Presentation - Burns

7/31/2019 Presentation - Burns

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BURNMANAGEMENT

Presented by Dr. Ali Hasan

Senior Surgical Resident

Salmaniya Medical Complex


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Contents

Types of burn injury Severity of burn injury

Classification of burn depth

Extent of burn injury

Location of burns

Patient risk factors Prehospital care

Emergent phase

Fluid therapy

Wound care

Areas requiring special care Other considerations

Summary

References


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Burns

Are a result of damage to the skinor other body parts caused by

extreme heat, flame, contact withheated objects, or chemicals.


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Types of Burn Injury

Thermal burns: flame, flash, contact with hotobjects.

Scald burns: hot fluids.

Chemical burns: necrotizing substances(acids, alkali).

Electrical burns: intense heat from anelectrical current

Smoke & inhalation injury: inhaling hot airor noxious chemicals

Cold thermal injury: frostbite.


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Severity of Burn Injury

Severity is determined by: Depth of burn

Eextent of burn calculated in percent of

total body surface (TBSA) Location of burn

Patient risk factors


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Classification of BurnDepth Burn depth is classified into:

First degree

Second degree:

-Partial thickness

-Deep partial thickness

Third degree

Fourth degree


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Classification of BurnDepth First-degree

Minor epithelial damage

Redness

Tenderness No blistering


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Classification of BurnDepth Second-degree

Partial-thickness Epidermis/superficial dermis Pink, moist and tender

Very tender

Heals in 2-3 weeks No scarring

Deep-partial thickness Deep dermal injury

Red and blanched white

Capillary refill slow Blisters

Heals in 3-6 weeks Scarring present Contractions may occur


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Classification of BurnDepth

Third-degree Usually result of

immersion scalds,

flame burns, chemical

and high-voltage electricalinjuries

Full thickness

Destroys

epidermis/dermis Capillary network

Skin white/leathery


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Classification of BurnDepth

Fourth-degree

Full-thicknessdestruction ofskin/subcutaneous

tissue Involves underlying

fascia, muscle, bone orother structures

Prolonged disability


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Extent Of Burn Injury

Lund-Browder Chart Rule of Nines

Adult1510510Age in years

345689A-head (back or front)

444432B-1 thigh (back or front)

333222C-1 leg (back or front)


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Location of Burns

Vital organs of burn: Face, neck

Chest

Perineum

Hand

Joint regions

Other areas


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Patient risk factors

Associated trauma

Inhalation injuries

Circumferential burns

Electricity

Age (young or old)

Pre-existing disease


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Pre-hospital Care

Remove from area! Stop the burn!

If thermal burn is large--FOCUS onthe ABCs

A=airway-check for patency, soot aroundnares, or signed nasal hair

B=breathing- check for adequacy of

ventilationC=circulation-check for presence and

regularity of pulses


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Emergent Phase(Resuscitative Phase)

Lasts from onset to 5 or more days butusually lasts 24-48 hours

Greatest initial threat ishypovolemic shock in a major burnpatient!


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Fluid Therapy

1 or 2 large bore IV lines Fluid replacement based on:

size of burn age of pt.

RL , dextrose containing salines forpediatrics

The formulas for replacement: Parkland formula Modified Brooke formula


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Parkland Formula

% BSA burned x patients weight

( kg) x4cc=

Total amount of fluid (cc) infusedover 24 hours.

Half of which is transfused over the first8hrs and the remaining half is transfusedover the next 16hrs.


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The Modified Brooke formula

%BSA burned x patients weight(kg) x 2cc=

Total amount of fluid (cc) infusedover 24 hours.

Half of which is transfused over the first

8hrs and the remaining half is transfusedover the next 16hrs.


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Assessment of adequacy offluid replacement

Urine output is most commonly usedparameter

Adults = 0.5 to 1.0 ml /kg/hr

Children under 30 kg = 1.0ml/kg/hr.


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Wound care

Debridement

Dressing

Prophylaxis and treatment ofwound infection

Escharotomy / Fasciotomy

Splinting Temporary graft

Skin graft


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Debridement

The greatest dangerto the burn patient isthe presence of non-

living tissue. Bacterialgerms may live in thisdead tissue causing a

delay in woundhealing and maycause a life-

threatening infection.


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Dressing

Dressing is required in allburns except minorsuperficial ones.

