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a.        Pain (Pain score, Why morphine? Appropriate? Alternative?)

what is pain score

-Numeric Rating Scale (NRS) rate pain from 0 to 10, where 0 means no pain and 10 means the worst pain.

- Faces Pain Scale-Revised (FPS-R) scale uses a series of faces showing different levels of pain. It is used primarily for children who may have difficulty using the numerical scale.

#Based on the analysis reported in the NIH article from Pain Research and Treatment,,For second-degree burns, patients might rate their pain as moderate to severe

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077524/

possible morphine not working? bcs second-degree burns caused more pain than third-degree burns because, in third-degree burns, nerve endings are destroyed.

1. Severe Burns-sometimes morphine isn’t enough for the most intense pain.

2. Infection- After a week, AA’s burn got infected. When burns get infected, they usually hurt more. Morphine might not handle that extra pain from the infection very well.

3. Tolerance- For long term use of morphine, his body might have gotten used to it, making it less effective.

4. Dosage: The amount of morphine given at first might not have been enough for the level of pain. Sometimes, the dose needs to be adjusted.

Any other drugs?

Fentanyl, which is a stronger and faster-acting opioid, might be used for severe pain. Hydromorphone, another potent opioid, can be more effective than morphine. Lidocaine might also be administered intravenously as an additional option for pain management. For less severe pain or in combination with opioids, medications like acetaminophen, ibuprofen or naproxen can be used.

NO ASPIRIN

b.        Wound care

For initial burn management, start with a tetanus shot to prevent tetanus Infection.

Next clean and debride the burn by removing dead tissue and using a mild antiseptic like chlorhexidine, avoiding alcohol-based solutions which can irritate the wound.

Apply a thin layer of silver sulfadiazine as an antibiotic cream to help prevent infection and promote healing. AND

ALSO Cover the burn with petroleum gauze and dry gauze to keep the wound contained and protected from external contaminants, which helps in managing the burn more effectively and reduces the risk of infection.

silver dressings can be beneficial as they may not require daily changes, helping to cover the wound and reduce visibility.

When it comes to skin grafts, sheet grafts are best for visible areas but need careful monitoring, meshed grafts are suitable for larger areas and leave a mesh pattern, and full-thickness grafts are used for reconstructive purposes and are treated like a burn.

To maintain skin health, apply an unscented moisturizer several times a day to prevent blisters and skin tears, but avoid over-moisturizing to prevent clogged pores.

for blisters, use a clean sterile needle to gently make a small hole and let the fluid drain out. Then cover the area with a nonstick bandage.

https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/surgical-care/imeesc-toolkit/best-practice-safety-protocols/burn-management.pdf?sfvrsn=90e35f3d_5

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5. Skin Structure (Before and After burns)

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5. Skin Structure (Before and After burns)

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Healthy Skin:

Color: Typically even-toned, ranging from light to dark depending on melanin levels.

Texture: Smooth and supple with a uniform texture.

Structure: Contains a healthy layer of the epidermis (outer layer) and dermis (inner layer). The epidermis includes a layer of cells that provide protection and the dermis houses blood vessels, nerves, and connective tissue.

Appearance: Generally free of visible damage, with a consistent appearance and elasticity.

Burnt Skin:

Color: Can vary from red (mild burns) to white, black, or charred (severe burns). The discoloration is due to damage to blood vessels and tissue.

Texture: May appear swollen, blistered, or cracked. In severe cases, the skin can be leathery or appear charred.

Structure: Damage can range from superficial (affecting only the outer epidermis) to deep (affecting the dermis or even underlying tissues). Blisters form as the body tries to heal the damaged skin.

Appearance: Often has a glossy or wet appearance due to fluid accumulation or may appear dry and peeling as it heals. There may be visible signs of damage like blisters, peeling skin, or open wounds.

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Fluid resuscitation

The severity of burns is determined by the intensity of the thermal energy sustained, duration of exposure, and the area of the body affected. These parameters determine whether a patient will require treatment at a dedicated burn center. This activity emphasizes the importance of burn fluid resuscitation and highlights the role of the interprofessional team in managing burn patients. Arguably the greatest issue surrounding patients sustaining burn injuries is fluid loss. Therefore, volume replacement is crucial.

Objectives:

Identify the formula used to estimate fluid resuscitation in burn patients.

Describe the types of fluids used to resuscitate and maintain patients with burns.

Review the complications of burn fluid management.

Outline the importance of improving care coordination among the interprofessional team to enhance fluid resuscitation in burn patients.

The Parkland formula (also called the Baxter formula), developed in 1968 by Dr. Charles Baxter, is perhaps the most widely recognized fluid replacement formula for burn injuries. It stipulates that 2 to 4 ml of Ringer's Lactate per kilogram of weight per percentage of body surface area burned, with the first half given over the first 8 hours and the remainder given over the next 16 hours.

The original Parkland formula incorporates both crystalloids and colloids. Crystalloids have a more negligible volume expansion effect than colloids because of the increased capillary permeability during early burn injury. However, colloids will pass into the extravascular space, creating a shift in oncotic pressure that expands into the third space.

References

https://www.google.com/search?q=fluid+resuscitation+for+burn+management&oq=&gs_lcrp=EgZjaHJvbWUqCQgBECMYJxjqAjIJCAAQIxgnGOoCMgkIARAjGCcY6gIyCQgCECMYJxjqAjIJCAMQIxgnGOoCMgkIBBAjGCcY6gIyCQgFECMYJxjqAjIJCAYQIxgnGOoCMgkIBxAjGCcY6gLSAQszNzUwNTY1ajBqN6gCCLACAQ&sourceid=chrome&ie=UTF-8

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fluid resuscitation for burn management - Google Search

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Charles Baxter, is perhaps the most widely recognized fluid replacement formula for burn injuries. It stipulates that 2 to 4 ml of Ringer’s Lactate per kilogram of weight per percentage of body surface area burned, with the first half given over the first 8 hours and the remainder given over the next 16 hours.

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1. Identify and how to classify degrees of burns (Nationwide Children's)

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1. Identify and how to classify degrees of burns (Nationwide Children's)

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1. First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and has no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color.

2. Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful.

3. Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred.

4. Fourth-degree burns. Fourth-degree burns go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle and bone. There is no feeling in the area since the nerve endings are destroyed.

