Burn Terapi Topikal 1

7/30/2019 Burn Terapi Topikal 1

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PATHOPHYSIOLOGY

OF BURNS

Dr. Shiara Ortiz-Pujols

Burn Fellow

NC Jaycee Burn Center


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Objectives

PART 1

Anatomy Overview

Causes of Burns

Estimating Burns(Depth & %)

Categories & Zones

PART 2

Physiologic

Implications

PathophysiologyResuscitation

Post-Resuscitation

Board Questions


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Anatomy

Adult skin surface 1.5-2.0 m2 (0.2-0.3 innewborns); largest organ

Skin thickness 1-2 mm; peaks age 30-40; M>

F Functions include:

protection from external environment

maintenance of fluid/electrolyte homeostasis

Thermoregulation

immunologic function

sensation

Metabolic organ (i.e., Vit D synthesis)


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Causes of Burns

Usually caused by heat, electricity, chemicals,radiation, and friction

Thermal burns are caused by steam, fire, hotobjects or hot liquids.

Most common burns for children and the elderly Electrical burns are the result of direct contact

with electricity or lightning Chemical burns occur when the skin comes in

contact with household or industrial chemicals

Radiation burns are caused by over-exposure tothe sun, tanning booths, sun lamps, X-rays orradiation from cancer treatments

Friction burns occur when skin rubs against ahard surface, e.g. carpet, gym floor, concrete or a

treadmill


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Effect of Heat

Temporal and quantitative

40-44C, enzymes malfunction, proteins

denature and pumps fail

> 44C, damage occurs faster than repair

mechanisms can keep up with

Damage continues even when thesource is withdrawn


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Effect of Electricity

Effects of current dependon several factors

- Type of circuit

- Voltage

- Resistance ofbody

- Amperage

- Pathway ofcurrent

- Duration of contact

High voltage (>1000V)causes underlying tissuedamage. Deep tissuesact as insulators andcontinue to be injured.

Resistance of varioustissues from LH:nerve, vessels, muscle,skin, tendon, fat, bone

Ohms Law- V=IR

Damage more related tocross-sectional areawhich explains extremityinjuries without trunkinjuries.


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Electrical Storms/Lightning

Burns are characteristically

superficial and present as a

spidery or arborescent

pattern.

Cardiopulmonary arrest iscommon following lightning

injury.

Coma and neurologic defects

are also common but usually

clear in a few hours or days. Watch for tympanic

membrane rupture

Usually lethal in 1/3 of

patients.

World record for survivinglightning strikes is Roy C.Sullivan who was a parkranger from VA. Roy wasstruck 7 times from 1942-

1977.


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Electrical Pruning


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Effect of Chemicals

Acids and alkalis cause injury viadifferent mechanisms.

Petroleum products can causedelipidation and depth ofwound 2 tendency to adhere toskin

Acids:

coagulation necrosis

denaturing proteins upon tissuecontact

area of coagulation is formed

and limits extension of injury exception is hydrofluoric

acid, which produces aliquefaction necrosis similar toalkalis.

Acid damaged skin can look

tanned and smooth; do notmistake for a suntan.

Alkalis:

liquefaction necrosis

potentially moredangerous than acidburns

liquefy tissue bydenaturation of proteins andsaponification of fats

In contrast to acids, whosetissue penetration islimited by the formation ofa coagulum, alkalis cancontinue to penetrate verydeeply into tissue

Can cause severeprecipitous airway edema

or obstruction.


