Post on 15-Apr-2017
transcript
BURN WOUND MANAGEMENT
ByDr E Aravind
Under Guidance ofDr DSVL Narasimham MS
There is no greater trauma than a major burn injury
Mortality occurs immediately or after several weeks due to multi organ failure
Burns are seen mostly in extremes of ages either young or older people
Location plays a major role in treatment and outcome
DEPTH First degree—injury localized
to the epidermis Superficial second degree—
injury to the epidermis and superficial dermis
Deep second degree—injury through the epidermis and deep into the dermis
Third degree—full-thickness injury through the epidermis and dermis into the subcutaneous fat
Fourth degree—injury through the skin and subcutaneous fat into underlying muscle or bone
ESTIMATION OF BURN AREA BY RULE OF NINE
Adult Pt Pediatric Pt
PRE HOSPITAL CARE OF THE BURN WOUND It is basic and simple Only protection from the environment
with application of a clean dry dressing or sheet to cover the involved part.
By covering the wounds, contact to exposed nerve endings is prevented thus dimenishing the pain
Damp dressings should not be used Wrap in a blanket to minimize heat loss
ESCHAROTOMIES Done in deep second- and third-degree burn wounds
encompass the circumference of an extremity When peripheral circulation to the limb is
compromised Edema beneath a non yielding eschar impedes
venous outflow and eventually affects arterial inflow to the distal beds
This is recognized by numbness and tingling in the limb and increased pain in the digits
Tissue pressures greater than 40 mm Hg require escharotomy
Performed at the bedside by incising the lateral and medial aspects of the extremity with a scalpel or electrocautery unit
WOUND CARE Depends on the characteristics and size
of the wound Aim is rapid and painless healing Wound should be dressed with an
appropriate covering
It should protect the damaged epithelium, minimize bacterial and fungal colonization, and provide splinting action to maintain the desired position of function
It should be occlusive to reduce evaporative heat loss and minimize cold stress
It should provide comfort over the painful wound.
First-degree wounds Minor with minimal loss of barrier
function No dressing reqiured Treated with topical salves to decrease
pain and keep the skin moist Oral Nonsteroidal antiinflammatory
agents given to assist in pain control.
Second-degree wounds Require daily dressing changes with
topical antibiotics, cotton gauze, and elastic wraps
The wounds can be treated with a temporary biological or synthetic covering to close the wound
Deep second-degree and third-degree wounds
These wounds require excision and grafting for sizable burns
Choice of initial dressing should be aimed at holding bacterial proliferation in check and providing occlusion until the operation is performed
ANTIMICROBIALS These are divided into those given
topically and those given systemically Topical antibiotics can be divided into
two classes: salves and soaks
Slaves Salves are generally applied directly to
the wound with cotton dressings placed over them
Salves may be applied once or twice a day but may lose their effectiveness between dressing changes
Soaks Soaks are generally poured into cotton
dressings on the wound Remain effective because of antibiotic
solution
Synthetic and Biological Dressings Alternative to antimicrobial dressings They provide stable coverage without
painful dressing changes, provide a barrier to evaporative losses, and decrease pain in the wounds
These do not inhibit epithelialization Should be applied within 72 hours of the
injury, before high bacterial colonization of the wound occurs
Used to cover second-degree wounds while the underlying epithelium heals
To cover full-thickness wounds for which autograft is not yet available
Biological dressings include xenografts from swine and allografts from cadaver donors.
Applied to the wounds as of skin grafts perform the immunologic and barrier functions of
normal skin. Biological dressings are the optimal wound
coverage in the absence of normal skin. Latter biological dressings will be rejected by
usual immune mechanisms, causing the grafts to slough.
The open wound can be covered with autograft skin from the patient.
Severely burned patients are immunosuppressed, and biological dressings that have adhered will not reject for several weeks
Excision Done in deep second- and third-degree
burns They do not heal without autografting Early excision of the wound and
autografting has significantly reduced mortality
Done with hand skin graft knife, power dermatome
Sharp excision with knife or electro cautery is done in areas of cosmetic importance
Tangential Excision Repeated shaving of wound At depths of 0.005 to 0.01 inch till viable
dermal bed is reached Full thickness Excision Done with hand knife or dermatome at
thickness set at 0.015 to 0.03 inch till viable fat is reached
Fascial Excision Done in cases of involvement of deeper
tissues or infection Done with sharp No 11 blade It is mutilating and has permanent
disfuguration Bleeding will be more
Burn Wound Coverage Auto grafts are the main stay of
treatment If adequate auto graft is not available
cadaveric graft or xeno graft can be used temporarily
Cultured epithelial autografts are the present coverage of choice
Presently autograftwhen used along with allograft in mesed fashion gives good cosmetic results