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Burn wound infection microbes and their effect on a burn patient. 

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Burn wound infection microbes and their effect on a burn patient. 

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Microbial infections in burn patients - PMC (nih.gov)

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Bacterial pathogens and percentage of occurrence

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Bacterial pathogens and percentage of occurrence

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Microbial infections in burn patients - PMC (nih.gov)

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Foul odor

The odor of burn wounds can be attributed to a combination of two factors (necrotic tissue and bacteria).

Although anaerobic bacteria are considered the major producers of malodor, study showed that both aerobic and anaerobic bacteria contribute to unpleasant odor in the wound environment

Odor is frequently used as an indicator of bacterial colonization in the wound bed. Colonization is typically accompanied by formation of a biofilm.

Reference:

Topical odor management in burn patients - PMC (nih.gov)

A Comprehensive Review of Topical Odor-Controlling Treatment Options for Chronic Wounds - PMC (nih.gov)

Swelling

In normal circumstances, swelling occur due to fluid leaking from blood vessels and collecting around damaged areas.

Swelling tends to occur soon after injury and generally decreases after 48–72 hours.

As skin blistered and filled with fluid, it becomes more vulnerable to infection. Hence, sign that indicate infection include swelling with purplish discoloration and increased thickness of the burn with it extending deep into the skin.

Reference:

Management of oedema after a burn — Chelsea and Westminster Hospital NHS Foundation Trust (chelwest.nhs.uk)

Does This Look Bad: 5 Signs of Infected Burn | Oxford Urgent Care (oxfordurgentclinic.com)

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CPG Wound Care Manual

Wound_Care_Manual.pdf (moh.gov.my)

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Wound_Care_Manual.pdf (moh.gov.my)

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What is penicillin?

Penicillin is a group of antibiotics (medications used to treat bacterial infections) that work in a specific way to destroy bacteria in your body. Types of penicillin and drugs closely related to them are called “penicillins.” They’re a subclass of beta-lactam antibiotics.

Penicillin antibiotics come in oral form (pills or liquid you swallow) and IV form (liquid that a provider injects directly into your vein).

What are the types of penicillin?

Two of the major differences between the types of penicillin are the way they’re made and what kind of bacteria they’re effective against. Types of penicillin include:

Natural penicillins. Natural penicillins are found in the world around us (they aren’t made by people). Scientists isolate (purify) just the penicillin from where it’s found to make it into medications.

Semi-synthetic penicillins. Scientists alter penicillin’s natural form to make more effective antibiotics. These are called semi-synthetic penicillins. They include penicillinase-resistant penicillins, aminopenicillins and extended-spectrum penicillins.

Combination medications. Penicillins are often combined with other medications into one drug to help them work better.

Natural penicillins

Penicillin G and penicillin V (also known as penicillin V potassium) are natural penicillins. Providers use natural penicillins to treat a range of infections, including strep throat, syphilis and Lyme disease. Penicillin G comes in IV form. Penicillin V you can take by mouth.

Semi-synthetic penicillins

Semi-synthetic penicillins include:

Penicillinase-resistant penicillins. Nafcillin, oxacillin and dicloxacillin are penicillinase-resistant penicillins. They come in both IV and pill form and are often used to treat staph infections. Methicillin, which is rarely used anymore, is also a penicillinase-resistant penicillin.

Aminopenicillins. Amoxicillin and ampicillin are aminopenicillins. Amoxicillin is one of the most commonly used penicillins. Providers use it to treat ear infections, UTIs, pneumonia and other common infections. It comes in a pill or liquid you can swallow. Ampicillin comes in pill or IV form.

Extended-spectrum penicillins. Piperacillin is an extended-spectrum penicillin. Providers use it for hard-to-treat infections, like Pseudomonas aeruginosa. Other extended-spectrum penicillins, like carbenicillin and ticarcillin, are discontinued in the U.S.

Combination penicillins

Penicillin can be combined with other drugs, called beta-lactamase inhibitors, to help them work better. Beta-lactamase inhibitors work by preventing bacterial enzymes (beta-lactamases) from destroying the antibiotic. Some penicillin/beta-lactamase inhibitor combinations include:

Augmentin® (amoxicillin and clavulanic acid).

Unasyn® (ampicillin and sulbactam).

Zosyn® (piperacillin and tazobactam).

How does penicillin work?

Penicillin works by attaching to the wall of bacteria cells. It damages the cell wall and eventually destroys the bacteria.

Over time, bacteria have developed resistance to natural penicillins. This means that certain types of bacteria can prevent antibiotics from damaging their cells. This has happened many times since penicillin’s first use. Each time, scientists developed new antibiotics that worked in the same ways as natural penicillin — by attaching to the cell wall — but had methods for avoiding antibiotic resistance.

Some bacteria, like MRSA (methicillin-resistant Staphylococcus aureus), resist all types of penicillins. This can make them very hard to treat. Scientists have developed antibiotics that work in different ways to try to treat these infections.

How long will I need penicillin?

Providers usually prescribe penicillin medications for one to three weeks, depending on which infection you have. It’s important to take penicillins as prescribed. Take them on schedule until you finish the entire course, even if you feel better.

The most common risks of taking penicillins include:

Allergic reactions.

Hard-to-treat bacterial infections, like C. diff.

Antibiotic resistance.

Penicillin allergy

The most serious risk of penicillin medications is an allergic reaction. Experts estimate that only about 1% of people have a penicillin allergy, even though about 10% of people report being allergic. If you experience vomiting or trouble breathing, call 911 or get emergency medical attention right away — you might be having an allergic reaction.

C. diff

Some people can develop the bacterial infection Clostridioides difficile (C. diff) from taking antibiotics. While it sounds like the opposite of what should happen, penicillin antibiotics don’t kill off C. diff but they can kill off bacteria that prevent C. diff from growing out of control. C. diff infections cause severe diarrhea, stomach pain and fever and can be hard to treat. Go to the emergency room if you have severe diarrhea and stomach pain while taking antibiotics.

Antibiotic resistance

Bacteria are constantly developing ways to protect themselves from antibiotics (antibiotic resistance). This is dangerous because it makes bacterial infections harder to treat, and more likely to cause life-threatening complications.

