injuries poisoning
Burns
Treatment of Burns
IV fluids for partial and full thickness burns>10% of total body surface area (TBSA) Wound cleansing, dressing, and serial assessment Supportive measures Transfer or referral of selected patients to burn centers Surgery and physical therapy for deep partial-thickness and full-thickness burns Treatment begins in the prehospital setting. The first priorities are the same as for any injured patient: ABC (airway, breathing, and circulation). An airway is provided, ventilation is supported, and possible associated Smoke Inhalation is treated with 100% oxygen. Ongoing burning is extinguished, and smoldering and hot material is removed. All clothing is removed. Chemicals, except powders, are flushed with water; powders should be brushed off before wetting. Burns caused by acids, alkalis, or organic compounds (eg, phenols, cresols, petrochemicals) are flushed with copious amounts of water continuing for at least 20 min after nothing of the original solution seems to remain. IV fluids are given to patients in shock or with partial and full thickness burns>10% TBSA. A 14- to 16-gauge venous cannula is placed in 1 or 2 peripheral veins through unburned skin if possible. Venous cutdown, which has a high risk of infection, is avoided. Initial fluid volume is guided by treatment of clinically evident shock ( Treatment references ). If For example, in a 100-kg man with a 50% TBSA burn, fluid volume by the Parkland formula would be 30 kg). Additional Maintenance fluid should be calculated and added separately because children are at risk of hypoglycemia in high volume resuscitation. When giving typical large volumes of fluid, it is also important to avoid fluid overload and consequent heart failure and The Parkland and other burn fluid resuscitation formulas are only a starting point; fluid volume and rate are adjusted based on clinical response. Some clinicians give colloid, usuallyalbumin, after 12 hours to patients who have larger burns, are very young or very old, or have heart disease and require large fluid volumes. was shown to decrease total fluid volumes by about half at 72 hours post-injury. Meta-analyses suggest that additional trials are required to determine the effect on mortality and morbidity of the administration of colloid with crystalloid ( Treatment references ). For patients with Rhabdomyolysis , fluid administration is the mainstay of treatment, and the goal should be to maintain urine output of at least 0.5 and 1.0 mL/kg/hour. Although some authorities have recommended alkalinizing the urine by giving IV fluids containing After adequate analgesia, the wound is cleansed with soap and water, and all loose debris is removed. Water should be room temperature or warmer to avoid inducing hypothermia. Ruptured blisters, except for small ones on palms, fingers, and soles, are debrided. Unruptured blisters can sometimes be left intact but should be treated by application of a topical antimicrobial. In patients who are to be transferred to a burn center, clean dry dressings can be applied (burn creams may interfere with burn wound assessment at the receiving facility), and patients are kept warm and relatively comfortable with IV opioids. After the wound is cleansed and is assessed by the final treatment provider, burns can be treated topically. For shallow partial-thickness burns, topical treatment alone is usually adequate. All deep partial-thickness burns and full-thickness burns should ultimately be treated with excision and grafting, but in the interim, topical treatments are appropriate. Topical treatment may be with Antimicrobial salves (eg, 1%silver sulfadiazine,mafenideacetate) Commercial dressings incorporating silver (eg, sustained-release nanocrystalline silver dressings) Biosynthetic wound dressings (also called artificial skin products) Silver dressings should be considered only in partial-thickness burns with significant wound moisture because activation of silver requires wound moisture.Silver sulfadiazinemay induce transient leukopenia. Some (but not all) silver-impregnated dressings must be kept moist but can be changed as infrequently as every 7 days (to minimize pain associated with repeated wound care). Topical salves must be changed daily. Artificial skin products and silver impregnated dressings are not changed routinely but can result in underlying purulence necessitating removal, particularly when wounds are deep. Burned extremities should be elevated. Compression dressings such as elastic wraps should be used to reduce edema and improve wound healing. Preparations (subcutaneously or IM) is given to patients with all but minor burns who have been previously fully vaccinated and who have not received a booster within the past 5 years. Patients whose booster was more remote or who had not received a full vaccine series are given tetanus immune globulin (human) 250 units IM and concomitant active vaccination (see Escharotomy (incision of the eschar) of constricting eschars may be necessary to allow adequate expansion of the thorax or perfusion of an extremity. However, constricting eschars rarely threaten extremity viability during the first few hours, so if transfer to a burn center can occur within that time, escharotomy can typically be deferred until then. If timely transfer is not possible, escharotomy should be done with the input of a consulting burn center. Treatment , and pain is relieved. Opioids (eg, Overview of Nutritional Support is indicated for patients with burns After initial treatment and stabilization, the need for transfer and/or hospitalization is assessed. Consultation with a burn center to discuss treatment options is strongly suggested for Full-thickness burns>1% TBSA Partial-thickness burns>5% TBSA Burns of the hands, face, feet, or perineum (partial-thickness or deeper) Because of the many factors involved in burn outcome, early discussion of the specifics of each case with a burn center is probably more helpful than applying rigid criteria without consultation. In addition, transfer and/or hospitalization may be necessary if Patients are<2 years or>60 years. Adherence to home care measures is likely to be poor or difficult (eg, if continuous elevation