Burn rubel

Prof. AMSM Sharfuzzaman
Professor of Surgery

Tuesday, January 8, 2013 DR. RUBEL, SBMC 1

BURN
• Introduction :
 Burn trauma represents one of the most devastating conditions encountered
in surgery .
 A vast spectrum of injuries can arise from a burning accident,from the
trivial to some of the most dramatic injuries that humans survive. The
management of the major burn injury represents a significant challenge to
every member of the burns team – burns doctors, surgeons, anaesthetists,
ward and theatre nurses, physiotherapists, occupational therapists,
dietitians, bacteriologists, physicians, psychiatrists, psychologists and the
many ancillary staff whose cleaning and supply services are vital to the
successful running of a burns unit.
 The correct treatment of these injuries is vital to ensure a favourable
outcome & encompasses accurate assessment, careful resuscitation & precise
surgical management .


Epidemiology
• 1% of total population of a country in each year
• U.S - >1.2 million people per year.
• 50000 burns patients –
- Moderate to severe .
- Require hospitalization .
• Among them >3900 people die of complications
related to burns .
• Mechanism is age-related & situational:
• < 8 yrs. → scalds
• all others → flame burns
• work → chemical/electrical/molten


Definition

• Tissue injury from thermal application
( heat and cold ) , absorption of physical
energy ( electricity , friction and ionising
radiation ) and chemical ( corrosive
substance ) contact .


Classification
A. According to causative agent:
1. Flame .
2. Scald .
3. Contact .
4. Chemicals .
5. Electricity .
6. Radiation.


B. According to depths :

1. 1st degree :

2. 2nd degree :
(i) Superficial
(II) Deep

3. 3rd degree .

4. 4th degree .


Pathophysiology of Burn
Burns cause damage in a number of different ways, but by
far the most common organ affected is the skin

• A. Local changes :

1. Zone of
coagulation

2. Zone of stasis .

3. Zone of
hyperaemia


3 Zones of T her mal
Injur y
Hyperemia

Stasis

Coagulation

B. Systemic changes
 1.Inflammation and oedema
 2.Respiratory changes
 3.Effects on the renal system
 4.Effects on GIT
 5.Effects on immune system
 6. Hypercatabolism


B. Systemic changes


6. Hypercatabolism


FACTORS DETERMINING THE
SEVERITY OF BURN
• As burn is the only truly quantifiable form
of trauma, there are so many factors
predicting burn related mortality &
morbidity.
1) Age
 Reaction to burn
 Different healing process

2) Source of burn

Candle fire
Stove fire


Chemical fire


DIATHERMY BURN

2. Burn size:
• A General idea of the burn size can be made by
using the rule of nines.
• Smaller burns can be calculated by using the pts
palmer hand surface including the digits which is
about 1% of T B S A.
• Calculation of burn size is necessary for diagnosis,
treatment, prognosis & statistics.


3. Burn depth:
• Burn depth is dependent upon the temperature of the burn
source, the thickness of the skin, the duration of contact,
the heat dissipation capability of skin (blood flow).
Thickness further depends upon age, sex & the area of the
body.

• Depth may be non uniform through out the burn extent
and depth may progress ē time.


Burn severity map according to
depth


Depth of Burn
• First- degree or epidermal:
• Involves only epidermis, erythematous, non blistering quite
painful
• Second-degree or superficial partial:
• Includes papillary layers of dermis.
• Second-degree or deep partial:
• Extend into the reticular layers of the dermis
• Third degree or full thickness:
• Involve all the layers of dermis
• Fourth degree:
• Involves skin, subcutaneous tissue & deeper structures


Depth of Burn
Appearance of Sensitivity to Healing time
Depth of Burn Tissues destroyed
burns pain Prognosis
- Epidermis & - Red -Painful and - 7 - 14 days
Superficial upper layer of - Blisters hypersensitive - Pigment
Partial dermis change
thickness - Hair follicles, - Blanching possible
or sweat and
Superficial sebaceous
dermal glands intact.