Taking penicillins and other antibiotics when you don’t need to or not taking them properly can increase the risk that bacteria will develop resistance. If you stop taking penicillin before you’ve completed the course, you might not kill all the bacteria. The remaining bacteria might develop resistance, making your infection harder to treat.

Dosage and useful of cephalosporins
https://globalrph.com/infectious-disease-list/cephalosporins/
https://www.mims.com/malaysia/drug/info/cefalexin?mtype=generic

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Test that can be done to identify bacterial infection (skin infection):

Blood test:

full blood count: bacterial infection often cause increase if neutrophilia

C-reactive protein (CRP):

protein that elevates in response to inflammation (>50, severe bacterial infection)

Procalcitonin:

marker that indicates generalised sepsis (cause by bacterial infection of circulating toxin in systemic route)

Blood culture:

(if T>38, leukocytosis, septic shock, suspected endocarditis or prior to starting antimicrobial treatment): golden standard for bloodstream infection (identify bacteria, fungus in bloodstream)

References:

https://dermnetnz.org/topics/laboratory-tests-for-bacterial-infections

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863885/

Wound Culture

Surface Swab

commonly used technique as it is practical, noninvasive, reproducible, and inexpensive

Levine technique is considered one of the best methods to obtain a swab culture.

for quantitative swab cultures, the wound fluid-stained swab is placed in 1 mL of diluent and vortexed to release microorganisms. After incubation under aerobic condition, the type and the number of bacteria are measured and reported as the number of organisms per swab.

Major concern of swab culture:

1) only the surface-colonizing bacteria will be reflected

instead of the pathogenic strain invading deeper

tissues.

2) swab cultures can be unreliable in the context of

biofilm infection.

Tissue Biopsy

qualitative and quantitative culture of wound tissue,

aseptic technique is used to obtain a tissue sample by punch biopsy, needle biopsy, or a scalpel.

by performing microscopic examinations, biopsy results are usually reported as the number of organisms per gram of tissue.

more conclusive and accurate for the detection of microorganisms invading wound tissue compared to other test methods (golden standard)

Major concern: time-consuming, costly, invasive, and painful, requires special equipment, special training, high risk for postsurgical trauma, wound disruption, and bacteremia

Reference:

Diagnostics for Wound Infections - PMC (nih.gov)

Phenotypic method (Bacterial Identification)

Staining reaction

Gram positive – purple

Gram negative – pink

Cell morphology:

Gram positive - Cocci

Gram negative – Bacilli

Colony morphology (shape, size, texture)

Motility

Atmospheric requirement (whether oxygen is needed

Nutritional requirement (MH agar)

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Significance: Infections can significantly delay the healing process in chronic wounds, placing an enormous economic burden on health care resources. Identification of infection biomarkers and imaging modalities to observe and quantify them has seen progress…

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AA's symptoms of fever , pus & warmth around the wound

Correlation with Wound Infection :

1. Fever (38.6°C) :

-A fever is the body's reaction to an infection. The body generates pyrogens in response to pathogen detection, which alerts the hypothalamus to raise body temperature. This lowers the development of bacteria and boosts immunity.

- In the instance of AA, the fever appeared one week following his burn injuries, indicating the possibility of a wound infection. This systemic reaction suggests that the infection may have spread beyond the immediate area of the lesion, causing the body to mount an immunological response.

2. Pus ( Purulent Drainage ) :

- The development of dead white blood cells, bacteria, and tissue debris is indicated by the presence of yellow pus from the wound. This indicates that you have a bacterial infection.

- The purulent leakage in AA's case was seen in the cut on his torso. An infection was confirmed by microscopic analysis, which revealed a combination of Gram-positive and Gram-negative bacteria. The body produces pus as a means of trying to attempt and fight the illness.

3. Warmth Around the Wound

- A warm area surrounding the incision indicates localized inflammation. An infection causes the area to feel warmer because increased blood flow there attracts immune cells to the infection site.

- This local inflammatory response is part of the body's defense mechanism to isolate and combat the pathogens present in the wound.

https://www.medicalnewstoday.com/articles/325040

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A wound infection occurs when germs, such as bacteria, grow within the damaged skin of a wound. Symptoms can include increasing pain, swelling, and redness. More severe infections may cause nausea, chills, or fever.

A person may be able to treat minor wound infections at home. However, people with more severe or persistent wound infections should seek medical attention.

In this article, we describe how to prevent, recognize, and treat an infected wound. We also cover risk factors, complications, when to see a doctor, and medical treatment.

A person with a small wound or infection can usually treat them at home.
People can usually safely treat small wounds, such as minor cuts and scratches, at home. With proper care, most small wounds will gradually get better until they fully heal.

warm skin around the wound

yellow or green discharge coming from the wound

the wound giving off an unpleasant odor

red streaks on the skin around the wound

fever and chills

aches and pains

nausea

vomiting

If a wound becomes infected, however, it can get worse instead of better. Any pain, redness, and swelling will typically increase in intensity.

Wound infections can also lead to other symptoms, such as:

1. Before beginning, ensure that all necessary equipment is clean. For example, if using tweezers, clean them with rubbing alcohol first.

2. Thoroughly wash the hands with soap and warm water, then rinse and dry them.

3. Clean the cut or scrape by running warm water over it for several minutes. Use warm, soapy water to clean the surrounding skin, but avoid getting soap in the wound.

4. Make sure that there is no dirt or debris, such as glass or gravel, in the wound. To remove debris, either use tweezers or carefully and gently rub the wound with a soft, damp cloth.

5. If desired, apply a thin layer of antiseptic ointment or petroleum jelly to the cut or scrape.

6. Allow the skin to air-dry before covering it with gauze or a bandage. There is usually no need to cover minor cuts and scrapes.

People with a mild infection of a small wound may be able to treat the wound at home. However, more severe wound infections require prompt medical attention, particularly those that occur along with other symptoms, such as fever, feeling unwell, or discharge and red streaks coming from the wound.

Change the wound dressing at least once a day. Replace it immediately if it gets damp or dirty.

Gently wash the wound each day.

Avoid using hydrogen peroxide or iodine on the wound as these may cause skin irritation in some people. Stop using other antiseptic ointments if they cause skin irritation.

Do not pick at the skin or the scab as this can lead to scarring, slow down healing, and increase the risk of infection.

If the wound does not show signs of improvement within 1-2 days, see a doctor.

