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TREATMENT SUMMARY (0 TO 24 HOURS)

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Presence of soot on face and in the mouth especially with a facial burn are signs of smoke inhalation. However, these signs can be absent in the presence of significant smoke injury.

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Massive facial edema can be anticipated with a facial burn especially involving lips and mouth. Early endotracheal rather than nasotracheal intubation is preferred using an 8mm. I.D. tube in an adult male.

DEEP CHEST WALL BURN

Rigid eschar[m1] 

 [m1]This is a dry scab that forms on skin that has been burned or exposed to corrosive agents.

can markedly impede chest wall movement impairing ventilation. Severing the eschar to allow for respiratory excision if oxygenation or ventilation is impaired, or if work of breathing is clearly increasing.

CHEST WALL ESCHAROTOMY


The incision lines for chest and extremity escharotomies are shown. For the chest, longitudinal incisions are made 
thru burn in the mid-axillary line followed by a connecting subcostal incision.


Chest wall escharotomy being performed on full thickness burn. Incision in mid-axillary lines must go thru 
the entire eschar to allow tissue expansion. Bleeding can be controlled with cautery or often with pressure alone.


SUMMARY SECTION

Maintenance of Hemodynamic Stability (0-24 hrs) Maintenance of Hemodynamic Stability (0-24 hrs)

Fluid Resuscitation


All patients with burns more than 20% Total Body Surface

  • Large Bore Peripheral Intravenous Lines

  • Begin lactated Ringers Solution; Estimate Initial Rate: 4cc/kg/%TBS burn (half in first 8 hrs)

  • Can add colloid 5% albumin or hetastarch of fluid requirements exceeding the predicted formula

  • Infuse at constant rate instead of by bolus

  • Adjust fluid rate according to patient response

  • Expect increase in fluid requirements in

-elderly, small children

-smoke inhalation

-electrical burns

  • Consider low dose dopamine if urine output low in the presence of hemodynamic stability

Monitoring Guidelines

  • Blood pressure - only reliable as volume indicator if low

  • Pulse: young patient - pulse less than 120, reasonable perfusion; pulse > 130, increase fluid

Elderly or with heart disease - pulse not accurate reflection of perfusion

  • Urine output - 0.5 to 1 cc/kg/hr is adequate in absence of diuretic such as alcohol

Exception: Myoglobin or hemoglobinuria where over 1cc/kg/hr is indicated

  • Base deficit > 5 meq / liter reflects decreased tissue oxygenation. Look for progressive decrease in base deficit as marker of adequacy of resuscitation.

  • Electrocardiogram - particularly important for patient more than 45 years old

  • Temperature - Avoid hypothermia

  • Peripheral perfusion: for circumferential arm, leg burns

- Use of Doppler to monitor

- If circumferential burn with decreasing pulse pressure consider escharotomy

  • Blood gases - High risk of hypoxemia, hypercapnia due to direct pulmonary complications of burn and treatment.

  • Acid-base - Base deficit very useful indicator of tissue oxygenation (if increasing give more fluid)

  • Pulmonary artery wedge pressure - for high risk patient (elderly) inhalation, cardiac output, mixed venous oxygen pressure, if cardiopulmonary stability cannot be achieved.

  • Hemoglobin (increasing value indicator of decreasing blood volume

  • Electrolytes - initial abnormality may be hyper- or hypokalemia, HCO` 3 value dependent on acid-base balance 

  • Prothrombin time, partial thromboplastin time, platelets - moderate burn: usually near normal.

  • -more than 50% total body surface: abnormal due to consumption coagulopathy

 

 

 

 

 


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