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Burns and the Reconstructive Lader

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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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    THANK YOU!


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