1. Wash the wound immediately by running clean water over it for several minutes. Then, clean the skin around the wound with warm, soapy water. If it is not possible to use clean water, treat the wound with alcohol wipes.

2. Allow the skin to air-dry.

3. Apply an antiseptic ointment to the wound.

4. Protect the injury with gauze or another suitable dressing.

A person should wash the wound immediately to prevent infection.
To treat an infected wound at home, follow these steps:

Other tips for treating wounds at home include:

Cleaning and protecting a wound can reduce the risk of infection. After sustaining a minor cut or scratch, a person should:

People with larger wounds or excessive bleeding will require medical treatment. A healthcare professional can treat the injury to prevent infection and other complications.

People with animal bites or wounds from dirty or rusty objects may be at risk of tetanus and should also seek medical attention. A healthcare professional can clean the wound and give the person a shot to protect against tetanus infection if necessary.

the wound is large, deep, or has a jagged edge

dirt or foreign particles entered the wound

the cause of the wound was a bite from an animal or another person

the cause of the wound was an injury involving a dirty, rusty, or contaminated object

Tetanus is a potentially fatal condition that occurs when certain bacteria enter the body and release toxins that affect the nerves. The symptoms of tetanus can include painful muscle spasms, lockjaw, and fever.

poor blood circulation

a weakened immune system, such as in people living with HIV or those taking immunosuppressant medications

lack of mobility, for example, in people who spend most of their time in bed

advancing age - older adults are more at risk of wound infection

nutrient and vitamin deficiencies

Cuts, grazes, and other breaks in the skin can become infected when bacteria enter the wound and begin to multiply. The bacteria may come from the surrounding skin, the external environment, or the object that caused the injury.

It is important to clean and protect the wound properly to reduce the risk of infection.

Cellulitis is an infection of the deeper layers and tissues of the skin, and it can cause swelling, redness, and pain in the affected area. Other symptoms can include fever, dizziness, and nausea and vomiting.

Osteomyelitis is a bacterial infection of the bone, and symptoms include pain, redness, and swelling around the infected area. Fatigue and fever are other symptoms that may affect those with osteomyelitis.

Sepsis is an extreme immune reaction that can sometimes occur when an infection enters the bloodstream. Sepsis can lead to multiple organ failure and is life-threatening. According to the , nearly 270,000 people in the U.S. die each year due to sepsis.

Necrotizing fasciitis is a rare condition that occurs when a bacterial infection spreads into a tissue called the fascial lining that lies deep beneath the skin. Necrotizing fasciitis is a medical emergency that causes severe skin damage and pain and can spread throughout the body.

The risk of wound infection is higher if:

the wound is large, deep, or has jagged edges

the edges of the wound do not stay together

symptoms of infection occur, such as fever, increasing pain or redness, or discharge from the wound

it is not possible to clean the wound properly or remove all debris, such as glass or gravel

the cause of the wound was a bite or an injury from a dirty, rusty, or contaminated object

Certain health conditions and environmental factors can also increase the risk of infection. These include:

A doctor may treat an infection with antibiotics.
Rarely, incision wounds from surgical procedures can also become infected. According to the Centers for Disease Control and Prevention (CDC), between 2006 and 2008, about 1.9 percent of surgical wounds became infected in people having operations in the United States.

If a person does not receive treatment for a wound infection, it can spread to other parts of the body, which may lead to serious complications, including:

A person with a wound should seek medical attention if:

Seek urgent medical attention if blood is spurting from the wound or if applying pressure to the wound does not stop the bleeding.

Doctors can treat a bacterial infection with antibiotics. It is important for a person to complete the course of antibiotics to treat the infection fully and to prevent the bacteria from becoming resistant to the drug.

In addition to cleaning, some wounds may require further treatment. If the cut is large or deep, for example, a doctor or nurse may have to use stitches to close it. They can often close smaller cuts with medical glue or strips of tape instead.
Read the article in Spanish.
If the wound contains dead or contaminated tissue, a doctor may remove this tissue in a procedure called debridement. Debridement should promote healing and prevent the infection from spreading.

A person might require a tetanus shot if the cause of the wound was a bite or an injury from a dirty or rusty object.

The recommend that adults get a tetanus booster shot every 10 years to protect them against tetanus infection. However, for certain types of wound, a doctor may still prescribe a tetanus shot for people who have not had one in the past 5 years.

A wound infection can occur if bacteria enter and multiply inside the wound. Immediately cleaning and dressing cuts, grazes, and other small wounds is the best way to prevent infections. However, people with larger, deeper, or more serious wounds should have a trained healthcare professional treat the injury.

The signs and symptoms of wound infection can include increasing pain, swelling, and redness around the affected area. A person may be able to treat a mild infection of a small wound at home by recleaning and redressing the wound.

However, more severe wound infections require prompt medical attention, particularly those that occur along with fever, feeling unwell, or discharge and red streaks coming from the wound.

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Infected wound: Recognition, treatment, and when to see a doctor

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Symptoms of an infected wound can include increasing pain, redness, and swelling in the affected area. A person may be able to treat minor wound infections at home. However, people with more severe symptoms or larger wounds should seek medical attention. Learn more here.

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Mueller-Hinton agar is used to screen for antibiotic susceptibility throughout the diagnosing process. In the current case, the agar was utilised to find bacteria in the patient AA's infected wound. The test assists in identifying the particular microorganisms and determines their antibiotic sensitivity.

What is Mueller-Hinton Agar ?

For this kind of testing, Mueller-Hinton agar is a typical medium because it enables the diffusion of antibiotics and yields reliable, repeatable findings. The medium in AA's case was supplemented with 6 µg/mL oxacillin and 4% NaCl, suggesting that methicillin-resistant Staphylococcus aureus (MRSA) was the target organism. Vancomycin was administered as a result of the growth of this agar, which indicated that the infection was caused by bacteria resistant to some of the first medicines prescribed. Vancomycin proved to be a successful treatment for the infection.

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The Role of MHA in antibiotic susceptibility testing :

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The Role of MHA in antibiotic susceptibility testing :

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1. Uniform Growth Medium:

- MHA's standardized composition enables constant bacterial growth, which is required for reliable AST results.

- Ingredients include beef extract and casein hydrolysate, which promote bacterial development.

- Starch, which helps absorb toxins that bacteria may produce, preventing them from interfering with the antibiotics' effectiveness.