- Epidermal and - white with red Generally - 21- 35 days
deeper dermis - No blisters insensitive to - Severe
Deep partial - Most nerve - No blanching pain scarring
thickness endings, hair - Eschar forms - Risk of
or follicles and contractures
Deep dermal sweat glands - May need
destroyed. grafting

All skin layers White charred, No pain - No skin
Full-thickness January 8, 2013
Tuesday, destroyed DR. RUBEL, SBMC
dry, inelastic 20
regeneration

Superficial partial
thickness burn

Deep dermal burn

Full thickness burn


4. Site of Burn
Inhalation injury should be
suspected in a flame burn.
Burn to the face could affect airway
management or the eyes.
Burn to the hand and feet could
impede movement of fingers and
toes.


6. Co-morbid factors:
• Associated trauma
• Impaired sensation due to diabetes or
intoxication
• Pre-existing cardiovascular, respiratory, renal
disease.
• Seizure disorders
• Pre existing hypovoluaemia or shock
• Immunization history
• Known allergy
• Social circumstances
• Suicide or homicide attempts
• Child abuse
• Lack of care

Management of Burn
The priorities in management of burn

A. Air way control .
B. Breathing and ventilation .
C. Circulation .
D. Disability - neurological status .
E. Exposure with environmental control.
F. Fluid resuscitation .


Pre-hospital car e
The principles of pre-hospital care are:
• Ensure rescuer safety.
• Stop the burning process.
• Check for other injuries. A standard ABC (airway,
breathing, circulation) check followed by a rapid
secondary survey will ensure that no other significant
injuries are missed.
• Cool the burn wound. This provides analgesia and
slows the delayed microvascular damage that can
occur after a burn injury. Cooling should occur for a
minimum of 10 min and is effective up to 1 hour after
the burn injury. It is a particularly important first aid
step in partial-thickness burns, especially scalds. In
temperate climates, cooling should be at about
15°C, and hypothermia must be avoided.

Pre-hospital care-contd.
• Give oxygen. Anyone involved in a fire in an
enclosed space should receive oxygen,
especially if there is an altered consciousness
level.
• Elevate. Sitting a patient up with a burned
airway may prove life-saving in the event of a
delay in transfer to hospital care. Elevation of
burned limbs will reduce swelling and
discomfort.


Initial assessment :
Primary survey
Immediate life threatening
conditions are quickly identified
and treated

Secondary survey
Thorough head to toe evaluation.


• Indications for intubation:

(I) Erythema / swelling of the oropharynx on
direct visualization .
(II) Change in voice with hoarseness / harsh
cough
(III) Stridor.
(IV) Dyspnoea.


 In an explosion or deceleration
accident -- appropriate cervical
spine stabilization until the condition
can be evaluated .


C. Initial Wound care
• Cover the wound with clean dry dressing or
sheet Pain reduced by cover the wound to
prevent contact to exposed nerve ending.

• I.V. narcotics .

• The parts should be immobilized to a safe
functional position and the injured extremity
elevated if possible .


D. Transport :
What ever the mode of transport it should
be to appropriate place having emergency
equipment available and trained personnel
with necessary facilities .


Criteria for hospitalization :
• Age : < 5yrs or > 60 yrs.
• Site : face , hands , feet , perineum or fracture.
• Inhalation injury .
• Mechanism of injury.
 Chemical injury >5% TBSA.
 Exposure to ionizing radiation .
 High pressure steam injury
 High tension electrical injury .
 Suspicion of non accidental injury .
 Hydrofluoric acid injury > 1% TBSA .
• Size : < 16yrs - > 5% TBSA
16 yrs or > 16 yrs - > 10% TBSA
• Require fluid resuscitation.
Require surgery .
• Psychiatric patient .
• Coexisting condition.

Assessment of burn wound :
(I) Assessment of burn size by
- Wallace’s rule of nines
- Patients whole hand ( palm and digit )
- Lund and Browder chart .

(II) Assessment of burn depth
- From history – temperature , time of exposure and
burning material .
- Superficial burns have capillary filling .
- Deep partial thickness burns don’t blanch but have
some sensation .
- Full thickness burns feel leathery and have no
sensation.

