الحروق
Burns
Burns are among the most common & devastating injuries seen in
emergency department. They range in severity from sun burn to lethal
injury. االصابات املميتة ﺗﺘﺮواح ﻣﻦ ﺣﺮوق ﺑﺴﯿﻄﺔ ﺣﺮوق اﻟﺸﻤﺲ اﻟﻰ ﺣﺮوق ﺧﻄﯿﺮة ﺗﻜﻮن ﻣﻤﯿﺘﮫ
* Causes: (types)
1-Thermal burns: by direct exposure to a flame of fire, scalds, hot
objectives & sun.
2-Electrical burns: passage of electrical current through the body & usually
present with minimal surface damage & extensive internal injury.
3-Chemical burns: by exposure to acids or alkalis.
4-Radiation burns: by radiation to the whole body or localized.
5-Frostbite: which appears after exposure to temperature near freezing
(10oC ).
* Predominant Victims: are 4 groups of people.
1-Children 2-Eldery 3-Careless person
4- Patients with Medical disease (epilepsy).
* Pathophysiology: Burns causes damage to many orange of the body
in different ways:
(A) – Injury to the airways & lungs: :إصابة الشعب الهوائية والرئتني
1-By direct thermal injury to the upper airways or by inhalation of hot
gases lead to swelling of the Respiratory epithelium. & detach which can
obstruct the airways.
2-CO poisoning: this is the usual cause of loss of consciousness at the
scene of fire because CO has 240 times greater affinity to Hb than O2.
3-Inhalational injury: minute particles with in the inhaled smoke cause
chemical pnenmonitis & often give rise to bacterial pneumonia.
4-Mechanical block on Respiratory rib movements by thick stiff Eschar if
there is circumferential full thickness burn arround the chest.
(B) – Inflammation & circulatory changes: :االلتهابات وتغيرات الدورة الدموية
Burns produces an inflammatory reaction.
This leads to increase vascular permeability.
Water, solutes & proteins move from intra to extra vascular spaces.
The volume of fluid loss is directly proportional to the area of burn.
Above 15% of BSA burn, the loss of fluid lead to shock .
1
(C) – Other life threatening events with Major Burns.
1- Immun depression which leads to bacterial & fungal infections.
2-Inflammatory changes lead to Microvascular damage which in turn lead
to bowel Ischaemia & bowel stasis (paralytic elius).
3- Hypovolaemia leads to acute tubular necrosis and Renal Failure.
3-Circumferantial full thickness Burns to a limb act as a tourniquet after
the limb swells. If this untreated lead to limb Ischaemia. نقص تروية الدم باالطراف
‼ مهم
* Management:
- Pre Hospital First aid care:
Remove the victim from the source of burning by means that prevent
the rescuer from coming in direct contact with
السوء بله زودنهsource.
إذا نطفي الحرك بالنفط نطفي باملي بهالحالة
Clothes should be extinguished, or chemicals should be washed away
from body by water. الن باودر ومي تصير احتراق اكثر فالزم نكنسه
Resuscitate the patient by cardio respiratory resuscitation if needed.
الزم نوفر Cool the burn wound this provide analgesia & slows damage.
ﻛﻤﺎدات ﻧﻀﯿﻔﮫ ﻧﺴﺘﺨﺪم
ضروف Cooling should occur for a minimum of 10 min. & is effective up to
مناسبه حتى
نرجع املنطقة an hour after burning & should be at about 15 oC & hypothermia
دافية نقلل most being avoided.
حرارة جسمه في حالة الحرق يتكون احادي اوكسيد الكاربون ويتسمم فالزم ننطي الترياق مالته اللي هو االوكسجني
Anyone involved in a fire in an enclosed room should receive
Oxygen. edema رفع الرجلني واالدين اذا كانت محروقه حتى نقلل
Elevation: Sitting the pt with burned airways improve life saving &
elevation of burned limbs will reduce swelling & discomfort.