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Inhalation Injury

Heat dispersed in upper airways leads to edema

Cooled smoke and toxins carried distally

Increased blood flow to bronchial arteries

causes edema Increased lung neutrophils mediators of

lung damage release proteases andoxygen free radicals (ROS)

Exudate in upper airways formation of fibrincasts


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Stages of Inhalation Injury

Stage 1 acute pulmonary insufficiency

Signs of pulmonary failure at presentation

Stage 2 72-96 hrs after presentation (ARDS

picture) extravasation of water Hypoxemia

Lobar infiltrates

Stage 3 bronchopneumonia Early Staph pneumonia (frequently PCN resistant)

Late - Pseudomonas


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Inhalation Injury

Bronchoscopy:

- erythema

- intraglottic soot

- ulceration


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Grading of Burn Wounds

Mild: < 5% TBSA

Moderate: 5-15% TBSA

Severe: > 15% (95% of burns seen)

May require Burn Unit care because of

potential for disability despite small TBSA (face,hands, feet, perineum)


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Area of BurnRule of 9s

Note that a patient's palm is approximately 1% TBSA and can be used for estimating patchy areas.


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Area of Burns - Pediatric


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Estimation of Burn Wound

Depth

Initial assessment is often unreliable

Ignore mild erythema when calculating fluid

requirements

Pink areas that blanch are usually superficial

Deeper wounds are dark red, mottled or pale

and waxy

Insensate areas are usually deep(3rd degree orgreater)


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Factors Influencing Wound

Depth

Temperature and duration

Thickness of skin (thin on eyelids, thick on back)

Age (children and elderly have proportionally

thinner skin in comparison to adults)

Vascularity

Agent oil vs water; acidic vs alkalotic

Time to definitive care


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Burn Zones

Circumferential zones radiating from primarily burned

tissues, as follows:

1. Zone ofcoagulation - A nonviable area of tissue at the

epicenterof the burn

2. Zone ofischemia or stasis - Surrounding tissues (both deepand peripheral) to the coagulated areas, which are not

devitalized initially but, 2microvascular insult, can progress

irreversibly to necrosis over several days if not resuscitated

properly

3. Zone ofhyperemia - Peripheraltissues that undergovasodilatory changes due to neighboring inflammatory mediator

release but are not injured thermally and remain viable


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Zone of

Coagulation

Zone of

Ischemia

Zone of

Hyperemia


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Layers of the Skin


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Categories of Burns First

degree

Burns are divided into 4 categories, depending on the depth

of the injury, as follows:

First-degree burns are limited to the epidermis.A typical sunburn is a first-degree burn.

Painful, but self-limiting.

First-degree burns do not lead to scarring and require

only local wound care.


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First degree Burn


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Categories of Burns Second

degree

Second-degree burns

point of injury extends into the dermis,

with some residual dermis remaining viable

Partial thickness or Full thickness

those requiring surgery vs those which do

not


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Superficial Second degree Burn


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Deep Second degree Burn

C i f B Thi d


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Categories of Burns Third

degree

Third-degreeor full-thickness burns

involve destruction of the entire

dermis, leaving only subcutaneous

tissue exposed.


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Third degree Burn


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Escharatomy Sites

Preferred sites for escharotomy incisions.Dotted lines

indicate the escharotomy sites.Bold lines indicate areas

where caution is required because vascular structures and

nerves may be damaged by escharotomy incisions. (From

Davis JH, Drucker WR, Foster RS, et al: Clinical Surgery.St. Louis, CV Mosby, 1987.)

C t i f B 4th


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Categories of Burns 4th

degree

- Fourth-degree burn is usually associated with

lethal injury.

- Extend beyond the subcutaneous tissue,

involving the muscle, fascia, and bone.- Occasionally termed transmural burns, these

injuries often are associated with complete

transection of an extremity.


