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BURNS AND THE
RECONSTRUCTIVE LADDER
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Anatomy of the Skin
The skin is the body's largest organ
Acts as a protective shield against heat, light,
injury, and infection.
The skin is made up of the following layers:
Epidermis
DermisSubcutaneous fat layer (subcutis)
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Epidermis-Is the thin outer layer of the skin.
Dermis-The dermis is the middle layer of the
skin. Subcutis-The subcutis is the deepest layer of
skin
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Burns
Thermal burns- contact with hot object or flames
Electrical burns-severity depends on strength and
duration
Chemical burns-caustic material
Radiation-local erythema that may followsuperficial radiotherapy
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Classification
First Degree (superficial partial thickness):
Affects only the epidermis. The burn site is red,
painful, dry, and with no blisters. Long-term
tissue damage is rare and usually consists of an
increase or decrease in the skin color.
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Second degree( deep partial thickness):
Involves the epidermis and part of the dermis
layer of skin. The burn site appears red,
blistered, and may be swollen and painful.
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Third degree (full thickness):
Destroys the epidermis, dermis and epidermal
appendages. The burn site appears white or
charred. There is no sensation in the area since
the nerve endings are destroyed.
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Fourth Degree :
Burn injury into bone or muscle
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Burn Classification
Superficial Partial Thickness Burn Deep Partial Thickness Burn
Blistering, underlying dermis is pink and
moist. The capillary return is clearly
visible when blanched.
The epidermis is lost and the underlying
dermis not as moist. Colour does not
blanch with pressure.
Pinprick sensation is normal. Sensation is reduced; the patient is
unable to distinguish sharp from blunt
pressure.
Healing without residual scarring within 2
weeks.
Healing takes 3 or more weeks without
surgery and usually leads to hypertrophic
scarring.
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Effects of Burns
Destruction of tissue:
Loss of barrier to infection
Fluid loss from surface ( up to 200ml/m
2
/hr inthe first few hours)
Red cell destruction
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Increased capillary permeability:
Exudate formation ( max : first 12 hrs)
Oedema
Loss of circulating fluid volume
Hypovolaemic shock
Permeability returns to normal within 48 hrs.
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General Clinical Features
1. Pain
2. Plasma loss (proportional to surface area andnot depth)
3. Hypovolaemic shock
4. Anaemia
5. Respiratory distress
6. Stress reaction
7. Toxaemia
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Assessment & Management
Remove to safe area, if possible
Stop the burning process
Extinguish fire - cool smoldering areas
Remove clothing and jewelry
Cut around areas where clothing is stuck to skin
Cool adherent substances (Tar, Plastic)
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Varies according to the extent of the burns.
Patient should be evaluated properly andcompletely before assessing burn wound.
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Airway and Breathing
Assess for potential airway involvement
soot or singing involving mouth, nose, hair, face, facial hair
coughing, black sputum
Assist ventilations as needed
100% oxygen via NRB if:
Moderate or critical burn
Patient unconscious
Signs of possible airway burn/inhalation injury
History of exposure to carbon monoxide or smoke
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Circulatory Status
Burns do not cause rapid onset of
hypovolemic shock
If shock is present, look for other injuries
Circumferential burns may cause decreased
perfusion to extremity
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Other
Assess Burn Surface Area & Associated
Injuries
Analgesia
Fluid Therapy
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Fluid Replacement
Burns fluid replacement depends on the
amount of surface area involved; we use the
rule of nines theory to estimate the surface
area of burnt surface.
Consider Fluid Therapy for
>10% BSA 30
>15% BSA 20
>30-50% BSA 10with accompanying 20
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Fluid therapy
Objective
HR < 110/minute
Normal sensorium (awake, alert, oriented)
Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi)
Resuscitation formulas provide estimates, adjust to
individual patient responses
Start through burn if necessary, upper extremitiespreferred
Monitor for Pulmonary Edema
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Analgesia
Morphine Sulfate
2-3 mg repeated q 10 minutes titrated to adequate
ventilations and blood pressure 0.1 mg/kg for pediatric
May require large but tolerable total doses
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Blood should be drawn for determination of
haematocrit, urea and electrolytes, arterial
blood gas and carboxyhaemoglobin levels (if
exposed to smoke).