- Hospital care:
1st in the Emergency Room Rangerالن ديفقد هواي من داخل الخاليا ونحتاج امالح هواي ننطي للمحترق اول يوم
I-Triage of burned patient (A B C D E) Foly catheter الزم نخلليله
A: maintain patent airways: by remove any foreign bodies or fractured
tooth that obstruct the airways & early intubation in the following
conditions:
1-face & neck burns & upper airways. 2- >40-50% burn of body surface
3-Inhalational injury (burning in enclosed room)
4- To prevent airway obstruction from progressive oedema especially after
fluid resuscitation, severe oedema makes intubation difficult so in such
اشكاراتومي نسوي فنوخر الجلد امليت
case, cricothyrodotomy or tracheostomy will be mandatory. الجلد امليت اسمه شكار
B: Restore effective breathing & if the patients breathing deteriorates
assisted ventilation required.
2
C: Circulation support by intravenous access & I.V. fluid administration of
Isotonic salt solutions used for resuscitation. Glucose should be avoided
because burn pt frequently hyperglycemic by stress response.
D: Diagnosis & treatment of concomitant life threatening injuries by
History & thorough examination & radiology evaluations due to blunt or
penetrating trauma. Such as:
1-Head injury 2-Spinal injury
3-Chest or abdominal injury 4-long bone #
E: Escharatomy by using a knife incising of constricting Eschars
(circumferential full thickness burned Skin) around the chest that interfere
with Respiration or around the limbs which may progress to limb
threatening ischemia. نقص تروية الدم
ًثانيا
II-Assessment of the Burn wounds تقييم الحروق:
A: Assessing the area (percentage of burn) by one of the following ways:
1-The pt whole hand is 1% Total body surface area (TBSA) (useful in
small burns)
2- Rule of nines. (Adequate for first approximation only) as the following:
Arm, A/P legs, head and neck = 9% each مهم
A/P torso= 18% each ٩*٩ إذا اثنينهم أطراف العلوية
In children, 18% for head.
3-Lund & Browder chart useful in large burn area & is the most accurate.
B: Assessing the depth of burn wound مهم …تقيمم
- By history of the degree of Temperature of burning, duration of burning
& type of burning materials..ونوع املواد املحترقة
1-1st degree sun burn; dry, erythematus, slightly painful, heals in 48-72 hr.
2-2nd degree:- يتلوى من األلم
Superfacial burn; moist, blanch, very painful, cherry red & blister is the
hall mark, heal after 2w with minimal scars.
Deep partial thickness burns; do not blanch, little sensation & pain, dry
mottled white & red heals by scaring after weeks to months.جاف وماكو الم عبالك
3-3rd degree Full thickness burn; feel leathery, waxy & have no شي ماكو
sensation
or pain, thrombosed vessels is a pathognomonic sign. نشوف اورده متخثره
C: major determinant of outcome of burned patient:
1-percentage 2-Depth 3-presence of inhalational injury
شنو الشروط اللي ع اساسها ادخل املريض ردهة الحروق
إذا عنده اثنني او اكثر منهن فندخل املريض
مهمIII-Indication of patient Admission to burn unit
1-2nd degree burns of > 15% in the age group < 10 y & > 50 y
2-2nd degree burns of > 25% in the age group bet 10-50 y
3 نقاط تعتمد ع نسبة٣ اول
physiological conditions اذا احترك فوك الربع من جسمة وهو شاب فتصير
معرض لإلصابةimmune compromised املريض املحروك
infection بال
النسبة نقللها اكثر
3-3rd degree (full thickness) burn > 5%حروق TBSA
فاألفضل نتابعه وندخلة ردهةdangerous ares إذا مناطق محددة بالجسم محروقة وهاي
4-2nd or 3rd degree burns in special dangerous areas include face, hands,
feet & genetalia. chest داير مداير األطراف او
5-circumferential
Arrhythmia ممكن يصير عنده
burns
يصير تفاعل كيمياوي ممكن يستمر اليام استنشق غازات حاره او لهب حار فممكن يصير عنده
6-Electrical injury 7-chemical injury 8-inhalational injury pneumonia
9-Associated medical diseases (Diabetes, HT , epilepsy) السكر والضغط يتخربط وي الحرق
10- Associated surgical injuries. Thoracic ًمثال
يجي سؤال
Write about
نذكرهن عشر نقاط IV-Pre Hospitalization admission measures.