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4th degree Burn


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PART 2

Physiologic Implications

Pathophysiology

ResuscitationPost-Resuscitation

Board Questions

Ph i l i I li ti f B


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Physiologic Implications of Burn

Injury

Predictable changes

Related to period of injury

Can be anticipated


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Pathophysiology of Burns

Cell damage and death causes vasoactive mediator

release:

Histamines

Thromboxanes

Cytokines

Increasing capillary permeability causes edema, third

spacing and dehydration

Possible obstruction to circulation (compartmentsyndrome) and/or airway


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Resuscitation Period

early ebb with late flow; days 0-3

Hypodynamic, with need for close fluid resuscitationmonitoring

Massive, diffuse capillary leak2 to inflammatory mediators; abates

18-24 hrsafter injury and volume requirements abruptly decline

leak can be seen in those with delayed resuscitation 2 systemicrelease of O2 radicals upon reperfusion

Extravascularextravasation of fluid, lytes, colloid molecules

Other variables affect resuscitation: preexisting fluid deficits, delay untiltreatment, inhalation injury, depth of wound

Must reevaluate resuscitation progress and endpoints frequently; do not

just use a formula


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Resuscitation Guidelines


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Postresuscitation Period

Day 3 until 95% wound closure

Hyperdynamic, febrile, protein catabolic state

Tachycardia can be normal in burn patients

Blood pressure may be hard to obtain due to circumferential burns

Release of more inflammatory mediators, cortisol, glucagon,

catecholamines, bacteria from wound

High risk of infection and pain

Remove non-viable tissue or close wounds to avoid sepsis

Nutritional support essential Maintain and support body temperature with high ambient temps

and humidity


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Recovery Period

95% wound closure until 1 year post-injury

Continued catabolism and risk of non-healing

wound

Anticipate septic events, treat complications,and continue nutritional support

Pathoph siolog of Electrical


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Pathophysiology of Electrical

Burns Small cutaneous lesions may overlie extensive areas of damaged musclemyoglobinARF.

Monitor for at least 48 hours after injury for cardiopulmonary arrest

May see vertebral compression fracturesfrom tetanic contractions orother fractures from a fall.

Visceral injury is rare but liver necrosis, GI perforation, focal pancreatic

necrosis and gallbladder necrosis have been reported. Look for motor and sensory deficitsmotor nerves are affected more than

sensory nerves.

Thrombosis of nutrient vessels of the nerve trunks or spinal cord can causelate onset deficits. Early deficits are direct neuronal injury.

Delayed hemorrhage can occur from affected vessels

Cataracts may form up to 3 or more years after electrical injury

Microwave radiation damages tissues via a heating effect. Subcutaneousfatty tissue is often spared given its lower water content.


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Burn Edema and Inflammation

Generalized edema found in burns > 30%TBSA

Heat directly damages vessels and causes

permeability Heat activates complement histaminerelease and more permeability thrombosisand coagulation systems

+

Systemic Response to Burn


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Systemic Response to Burn

Injury

Accelerated fluid loss 2 leaky capillaries

Host resistance to infection Multisystem Organ Failure

Infections in burns 40% TBSA with infection has very low survivalrate

Initially CO, subsequent hypermetabolic statew/ doubling of CO in 24 48 hours


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OR Pictures


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Burn Questions

Select the true statements regarding the


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epidemiology of a burn injury

a. Scald burns are the most frequent forms of burninjury.

b. Flame burns are the most frequent forms of burn

injury admitted to burn centers.

c. Burn injuries are most common among adults

d. About 15% of pediatric burn injuries are attributedto abuse or neglect.

e. Burn-related deaths are highest among adults.



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depth of burn

a. First-degree burns are physiologically

important and therefore considered when

calculating TBSA.

b. Second-degree burns always affect the

epidermis and dermis of the skin.

c. Third-degree burns are very painful.

d. All first-degree burns heal within 2 to 3 days.


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A 50 year-old man sustains a flame burninvolving the entire upper left extremity, entireanterior trunk, genital area, and half of the left

lower extremity. Approximately what percentageof the total body surface area is burned?

a. 24%

b. 28%

c. 37%d. 45%

e. 30%

According to American Burn Association criteria,f f f


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which of the following patients should be referredto a burn center?

A. Second- and third-degree burns involving more than 20%of the total body surface area (TBSA) in patients youngerthan 10 or older than 50 years of age.

