BURNS Epidemiology: Quality of Burn Care Survival Long-term Function Appearance Surgeon’s Goal Well-healed, durable skin with normal function and near-normal appearance *Depth of Injury is directly proportional proportional to: Temperature Temperature applied Duration of contact Thickness of the skin Etiology: 1. Scald Burns - usually household from hot water - most common among civilians injuries especially children 2. Flame Burns - 2nd most common mechanism - secondary to house fires, MVA 3. Flash Burns - explosion of gases & other combustible liquids - covers larger TBSA - with thermal damage to upper airway 4. Contact Burns - contact with hot metals, plastics, glass - common common in industrial accidents - often 4th degree 5. Electrical Burns - either occupational or household household injuries - severity based based on voltage, duration duration of contact & resistance of the patient 6. Chemical Burns - due to strong acids or alkalis - industrial accidents or assaults assaults PHASES OF BURN INJURY •Acute
Phase Fluids & Electrolytes Pain Control Burn Wound Care & Coverage Septic Complications Nutritional Management •Chronic Phase Rehabilitation Reconstruction
Psychological Support
Pathophysiology Pathophysiology of Burn Injury 1. Coagulation Necrosis 2. Increased Capillary Permeability 3. Hemolysis ACUTE PHASE •Immediate Care Rescue and First Aid = on scene - remove source of heat - CPR if necessary; O2 inhalation Assessment and Resuscitation = at the ER - ABC’s take priority - Intubation if necessary Preparation for transfer to a burn facility - for burns more than 5 – 10% TBSA •Immediate first aid measures Cooling the burned area - application of cool water NOT iced water Removal of patient’s clothing - remove source of heat & exposure of injuries Prevention of hypothermia - wrap patient in clean blanket •Admission Criteria to a Burn Facility Partial Thickness Burns =/> 15% Full Thickness Burns =/> 5% Burns on Face, Feet, Hands & Perineum All Electrical & Chemical Burns Presence of Smoke Inhalation Injury Associated Injuries
Admission Criteria Child Abuse Patients <10 y.o. & >50 y.o. Patients w/ Associated medical illness All infected burns Dependent persons Patient Assessment 1. History Time of Injury Place of Injury Mechanism of Injury 2. Physical Exam Primary Survey = ABC’s 2ndary Survey = Other injuries
Estimation of Burn Injury Severity Burn Size: Rule of Nines = massive burns Patient’s Palm = patchy burns Lund-Browder Chart = pediatrics “Rule of Nines” for estimating TBSA Anatomic Area % body surface Head 9 Rt. Upper extremity 9 Lt. Upper extremity 9 Rt. Lower extremity 18 Lt. Lower extremity 18 Anterior trunk 18 Posterior trunk 18 Perineum 1
(2nd Degree Burns) - form blisters, pink & wet - hypersensitive to pain - blanch with pressure - spontaneously heal < 3 weeks 2. Deep Burns a) Deep Partia Partiall-Thic Thicknes kness s Burns Burns (2nd Degree) - blisters, mottled pink and white - capillary refill is slow to absent - less sensitive to pain - heals in 3 to 9 weeks
b) Full Thickness Burns (3rd Degree) - all layers of dermis - leathery, dry white, firm & insensate - develop “ESCHAR” - heal by contracture or skin grafting c) Fourth Degree Burns - full thickness skin, SQ fat,fascia & muscles - electrical, contact, immersion burns in an unconscious unconscious patient
Assessment of Burn Depth
Estimation of Burn Injury Severity Burn Depth is dependent on: a. Temperature of burn source b. Thickness of the skin c. Duration of contact d. Heat dissipating capability of skin
Classification Classification of Burn Depth 1. Shallow Burns a) Epidermal Burns (1st Degree Burns) - do not blister but erythematous - relatively painful ex. Sunburn b) Superficial Partial-Thickness Partial-Thickness Burns
Methods: 1. Clinical observation – only 70% accurate 2. Detection of Dead cells or denatured collagen collagen - biopsy, ultrasound, use of vital dyes 3. Assessment of Change in Blood Flow - fluorometry, laser Doppler, thermography 4. Analysis of Wound Color - light reflectance method 5. Evaluation of Physical Changes - magnetic resonance imaging
Physiologic Response Response to Burn Injury
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) - pathologic alterations in metabolic, cardiovascular, gastrointestinal and coagulation systems - hypermetabolism, increased cellular, endothelial and epithelial permeability permeability - extensive microthrombosis BURN SHOCK - circulatory circulatory dysfunction