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Treating the Burn Wound
Superficial PartialThickness Burn
Will heal on theirown and require
simple dressings If heavily
contaminated,may requirecleaning under GA
Deep PartialThickness Burn
For deep dermalburns, the top
layer of deaddermis is shavedoff until punctatebleeding isobserved and thedermis is free ofany thrombosedvessels.
Full Thickness Burn
Full thicknessburns require full
thickness excisionof the skin.
In most cases, theburn excision isdown to viable
fat. If possible, a skin
graft should beappliedimmediately.
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Treating the Burn Wound
Circumferential full thickness burns to the limbsrequire emergency surgery due to the tourniquet effectof this injury. Treatment is by incising the whole lengthof full thickness burn.
Following this, the burn needs to the cleaned and thesize and depth needs to be assessed.
Any deep partial thickness and full thickness burn(except those that are less than about 4cm2) requiresurgery. These burns need to be dressed with anantibacterial dressing to delay on the onset ofcolonization of the wound.
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Eschar formation
Skin denaturing
hard and leathery
Skin constricts over wound increased pressure underneath
restricts blood flow
Respiratory compromise
secondary to circumferential eschar around the thorax
Circulatory compromise
secondary to circumferential eschar around extremity
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If circulation compromise is anticipated: relief
of constriction(escharotomy). Incisions are
made from the top to the bottom of
circumfrential deep burns, may be needed infirst few hours after injury.
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Complications
Respiratory: infection, carbon monoxidepoisoning.
Renal Failure: Acute tubular necrosis caused
by massive red cell or muscle destruction. Sepsis: Constant threat until skin cover is fully
restored.
Curlings ulcer and gastric erosions: decreasedby early feeds and H2-receptor antagonist eg:ranitidine.
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Electrical Burns
Most damage done is due to heat produced as
current flows through tissues. More internal
damage.
Skin burns where current enters and leaves
can be almost trivial looking
Everything between can be burned
Higher voltage may result in more obvious
external burns
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Electrical Burns
Alternating Current (AC) Tetanic muscle contraction may occur resulting in:
Muscle injury
Tendon Rupture
Joint Dislocation
Fractures Spasms may keep patient from freeing oneself from current
Contact with Alternating Current can also result in: Cardiac arrhythmias
Apnea
Seizures
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Electrical Burn-Management
Make sure current is off
-Do not go near patient until current is off
ABCs
Ventilate and perform CPR as needed
Oxygen
ECG monitoring
Treat dysrhythmias
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Chemical Injuries
Usually occur within an industrial setting.
Most common injuries caused by acids or alkalis.
Two aspects of injury: physical destruction of the skinas well as poisoning following systemic absorption
Initial management: 1. Removal of clothing andcopious lavage with water (20-30mins) 2. Identifychemical and its concentration and whether there is athreat to life if systemic absorption occurs.
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Radiation Injury
Can be divided into groups based on whether exposurewas to the whole body or localized.
Localized radiation damage usually treatedconservatively until the true extent of injury isapparent. If an ulcer is present, excision and coveragewith vascularized tissue is required.
Whole body radiationrequires supportive treatment.A patient who has suffered whole body irradiation andis suffering from acute desquamation has received alethal dose of radiation.
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RECONSTRUCTIVE LADDER
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The reconstructive ladder is a term developed
by plastic surgeons to describe increasingly
complex methods of wound closure.
