Burn
Question 1. What is Wallace’s rule of nine? Calculate the amount of fluid that should be ideally transfused to an adult weighing 60 kg and having 50% deep burns in the first 24 hours.
Answer. Wallace’s rule of nine is given by Wallace for early assessment of the extent of the burn in terms of body surface area.
Burn: A burn is a wound in which there is coagulative necrosis of tissue.
Read And Learn More: General Surgery Questions and Answers
The amount of fluid that should be ideally transfused in case of burn is calculated by:
Burn Muir and Barclay Formula
1 ration =% of burn × Body weight (kg)/2
3 rations in 12 hours, 2 rations in the next 12 hours, and 1 ration in the next 12 hours.
50% burns patients weighing 60 kg
1 ration = 50 × 60/2= 1500 mL
1st 12 hours: 1500 × 3 = 4500 mL
2nd 12 hours: 1500 × 2 = 3000 mL
Total 7500 mL fluid in 24 hours.
Question 2. Describe the causes of burn and management of face and neck burn.
Answer. Burn: A burn is a wound in which there is coagulative necrosis of tissue.
Causes of Burn
- Ordinary causes: Dry heat, fire, hot metal, airplane crash.
- Due to moist heat, e.g. boiling liquid or lipids, it is called a scald.
- Electric burn: Due to high voltage current.
- Chemical burns: Due to strong acid and alkali
- Radiation burn: Due to X-ray and radiation
- Cold burn: It is caused by prolonged exposure to cold.
Management of Face and neck Burn
First Aid of Face and neck Burn
- Stop the burning process and keep the patient away from the burning area.
- Cool the area with tap water by continuous irrigation for 20 minutes.
Definitive Treatment of Face and Neck Burn
- The patient should be admitted.
- Airway, breathing, and circulation are maintained.
- Percentage, degree, and type of burn are assessed.
- Patients should be kept in a clean environment.
- The patient is sedated and proper analgesia is given.
Fluid resuscitation of Face and neck Burn
- Fluid replacement is done by calculating with various formulas such as Parkland regime, Muir and Buckley regime, etc.
- The fluids used are normal saline, Ringer lactate,
- Hartmann’s flid. Ringer lactate is the choice of fluid.
Blood is transfused in a later period after 48 hours.
General treatment of Face and neck Burn
- For the first 24 hours, only crystalloids should be given.
- After 24 hours up to 30–48 hours, colloids should be given to compensate for plasma loss. Plasma, haemaccel (gelatin), dextrans, and hetastarch are used. Usually at a rate of 0.35–0.5 mL/kg% burns is used in 24 hours.
- Urinary catheterization to monitor output; 30–50 mL/hour should be the urine output.
Tetanus toxoid. - Monitoring the patient: Hourly pulse, BP, PO2, PCO2 electrolyte analysis, blood urea, nasal oxygen, often intubation is required. Endotracheal intubation is secured in such a way as to minimize pressure necrosis of the lip.
- IV ranitidine 50 mg 8th hourly is given.
- Ryle’s tube insertion was initially for aspiration purposes later for feeding.
- Antibiotics: Penicillins, aminoglycosides, cephalosporins, and metronidazole should be given.
- Culture of the discharge; total white cell count and platelet count at regular intervals are essential to identify the sepsis along with fever, tachycardia, and tachypnea.
- In burns of the oral cavity, a tracheostomy may be required to maintain the airway.
- Total parenteral nutrition (TPN) is required for faster recovery, using carbohydrates, lipids, and vitamins.
- A tracheostomy/intubation tube may be required in impending respiratory failure or upper airway block.
Intensive nursing care.
Local Management of Face and neck Burn
- Dressing at regular intervals under general anesthesia using paraffin gauze, hydrocolloids, plastic films, vaseline-impregnated gauze or fenestrated silicone sheet, or biological dressings like amniotic membrane or synthetic biobrane.
- Open method with application of silver sulfadiazine without any dressings, used commonly in burns of the face and neck.
- The closed method is with dressings done to soothe and protect the wound, to reduce the pain, and as an absorbent.
- Tangential excision of burn wounds with skin grafting can be done within 48 hours in patients with less than 25% burns.
It is usually done in deep dermal burn wherein dead dermis is removed layer by layer until fresh bleeding occurs. Later skin grafting is done. - In burns of the head and neck region, exposure treatment is advised.
- Slough excision is done regularly.
- After cleaning with povidone iodine solution silver sulfadiazine ointment is used. It is an antiseptic and soothing agent.
Wound Coverage of Face and neck Burn
- Better outcomes can be achieved if the non-healing areas are excised (likely to take 3 weeks or more) and then skin grafted.
- The donor skin needs to be taken from the area above the nipple for the best color match.
Many surgeons favor the scalp skin but, alopecia and hair growth from trans-planted skin are of concern whereas the upper part of the back has thick skin. - Facial excision is carried out using Goulian knives or Versajet water dissector. Exposed cartilage needs excision with closure of the skin.
- Sheets of autografts are used as the meshed grafts are cosmetically unacceptable.
- Epinephrine lysis is essential to limit hemorrhage.
- A face mask should be placed to help immobilize of skin graft.
- Grafts should be placed in such a fashion as to mimic the esthetic units. Fibrin glue can be used to enhance graft adherence.
- Postoperative facial elastic mask compression helps in avoiding hypertrophic scars.
Question 3. Classify the types of burns and describe the management of a case of 30% burns.
Answer.
Classification of Types of Burns
Depending on the Percentage of Burns
Types of Burns Mild:
- Partial thickness burns < 15% in adults or < 10% in children
- Full-thickness burns less than 2%
- Can be treated on an outpatient basis.
Types of Burns Moderate:
- The second degree of 15–25% burns
- Third degree between 2–10% burns
- Burns that do not involve eyes, ears, face, hand, or feet.
Types of Burns Major
- Second-degree burns are more than 25% in adults and more than 20% in children.
- All third-degree burns of 10% or more
- Burns involving eyes, ears, feet, hands, perineum
- All inhalation and electric burns
- Burns with fractures or major mechanical trauma.
Types of Burns Depending On Thickness Of Skin Involved
- First degree: Epidermis look red and painful, no blisters, heal rapidly in 5 to 7 days by epithelialization without
scaring. - Second degree: The affected area is mottled, red, and painful with blisters, and heals by epithelialization in 14 to 21 days.
- Superficial second-degree burn heals causing pigmentation
- Deep second-degree burn heals causing scarring and pigmentation.
- Third degree: The affected area is charred, parchment-like, painless, and insensitive with thrombosis of superficial vessels.
It needs grafting. Charred, denatured, insensitive, contracted full-thickness burn is known as eschar. - Fourth degree: It involves deeper structures, i.e. muscles and bones.
Types of Burns Depending On Thickness Of Skin Involved
- Partial thickness burns: It is a first or second-degree burn that is red and painful often with blisters.
- Full thickness burns: It is a third-degree burn that is charred, insensitive, and deep involving all layers of skin.
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