B. Full-Thickness burns that involve 2% of the TBSA inpatients of any age.

C. Significant burns of the face, hands, feet, genitalia,perineum, or skin overlying major joints.

D. Burn Injury in children with suspected or actual childabuse or neglect.

E. Acute massive skin loss syndromes (e.g., Stevens-Johnson syndrome/toxic epidermal necrolysis,large traumatic de-gloving injuries)

All of the following are true regarding the


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All of the following are true regarding the

Pathophysiology of thermal injury, except?

A. Increased capillary permeability is due todirect

effect of heat and the liberation of vasoactive

mediators.B. Increased pulmonary vascular resistance

occursduring the immediate postburn period.

C. Elevated thyronine (T3) and thyroxine (T4)levels.

D. Elevated interleukin-6 (IL-6) levelE. Decreased immoglobulin G (IgG) level


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A 60-year-old, 80-kg man has sustained a second-degreeburn to 40% TBSA with a significant inhalation injury. He wasadmitted to the burn unit 30 minutes after the accident.

According to the Parkland formula, resuscitation was startedwith lactated Ringers solution at 800 ml/hr. Six hours laterthe patient was found to be oliguric. What should be the nextstep in resuscitation of this patient?

A. Swan-Ganz catheter placement and measurement ofpulmonary

wedge pressure.B. Trial of small dose of furosemideC. Low does of dopamine (2-3 ug/kg/min).D. Increase in volume of the lactated Ringers solution

infusion.

E. Bolus of colloid solution

Which of the following statements is/are true


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regarding resuscitation of patients with burn

injury during the first 24 hours?

a. Parkland formula uses a balanced electrolyte solution& the fluid requirement is calculated as 3 ml/kgbody weight per %TBSA burned.

b. Patients with 15% or more TBSA burn require

intravenous fluid resuscitation.c. Adequate urine output implies hemodynamic stability

and adequate organ perfusion.d. Crystalloid resuscitation restores cardiac output more

rapidly

than colloid alone.e. Late pulmonary morbidity and mortality are higher in

colloid-resuscitated patients.


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Match the items in two columns

Topical Agents

A. Sodium mafenide

(Sulfamylon)

B. Silver nitrate 0.5%

Solution

C. Silver sulfadiazine

(Silvadene)

Characteristics

A. Limited escharpenetration, resistant

organisms neutropenia,thrombocytopenia

B. Painful application,hyperchloremic reactionsgood eschar penetration

C. Hyponatremia,hypokalemia,hypocalcemia,methemoglobinemia



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Which of the following statements is/are trueregarding metabolism in the burn patient?

a. Postburn hypermetabolism is mediated by catecholamine

release.

b. IL-1 and IL-6 are elevated in burn injuries and enhance thehypermetabolic response by increasing oxygenconsumption.

c. Elevated core and skin temperature and lower core-to-skin

heat transfer are manifested in postburn hypermetabolism.

d. Increased blood flow to the muscles in the burned limb.

e. The burn wound preferentially utilizes glucose by

anaerobic glycolytic pathways despite increased blood

flow to the wound.

Which of the following can minimize


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Which of the following can minimize

metabolic expenditure in burn patients?

A. Nursing the patients at ambient temperature

below 30oC.

B. Adequate analgesia and sedation.

C. Early excision of the burn and complete woundclosure.

D. Early diagnosis and treatment of infection.

E. Use ofB-adrenergic blockers.

Select the correct statements regarding


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Select the correct statements regarding

nutrition in burn patients.

a. The optimal calorie/nitrogen ratio variesbetween 150:1 & 160:1.

b. Fat is the best source of non-proteincalorie.

c. Glutamine deficiency results in atrophyof gut mucosa

d. Long-chain triglycerides for maintaining

lean body mass.e. Overfeeding is associated with

hyperventilation.



