00:00
Okay, this slide will be
available for you to view as well.
00:03
This is a good slide because
it gives a very good a...
00:09
full chart on what
do you expect to see.
00:12
This is what they
give in the exam.
00:13
This is taken from
the exam question.
00:16
This exactly is what they give
and ask what you think it is.
00:20
Okay, so whenever you get
anything, no blisters, superficial,
blisters,
superficial partial thickness,
blisters may be
present deep partial,
but then you are going more
towards a full thickness area.
00:34
Definitely, no capillary refill.
00:36
Okay, and that is painless,
leathery skin,
loss of capillary refill.
00:48
Say it again, Lo.
00:51
Oh, no, no, no, this much as 1%,
whole limb is 9 percent, right?
Yeah.
00:59
So same with the leg as well,
bit of the like 3% 4% 1%.
01:04
Yeah,
the whole of the leg is 18%.
01:11
You're intrigued or you're...
01:14
Okay, Fluid Management.
01:17
Probably, you know, that's the
most important thing that burn,
now the question in your exam
will be why is it important?
Why is fluid management
important is very simple logic.
01:27
You have three zones in a burn.
01:29
You have a zone of
coagulation in the middle,
surrounding into
the zone of stasis
and the zone of hyperemia.
01:36
So zone of coagulation is where
the maximum heat is conserved.
01:40
That is the maximum, that's the
area where it's burned the most.
01:44
Now, if you resuscitated
the patient adequately,
the zone of stasis is
preserved, doesn't expand.
01:52
The patient is inadequately
resuscitated, that zone of,
zone of coagulation expands.
01:59
So in other words, we have a patient
coming in with 18% burnt any.
02:05
You delay for hours
by not resuscitating them.
02:08
They'll end up with 35%.
02:11
Okay, that's a whole concept.
02:14
So that's why fluid
resuscitation is
extremely important not just
for their physiological status,
but also to make sure the burn does
not increase in body surface area.
02:26
Got that?
Okay.
02:31
Another physiology question.
02:32
Which comes up either in burn,
critical care or
in real physiology?
You need to know the
difference between those.
02:44
Okay.
02:50
So that's a blood vessel.
02:53
So this is intravascular volume,
and this is extravascular space.
02:59
Similar to our
Monro-Kellie principle,
the fluid between the
intravascular space
and the extravascular
space has to be constant.
03:08
How is it maintained constant?
By four forces.
03:13
Two inside and two outside.
03:16
So, you have
the hydrostatic pressure
and the oncotic pressure,
hydrostatic pressure and
the oncotic pressure.
03:28
Both sides.
03:29
This is capillary.
03:30
This is interstitial,
on the tissue.
03:35
Simply put if you are
a lot of fluid here,
that will go and leak out.
03:41
So how do you prevent
that happening?
We increase the colloid osmotic
pressure by giving more colloid.
03:47
So that fluid will
be pulled back in.
03:49
So how is it relevant in burn?
It's relevant because when you
have a patient with a burn,
what do you do?
You give them fluid.
03:55
You're not really worried
about all these pressures.
03:58
You just need increase
the circulating volume.
04:01
So, normally you end up giving
nearly three times some more fluid
than the patient really
request physiologically.
04:10
But at that point you're
not worried about that.
04:12
You just need to make sure
the circulation is maintained.
04:15
So you end up giving more fluid.
04:16
So you increase the capillary
hydrostatic pressure.
04:21
After 6 hours, 8 hours,
because burn is a
critical assault.
04:26
These endothelial cells
will start becoming a leaky.
04:29
So that's called
leaky capillaries
and the fluid will
begin to leak.
04:34
Okay.
04:36
So after 24 hours,
you convert your
crystalloid to a colloid,
by increasing the
oncotic pressure.
04:43
So that whatever fluid is
lost will be pulled back in.
04:48
So, hydrostatic pressure
pushes the fluid out,
and the oncotic pressure
pulls it back in.
04:55
This is exactly what happens
in the RDS in the lung.
04:59
Same concept,
anywhere you are giving more fluid.
05:02
If you are asking about fluid challenge
CVP monitoring, capillary wedge pressure.
05:07
This is the concept
they're looking for,
whether you if you understand
this, you understand,
why you'd give a
fluid challenge.
05:13
Why are you why do
you give gelofusine.
05:16
Why do you do a
crystalloid, okay?
Is that clear?
I'll give you 30 seconds to
make sure they got that right.
05:29
You will seem a bit worried.
05:31
It just middle finger going
up, I was thinking.
05:34
No.
05:35
Okay.
05:35
So, this is why you start off with
crystalloid, the first 24 hours,
and then you move on to colloid.
05:42
Okay,
Absolute values,
you need to remember for the exam.
05:49
Fluid resuscitation any child,
sorry.
05:51
Any child more than
10% body TBSA burned
and any adult more
than 15% needs fluids.
05:59
That's a standard rule, okay,
and that is guided
by blood pressure,
pulse, temperature,
urine unit output, CVP.
06:11
To the body surface area, yeah.
06:14
Okay.
06:17
Parkland's formula we said,
always remember
this Crystalloid.
06:21
He says 3 to 4 ml.
06:24
When do you give 3?
When do you give 4?
What is the range?
Okay, fair enough,
so extremes of each?
Comorbidities,
I'll take both of those.
06:44
What else?