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From the least complex to the most complex itinvolves:
1. Healing by secondary intention
2. Healing by primary intention
3. Delayed primary closure
4. Split thickness skin grafts5. Full thickness skin grafts
6. Tissue expansion
7. Random flaps
8. Axial flaps
9. Free flaps
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The Reconstructive Ladder
Wound Assessment
Size
Depth
Loss of tissues
Injury to nerve, vessels, tendon, bone
Devitalised tissue
Contamination
Loss of function
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Healing by Secondary Intention
A wound healing by itself without apposition of
the wound edges. It heals via contraction and the
formulation of granulation tissue from the
wound base upwards. The skin edges are notsutured together and the wound is left open
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Dressings are applied regularly to keep the
wound clean and moist and the wound
gradually closes and heals on its own (by
myofibroblast proliferation and re-epithelialisation.)
Healing dependent on well vascularised bed
Suitable for relatively small wounds
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Healing by Primary Intention
Wound healing where the wound edges are
brought together by either stitches, glue, steri-
strips or any other technique where the
wound edges are held together.
Advantages: 1. Simplified wound care 2. Fewer
problems with abnormal scarring 3. Vital,
underlying structures are covered.
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Contraindications:
An acute wound >6 hours old (with the exception of
facial wounds)
Highly contaminated/ actively bleeding wounds
Wounds with dead space under the skin closure
(dead space occurs due to loss of subcutaneous
tissue or oedema of the skin around the wound)
Wounds which cannot be closed without tension. Atight skin closure decreases blood circulation to the
skin edges, causing the tissues to become ischaemic.
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Delayed Primary Closure
Considered for wounds with characteristics thatrequire secondary closure (e.g. wound over 6hours old) in which primary closure is preferred(e.g. a large wound)
Wound is initially dressed for 2-3 days with thehope of suturing the wound closed within (3-4days)
During the days of dressing changes, the reasonsfor not closing the wound initially may resolvee.g. oedema may subside and haemostasis
achieved
k f
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Skin Grafts
Skin grafting involves taking a piece of skin from
an uninjured area of the body (donor site) and
using it to provide coverage for an open wound.
Used when primary closure is impossible
because of tissue loss and healing by secondary
intention is contraindicated.
Two types: Split thickness skin graft and Full
thickness skin graft.
l h k
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Split thickness
Split thickness skin grafts are used in the coverageof chronic unhealing cutaneous ulcers, temporary
coverage to allow observation of possible tumor
recurrence, surgical correction of depigmenting
disorders.
Consists of epidermis and a variable quantity of
dermis. Depending on the thickness of the dermis
a split thickness skin graft can be divided into thin,
intermediate or thick.
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Most frequently useddonor site is the thigh
Grafts are taken with adermatome or a skin-graft
knife.
Can be meshed to createfine cuts in the graft andallow expansion
Preparation of the woundbed is essentialgraftfailure commonly causedby pus, exudate, devitalizedtissue or shearing forces.
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Full thickness
Full thickness skin grafting is indicated in
defects in which the adjacent tissues are
immobile or scarce. FTSG use is also indicated
if that adjacent tissue has premalignant ormalignant lesions and precludes the use of a
flap.
Consists of epidermis and the entire thicknessof dermis.
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F ll Thi k Ski G ft
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Full Thickness Skin Grafts
Includes epidermis and entire dermis but no subcutaneous fat.
Rarely done, because the wound must be very clean for the graftto survive.
Most often used for small wounds (e.g. those created surgically)and wounds on the palmar surface of the hands and fingers)
Small dermal grafts can be taken from behind the ear, groincreases and the neck with easy direct closure of the donor site.
Shape of the graft needed is drawn over the donor site and fullthickness skin is cut
The graft is applied with normal skin tension and tied down withpressure dressing
Graft failure
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Graft failure
Haematomawhich is the most common cause of graftfailure; the use of a meshed graft and the application of apressure dressing.
Infection
Shearthis occurs when a lateral force is applied to the graftresulting small movements of the graft which disrupt thedelicate connections between the graft and its bed.Disruption of these connections makes it less likely that graft
take would occur. Seromais the collection of serous fluid under the graft
which reduce the likelihood of graft take.