- Agar solidifies the medium.

2. Optimal Antibiotic Diffusion:

- MHA promotes the appropriate diffusion of antibiotics from discs into agar.

- This diffusion generates concentration gradients around the discs, resulting in distinct zones where bacterial growth is hindered if the bacteria are susceptible to the antibiotic.

3.Reliable Results Interpretation :

The size of the inhibition zones around the antibiotic discs is measured and compared with standardized charts to assess whether the bacteria are :

Sensitive (S)

Intermediate (I)

Resistant (R)

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Benefits of MHA in Antibiotic Susceptibility Testing :

- Reproducibility and Reliability

- Wide Applicability

- Consistency in testing

Key Limitations of MHA in AA's Case:

In AA's case of wound infection, the limitations of Mueller-Hinton agar (MHA) that could potentially affect the results of antibiotic susceptibility testing include:

1. Medium Formulation and pH

Particularly its nutrient content, can influence bacterial growth and antibiotic efficacy.

Variations in pH can affect the activity of antibiotics—some antibiotics lose their effectiveness in acidic or basic environments, leading to inaccurate test results.

2. Divalent Cation Concentration

Variation in the concentration of divalent cations, such as calcium (Ca²⁺) and magnesium (Mg²⁺), significantly affects the results of susceptibility tests with antibiotics like aminoglycosides, tetracyclines, and colistin against Pseudomonas aeruginosa isolates

3. Drug Inactivation due to the prolonged incubation time of the Slow Growers

For slow-growing bacteria, extended incubation times may cause antibiotics to lose potency ( effectiveness of bacteria ) before the test concludes.

Some antibiotics degrade or become less active over time, leading to inaccurate susceptibility results, particularly when testing slow-growing organisms like Mycobacterium species.

https://microbiologyinfo.com/mueller-hinton-agar-mha-composition-principle-uses-and-preparation/

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Mueller and Hinton developed Mueller Hinton Agar (MHA) in 1941 for the isolation of pathogenic Neisseria species. Nowadays, it is more commonly used for the routine susceptibility testing of non-fastidious microorganism by the Kirby-Bauer disk diffusion technique.

Five percent sheep blood and nicotinamide adenine dinucleotide may also be added when susceptibility testing is done on Streptococcus species. This type is also commonly used for susceptibility testing of Campylobacter.

Composition of MHA

Final pH 7.3 ± 0.1 at 25ºC

Principle of MHA

Mueller Hinton Media contains Beef Extract, Acid Hydrolysate of Casein, Starch and Agar. Beef Extract and Acid Hydrolysate of Casein provide nitrogen, vitamins, carbon, amino acids, sulphur and other essential nutrients. Starch is added to absorb any toxic metabolites produced. Starch hydrolysis yields dextrose, which serves as a source of energy. Agar is the solidifying agent.

The use of a suitable medium for testing the susceptibility of microorganisms to sulfonamides and trimethoprim is essential. Antagonism to sulfonamide activity is demonstrated by para-aminobenzoic acid (PABA) and its analogs. Reduced activity of trimethoprim, resulting in smaller inhibition zones and innerzonal colonies, is demonstrated on unsuitable Mueller Hinton medium possessing high levels of thymidine. Both the PABA and thymine/thymidine content in Mueller Hinton Agar are reduced to a minimum, thus markedly reducing the inactivation of sulfonamides and trimethoprim when the media is used for testing the susceptibility of bacterial isolates to these antimicrobics.

Uses of MHA

1. The major use of Mueller Hinton Agar is for antimicrobial susceptibility testing. It has become the standard medium for the Bauer Kirby method and its performance is specified by the NCCLS.

2. It can be used to cultivate Neisseria

3. It is specified in FDA Bacteriological Analytical Manual for food testing, and procedures commonly performed on aerobic and facultative anaerobic bacteria.

Why MHA is used for antibiotic susceptibility testing?

1. It is a non-selective, non-differential medium. This means that almost all organisms plated on here will grow.

2. It contains starch. Starch is known to absorb toxins released from bacteria, so that they cannot interfere with the antibiotics. It also mediates the rate of diffusion of the antibiotics through the agar.

3. It is a loose agar. This allows for better diffusion of the antibiotics than most other plates. A better diffusion leads to a truer zone of inhibition.

4. MHA shows acceptable batch-to-batch reproducibility for susceptibility testing.

5. MHA is low in sulfonamide, trimethoprim, and tetracycline inhibitors (i.e. concentration of inhibitors thymidine and thymine is low in MHA).

6. Both the para-aminobenzoic acid (PABA) and thymine/thymidine content in Mueller Hinton Agar are reduced to a minimum, thus markedly reducing the inactivation of sulfonamides and trimethoprim when the media is used for testing the susceptibility of bacterial isolates to these antimicrobics.

Preparation of MHA

1. Suspend 38 gm of the medium in one liter of distilled water.

2. Heat with frequent agitation and boil for one minute to completely dissolve the medium.

3. Autoclave at 121°C for 15 minutes. Cool to room temperature.

4. Pour cooled Mueller Hinton Agar into sterile petri dishes on a level, horizontal surface to give uniform depth.

5. Allow to cool to room temperature.

6. Check for the final pH 7.3 ± 0.1 at 25ºC.

7. Store the plates at 2-8 ºC.

Quality control of MHA

Positive controls:

Expected results

Escherichia coli ATCC® 25922

Good growth; pale straw colored colonies

Pseudomonas aeruginosa ATCC® 27853

Good growth; straw colored colonies

Staphylococcus aureus ATCC® 25923

Good growth; cream colored colonies

Un-Inoculated medium

No change

Limitations of MHA

1. Numerous factors can affect results: inoculum size, rate of growth, medium formulation and pH. Strict adherence to protocol is required to ensure reliable results.

2. Drug inactivation may result from the prolonged incubation times required by slow growers.

3. Variation in the concentration of divalent cations, primarily calcium and magnesium affects result of aminoglycoside, tetracycline, and colistin test with P. aeruginosa isolates.

Similar Posts:

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Mueller Hinton Agar (MHA) - Composition, Principle, Uses and Preparation

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Mueller and Hinton developed Mueller Hinton Agar (MHA) in 1941 for the isolation of pathogenic Neisseria species. Nowadays, it is more commonly used for the routine susceptibility testing of non-fastidious microorganism by the Kirby-Bauer disk diffusion technique. Five percent sheep blood and nicotinamide adenine dinucleotide may also be added when susceptibility testing is done on Streptococcus species.

