[MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] 7 00:00:43,211 --> 00:00:47,702 Now, professor, Mr. Casale has just arrived >> Good day! >> with the paramedics. It's a severe work accident. The patient suffered from severe burn injuries. His circulation is currently stable. He already has received Citanesk as pain medication. He is vaccinated against tetanus. >> And how bad is your pain right now? Is it ok? >> It's alright. >> Or do you require some medication? >> No, it's ok for the moment. >> And how exactly has this happened to you? >> Well. I work in a restaurant as a chef. And it was very stressful today. I realized that the pan was too hot. And then I wanted to take it off the stove and then I was accidentally pushed from behind by a colleague and when I tried to hold on to the pan, I frontally crashed into a shelf or something, I'm not sure. And then the boiling hot oil spilled over my arm. >> Yes, please don't move your arm so much. >> I was wearing a coat. But, the oil burned through it and spread over my whole arm. And we then took off the coat. >> It was a good decision to immediately take off the coat. Have you cooled the wound with water? >> No, we haven't. We instantly drove to the clinic. >> After burn injuries you intitally stop the progression of the burn by means of cooling, for example with tap water. Too much cooling can lead to an additional hypothermia. Afterwards, remove the burnt clothes, initiate analgesia and an according volume therapy. Cover the burnt wounds sterilely. The degree of severity is established by the depth and extent of the burn injury. Burn injuries are classified according to grades I to IV. Grade I equals a simple sunburn with reddened skin. Grade II is accompanied by blistering of the skin, IIA partially affects the corium, IIB completely affects the corium. This differentiation is made by means of a sensation test with a needle. In case of grade IIB, the skin's pain sensation is already reduced so that the sensation test is negative. Grade III is a necrosis of the skin and grade IV equals complete charring. The local treatment of burn injuries should initially include cleaning of the wounds with water. Please fo not use additional disinfectants such as Betaisodona ointment etc. Blisters should be debrided in case they are open. Please do not aspirate blisters, as you can therefore increase the risk of infection. Localised treatment of burn injuries can either be performed with polyhexanide cream or silver sulfadiazine cream. From Grade IIB onwards, an additional selective necrectomy in specialised centres for burn injuries should be considered. 63 00:03:56,110 --> 00:04:03,940
The severity of burn injuries
is not determined by their depth. Their extent on the skin surface is also a crucial factor. For quantitative determination, the Rule of Nines has been established. It stipulates that 9% of the skin surface are determined by: the upper arm and the forearm, 2 times 9 for the thorax, 2 times 9 for the back, 9 for the upper and 9 for the lower leg. And 9 for the head. Thus, 1% for the genital area adds up to full 100%. For the assessment of the body surface of toddlers it is important that their head is relatively large compared to the rest of their body. Therefore, the counting method is slightly adapted in their case. The initial infusion therapy is performed according to the Parkland Formula. It stipulates 4 ml of Ringer lactate multiplied with the percental body surface multiplied with kg of body weight in 24 h. 50% of the infusion are administered within the first 8 h. This formula applies to grade II to grade III burn injuries. Moreover, urine excretion and central venous pressure should be monitored. >> And, well, the way it seems to me, this is a grade II to grade III burn injury and we have to remove all the destroyed skin and clean everything, right? We have to determine how deep the burn injury is and whether a skin graft might be necessary. >> What, does this mean that surgery is required? >> This can only be done in the OR, because otherwise you will be in too much pain. It can't be done here. >> Yes. >> We will now inform our anaesthesists. >> Anaesthesia, you mean anaesthesia? >> No, no. Modern anaesthetics are so good, you will get an injection and then you fall asleep. They are actually designed to make you feel no pain. This is why will go to the OR and you will receive anaesthesia. Because here, the conditions are not sufficient and we couldn't treat you accordingly. >> And how long will this take? >> Surgery will take about one hour. >> And then I can go home? >> No. I assume that you will have to stay in the hospital for about a week. >> What? >> And it's going to take 3 to 4 weeks - if everything goes well - until your healed completely. >> Doctor, I already had a burn injury to my left arm. Back then, it was with hot water. It only took three days. >> Yes, but that was no burn injury that went so deep down into your skin. It probably was only reddened with some blisters. But you see that this skin is completely burned and charred. It looks like charcoal. >> But when this wound is treated well, it maybe does not take so long. I'm a freelancer. And hired as a freelancer in this kitchen as a chef. I have to work, I have to get back as soon as... >> Well, we'll do our best, but you are not allowed to work in a kitchen with open wounds. Otherwise, you'll get into trouble with the trade office. >> Yes, but one week, will this be possible? Can I go back after one week? >> Are you insured? >> No, of course not. [CROSSTALK] >> We'll try our best to make it possible that you can go back to work as soon as possible, ok? We are not a garage. We cannot simply attach a new arm to you, but we have to give nature a chance. Now we wait how the situation develops and then we will talk after your operation. >> Alright then. I'll have to call my wife so that she can bring me fresh clothes. The clothes I'm wearing are all dirty from the kitchen. We'll bring you a telephone and then you can call your wife and then you please tell her that you have a burn injury to your arm. She doesn't have to be afraid, it's no life-threatening wound. And your wound has to be cleaned now and you will undergo anaesthesia because of the pain, alright. 