Dressing is essential to

- Help prevent infections

- Ease the pain of a burn.


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Prophylaxis and treatment ofwound infection Thoroughly removing devitalized tissue and

debris

Dressing and closure of wounds.

Topical antimicrobials for the prevention andtreatment of burn wound infection likemafenide acetate, silver sulfadiazine, silvernitrate solution, and silver-impregnateddressings.

Antimicrobial therapy directed at the pathogenrecovered on culture.

Empiric therapy for systemic infection.


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Escharotomy

Escharotomy is thesurgical division ofthe nonviable eschar

The underlyingtissues have anincreased available

volume to expandinto, preventingfurther tissue injury orfunctional

compromise.

Escharotomy to release thechest wall and allow forventilation of the patient.


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Escharotomy

Indications for emergencyescharotomy are the presence of acircumferential eschar plus:

Impending or established vascularcompromise of the extremities ordigits.

Impending or established respiratorycompromise due to circumferentialtorso burns.


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Escharotomy

Inadequate decompression can lead to : Muscle necrosis

Nerve injury

Gangrene resulting in amputation of the limb or

digits

Respiratory compromise due to inadequateventilation as a result of compressive effect ofchest and upper torso burns

Abdominal compartment syndrome with visceralhypoperfusion as a result of abdominal wall andupper torso burns

Systemic complications include myoglobinuria,

renal failure, hyperkalemia, and metabolic acidosis.


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Skin grafts

Types of skin grafts:

split-thickness

full-thickness

pedicle grafts.


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Skin grafts

Split-thickness grafts -consists of sheets ofsuperficial and some deeplayers of skin.

Once the graft is in place,the area may be coveredwith a compressiondressing or the area maybe

left exposed. Split-thickness grafts are

used for non-weight-bearing parts of the body.


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Skin grafts

Full-thickness grafts -are used for weight-bearing portions of thebody and friction prone

areas such as, feet andjoints. A full-thickness graft

contains all of the layers ofthe skin

The blood vessels willbegin growing from therecipient area into thetransplanted skin with in36 hours.


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Skin grafts

Pedicle grafts - a portionof the skin used from thedonor site will remainattached to the donor areaand the remainder isattached to the recipientsite.

The blood supply remainsintact at the donor locationand is not cut loose until thenew blood supply hascompletely developed.

This procedure is morelikely to be used for hands,face or neck areas of thebody.

Elbow Pedicle Graft


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Skin grafts

Before the surgery, the recipient anddonor sites must be free of infection andhave a stable blood supply.

Following the procedure moving andstretching the recipient site must beavoided.

Dressings need to be sterile and

antibiotics may be prescribed to avoidinfection.


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Skin substitute

INTEGRA

Dermal analogue bonded to thin silicone

Allowed to revascularise

Then STSG applied

Dermagraft

Cultured neonatal fibroblasts

Seeded into nylon mesh

Silicone membrane removed and graft applied

Alloderm

Cryopreserved allogenic dermis

Drovide demal scaffolding for STSG


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Splinting

Extremities affected bydeep partial-thicknessor full-thickness burns

are splinted infunctional positions assoon as possible and

kept splintedcontinuously untilhealing has occurred


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Other considerations

Drug Therapy Analgesics and Sedatives

Tetanus immunization

Antimicrobial agents:Silver sulfadiazine

Nutritional Therapy

Burn patients need more calories &failure to provide will lead to delayedwound healing and malnutrition.


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Summary

Care of B U R N SB - breathing

U - urine outputR - rule of nines

resuscitation of fluid

N nutrition and drugsS - surgery of wounds


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References

Schwartz's Principles of Surgery - 9thEdF. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter,

Jeffrey B. Matthews, Raphael E. Pollock

http://www.burnsurvivor.com/surgical_procedur

e_skingrafts.html http://www.uihealthcare.com/topics/medicaldep

artments/surgery/burninjury/hospital.htm http://emedicine.medscape.com/article/127749

6-overview http://emedicine.medscape.com/article/213595-

followup http://www.merck.com/mmpe/sec21/ch315/ch3

15a.html
http://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.merck.com/mmpe/sec21/ch315/ch315a.htmlhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htmhttp://www.uihealthcare.com/topics/medicaldepartments/surgery/burninjury/hospital.htm

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Presentation - Burns

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