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gfor invasive burn wound infection?

a. Common in burns larger than 30% total bodysurface area.

b. Characterized by conversion of a partial-thickness burn to full-thickness burn.

c. Definitive diagnosis can be made ifquantitative culture of the biopsy recoversmore than 105 organisms per gram ontissue.

d. Incidence of Candida wound infection hasincreased owing to topical antimicrobialchemotherapy.

e. Topical antimicrobial agents have markedlydecreased the incidence of invasive

Select the true statements regarding


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Select the true statements regardinginfection in the burn patient

a. Infection if the most frequent cause of deathin the burn patients.

b. Cell-mediated immunity is not altered inmajor burn injuries.

c. Hematogenous pneumonia is the mostcommon pulmonary infection in burnpatients.

d. Diminished granulocyte chemotaxis is animportant factor in burn infection.

e. Suppurative thrombophlebitis can be a majorsource of sepsis.

Which of the following statements is/are trueregarding administration of antibiotics to


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regarding administration of antibiotics toburn patients?

a. Prophylactic systemic antibiotics areindicated in patients with extensive burns.b. With invasive burn wound sepsis,

systemic antibiotics should not beinstituted before culture and sensitivityresults are available.

c. Positive wound cultures should be treated

with systemic antibiotics.d. Antibiotics effective against anaerobicorganisms are always indicated for burnwound sepsis.

e. Subtherpeutic serum antibiotic levels are

Which of the following statements is/are


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Which of the following statements is/are

true regarding burn wound excision?

A. Excision is indicated for deep partial-thickness and full-thickness burn wounds.

B. Early excision and closure of burn wounds has beenshown to reduce the incidence in invasive burn

wound infection, shorten the hospital stay,reduce pain, and improve functional recovery.

C. Excision should be performed after successful fluidresuscitation.

D. Tangential excision involves sequential excision of theeschar down to bleeding, viable tissue.

E. Excision of more than 10% of TBSA single procedure isassociated with significantly morbidity.



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regarding burn wound closure?

A. Split-thickness autograft is contraindicated ifwound culture is positive B-hemolytic

streptococci.

B. Xenograft is the most frequently used andeffective biologic dressing when an

autograft is not available.

C. Allograft dressings promote bacterial

proliferation.D. Cultured autologous keratinocyte sheets can

be used for permanent wound coverage

with good results.



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inhalation injury.

A. Presence of carbonaceous sputum is a

specific sign of inhalation injury.

B Normal carbon monoxide level on admission

excludes inhalation injury.

C. Chest radiography is sensitive for diagnosing

inhalation injury.

D. Combined fiberoptic bronschosocpy and 133 Xe

ventilation-perfusion lung scan has a diagnostic

accuracy of more than 96%

E. Pulmonary infection is the most frequent cause of

morbidity and mortality with inhalation injury.

Select the correct statements


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Select the correct statementsregarding electrical injury.

a. Depth of tissue injury is related to density andduration of the current flow.

b. High-voltage electric injury results in more severeinjury to the trunk than the extremities.

c. Risk of acute renal failure is relatively high with anelectrical injury due to myoglobinuria andunderestimation of fluid needs.

d. Incidence of cholelithiasis is high in patients afterelectrical injury.

e. With a lightening injury cardiopulmonary arrest iscommon, and burns are characteristically superficial.



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Which of the following statements is/are trueregarding chemical injuries?

a. Immediate wound care involves application of aneutralizing agent.

b. Acid burns cause liquefaction necrosis.

c. Alkali burns produce deeper injuries than acid burns.

d. Hydrofluoric acid burn is treated with local calciumgluconate gel.

e. Coal tar burn is best treated with immediateapplication of a petroleum-based ointment.



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g gpost burn sequelae

A. All second & third degree burns producepermanent scarring.

B. The incidence of hypertrophic scar formation isless after excision and skin grafting than with

wounds that heal spontaneously.C. Hypertrophic scars are best treated by early

excision and wound closure.

D. Basal cell carcinoma is the most common

carcinoma in an old burn scar.

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