of the hands or feet, usually difficult at home, is required). Many experts recommend that all burns, except for superficial burns<1% TBSA, be treated by experienced physicians and that urgent burn center follow-up treatments be strongly considered for all partial or full-thickness burns>2% TBSA. Maintaining adequate analgesia and exercise can be difficult for many patients and caregivers. Even patients who are not treated as inpatients can benefit from transferral or early referral to a burn center so that wound care, specialized dressings, and early range-of-motion exercises can be initiated. Prophylactic systemic antibiotics are not given. Initial empiric antibiotic treatment for apparent infection during the first 5 days should target staphylococci and streptococci (eg, withvancomycinfor inpatients who have a positive MRSA colonization swab). Infections that develop after 5 days are treated with broad-spectrum antibiotics that are effective against gram-positive and gram-negative bacteria. Antibiotic selection is subsequently adjusted based on culture and sensitivity results. Excision of a burn wound with deeper infection optimizes the chance of resolving the infection. Skin grafting should be delayed until infection is resolved. Surgery is indicated for burns that are not expected to heal within 2 weeks, including most deep partial-thickness burns and all full-thickness burns. Eschars are removed as soon as possible, ideally within 3 days to prevent Sepsis and Septic Shock and facilitate early wound grafting, which shortens hospitalization and improves the functional result. If burns are extensive and life threatening, the largest eschars are removed first to close as much burn area as early as possible. (See also After excision, grafting proceeds ideally using partial-thickness autografts (the patient’s skin), which are permanent ( Treatment references ). Autografts can be transplanted as sheets (solid pieces of skin) or meshed grafts (sheets of donor skin that are stretched to cover a larger area by making multiple, regularly spaced, small incisions). Meshed grafts are used in areas where appearance is less of a concern when burns are 40% TBSA and the supply of autograft material appears insufficient, an artificial dermal regeneration template can be used as temporary coverage ( Treatment references ). Allografts (viable skin usually from cadaver donors) or xenografts (eg, pig skin) can also be used temporarily; they are rejected, sometimes within 10 to 14 days. Both types of temporary coverage must ultimately be replaced with autografts. 30 mm Hg. Compartment syndrome is rare in burns other than high voltage Electrical Injuries ( Physical and occupational therapy are begun at admission to help minimize scarring and contractures, particularly for body surfaces with high skin tension and frequent movement (eg, face, hands), and to optimize function. Active and passive range-of-motion exercises become easier as the initial edema subsides (enhanced by appropriate elevation and compression); they are done once or twice daily. After grafting, exercises are often suspended for 3 days, then resumed, but at some centers are initiated within 24 hours of grafting. Extremities affected by deep partial-thickness burns or full-thickness burns are splinted in functional positions as soon as possible and kept splinted continuously (except during exercise) until the graft has been placed, healing has occurred, or both. Outpatient treatment includes keeping burns clean and, to the extent possible, keeping the affected body part elevated and, for extremities, compressed (eg, by elastic wraps over dressings). Dressings should be changed daily for burns treated with topical salves. The salve is applied and then covered with a dry nonadherent gauze dressing and compression wraps. Silver dressings should be changed every 7 to 10 days, depending on the specific product recommendation. Dressing change simply involves removing the older dressing and replacing it with a new one. Biosynthetic wound dressings should not be changed in the absence of purulence. Biosynthetic dressings should simply be covered with dry gauze, which is changed daily. (See also How To Debride and Dress a Burn .) Outpatient follow-up visits are scheduled as needed depending on burn severity (eg, for very minor burns, initial visit within 24 hours, then subsequent visits every 7 to 10 days). Visits include debridement if indicated, reassessment of burn depth, and evaluation of the need for physical therapy and grafting. Patients should return earlier if they note signs of infection, such as increasing redness extending from the wound edges, increasing purulence and pain, or a change in the appearance of the wound with development of black or red spots. Should these signs occur, medical evaluation should ensue urgently. Outpatient treatment is acceptable for minor burn-wound cellulitis in healthy patients aged 2 to 60 years; hospitalization is indicated for other infections. 1.Pham TN, Cancio CL, Gibran NS: American Burn Association practice guidelines burn shock resuscitation.J Burn Care ResJ 29(1):257-266, 2008. doi: 10.1097/BCR.0b013e31815f3876 2.Eljaiek R, Heylbroeck C, Dubois MJ:Albuminadministration for fluid resuscitation in burn patients: A systematic review and meta-analysis.Burns43(1):17-24, 2017. doi: 10.1016/j.burns.2016.08.001 3.Greenhalgh DG, Cartotto R, Taylor SL: Burn resuscitation practices in North America: Results of the Acute Burn ResUscitation Multicenter Prospective Trial (ABRUPT).Ann Surg10.1097/SLA.0000000000005166, 2021. doi: 10.1097/SLA.0000000000005166. 4.Navickis RJ, Greenhalgh DG, Wilkes MM:Albuminin burn shock resuscitation: A meta-analysis of controlled clinical studies.J Burn Care Res37(3):e268-278, 2016. doi: 10.1097/BCR.0000000000000201 5.Kagan RJ, Peck MD, Ahrenholz DH, et al: Surgical management of the burn wound and use of skin substitutes: An expert panel white paper.J Burn Care Res34:e60–79, 2013. doi: 10.1097/BCR.0b013e31827039a6 6.International Society for Burn Injury (ISBI) Practice Guidelines Committee: Steering Committee; Advisory Committee.ISBI Practice Guidelines for Burn Care.Burns42(5):953-1021, 2016. doi: 10.1016/j.burns.2016.05.013 