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Pulse: 110 per minute (Tachyarrythmia)

Respiratory rate: 19 per minute (normal)

range of a healthy adult is 10 to 20 breaths per minute.

Blood pressure: 118/83 mmHg

Systolic: < 120 mmHg

Diastolic: < 80 mmHg

Considered normal for his age

Body Mass Index (BMI):

20.3 (normal)

SPO2: 98%

cannot be lesser than 95% so it is normal

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4. What triggered the infection after 1 week getting worse?

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4. What triggered the infection after 1 week getting worse?

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Infection

Not keeping the burn clean or using non-sterile materials can lead to infections. Infections can slow healing and cause complications.

Improper Wound Care

Using the wrong types of dressings or ointments, or not changing dressings regularly, can hinder healing and increase the risk of complications.

Excess Moisture

too much moisture around the burn can lead to maceration (softening of the skin), which can delay healing and increase the risk of infection.

Allergic Reactions

Using products that cause allergic reactions can irritate the burn site, making it worse.

Heat Exposure

Continued exposure to heat or sunlight can aggravate the burn and delay recovery.(impossible in burn unit)

Lack of Moisturization

Not keeping the burn moisturized can lead to dryness and cracking, which may worsen the condition of the burn.

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Possible risk factors from burn injuries

Burn injuries come with several risk factors that can lead to complications, some of which can be life-threatening. Prompt treatment, infection control, and fluid resuscitation are crucial to minimizing these risks.

1. Infection: Burn wounds, especially severe ones, are prone to infections as the skin, a primary barrier to bacteria, is compromised. Common pathogens like Staphylococcus aureus (including MRSA) and Pseudomonas aeruginosa often infect burn wounds. Pseudomonas is not only the most ubiquitous burn wound pathogen, but also the most likely to be responsible for sepsis leading to burn-linked death. Fungal infections, particularly with Candida albicans and Aspergillus, are also significant concerns in patients with larger burns or extended hospital stays​. Burn patients are also very susceptible to viral infections such as Herpes viruses.

2. Dehydration and Fluid Loss: Burns can lead to significant fluid loss, especially in cases covering more than 10% of the body. This fluid shift can result in hypovolemic shock if not properly managed with intravenous fluid therapy​.

3. Respiratory Issues: Smoke inhalation from the incident can cause airway burns, leading to respiratory complications, including inhalation injury and respiratory failure. Patients may require ventilatory support​.

4. Multisystem Organ Dysfunction: Severe burns can induce systemic inflammation, potentially leading to multisystem organ dysfunction. This condition affects the kidneys, liver, and heart and can result in fatal outcomes if untreated​.

5. Joint and Mobility Issues: Burns affecting joints can cause long-term complications like joint contractures, where the skin tightens around the joint, limiting movement. In severe cases, heterotrophic ossification (bone formation in soft tissue) can occur​.

6. Hypothermia: After a burn injury, the body may develop hypothermia due to the significant loss of skin, which normally acts as an insulating barrier, coupled with fluid loss and evaporation from the exposed tissue. This loss of thermoregulation is especially dangerous in severe burns, as it can exacerbate shock and impede recovery.

References:

a)https://www.msdmanuals.com/professional/injuries-poisoning/burns/burns

b)https://www.merckmanuals.com/en-ca/home/quick-facts-injuries-and-poisoning/burns/burns

c)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4790211/#:~:text=Gram%2Dnegative%20bacteria-,Pseudomonas,death%20%5B2%2C14%5D.

d)https://www.msdmanuals.com/professional/injuries-poisoning/burns/burns

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Burns - Injuries; Poisoning - MSD Manual Professional Edition

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Burns - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the MSD Manuals - Medical Professional Version.

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AA=72%

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AA=42.5%

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Medium (green) – Survival and good outcome likely with aggressive care and comprehensive resource allocation (survival >50%).

Low (blue) – Survival and good outcome <50% probability even with prolonged aggressive and resource intensive treatment.

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Burn injuries management

Burns management can be divided into three phases: early resuscitative, wound management, and rehabilitative/reconstructive.

Like any trauma patient, fluid management based on weight and burn size should immediately occur after the primary airway evaluation. However, fluid bolus administration in patients with burns without any evidence of hypovolemia is unnecessary and has several consequences, including further exacerbation of edema formation, and therefore should be avoided.

Burn injury management depends on the severity of the burn, its location, and other patient factors. Here's a comprehensive overview of burn management along with references for further reading:

1. Initial Assessment and Stabilization

Primary Survey (ABCs): Ensure airway patency, breathing, and circulation are stable. Burns to the face, neck, or chest can cause airway compromise. If inhalation injury is suspected, consider early intubation.

Secondary Survey: Assess the extent and depth of the burns, and look for associated injuries or trauma.

Fluid Resuscitation: Initiated using formulas like the Parkland formula (4 mL/kg body weight per % Total Body Surface Area (TBSA) burned, half given in the first 8 hours, the rest over the next 16 hours). Adjust fluid resuscitation based on urine output (target of 0.5-1 mL/kg/h in adults).

2. Classification of Burns

Superficial (First Degree): Affects only the epidermis, causing redness, pain, and swelling (e.g., sunburn).

Partial Thickness (Second Degree): Involves the epidermis and part of the dermis, presenting with blisters and severe pain.

Full Thickness (Third Degree): Extends through the entire dermis, often painless due to nerve damage, with a leathery or charred appearance.

Fourth Degree: Involves muscle, bone, and tendons.

3. Wound Care

Debridement: Remove necrotic tissue to reduce infection risk and promote healing.

Topical Antibiotics: Common agents include Silver sulfadiazine, Mafenide acetate, or Bacitracin to prevent infection.

Dressing: Depending on the depth, moist dressings, biological dressings (e.g., porcine or amniotic membrane), or skin substitutes may be used.

4. Pain Management

Opioids: For severe pain, titrated to patient response.

Non-opioids: NSAIDs or acetaminophen for less severe pain or as adjuncts.

Sedation: May be needed during dressing changes or debridement.

5. Infection Control

Prophylactic antibiotics: Not routinely recommended unless there's evidence of infection.

