ส่วนที่ 1 ข้อมูลเอกสาร

ส่วนที่ 2 Initial Assessment

2.1 Primary Survey (ATLS)

• Airway: Assess for inhalation injury (facial burns, singed hair, soot, hoarse voice, stridor)
• Breathing: SpO₂, RR, chest expansion (circumferential chest burn → escharotomy)
• Circulation: IV × 2 large-bore (avoid through burned skin), BP, HR
• Disability: GCS, pupils, extremities
• Exposure: Remove all clothing, keep warm (hypothermia risk)

2.2 Burn Depth

2.3 TBSA Calculation — Rule of Nines (Adults)

⚠️ นับเฉพาะ 2nd + 3rd degree (ไม่นับ 1st)
Palm method: ผู้ป่วยฝ่ามือ = ~1% TBSA (ใช้ได้ดีกับ small burns)

ส่วนที่ 3 Fluid Resuscitation

3.1 Parkland Formula

4 ml × kg × %TBSA = total fluid in first 24 hours

• Fluid: Lactated Ringer's (LR)
• 50% in first 8 hours (from time of burn!)
• 50% in next 16 hours

Example

70 kg man, 40% TBSA burn:

• Total = 4 × 70 × 40 = 11,200 ml (11.2 L)
• First 8 hr: 5,600 ml (700 ml/hr)
• Next 16 hr: 5,600 ml (350 ml/hr)

3.2 Resuscitation Endpoints

3.3 ABLS Referral Criteria

Transfer to Burn Center if:

• Partial thickness > 10% TBSA
• Burns of face, hands, feet, genitals, major joints
• Full thickness burn any age
• Electrical, chemical, inhalation burns
• Burns + trauma
• Children in non-pediatric hospitals
• Comorbidities affecting care

ส่วนที่ 4 Nursing Care

4.1 Airway Management

• Early intubation if inhalation injury (airway swelling progressive)
• Humidified O₂
• Bronchoscopy to confirm inhalation injury
• ABG + carboxyhemoglobin (CO poisoning)
• 100% O₂ if CO suspected

4.2 Wound Care

• Initial: Cool water (not ice) × 20 นาที (within 3 hours of burn)
• Cleanse: Sterile saline, mild soap; remove blisters > 6 cm or dirty
• Topical agents:
  • Silver sulfadiazine (SSD) 1% cream — broad antimicrobial
  • Mafenide acetate — penetrates eschar, painful
  • Silver dressings: Acticoat, Aquacel Ag
  • Bacitracin — face, small burns
• Dressing change: Daily or q 2-3 days (depends on dressing)
• ⚠️ Escharotomy: Circumferential burn → emergency to release pressure

4.3 Pain Management

• IV opioid (Fentanyl, Morphine) — before wound care
• Acetaminophen + NSAIDs adjuncts
• Ketamine for procedural sedation
• Non-pharmacologic: music, distraction, VR

4.4 Infection Prevention

• Reverse isolation, sterile gloves/gown during dressing
• Monitor for: fever, tachycardia, hyperglycemia, leukocytosis, wound changes
• Wound cultures every 3-7 days
• No prophylactic antibiotics (selects resistant organisms)
• Targeted antibiotics for proven infection

4.5 Nutrition

• Hypermetabolic state — need 25-30 kcal/kg/day (or more)
• Protein 1.5-2 g/kg/day
• Early enteral feeding (within 24-48 hours)
• NG tube if > 20% TBSA
• Vitamin/mineral supplements: C, A, Zn, Se

4.6 Thermoregulation

• Warm environment (28-32°C) — burns lose heat rapidly
• Warm fluids, warm blankets
• Monitor core temp

4.7 Psychosocial

• Psychological support (PTSD, depression common)
• Family involvement
• Child protective services if child abuse suspected
• Body image issues
• Long-term rehabilitation planning

ส่วนที่ 5 Rehabilitation

• PT/OT early: ROM exercises, positioning (anti-contracture)
• Splinting: functional position
• Compression garments: reduce hypertrophic scars (6-12 months)
• Silicone sheets: scar management
• Psychological rehabilitation

KPIs

References

• ISBI Practice Guidelines Committee. (2016). ISBI Practice Guidelines for Burn Care.
• American Burn Association. (2018). Advanced Burn Life Support (ABLS) Provider Manual.
• Rae, L., et al. (2016). The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation. Critical Care Clinics.

เอกสารนี้จัดทำโดย AI เพื่อเป็นโครงร่างตั้งต้น ต้องผ่านการตรวจทานและอนุมัติจากทีมแพทย์/พยาบาลก่อนใช้งานจริง