Veterinary Clinical Medicine-I (General and Systemic)

I STAGE CARE : FROM ARRIVING TO 36 HOURS 

• The initial assessment should start with the general physical condition, systemic compromise, amount of body and surface affected, plus degree of local injury. If the lost area of skin are large enough, euthanasia can be recommended.
• People involved in fires have respiratory injury due to the inhalation of air heated to a temperature higher than 150°C that results in burns into the mouth, oropharynx, and upper airway. Pulmonary damage due to smoke inhalation, is the major cause of mortality in human beings. Deaths are associated to the fall of oxygen concentration in the environment, inhalation of carbon monoxide and dioxide during combustion and cyanide toxicity. This mechanism is more rare in small animals, apparently because they walk almost at floor level.
• Animals affected by smoke inhalation should be placed on 100% oxygen early after arrive to ICU. Inhalated heat produces upper airway obstruction due to airway edema. Early endotracheal intubation is crucial, and must be performed if physical exam shows signs of airway burn damage or if patient shows respiratory distress. It is important consider that pulse oximetry cannot evaluate the severity of hypoxia because its lacking capability to differentiate between oxygenated hemoglobin and carboxyhemoglobin.
• The initial therapy is oriented to pain relief with cold direct application in the burn area: chilly water, soak towels, cold tap water are good alternatives. Oxymorphine alone or combined with Acetylpromazine in neuroleptanalgesia is indicated for pain control in dogs. Cats can be treated with Diazepam plus Ketamine.
• Oxygen 100-150 ml/Kg/ per minute should be initiated, as soon as possible and a central catheter into jugular vein should be placed. Give fluid replacement at 4 ml/Kg per hour in dogs and 2 ml/Kg per hour in cats. Isotonic balanced electrolyte solution like Lactated Ringer's or normal Saline is the first choice. Free glucose fluids must be avoided because hyperglycemia and glucosuria will occur after deep burns.
• Potassium levels should be monitored because during the first 24 hours it will be a rise with severe hyperkalemia associated to cells destruction into the burned tissues. Solutions with contents of 4-5 mEq/L of potassium are recommended during this phase.
• Check out serum protein levels, urine production, hematocrit level, hemoglobin, electrolytes and blood gases. If total protein drops below 3 gm/dl, fresh plasma or colloids should be added. Acidosis can be corrected with Sodium bicarbonate 5 mEq/Kg of body weight, every hour or 30 minutes. If hematocrit falls below 20% or, hemoglobin falls below 7 g/dL, whole blood or washed red blood cells must be added to the treatment. Hct above 30% is the goal.
• After start analgesia treatment the hair must to be clipped, burn wound can be washed with antiseptic solutions as povidone iodine or chlorhexidine. Necrotic tissues, foreign material and debris must be removed.
• Burn wounds of first or second degree should be topically treated with antibiotic medication; (Silvadene is the first choice) and bandaged. With third degree burns, eschar must be removed soon and in a daily frequency. That is a very painful procedure, so anesthesia or proper analgesia should be considered. Eschar remove must to show healthy underlying granulation tissue.
• Systemic antibiotics do note penetrate eschar, so topical therapy is always indicated with antibiotic ointments and creams. Gentamycin, Polymyxin, Neomycin, and bacitracin are very effective against the contaminant flora in burn wounds, as well as fluoroquinolones.
• Last reports with Aloe vera shows certain antiprostaglandin effects that can help to maintain normal dermal vasculature.