Sepsis: Early recognition and treatment with broad-spectrum antibiotics are crucial. Look for systemic signs such as fever, tachycardia, and hypotension.

6. Nutritional Support

Hypermetabolic Response: Burn patients experience an increased metabolic rate, necessitating early and aggressive nutritional support, typically through enteral feeding.

Protein Requirements: Burn patients require 1.5-2.0 grams of protein per kg body weight per day to aid in wound healing.

7. Surgical Management

Escharotomy/Fasciotomy: May be necessary to relieve pressure from circumferential burns to prevent compartment syndrome.

Skin Grafting: Full-thickness or large burns may require skin grafting (autografts, allografts, or synthetic skin substitutes).

8. Rehabilitation and Long-term Care

Physical Therapy: Begin early to prevent contractures and maintain range of motion.

Psychosocial Support: Burns can lead to significant psychological trauma; early intervention with counseling may be needed.

Scar Management: Compression garments, silicone sheeting, and massage therapy can help minimize scarring.

9. Special Considerations

Pediatric Burns: Children are more susceptible to dehydration and require more careful fluid resuscitation.

Elderly Patients: Tend to have less skin elasticity and slower healing, with a higher risk of complications.

Electrical and Chemical Burns: May cause deeper damage than apparent, requiring specialized management.

References

a)Herndon DN. "Total Burn Care" (4th Edition). Saunders Elsevier; 2012. A comprehensive textbook on burn care and management.

b)American Burn Association (ABA) Guidelines. Available at: https://ameriburn.org/education/burn-care-resources/.

c)Peck MD. "Epidemiology of burns throughout the world. Part II: intentional burns in adults." Burns 2012;38(5):630-637.

d)Palmieri TL. "Burns in children: standard and new treatments." Lancet 2007;369(9571):372-378.

e)Jeschke MG, Chinkes DL, Finnerty CC, et al. "Pathophysiologic Response to Severe Burn Injury." Annals of Surgery 2008;248(3):387-401.

f)Davis JS, et al. "Burn wound infection: Current status." World Journal of Surgery 2019;43(3):617-624.

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In most cases, partial thickness second-degree burns are caused by the following:

Scald injuries

Flames

Skin that briefly comes in contact with a hot object

Sunburn

Chemicals ( HCL, nitric)

Electricity

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What are Cephalosporins?

Cephalosporins are a large group of antibiotics derived from the mold Acremonium (previously called Cephalosporium). Cephalosporins are bactericidal (kill bacteria) and work in a similar way to penicillins. They bind to and block the activity of enzymes responsible for making peptidoglycan, an important component of the bacterial cell wall. They are called broad-spectrum antibiotics because they are effective against a wide range of bacteria.

After the first cephalosporin was discovered in 1945, scientists improved the structure of cephalosporins to make them more effective against a wider range of bacteria. Each time the structure changed, a new "generation" of cephalosporins were made. There are five generations of cephalosporins. Most cephalosporins start with cef, ceph, or kef. Note that this classification system is not used consistently from country to country.

First generation cephalosporins

First generation cephalosporins refer to the first group of cephalosporins discovered. Their optimum activity is against gram-positive bacteria such as staphylococci and streptococci. They have little activity against gram-negative bacteria.

Cephalexin and cefadroxil can be given by mouth, whereas cefazolin can only be given by injection (IV/IM). There are also differences with regards to how frequently the different first-generation cephalosporins need to be dosed.

Second generation cephalosporins

Second-generation cephalosporins are more active against gram-negative bacteria, with less activity against gram-positive bacteria
Examples： cefaclor

Third generation cephalosporins

Third generation cephalosporins followed the second-generation cephalosporins. No single third-generation cephalosporin treats all infectious disease scenarios.

Cefotaxime and ceftizoxime (discontinued) offer the best gram-positive coverage out of all the third-generation agents; ceftazidime and cefoperazone (discontinued) are unique in that they provide antipseudomonal coverage.

Ceftriaxone has a long half-life which allows for once daily dosing and may be used for the treatment of gonorrhea, pelvic inflammatory disease, and epididymo-orchitis. It is also an alternative to penicillins for suspected meningitis.

All the third-generation cephalosporins except for cefoperazone (discontinued) penetrate cerebrospinal fluid.

Fourth generation cephalosporins

Fourth generation cephalosporins are structurally related to third-generation cephalosporins but possess an extra ammonium group, which allows them to rapidly penetrate through the outer membrane of gram-negative bacteria, enhancing their activity. They are also active against β-lactamase producing Enterobacteriaceae which may inactivate third-generation cephalosporins.

Some fourth-generation cephalosporins have excellent activity against gram-positive bacteria such as methicillin-susceptible staphylococci, penicillin-resistant pneumococci, and viridans group streptococci.

Cefepime is the only fourth generation cephalosporin available in the United States. Cefpirome is available overseas.

Next (fifth) generation cephalosporins

Ceftaroline is currently the only next-generation cephalosporin available in the United States. It is active against methicillin-resistant Staphylococcus aureus (MRSA) and gram-positive bacteria. It also retains the activity of the later-generation cephalosporins and is effective against susceptible gram-negative bacteria.

Are cephalosporins safe?

Cephalosporins are generally safe, with low toxicity and good efficacy against susceptible bacteria.

Allergic reactions have been reported with cephalosporins and symptoms may include a rash, hives (urticaria), swelling, or rarely, anaphylaxis. Up to 10% of people with a history of penicillin allergy will also be allergic to cephalosporins.

Rarely, seizures have been reported with some cephalosporins; the risk is greatest in those with kidney disease.

Cephalosporins have also been associated with a reduced ability of the blood to clot leading to prolonged bleeding times. People with kidney or liver disease, nutritionally deprived, taking cephalosporins long-term, or concurrently receiving anticoagulant therapy are more at risk.

What are the side effects of cephalosporins?

Cephalosporins generally cause few side effects. The most common side effects reported include abdominal pain, diarrhea, dyspepsia, headache, gastritis, and nausea and vomiting. Transient liver problems have also been reported.

Rarely, some people may develop a super-infection due to overgrowth of a naturally occurring bacterium called Clostridium difficile, following use of any antibiotic, including cephalosporins. Symptoms may include severe diarrhea.