140 00:07:47,703 --> 00:07:56,080
Due to burn injuries, the skin
suffers from a significant loss of elasticity. In case of pronounced burns of the thorax, this can cause an inability of patients to sufficiently expand their thorax and breath properly. These movement restrictions can be countered with escharotomy. In case of all external burn injuries, it is important to watch out for potential additional inhalation trauma. This can be caused by direct heat exposure on the mucosa and the formation of a supraglottic oedema. Indications are provided by facial or neck burn, fuliginous sputum, hoarseness, stridor or obstruction. Always reckon with the possibility of a displacement of the airway due to delayed oedema formation. If required, prophylactic intubation should be performed at an early stage. More than 30% of all burn injury patients who undergo inpatient treatment in burns centres suffer from concomitant smoke gas inhalation trauma. Irritant gas inhalation is constituted by gases and vapours, which can lead to the organism being injured. Among the typical symptoms are ocular stinging, conjunctivitis, irritable cough, dyspnoea, bronchospasm, and toxic pulmonary oedema. There is a differentiation into irritant gases of the immediate type, such as hydrochloric acid or chlorine gases. Therapy involves the administration of oxygen as well as beta-2 sympathomimetics. Irritant gases of the latency type are for example nitrous gases or phosgene. Their therapy also includes the administration of oxygen, beta-2 sympathomimetics sympathomimetics and, if applicable, inhalative glucocorticoids. In case of all burn injuries, cyanides can simultaneously be released. With a high level of affinity, cyanides bind to the cytochromes of the mitochondrial respiratory chain. In doing so, they inhibit cell breathing and within a few minutes lead to symptoms of an unspecified nature such as headaches, dyspnoea and nausea. In case of continued cyanide intoxication, the consequence is death. The procedure with suspected cyanide intoxication involves the administration of 100% oxygen via a face mask. It is important in this case that the patient should by no means breath into a reservoir. Furthermore, a cyanide-binding medication, e.g. hydroxocobalamin can be applied. Another essential secondary intoxication after burn injuries can be induced by carbon monoxide. It is important to know that the individual carbon monoxide tolerance can differ greatly. Heavy smokers for example have a significant carbon monoxide concentration without showing symptoms. Starting at concentrations of approximately 70%, death swiftly occurs due to cerebral anoxia. In case of a suspected carbon monoxide intoxication, you should administer the patient with 100% oxygen. For further therapeutic steps, it is important to ascertain whether additional symptoms such as a syncope or pregnancy are present. A 12-lead ECG can be used to rule out an ST elevation. In case of strong symptoms, hyperbaric oxygen therapy can be indicated. >> Ok, then we apply the patient with a Metalline gauze pad in the meantime, remove his T-shirt, because he cannot do so on his own and then we call the anaesthesists. They have to talk to you, of course, to rule out that you are allergic. >> Alright. >> Then, we also have to control your blood values and then we induce anaesthesia. We will not rush anything now, but under controlled conditions. >> Okay. >> We also have to obtain your informed constent, I'll just pick up the necessary documents. You have to give us your consent for surgery and further treatment. I'll be back in a second, ok? Please prepare the patient for surgery and help him out of his clothes. >> Okay! Alright I'll be back soon. >> Don't worry, we'll get you back in shape. >> Let me summarize. Initial treatment of burn injuries involves localised cooling. Provide sufficient analgesia and volume therapy. Please also watch out for supraglottic oedema or smoke gas inhalation. In the event of carbon monoxide or cyanide intoxication be aware of additionally necessary therapy. And don't forget decontamination by means of undressing the patient. Clean the burn injuries with pure water. If required, debride opened blisters. Do not aspirate fluids from non-opened blisters, as you would unnecessarily increase the risk of infection. Localised treatment can be performed with polyhexanide or silver sulfadiazine cream. From Grade IIB onwards, a patient transfer to a specialised centre for burn injuries should be considered for selective necrotomy. In case of all burn injuries, the level of tetanus protection should be clarified. [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC]
