it is about burn basics,classification,fluide management and surgical interuption

1. BURN
BY
DR BADAL KHAN PGR1
SURGICAL UNIT 3 BMCH10/22/2016 1

2. INTRODUCTION
Majorty of burns in children are SCALDS caused
by accidents with kettles,pans,hot drinks and
bath water
In young males burn caused by experimenting
With mathes and inflamable liquides
Electrical and chemical injuries occur in adults with
Associated conditions such as mental disease,
Epilepsy Alcohal and drug abuse
10/22/2016 2

3. ETIOLOGY OF BURNS
DRY HEAT
FLAME
ELECTRICT CONTACT
CHEMICAL
FROSTBITE
IONIZING RADIATION
10/22/2016 3

4. CLASSIFICATION OF BURNS
1.Depending on the percentage of burns
MILD
o Partial thickness burns <15% in adults and <10%
In children
or
o Full thickness <2%
o Can be treated on outpatient department
10/22/2016 4

5. Classification (cont…….
MODERATE
oSecond degree burn of 15-25% burns
oThird degree burn between 2-10% burns
oBurns which are not involving eyes,ears
Face,hand,feet and perineum
10/22/2016 5

6. CLASSIFICATION (CONT……)
SEVERE
oSecond degree burns more then 25% in adults
and More then 20% in children
oAll third degree burns more then 10%
oAll electrical burns and inhalation burns
oBurns with fracture
oBurns involving eyes,ears,feet,hands and
perineum
10/22/2016 6

7. Classification(cont…..)
2.Depending on thickness of skin involved
 First degree
 Second degree
 Third degree
 Fourth degree
 Partial thickness burns
I. Superficial
II. deep
 Full thickness burns10/22/2016 7

8. CLASSIFICATION(CONT…..)
a.First degree
 Epidermiss looks red and painfull
 No blisters formation
 Heals rapidly In 5-7 days by epithelialization
Without scarring
10/22/2016 8

9. Classification(cont…..)
b.2nd degree burns
affected area is red,mottled,painfull
Blister formation
Heals in 14-21
days by epithelialization With scaring
10/22/2016 9

10. CLASSIFICATION(CONT……)
C.3rd degree burns
Affected area is painless and insensetive with
Thrombosis of superficial
vessels
It requires grafting
D.4th degree burns
It involves underlying
Tissues
Muscles
bones10/22/2016 10

11. Degrees of burns.
Partial thickness and full thickness discuss in asessment of burn
10/22/2016 11

12. Pathophysiology of burn injury
Most common organ affected is the skin
Burn can also damage airways and lungs with life
Threatening consequenses
Respiratory system injuries occure if person trapped
In a burning vehicle,house,car and is forced to inhale
The hot and poisonous gases
Hot gases burn the lining of airway above the larynx
And lining start to swell later on block the airway
Steam causes damage to the lower airways,respiratory
Epithelium swells and detach from bronchial tree
10/22/2016 12

13. Pathophysiology(cont……)
Metabolic poisoning
Carbon monoxide is a product of incomplete combustion
That is often produced by fires in a closed space is one of
Many poisonous gases
Co binds to hb with an affinity of 240> O2 so block
Transport Of O2
Level of carboxyhaemoglobin in blood can be measure
Conc >10% dangerous and need treatment with pure
Oxygen for more then 24hours
Hydrogen cynide causes metabolic acidosis by interefering
With mitochondrial respiration10/22/2016 13

14. Pathophysiology(cont……)
Inhalational injury
caused by mainute particles within thick smoke because
Of their small size and are not filtered by the upper
Airwayand are carried down to
lung parenchyma
Stick to moist lining causes
intense reaction in alveoli
Causes chemical pneumonitis
followed by oedema within
Alveolar sac and dec gaseous
exchange
Bacterial pneumonia occures
10/22/2016 14

15. Pathophysiology(cont……)
Inflamtion and circulatory changes
Burn skin release of neuropeptides activation of
Complement are intiated by stimulation of pain fibers and
Alteration of proteins by heat
Activation of hageman factor alter archidonic acid
Thrombin and kallikrein pathways
10/22/2016 15