Uncommonly, an overgrowth of the yeast, Candida albicans, may occur following cephalosporin use, resulting in the symptoms of thrush.

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What causes a second-degree burn?

In most cases, partial thickness second-degree burns are caused by the following:

Scald injuries

Flames

Skin that briefly comes in contact with a hot object

Sunburn

Chemicals ( HCL, nitric)

Electricity

Goes into the second, deeper layer of skin, called the dermis (DUR-mis). These injuries are also known as partial-thickness burns. These burns cause pain, redness, and blisters. The burn may weep fluid, ooze, or bleed if you stretch it.

a. Factors that delay and Factors affecting duration?

Infection & Poor wound care :

- Burns create an open wound, making them vulnerable to bacteria. Infection can slow healing, increase pain, and lead to more serious complications.

- Inadequate cleaning, improper dressing changes, or exposure to contaminants can delay healing.

Burn Depth: Deeper 2nd-degree burns take longer to heal compared to superficial ones due to the greater extent of tissue damage.

Age: Older individuals often have slower healing rates due to reduced skin elasticity and a slower immune response.

Underlying Health Conditions: Conditions like diabetes, poor circulation, or immune system disorders can impair the body's ability to repair damaged tissue.

Medications: Certain medications, like steroids or immunosuppressants, can interfere with the body's natural healing mechanisms.

Stress: Chronic stress can weaken the immune system, potentially slowing the body’s ability to heal.

Location: Burns in areas with less blood flow, like the lower legs, may take longer to heal. Burns on joints (e.g., elbows, knees) may also experience delays due to movement.

b. How long does it take to heal (duration)?

Within 1–3 weeks.

After healing, your skin may become discolored. You may also have scars. The risk of scarring depends on the depth of the burn in the dermis and the time the wound takes to heal. Treatment for second-degree burns varies. In some cases, may need surgery for second-degree burns that are deep or slow to heal.

-> based on the size and location

Your second-degree burn will undergo three stages of healing:

React: When you get a burn, your body will activate your immune system via inflammation. This causes swelling and skin discoloration, as your immune system works to heal your body.

Repair ( Proliferative phase) :

The second stage is happening below the surface of your skin. Your cells are working together to fix the damage to your skin by getting rid of damaged tissue to make room for the new skin and tissue to grow. -> Neutrophil will get rid of dead cells

Lasts around 16 days

Remodel: The third stage of healing is when your body creates a scar. Your body closes any gaps in your tissue caused by the burn and fills it with collagen, a protein within your skin. Sometimes, your scar is visible and other times, the area where your skin closed together looks natural. -> Growth hormone, fibroblast

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a)     Post-burn Management

i.     Non-Pharmacological Action

a.     First Aid

It involves cooling the burn wound with cool running tap water. First aid cooling reduces thermal spread, burn depth and time to re-epithelialization. Time to re-epithelialization is the duration it takes for the skin to heal and regenerate a new layer of epithelial tissue over a wound or burn site.

b.     Wound Assessment

Burn wound assessment involves assessing both the size and the depth of the burns. Burn depth is very important to be determined by pharmacists. Usually, superficial burns can be managed as an outpatient, but all deep burns need to be referred for further management.

ii.  Food Suggested – Model Systems Knowledge Translation Center

High-protein foods include lean meat, eggs, tofu, beans, nuts, dairy products such as milk, yogurt and cheese. Foods with little nutritional value, such as sugary beverages, desserts, candy, fatty meats, white breads or crackers must be avoided.

A diet high in calories and proteins can help wounds heal faster, support the immune system to decrease the risk of infection, maintain the muscle mass and minimize weight loss to support rehabilitation. Vitamin or mineral supplements are also recommended for burn patients.

b)    Information on Drug Given - Medscape

Silver sulfadiazine is topical and antibacterial medication. It is useful in the prevention of the infections from second- and third- degree burns. It has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast. It has poor eschar penetration.

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What is vancomycin?

Vancomycin is an antibiotic. Oral (taken by mouth) vancomycin fights bacteria in the intestines.

Vancomycin is used to treat an infection of the intestines caused by Clostridium difficile, which can cause watery or bloody diarrhea. This medicine is also used to treat staph infections that can cause inflammation of the colon and small intestines.

Oral vancomycin works only in the intestines and is not normally absorbed into the body. vancomycin will not treat other types of infection. An injectable form of this medicine is available to treat serious infections in other parts of the body.

Dosing information

Usual Adult Dose for Pseudomembranous Colitis:

Clostridium difficile-associated diarrhea: 125 mg orally 4 times a day
-Duration of therapy: 10 days

Enterocolitis: 500 mg to 2 g orally per day, given in divided doses 3 to 4 times a day
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered by injection will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

Society of Healthcare Epidemiology of America (SHEA) and IDSA Recommendations:
Initial treatment of severe C difficile infection (CDI): 125 mg orally 4 times a day
-Duration of therapy: 10 to 14 days

Severe, complicated CDI: 500 mg orally 4 times a day AND 500 mg (in 100 mL normal saline) rectally every 6 hours with/without IV metronidazole

Comments:
-Rectal formulations should be administered as a retention enema.
-The first recurrence of CDI may be treated with the initial treatment regimen; a second recurrence of CDI may be treated with a tapered/pulsed regimen of this drug.

Uses:
-Initial treatment of patients with severe CDI
-Initial treatment of patients with complicated, severe CDI

Usual Adult Dose for Enterocolitis:

Clostridium difficile-associated diarrhea: 125 mg orally 4 times a day
-Duration of therapy: 10 days

Enterocolitis: 500 mg to 2 g orally per day, given in divided doses 3 to 4 times a day
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered by injection will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

Society of Healthcare Epidemiology of America (SHEA) and IDSA Recommendations:
Initial treatment of severe C difficile infection (CDI): 125 mg orally 4 times a day
-Duration of therapy: 10 to 14 days

Severe, complicated CDI: 500 mg orally 4 times a day AND 500 mg (in 100 mL normal saline) rectally every 6 hours with/without IV metronidazole

Comments:
-Rectal formulations should be administered as a retention enema.
-The first recurrence of CDI may be treated with the initial treatment regimen; a second recurrence of CDI may be treated with a tapered/pulsed regimen of this drug.

Uses:
-Initial treatment of patients with severe CDI
-Initial treatment of patients with complicated, severe CDI