within the first 24 hours of arrival.
Use sunscreen: Skin grafts and freshly epithelialized skin are particularly vulnerable to the sun and temperature extremes.
Limit access to electrical outlets and cords.

Separate common home chemicals.

Use the water heater's low setting (about 54°C).
Smoke detectors for homes, with an emphasis on upkeep
Plan for family and home evacuation
Use and storage of combustible compounds properly

First-degree burn prognosis: full recovery
For 2nd and 3rd degree burns, there is no chance of reepithelialization; a skin graft is necessary. For 2nd and 3rd degree burns, epithelialization occurs in 10 to 14 days.
The Baux score (the sum of age and TBSA burned), the Denver 2 score (pulmonary score ranging from 0 to 3, using PaO2/FiO2 cutoffs of 100, 175, and 250), the renal score (ranging from 0 to 3), the hepatic score (ranging from 0 to 3), and the cardiac score (ranging from 0 to 3 depending on the number and dosage of inotropes) can all be used to estimate mortality (6)[B].
The severity of the burn, the amount of smoke inhaled, any concomitant conditions, and the patient's age determine how long they must stay in the hospital and whether they require ICU care.
Burn size is connected with problems; mortality and morbidity are more likely in patients with burns that are >60% TBSA in children and >40% TBSA in adults.
A 50% chance of survival can be anticipated with a burn rate of 62% in patients under the age of 14, 63% in patients between the ages of 15 and 40, 38% in patients between the ages of 40 and 65, and 25% in patients above the age of 65.
90% of survivors should be able to find work that is comparable to what they were doing before the burn.

Complications 

 Marjolin ulcer: malignant squamous cell carcinoma forming in an old burn site Gastroduodenal ulceration (Curling ulcer) Signs of infection: discolouration, green fat, edema, eschar separation, and progression of a 2nd-degree wound to a 3rd-degree wound
The best method for determining wound infection is a biopsy.
Burn wound sepsis is typically caused by gram-negative bacteria, vancomycin-resistant enterococci, and S. aureus (including MRSA).
Pneumonia, decreased mobility with a potential for future flexion contractures, and the hypertrophic scarring that is typical of burn victims