1-I.V. access 2- continue on resuscitation fluids
3-foley catheter u.o.p. should be measured hourly (30-50 cc/hr in adult &
0.5-1 cc/Kg/hr in children)
4-in > 25% TBSA burn associated with bowel stasis So N/G tube needed
for gastric decompression
5-Analgesia 6-Sedation
Injections should be I.V but not Im, because of poor Im absorption.
7-Stress ulcer prophylaxis by H2 blockers
8-Tetanus prophylaxis should be determined & brought up to date.
9-warming the pt by (covering him with clean sheets, warm IV fluids
&O2)
10- No Topical or systemic. AB. indicated at this time.
اإلجراءات بوحدة الحروق
nd
2 in the Burn unit:
Fluid Management: Tissue
response to
Many fluid formulas have been proposed but Parkland formula has the trauma كبير
most satisfactory results on many pt as below: ايام٣ بأول
- Day 1 (1st 24 hr) من الحرق
Type of fluid: Ringer lactate. Volume / 24 hr = 4 cc/Kg/ % of BSA
½ of the total volume given in the 1st 8 hr & the other ½ in the next 16 hr
& adjust the infusion rate to keep u.o.p (30–50 cc/hr in adult & 1cc/Kg/hr
كل ماتزيد املساحه
in children)
يزيد معدل فقدان
- Day 2 (24-48 hr) السوائل
Type of fluid change to dextrows water & adjust the volume & rate of
infusion according to u.o.p as above.
Add colloid fluid as Albumin
But In pt with the following conditions:
1-inhallational injury 2-cardio respiratory problem
3-elderly 4-> 40% TBSA of burn
Can start Albumin at 8 hr after burning in the 1st day & continue on day 2.
4
لترات مغذي ياليعيش٣ يحتاج لترين إلى
-Day 3 (48-72 hr) change to maintenance fluid or begin oral intake.
Who to- Monitoring of fluid adminstration by:
1- Vital signs. 2- u.o.p. 3-serial haematocrit 4-acid base balance
5-invassive haemodynamic monitoring (indicated in elderly pt, > 40%
TBSA , inhalation injury & in cardio respiratory problem)
bradycardia and hypertension إذا انطينه فلود هواي يصير
- Routine Laboratory Studies:
1-Complete Blood count with differential
2-chemical profile & arterial Blood gases
3-Serum electrolytes & metabolic studies
Arrhythmia خاف يصير عنده
4-C X R 5-ECG 6-GUE Liver function test
7-surviallance for sepsis by culture & sensitivity & start the appropriate
AB on detection of infection فلهذا ناخذ عينات ونفحصها باستمرارinfectionممكن يصير عنده
شلون حنهتم بالحرق
-Wounds care:
Moist;warm
1- At a warm room with adequate analgesia. normal saline نكدر نغسله باملي والصابون او
2-Wound debridment made by removing foreign bodies & loose dead skin.
3-Bullae (blisters) can be lanced to act as a biological dressing after drain
Rich in protein فلهذا نسحبه
its transudate fluid (which may allow bacterial growth), while large
cream نستخدم
damaged bullae should be debrided.
4-Wound copiously lavaged with worm Saline or tape water & mild soaps
. Broad spectrum
5-Topical antimicrobial creams such as Silver sulfadiazine apply twice
daily on the wounds.
6-Either use open method without dressing or better to apply non adherent
moisture retaining dressing such as Biobrane .
If cellulitis occur at wound can be treated with penicillins.
7-Daily change of dressing & wound washing continue.
8-Superfacial 2nd degree burn will heal with in 2 weeks by epithelialization
while deep 2nd degree & 3rd degree burns need wound Excision & split
thickness skin grafting operations.
9- Protection of burned area from sun exposure by long clothes & sun
screens for at least 6 weeks to decrease skin hyperpigmentation after
healing.
10-Prescribe Antihistamins drugs for Itching especially at night
وصف حكة
-Maintain & encourage good nutrition of the pt.
-Physiotherapy should be started as early as possible on day 1.
-Follow up the patient .