16. Pathophysiology(cont……)
At cellular level
Complement causes degranulation of mast cells
Attracts neutrophils which also degranulate and releases
Large amount of free radicals and proteases
Mast cells also releases TNF@ which act as chemotactic
Agent to inflamatory cells
These inflamatory factors alter permeability of bld vessels
Large protein molecules can also escape with ease
Damaged collagen and extravasated proteins oncotic
Pressure further increase flow of water from intravascular
To extravascular space10/22/2016 16

17. Pathophysiology
Heat causes coagulation necrosis of skin and
subcutaneous tissue.
↓
Release of vasoactive peptides
↓
Altered capillary permeability
↓
Loss of fluid → Severe hypovolaemia
↓
Decreased cardiac → Decreased myocardial
output function
↓
Decreased renal blood → Oliguria
flow (Renal failure)
↓
Altered pulmonary resistance causing pulmonary
Oedema infection
Systemic Inflammatory Response Syndrome (SIRS)
↓
Multi Organ Dysfunction Syndrome (MODS).
10/22/2016 17

18. ASSESSMENT OF BURNS
1.ASSESSING SIZE
Burn size should be assessed in a controlled environment
To avoid hypothermia
In smaller burns just cut a piece a clean paper the size of
patient ,s whole hand (digit and palm)which present 1% TBSA
And match this to the area
Another accurate way of measuring the size of burns is to draw
The burn on a LUND AND BROWDER CHART
Age in
yrs
0 1 5 10 15 adult
A head 9 8 6 5 4 3
B thigh 2 3 4 4 4 4
C leg 2 2 3 3 3 310/22/2016 18

19. ASSESSMENT(CONT…..)
RULE OF 9 (wallace,s rule of 9
Each upper limb is 9% TBSA
Each lower limb is 18% TBSA
Torso 18% each side
Head and neck 9%
Perineum 1%
In children head and neck is 18% and
Lower limb is 13.5% each=13.5*2=27%
10/22/2016 19

20. Rule of 9
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21. ASSESSMENT(CONT…..)
2.Assessing depth from the history
Burning of human skin is temperature and time dependent
It takes 6 hours for skin maintained at 44c* for irreversible changes
A surface teperature of 70c* for 1 second produce epidermal
destruction
Example of Exposure to hot water at 65c*
45 second exposure produce full thickness burn
15 second exposure produce deep partial thickness burn
7 second exposure produce superficial partial thikness burn
10/22/2016 21

22. ASSESSMENT(CONT…..)
a) Superficial partial thickness burns
 No deeper then papillary dermis
 Blister formation
 Loss of epidermis
 Capillary return visible
When blanched
 Dermis is pink and moist
 Pin prick sensation normal
 Heal without scarring
In 2 weeks
 Treatment is non surgical
10/22/2016 22

23. Superficial partial thickness burns
After 24 hours after burn After 2 weeks
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24. Superficial partial thickness burn after 3 months
Pigment returning
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25. ASSESSMENT(CONT…..)
b)Deep partial thickness burn
Damage to deeper parts of dermis
Epidermis is usually lost
Fixed capillary staining
Colour does not blanch with pressure
Sensation is reduced
Pt is unable to distinguish sharp from blunt pressure
Takes 3 or more weeks to heal without surgery
Leads to hypertrophic scarring
10/22/2016 25

26. ASSESSMENT(CONT…..)
c) Full thickness burns
Whole of the dermis destroyed
Hard and leathery feel
No capillary return
Often thrombosed vessels can be seen under
The skin
These are completely anesthetised
No pain and no bleeding
10/22/2016 26

27. Causes of death in burns
a. Hypovolaemia and shock
b. Renal failure
c. Pulmonary oedema and ARDS
d. Septicaemia
e. Multiorgan failure
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28. Full thickness burn
Wraped in cling film
10/22/2016 28

29. Deep partial thickness burn
tangential shaving to remove dead dermis
Dermis remove layer by layer untill bleeding
10/22/2016 29

30. Hypertrophic scarring following a deep dermal burn.
After 3 or more weeks
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31. Management of burns
Management of burns is consist of
prehospital care
&
hospital care
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32. Management of burns
Prehospital care
Stop the burning process
Stop,drop and roll is a good method of extinguishing
Fire
Cool the burn wound
This provide analgesia and slow the delayed micro-
-vascular damage which occure after a burn injury
Cooling should be for minimum 10 mintues and up to
One hour to avoid hypothermia
Give oxygen
Give oxygen especialy if there is altered level concious_
-ness level10/22/2016 32