Degree of burn.
06:48
If the majority of areas
full thickness you go for 4,
If there is an associated
inhalation injury you go for 4,
and if it is an electrical
burn you go for 4.
06:59
The reason being that are occult
burns you are not able to see.
07:02
So patient may have
say 24% on the skin,
but the muscle is burnt
or the lung is burnt,
or the majority of deep dermal,
then you go for 4.
07:14
Otherwise,
it's safe to start with 3.
07:18
So 3 indications for
4 ml + extremes of age
and significant comorbidities.
07:27
Now this is what I
was explaining before,
first 24 hours is crystalloid,
beyond that you go for colloid,
human albumin solution.
07:36
Don't worry about this,
they will not ask you.
07:39
But they will ask you,
they may expect you to know that.
07:48
Okay, this is why in the UK,
the EMSB (Emergency Management
of Severe Burn) guidelines,
specifically says crystalloid,
colloid that's order and that's it.
07:58
No debating in that.
08:00
I agree, there are some units
in for example in Swansea.
08:03
They sort of on colloid straight
away, but then that's a unit protocol.
08:07
But for the purpose of your exam
stick to crystalloid then colloid.
08:12
Inhalation burn, very important
for the purpose of your exam.
08:16
History, symptoms, signs,
very logical.
08:20
If we have a fire in this room,
all of us we get
inhalation burn.
08:25
And these are the symptoms,
there is nothing really,
you know to memorize.
08:30
If you think logically you'll just get
a good burn, the face, hair, nasal hair.
08:35
Okay.
08:36
Why is it important?
Carboxy hemoglobin has got
a 240x affinity for oxygen
compared to hemoglobin.
08:45
So because of that,
if the patient is
breathing room air,
it takes nearly 4 hours
for them to exhale it.
08:52
But if they give a
hundred percent oxygen,
the whole thing is
exhaled in 40 minutes.
08:56
So that's why you need to
give a hundred percent oxygen,
normal level in non-smokers
will be 0 to 10,
0 to 5 is allowed,
more than 10 in smokers
truck drivers, etc.
09:11
That's it.
09:23
Okay.
09:26
Escharotomy.
09:29
Circumferential deep burn.
09:31
So to the check.
09:33
Sorry, chest, neck, limb, digit.
09:35
In the forex do
a shield pattern,
you go through the axillary
line axillary planes.
09:42
Then you go on the
neck and under the rib.
09:46
Special pattern in
the arms and legs,
the pre and the post
auxiliary lines.
09:53
We discuss escharotomy
versus fasciotomy.
09:59
Okay, now.
10:02
Let me get this
clarified here because
we always see people get
confused with in percentages.
10:09
I said fluid resuscitation
that is 10% in a child,
15% during in an adult.
10:15
But referral to the burns unit,
the threshold is much lower.
10:20
Any 5% in full thickness
has to be referred,
5% in a child and
10% in an adult.
10:27
Don't get confused between this and
fluid resuscitation, they are different.
10:32
Okay, and all of this.
10:33
You know burns is so
specialized in the UK
and pretty much
everything gets referred.
10:39
So you don't really have to memorize
but just remember these numbers.
10:49
Okay.
10:50
Now I'm not going to spend
any time on this slide
but this has been asked,
this is I would classify this as
one of the ten percent
you can take a chance.
10:59
Nutrition has been
asked in burns,
but then it's
it's quite tricky to
memorize, you know.
11:12
Full thickness burn in the
leg, no peripheral circulation.
11:17
Yeah, it has to be fully.
11:19
No, not automatically,
circumferential full thickness,
circumferential and there
is no distal blood flow.
11:28
Similar to the fingers.
11:30
You can get a full thickness
here, like this tunic effect.
11:33
No, no blood flow.
11:34
So you need to
release on the sides.
11:39
For mechanical, for ventilation,
trunk and the neck.
11:43
Yeah,
it has to be full thickness.
11:46
If this is not full thickness the rest
of the unburnt area with sufficient
to allow them to
breathe for circulation.
11:53
It has to be circumstantial,
full thickness.
12:00
No, face, you don't, because you don't
have the facial planes like that.
12:04
So we don't do for the face, no.
12:06
Solely for neck, thorax,
neck, trunk, limbs.
12:11
Okay, prognosis depends on age,
burn size and inhalation injury.
12:15
This is a rough predictor
of mortality, okay.
12:18
This...
spend about 30 seconds on this.
12:21
Five-year-old child with the 10%
burn has got a 15% mortality.
12:26
But a ninety-year-old adult
with just a 10% burned,
close to 100% mortality.
12:32
Okay.
12:33
Now, this might sound quite
extreme which is true.
12:36
For example, you can have
a very healthy 90-year-old.
12:39
Who can survive a 20-30% burn.
12:43
It's quite unlikely,
usually by the DH,
what we always see you get
a very fit 70-80-year-old
coming with a 12-13% burnt.
12:53
You think well 13% no
big deal 80-year-old.
12:56
The moment they have a
massive insult like that,
the whole physiology crumbles
and they just won't
recover from that
and maybe start with a little
bit of pulmonary edema,
going on to cardiac failure,
going on renal
failure, and that's it.
13:10
So the age is very
crucial in a burn.
13:15
Okay effects upon a patient pretty
much every system is affected.
13:19
Okay.
13:20
Anything else?