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Burn SurgeryBasic Science LectureGeneral SurgeryKanene Ubesie, M.D.Virginia Commonwealth University (VCU)Burn Surgery Fellow
ObjectivesBurn pathophysiology, classification, and anatomy
Non-operative and operative plans for burn wounds
Initial burn evaluation and management
Burn TBSA and resuscitation
Thermal Burn
Inhalation injury
Electrical Burn
Chemical Burn
Frostbite
History of Burn Surgery1940s: Early excision of burn to reduce mortality
1940s: Lund and Browder chart, Rule of 9s (G.A. Knaysi), Parkland formula (Charles Baxter and G. Tom Shires)
1947: First civilian US burn center at MCV by Dr. Everett I. Evans (Evans-Haynes Burn Center)
1960s: Zora Janzekovic developed the concept of tangential excision with an uncalibrated knife
Burn Epidemiology
Common populationsVery young
Elderly
Impaired
Low socioeconomic groups
Substance Abuse
Trauma
Nonaccidental
Self-induced
Thermal Burns: Classification
Dual layer skinEpidermis
Keratinocytes
Barrier (infection, toxins, UV, dehydration, thermal)
DermisConnective tissue, Mechanoreceptors, Glands, Lymphatics and Blood vessels
Durability/Elasticity
Papillary and Reticular
Classification of BurnsSuperficial epidermal (1st)
Partial thickness (2nd)Superficial
Deep
Full thickness (3rd)
Muscle/Bone (4th/5th)
Thermal Burns: Classification
Burn PathophysiologyZones of injury
Zone of CoagulationFull thickness burn
Necrotic
Irreversible
Must debride and graft
Zone of StasisPartial thickness burn
Vasoconstriction/Ischemia
Reversible
Protect from - edema, infection, or poor perfusion
Zone of HyperemiaSuperficial epidermal injury
Quickly heals without scarring
Not included in TBSA
Thermal Burns: Initial Management
ABCs!!!!! Secondary Survey
Stabilize and transfer to nearest burn center
Burn Center
Goal: early surgical excision and/or closure of burn wounds
Systematic Approach
Multidisciplinary team
Psychosocial support
Education
Rehabilitation
Reconstruction
Criteria to refer to a burn center:
Thermal Burns: Initial Management
Thermal Burns: Initial Management
Indication for hospitalizationInhalation injury
Large and/or infected wound
Wound care and education
Physical therapy
Pain management
Discharge planning
Prognostic Factors>60 years of age
Full thickness burn >40% TBSA
Inhalation injury
Question: Name the zones of injury
Total Body Surface Area
Rule of 9sMore surface area for pediatric head
1% for the palm (tips to wrist)
SAGE
Lund & Browder
Burn Resuscitation: Parkland Formula
Partial thickness and deeper
Adult >20% TBSA
Pediatric >10% TBSA
4 x kg x %TBSAGive half in the first 8 hours
Lactated Ringers in the first 8 hours
Maintenance fluid in pediatrics <20 Kg D5 ½ NS
No colloid until after at least 8 hours
Titrate by UOPAdult – 0.5cc/kg/hr
Pediatric – 1cc/kg/hr
Over-resuscitationCompartment syndrome, pulmonary edema, swelling, ARDS
Non-operative Management of BurnsSuperficial epidermal to dermal wounds
Daily dressing changeGently wash away fibrinous exudate and biofilm
Debride large blisters
Ointment
Protective non-adherent dressing
MOBILITYDecrease: edema, infection, pain, contractures
Non-operative Management of Burns:
AntimicrobialsSilver SulfadiazineBroad spectrum, Pseudomonas and fungal
Not very effective for Klebsiella, new resistance with Pseudomonas
Soothing however does not penetrate eschar
Can retard wound healing
Reversible granulocyte reduction
Mafenide Acetate (Sulfamylon)Cream and solution
Broadest spectrum, all strains of Pseudomonas
Painful – penetrates escharEars
Metabolic acidosis – ventilator complications
Silver NitrateStaph aureus, E. Coli, Pseudomonas
Activate with water (not NaCl)
Hyponatremia, Hypochloremia, Methemoglobenemia
Does not penetrate Eschar
Stains black
Sodium Hypochlorite (Dakins)
Toxic to tissue if not diluted
0.025% - Pseudomonas, MRSA, Enterococci
MupirocinMRSA
Operative Management of Burns
Full* thickness and deeper
Early excisionBetter survival rates
Shorter LOS
Lower costs
After 24 hours of initial management and within 7 days
Stage every 2-3 days, 20% at a time
Tangential vs FascialBlood Loss
Aesthetics
Length of stay
Allograft vs Autograft
Cultured Epidermal Autograft
Operative Management of Thermal Burns
EscharotomiesCircumferential burns
Fluid resuscitation
Skin only
Perform in anatomical position
No benefit for digital escharotomies
Can perform at the bedside with cautery
Question: What it the TBSA?