33. Management of burns
Elevate
Sitting a patient up with a burned airway may prove life
Saving
Elevation of burned limbs reduce swelling and discomfort
Check for other injuries
A standard ABC check followed by a secondary survey
Patients burned in explosions may have head and spine injuries
And other life threatening problems
10/22/2016 33

34. Management of burns
Indications for admission in burns
Susected airway or inhalational injury
Any burn require fluide resusciation
Any burn in extreme of ages
All electrical and chemical burns
Any burn which require surgery
Burn of any significance to hands,face,feet or perineum
Suspicious of non accidental injury
10/22/2016 34

35. Management of burns
Hospital care
Admit the patient
Airway control
Breathing and ventilation
Circulation
Disability
Exposure with environment control
Fluid resuscitation
Assess the %age,degree and type of burn
Keep the patient in clean environment
Sedation and proper analgesia
10/22/2016 35

36. Management of burns
A.AIRWAY CONTROL
Burned airway creates problems by swelling and can completely
Occlude the airway
Secure airway with an endotracheal tube until
swelling subsided which is Usually 48 hours
Delayed diagnosis of airway burn make difficult to intubate the
Patient in presence of lyrangeal oedema so cricothyroidectomy
Should be done
Early intubation of suspected airway burn is the treatment of
Choice in such patients
10/22/2016 36

37. Management of burns
B.BREATHING
A progressive increase in respiratory rate and effort ,anxiety
Rising pulse and confusion with decreasing o2 saturation
These symptoms take 24 hours to 5 days to appear
Treatment starts as soon as possible including
Physiotherapy
Nebulisers
Warm humidified oxygen
10/22/2016 37

38. Management of burns
Fluide resuscitation
Iv volume must be maintained following a burn in order to
provide sufficient circulation to perfuse not only the organs but
also the peripheral tissues,especially damaged skin
Iv resuscitation is appropriate for any child with a burn greater
Then 10% and 15%for TBSA for adults
If oral resuscitation is to be commenced then water is given
Should not be salt free
It is appropriate to give oral rehydration with a solution such as
DIORALYTE*
Most common fluid used is ringer lactate
10/22/2016 38

39. Management of burns
Fluid volume is relatively constant in proportion to the area
Of body burned therefore there are formulate that calculate
The approximate volume of fluid needed for the pt of a given
Body weight with a given %age of the body burned
Formulas to calculate the fluid replacement
1.parkland regime (commonly used)
4ML/%burn/kg body weight/24 hours
4*50*60=12000ml in 24 hours
Half this volume is given in the frist 8 hours
Second half is given in the subsequent 16 hours
Others
1. Evan,s formula
2. Muir and barclay
3. Modified brook formula10/22/2016 39

40. Management (cont…)
Fluids used
Crystalloid resuscitation
Ringer lactate is the most commonly used crystalloid
These are as effective as colloids for maintaining intra-
-vascular volume
Less expensive
In children
Dextrose saline given for maintanaince
100ml/kg for 24 hours for frist 10kg
50ml/kg for 24 hours for next 10kg
20ml/kg for 24 hours for each kg above 20kg body weight
10/22/2016 40

41. Management (cont…)
hypertonic saline
 it produces hyperosmolarity and hypernatremia
Reduces shift of intracellular water to extracellular space
Advantages
Include less tissue oedema and a resultant decrease in
Escharotomies and intubations
10/22/2016 41

42. Management (cont…)
Colloid resuscitation
Plasma proteins are responsible for the inward oncotic
Pressure that counteracts the outward capillary hydrostatic
Pressure.
Without proteins there will be oedema
Proteins should be given after frist 12 hours of burn before
This time proteins will leak out of cells
Given through muir and barclay formula
0.5*%age bsa burn*weight=one portion
Periods of 4/4/4, 6/6, 12 hours respectively
One portion to b given in each period
10/22/2016 42