Inappropriate bedfor example when grafting onto bone, itis essential that the periosteum of the bone is intact. A graftwill not survive on bone denuded of periosteum as it containsblood vessels which are essential for graft take.
Technical errorthese include placing the graft on therecipient site with the wrong surface in contact with the bedand applying the graft to its bed prior to allowing sufficienttime for the bed to dry out.
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Tissue Expansion
Tissue expansion can be defined as anincrease in the surface area of tissue
brought about by exerting a mechanical
force on the tissue. Increases amount ofskin locally available.
This causes the tissue to expand via a
two processes, 1.creepand 2.stress
relaxation.
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Creep is the time-dependent plastic
deformation that any material or tissue
undergoes on application of a constant
mechanical stress to it.
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Stress relaxation occurs when the force
required to stretch the material or tissue
reduces over time. This reduction in force is
due to the tissue having expanded over time.
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A tissue expander is essentially a saline filled
bag placed underneath the skin which
expands the more you fill it with saline.
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Flaps Many wounds, such as fracture sites and exposed bone or tendon, are not
suitable for grafting, and techniques further up the reconstructive ladder, suchas a flap reconstruction, must be used.
A flap is a piece of tissue with a blood supply that can be used to cover anopen wound.
Classified based on:
Vascularity
Axial flaps
Random Flaps
Movement
Local
Regional Distant
Tissue Type
Cutaneous
Fasciocutaneous Musculocutaneous
Bone
Combinations
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Axial Flaps Axial flaps - supplied by a
named artery and vein.Circulation based onspecific vessels results in ahighly reliable blood supplyand a reliable flap.
An axial flap can becompletely detached fromall surrounding tissue aslong as it remainsconnected to its supplyingblood vessels. These vesselsserve as the pedicle.
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Axial flaps can be divided into: Direct.
Fasciocutaneous, Musculocutaneous and
Venous
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Random Flaps Random flaps - no named blood supply.
Circulation to a random flap is provided in a diffusefashion through tiny vascular connections from thepedicle into the flap. The more vascular connections,the better the circulation to the flap.
The better the circulation to the flap, the better its
survival. A random flap does not have as reliable ablood supply as an axial flap. Relative ease of creatingrandom flaps makes them useful almost anywhere onthe body.
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Local Flaps
Local flaps are created by freeing a layer of
tissue and then stretching the freed layer to
fill a defect. This is the least complex type of
flap and includes advancement flaps, rotationflaps, and transposition flaps, in order from
least to most complex.
Advancement flaps -
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Advancement flap
Advancement flaps
incisions are extended out
parallel from the wound,
creating a rectangle with
one edge remaining intact.
This rectangle is freed from
the deeper tissues and
then stretched
(or advanced) forward to
cover the wound.
A rotation flap is similar except instead ofbeing stretched in a straight line, the flap is
stretched in an arc.
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Transposition flap -
involves rotating
an adjacent piece oftissue, resulting in
the creation of a
new defect whichmust then be closed
or grafted.
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Distant Flaps
A distant flap involves moving tissue from one
part of the body, where it is dispensable, to
another part, where it is needed.
Required when there is no healthy soft tissueadjacent to an open wound with which to
provide adequate coverage.
Divided into 2 categories: attached and free.
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Distant Flaps
An attached distantflap implies that thearea with the openwound initially isattached to the flap at
the distant donor site
Example: A. Openwound on the dorsumof the hand B. A chestflap is created tocover the defect.
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Distant Flaps
Free Flaps
Tissue supplied by a named vascular pedicle isdetached completely from the donor site. The
flap is then transferred to the open wound. The survival is dependent on anastamoses of
vessels using microsurgical techniques.
Requires time, expertise, equipment andcareful post-op monitoring.
Can fail.
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