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What is Safest strategy of treatment for a patient of inhalational burn injury who has presented within 4-5 hours and explain in detail?
Ans. d (Elective endotracheal intubation) (Ref. Bailey and Love Surgery 25th/pg. 381 Box 28.8).MANAGEMENT OF BURNED AIRWAY# Early elective intubation is safest.# Delay can make intubation very difficult due to swelling.# Be ready to perform an emergency cricothyroidotomy if intubation is delayed.Summary box 28.8Initial management of the burned airway- Early elective intubation is safest- Delay can make intubation very difficult because of swelling- Be ready to perform an emergency cricothyroidotomy if intubation is delayedThe criteria for acute admission to a burns unit- Suspected airway or inhalational injury- Any burn likely to require fluid resuscitation- Any burn likely to require surgery- Patients with burns of any significance to the hands, face, feet or perineum- Patients whose psychiatric or social background makes it inadvisable to send home- Any suspicion of non-accidental injury- Any burn in a patient at the extremes of age- Any burn with associated potentially serious sequelae including high-tension electrical burns and concentrated hydrofluoric acid burns.Recognition of the potentially burned airway- A history of being trapped in the presence of smoke or hot gases- Burns on the palate or nasal mucosa, or loss of all the hairs in the nose- Deep burns around the mouth and neckAssessing the area of a burn- The patient's whole hand is 1% TBSA, and is a useful guide in small burns- The Lund and Browder chart is useful in larger burns- The rule of nines is adequate for a first approximation onlyFluids for resuscitation- In children with burns over 10% TBSA and adults with burns over 15% TBSA, consider the need for intravenous fluid resuscitation- If oral fluids are to be used, salt must be added- Fluids needed can be calculated from a standard formula- The key is to monitor urine output.Assessing the depth of a burn- The history is important - temperature, time and burning material- Superficial burns have capillary filling- Deep partial-thickness burns do not blanch but have some sensation- Full-thickness burns feel leathery and have no sensation.Major determinants of the outcome of a burn- Percentage surface area involved- Depth of burns- Presence of an inhalational injury.Options for topical treatment of deep bums- 1% silver sulphadiazine cream- 0.5% silver nitrate solution- Mafenide acetate cream- Serum nitrate, silver sulphadiazine and cerium nitrate