43. Management (cont…)
Monitoring of resuscitation
The key to monitoring of resuscitation is urinary output
Output should be between 0.5ml and 1.0ml/kg/hour
If urine output is below this infusion rate should increase
By 50%
If still output is inadequate then a bolus of 10ml/kg given
2ml/kg/hr urinary output signals decrease in the rate of
Perfusion
Haematocrit measurement is a usefull tool in confirming
Suspected under or overhydration
10/22/2016 43

44. Management (cont…)Treating the burn wound
Dressings
Paraffine guaze
Hydrocolloids (duoderm)
Biological dressings
synthetic (biobrane)
natural (amniotic membrane)
Full-thickness and deep dermal burns need antibacterial
dressings to delay colonisation prior to surgery
Open method
Silver sulfadiazine application without dressings commonly
Used in burns of face,head and neck.
Closed method
Dressing done to soothen and to protect the wound
To reduce the pain
As an absorbent
10/22/2016 44

45. Management (cont…)
Treating the burn wound (cont……
Tangential excision
Can be done within 48 hours with skin grafting in patients with less
Then 25% burn
Usually done in deep
dermal burns
Dead dermis is removed
layer by layer Untill fresh
bleeding occurs
Later skin grafting done
10/22/2016 45

46. Treating the burn wound
(cont……
Treating the burn wound (cont……
escharotomy
Circumferential full-thickness burns to the limbs require emergency
Surgery
The tourniquet effect of this injury
is easily treated by incising the whole length of full-thickness
burns.
This should be done in the mid-axial line, avoiding major
Nerves
The burn needs to be cleaned and the size and depth need to be
Full thickness burns and deep partial-thickness burns that will
requireoperative treatment will need to be dressed with an
antibacterialdressing to delay the onset of colonisation of the
wound10/22/2016 46

47. A full-thickness burn to the upper limb with a mid-axial
escharotomy.
The soot and debris have been washed off.
10/22/2016 47

48. Topical agent advantages problems
Silver sulfadiazine 1
%
-Antiseptic (G +ve
and G –ve
-Soothening, good
penetration
- Hydration and
softening of eschar
occurs
-Neutropenia,
pseudoeschar
-- Causes wound
maceration
Sulfamylon – 5% -
(Mafenide acetate)
Antipseudomonal,
anticlostridial
- Penetrates very
well in to tissues
Very irritant,painful
Causes acidosis
Silver nitrate – 0.5% - Antiseptic Stains burn area
Povidone iodine
(5%) - Used on
granulation tissue -
after eschar
separation
Irritant
Painfull
Not used in partial
burns
Silver sulphadiazine
and cerium nitrate
- Boosts cell
mediated immunity
and forms sterile
eschar10/22/2016 48

49. Additional aspects of treating burn
patient
Analgesia
Oral form of paracetamol and nsaids in superficial burns
Iv opiates for large burns
Im should not be given in over 10% of TBSA as absorption is
Unpredictable
Short acting analgesia given before dressing
Energy balance
Feeding should start within 6 hrs of injury to reduce gut mucosal damag
Burns patients need extra feeding
A nasogastric tube should be used in all patients with burns over 15%
of TBSA and 10% in case of children
 Burn injuries are catabolic in the acute episode.
Removing the burn and achieving healing stops the catabolic drive
10/22/2016 49

50. Additional aspects of treating burn
patient
control of infection
Patients with major burns are immunocompromised,
pathogenic and opportunistic bacteria and fungi enter via the burn
wound,cathetars and iv lines
They have compromised local defences in the lungs and gut due to
oedema
Sterile precautions must be rigorous
 Swabs should be taken regularly
 A rise in white blood cell count, thrombocytosis and
increased catabolism are warnings of infection
Nursing care
Physiotherapy
Psychological support10/22/2016 50

51. SURGERY FOR THE ACUTE BURN
Any deep partial-thickness and full-thickness burns except
those that are less than about 4 cm2, need surgery
A topical solution of 1:500 000 adrenaline also helps to reduce
bleeding,
deep dermal burns, the top layer of dead dermis is shaved
off until punctate bleeding is observed and the dermis can be
seen to be free of any small thrombosed vessels
Full-thickness burns require full-thickness excision of the
Skin
Postoperative management of these patients obviously
requires careful evaluation of fluid balance and levels of haemoglobin.
10/22/2016 51