Question: Calculate Burn Resuscitation
(20kg)#12% TBSA
Burn: Inhalation InjurySignificant increase in morbidity and mortality when combined with cutaneous burn
History and examClosed space
Toxic fumes
Facial burn
Singed nasal/facial/scalp hair
Soot
Flexible laryngoscopy
When to intubateCarbonaceous sputum below the vocal cords
Respiratory distress or failure
Altered mental status
Hoarseness, wheezing, stridor
Large burns undergoing resuscitation (>40% TBSA)
Burn: Inhalation InjuryCarbon Monoxide (CO) poisoning
Petroleum
200x higher affinity than oxygen to bind Hgb (carboxyhemoglobin)
Most common symptoms: Nausea, dizziness, fatigue, headache
Increasing altered mental status with increasing levels
100% FiO2
Hyperbaric
Burn: Inhalation Injury#
Cyanide poisoningNatural/Synthetic compounds
Structural fires
Disrupts cellular oxidation Lactic Acidosis
CyanoKit (hydrocobalamin, Vit B12)
Hypertension
Burn: ElectricalCategories
Low voltage, <1000V
High voltage, >1000V
Super-high voltage, Lightening
Tissue injuryLow voltage: localized, oral cavity
High voltage: deep tissue and organ injury
Lightening: Cardiopulmonary arrest, ruptured TMs
Thermal injury
Tetanic contractionsSpinal fractures
Concomitant injuries (Fall)
Burn: ElectricalWork up
Complete trauma evaluation
Neurologic exam
Ophthalmology exam
MonitoringTelemetry
Foley insertion
Neurovascular exams
TreatmentCompartment Syndrome
Fasciotomies
RhabdomyolysisUOP >100cc/hr
Alkanalize Urine
Rarely need mannitol
Question: Best, painless, colorless
antimicrobial with the least side effect profile?
#
Burn: ChemicalDo not soak affected area
Avoid neutralizing agents
LiquidAlkali vs Acid
Irrigate with water x30 minutes
PowderBrush away
Avoid water
Hydrofluoric acidSevere hypocalcemia
Irrigation and topical calcium gluconate are soothing
Gold Standard treatment:Intra-arterial calcium gluconate over 4 hours
TarRemove with lipophilic solvent (Medi-Sol)
Treat thermal injury
Frostbite
EtiologyDirect freezing or chronic exposure to extremely cold environment
Pathologic process is provoked by repeat exposure
Higher risk in patients with alcohol abuse, impairment, or psychiatric issues
TreatmentRemoval from cold environment
ABCs
Elevation of affected limb and protect from further trauma
Up to date Tetanus
Correct hypothermia
CONTINUOUS rewarming at room temperature
Warm bath, 37-39C, 30 minutes
Warm IVFs
Narcotics
Delay operative intervention until rewarming complete
Do not rub/massage
Do not unroof blisters
DONE!