- increase in vascular permeability permeability & microvascular hydrostatic pressure Mediators: 1. Histamine – release mast cells which disrupts venular endothelial junctions 2. Serotonin – increase pulmonary vascular resistance 3. Eicosanoids – increase levels of vasodilator PG’s
4. Tetanus Tetanus prophylaxis
Compartment syndrome: a) Clinical Manifestations 6 P ’s ’s: Pulselessness Paresis/Paralysis Pallor Paresthesia Pain Poikilothermia b) Definitive Treatment: Treatment: ESCHAROTOMY ESCHAROTOM Y FASCIOTOMY
Diagnostic Work-up Complete Blood Count Urinalysis, BUN & Serum Creatinine Baseline electrolytes Arterial blood gas determination determination X-rays (Chest, other areas) Electrocardiography Fluid Resuscitation Recommended Fluids: Plain Lactated Ringer’s Solution = 1 st 24 hours Colloids or D5Water = after 24 hours Fluid Computation & Administration a) 1st 24 hours “Parkland Formula” TFR = BW x TBSA x 4 mg/kg/%burns (1/2 given in1 st 8H; 1/2 next 16H) b) 2nd 24 hours D5W replace evaporative losses Colloids maintain plasma volume c) After 48 hours Maintenance Fluids = 30-40 cc/kg/day
Parameters for Monitoring Fluid Therapy 1. Urine Output Adults: 0.5 cc/kg/hour Pedia : 1 cc/kg/hour 2. Vital Signs Blood pressure & Heart rate Central Venous Pressure 3. Sensorium Reasons for Failed Resuscitation 1. Delayed resuscitation resuscitation 2. Presence of electrical burns 3. Smoke inhalation injury 4. Coronary artery disease Ancillary Management Measures 1. Gastric decompression 2. Pain control & sedation 3. Antibiotics
Inhalation injury: 1. Carbon Monoxide Poisoning Effects: a) prevents reversible displacement of O2 b) decrease O2 unloading at tissue level c) less effective intracellular respiration d) directly toxic to cardiac & skeletal muscles Treatment: Hyperbaric Oxygen ???
2. Thermal Airway Injury Manifestations: - mucosal & submucosal erythema - edema, hemorrhage & ulceration - potential for upper airway obstruction Treatment: Endotracheal Intubation 3. Smoke Inhalation Factors: a) Type and amount of smoke inhaled b) Size of particulates c) Duration of Toxic Exposure d) Magnitude of thermal injury Clinical Manifestations: a) dyspnea b) burned vibrissae c) carbonaceous sputum Diagno agnos sis: is:
a) Ch Chest est X-r X-ray ay b) Bronchoscopy
c) Arterial blood gas Management: a) Endotracheal intubation b) Mechanical ventilation
Electrical Burns: Classification: Low voltage: <1,000 volts High voltage: >1,000 volts Mechanisms of injury: a) Direct contact b) Conduction arc c) Secondary ignition Physiologic Alterations: Alterations: a) Arrhythmias b) Acute Renal Failure c) CNS & PNS Deficits d) Hemorrhage & Hematomas
Chemical Burns: Factors to consider: a) Contact time b) Chemical involved Primary Management: Rapid termination of burning process
Burn Wound Care Salient Aspects: Debridement of necrotic tissue Daily dressing of burn wound Surgical Management: a) Tangential Tangential excision b) Fascial excision Topical Topical Antimicrobials a) Aqueous silver nitrate b) Mafenide acetate c) Silver sulfadiazine d) Povidone-iodine Povidone-iodine
Nutritional Support State of hypermetabolism - exaggerated energy expenditure - massive nitrogen loss Formula: TCR = 25 kcal/kg BW + 40 kcal/%TBSA Route: Total Enteral Nutrition (TEN) Adv: maintain integrity of GI tract reduce bacterial translocation & sepsis
Burn Wound Infection
Clinical Manifestations 1. Conversion from partial to full thickness 2. Dark-brown/blackish Dark-brown/blackish discoloration 3. Neo-eschar formation formation 4. Rapid eschar separation 5. Violaceous wound margins 6. Metastatic septic lesions
Burn Complications Complications A) Distant infections 1. Pneumonia 2. Bacterial Endocariditis 3. Urinary Tract Infection 4. Suppurative chondritis 5. Vascular Catheter-Related Infection B) Other 1. 2. 3.
complications Curling’s ulcer Acute Acalculous Cholecystitis Myocardial Infarction
Burn wound coverage a) Temporary 1. Biologic wound coverings Allograft Xenograft Amnion 2. Hydrocolloid dressings b) Permanent 1. Skin Skin Graf Grafti ting ng a) Split-thickness Split-thickness b) Full-thickness 2. Skin Fl Flaps 3. Skin Skin Sub Subst stit itut utes es a) AlloDerm b) INTEGRA 4. Cult Cultur ured ed Skin Skin a) Apligraf b) Epicel Chronic Phase 1. Rehabilitation: Range of motion exercises Ambulation training Return Return to functional status 2. Psychological Support: Anxiety, Depression, Denial Withdrawal, Regression 3. Reconstruction: Burn contractures Keloids Hypertrophic scars Marjolin’s ulcer