52. Delayed reconstruction and scar
management
is common for large Full thickness burns
Eyelids must be treated before exposure keratitis arises
 Transposition flaps and Z-plasties with or without tissue
expansion are useful
 Full-thickness grafts and free flaps may be needed for large
or difficult areas
 Hypertrophy is treated with pressure garments to be worn
for 6-18 months
Smaller areas of hypertrophy, silicone patches will speed
scar maturation,as will intralesional injection of steroid.
 Pharmacological treatment of itch is important
10/22/2016 52

53. Effects of burn
 Shock due to hypovolaemia
 Renal failure(toxins from burn&myoglobin)
 Pulmonary oedema,resp infections,ARDS,resp failure
Infection by staph aureus,pseudomonas,klebsella leads to
Septicemia
 Fungal and viral infections of dangerous type can occure
GIT: Hypovolaemia, ischaemia of mucosa, erosive
gastritis—Curling’s ulcer (seen in burns > 35%).
 Fluid and electrolyte imbalance.
immunosuppression predisposes to severe opportunistic infection.
Eschar formation and its problems like defective
circulation, ischaemia when it is circumferential.
Electrical injuries often cause fractures, major
internal organ injury, convulsions.
10/22/2016 53

54. Effects of burn(cont…..)
Inhalation burn causes pulmonary oedema,
respiratory arrest, ARDS.
Chemical injury causes severe GIT disturbances like
erosions, perforation, stricture oesophagus (alkali),
pyloric stenosis (acid), mediastinal injury.
Other problems
DVT, pulmonary embolism
bed-sores,
severe malnutrition with catabolic status,
 Toxic shock syndrome:
It is a life-threatening exotoxin mediated disease caused by
Staphylococcusaureus. It is common in children, presents with
rashes, myalgia, diarrhoea, vomiting, and multiorgan
failure with high mortality
.
10/22/2016 54

55. Effects of burn(cont…..)
Development of contracture is a late problem. It
leads to ectropion, microstomia, disability of
different joints, defective hand functions, growth
retardation causing shortening
COMPLICATIONS OF BURNS CONTRACTURE
Ectropion of eyelid causing keratitis and corneal
ulcer.
Disfigurement in face.
Narrowing of mouth microstomia.
Contracture in the neck causing restricted neck movements.
Disability and nonfunctioning of joints due to contracture
Hypertrophic scar and keloid formation.
10/22/2016 55

56. COMPLICATIONS OF BURNS CONTRACTURE
Marjolin’s ulcer
It is a very well-differentiated squamous cell carcinoma
occurring in a scar ulcer due to repeated breakdown (unstable
scar of long duration).
• It is locally malignant.
• As there are no lymphatics in the scar, so there
is no spread to lymph nodes.
• As there are no nerves in the scar it is painless.
• It has raised and everted edge with induration.
• Biopsy confirms the diagnosis.
Treatment
Radiotherapy is not given for Marjolin’s ulcer.
Treatment is either wide excision or amputation. It is curable.
Once it spreads out of the scar tissue it behaves like
any other squamous cell carcinoma and so can spread to
regional lymph nodes10/22/2016 56

57. Marjolin’s ulcer developed over burns contracture
10/22/2016 57

58. Contracture at different parts of body
chest and neck
10/22/2016 58

59. Contracture at different parts of body
Severe contracture at knee joint
causing deformity Contracture at face
10/22/2016 59

60. Complication of contracture
Hypertrophic scar Keloid formation
10/22/2016 60

61. Treatment of burn contracture
• Release of contracture surgically and use of skin graft
or “Z” plasty or different flaps.
• Proper physiotherapy and rehabilitation is essential.
• Pressure garments to prevent hypertrophic scars.
• Management of itching in the scar using aloe vera,
antihistamines and moisturizing creams.
10/22/2016 61

62. Prevention of development of
contracture
• Joint exercise in full range during recovery period of
burns
• Pressure garments for a long period
• Topical silicon sheeting
• Saline expanders for scars
10/22/2016 62

63. NON THERMAL INJURIES
Electrical burns
Chemical burn
Cold injuries
Ionising radiation
10/22/2016 63

64. Non thermal(cont……)
Electrical burns 1000v
Low tension injuries
Low tension injuries do not have enough energy to cause
Significant destruction
Entry and exit points normally in the fingers suffers small
Deep burns may damage underlying nerves and vessels
Ac creates a tetany within muscles so patient unable to
Release the device untill the power was turned off
May interfere with normal cardiac pacing and can cause
Cardiac arrest
10/22/2016 64

65. Electrical burns(cont…..)
high tension injuries
3 sources of damage
1) The flash
2) The flame
3) The current
When a high tension line is earthed it can arc over the pt
And causes a flash burn
Extremely rapid heating of the air causes an explosion
That propel the victim backward
It is always a major burn
There is a wound of entry and wound of exit
Major internal organ injuries occures
Convulsions can develope10/22/2016 65

66. Electrical burns(cont…..)
Management
Depending on injury it is managed accordingly
Patient should always be admitted and should be assessed by
i. ECG
ii. u/s abdomen
iii. Chest x-ray
iv. Ct scan head sometimes
v. Cardiac enzyme analysis
Acidosis is common so bicarbonate infusion needed
Fractures and dislocations common so managed accordingly
Release of myoglobin can cause renal tubular damage and renal
Failure so manitol is used to prevent myoglobin induced renal
failure (compartment syndrome)
10/22/2016 66

67. Wound of entry in an electric burn.
Electric burn
10/22/2016 67

68. Electrical burns(cont…..)
An exit wound of a high-tension
injury,
Amputation and cover with the
lateral portion of the second toe.
10/22/2016 68

69. Chemical burns
There are 70000 different chemicals in regular use within industry
Occasionally these cause burns
There are two aspects to a chemical injury
1. Physical destruction to the skin
2. Systemic absorption
The initial management of any chemical injury is copious lavage
With water but some need to be remove physically eg.phosphorus
A component of millitary devices
The more common injuries are caused by either
1. Alkalis
2. acids
10/22/2016 69

70. Chemical burns(cont…)
After copious lavage, the next step in themanagement of any
chemical injury is to identify the chemical
and its concentration and to elucidate whether there is any
underlying threat to the patient’s life if absorbed systemically
Alkali burns occur in oral cavity and oesophagus
which leads to multiple oesophageal strictures.
Alkalis
alkalis are more destructive and especially when come in contact
With eyes
Commonly used alkalis are sodium hydroxide,lime,bleach
They cause fat sponification,fluide loss,release of alkali proteinase
10/22/2016 70

71. Chemical burns(cont…)
Acids
Acid burn occurs in skin, soft tissues and GIT. In GIT,
Burns affecting the fingers and caused by dilute acid are relatively
common.
The initial management is with calcium gluconate gel topically
 severe burns or burns to large areas of the hand can be
subsequently treated with Bier’s blocks containing calcium
gluconate 10 per cent gel
it is common in stomach either due to nitric acid or sulphuric acid
which may lead to severe gastritis or pyloric stenosis.
Other acids are formic acid, hydrofluoric acid.
They cause metabolic acidosis, renal failure, ARDS, haemolysis.
Acidaemia should be corrected by IV sodium bicarbonate.
10/22/2016 71

72. Cold injuries
Cold injuries are principally divided into two types
1. Acute cold injuries from industries
2. Frost bite
inflammatory reaction is not as marked.
The tissue is more resistant to cold injury than to heat injury
The assessment of depth of injury is more difficult,
Frostbite
injuries affect the peripheries in cold climates
cold injury produces delayed microvascular damage similar to
that of cardiac reperfusion injury.
The initial treatment is with rapid rewarming in a bath at 42°C.
The level of damage is difficult to assess
surgery usually does not play a role in its management10/22/2016 72

73. Ionising radiation
These injuries can be divided into
1. Localised
2. Whole body exposure
The management of localised radiation damage is usually
Conservative until the true extent of the tissue injury is apparent.
If damage have caused an ulcer, then excision and coverage with
vascularised tissue is required.
A patient who has suffered whole-body irradiation and is suffering
From acute desquamation of the skin has received a lethal dose of
Radiation which can cause a particularly slow and unpleasant death
Dose may be lethal and may not be lethal
Giving iodine tablets, the management of these injuries is supportive
10/22/2016 73

74. THANKS
10/22/2016 74