Lund and
Browder
chart .


Resuscitative fluid management :

Principle :
Maintenance of intra vascular volume in
order to provide sufficient circulation to
perfuse not only the essential visceral organs
such as the brain , kidneys and the gut but
also the peripheral tissues.


Resuscitation by oral fluid :

Indication :
< 10 % TBSA in child.
< 15% TBSA in adult .

Fluid :
Salt containing oral fluid e.g. ORS , fruit
juice .

Resuscitation by I V fluid
Indication :
>10% TBSA in child .
>15% TBSA in adult .

Fluids: a.
Crystalloids
I) Ringer's lactate, Hartmann’s solution.
II)0.9% NaCl solution
III) Hypertonic saline solution .
IV) 5% DNS.
b. Colloids
I) Plasma
II) Plasma substitutes

Formula :
1. Parkland Formula :
1st 24 hrs
Total fluid = 4 ml X body weight in kg X % of burn =
ml Fluid : Ringer’s lactate .
Schedule :
1st 8 hours = ½ of total fluid .
2nd 8 hrs = ¼ th of total fluid.
3rd 8 hrs = 1/4th of total fluid.
Next 24 hrs
I) .5 ml X body weight in Kg X % of burn.
fluid – usually colloid or plasma.
II) 5% DA to get urine out put.
{.5 – 1.5 ml / Kg /hrs .}
5% DNS instead of 5% DA

2. Muir and Barclay formula
Six rations in 1st 36 hours -4/4/4, 6/6 and 12 hours respectively
Each ration= % burn X body weight in Kg/2 = ml.
Fluid : Plasma

3. Galveston ( Pediatric )
5000 ml/ m2 TBSA burned+1500 ml / m2 TBSA.
Fluid- 5% dextrose , Ringer’s lactate .


Monitoring
• Clinical.
• Biochemical & Hematological.
• Invasive.


Clinical :
• Pulse - <120/Min.
• BP-
• Urinary output*
0.5 ml – 1.5 ml /kg/hr. in adult.
10-20 ml / hr. in child.
• Core & Shell temp.
• Thirst.

* If the urine output is below this, the infusion rate should be
increased by 50%. If the urine output is inadequate and the patient
is showing signs of hypoperfusion (restlessness with tachycardia,
cool peripheries and a high haematocrit), then a bolus of 10 ml/kg
body weight should be given. It is important that patients are not
over-resuscitated, and urine output in excess of 2 ml/kg body
weight per hour should signal a decrease in the rate of infusion.


Management Contd.
Biochemical
1. Hb%
2. Urinary osmolality
3. Serum electrolytes
4. Serum creatinine & Blood urea
Invasive
1. CVP
2. Invasive arterial pressure

MANAGEMENT OF BURN WOUND


Wound management
• Depends on –

1. Types of burn.
2. Site of burn .
3. Percentage of burn .
4. Depth of burn .
5. Age of the patient .
6. General condition of the patient.


Flame burn (Carelessness)


Scald


Homicidal


Electric Burn

y by - Prof. Dr. A. January 8, 2013
Tuesday,
J. M. Salek DR. RUBEL, SBMC 50


Electric Burn


lectric Burn


Electric Burn


Electric Burn

Courtesy by - Prof. Dr. A. J. M. Salek

Diathermy Burn


Sharee

Floor level cooking


Epilepsy

Perineum
 warming


Warming


Gas misuse


Burning ash


Children Playing with Fire




Electric Burn


Wound Management

Infection is a common problem
& Major cause of late death

Skin – ‘keeps the outsides out and the insides
in’.
Universal precautions.
Barrier nursing.
Tetanus prophylaxis.
Do not routinely give strong antibiotics


Wound Management

Wound Dressing

• Various dressings
• Review at 48 hours
• Then dress accordingly


Wound Management

Wound Dressing – Special Areas

• Face - expose with antiseptic
• Hands – In bags
• Perineum – Expose with cream


Dressing description
1. Antimicrobials.
 Silver sulfadiazine.
 Mafenide acetate.
 Bacitracin.
 Neomycin.
 Polymyxin B.
 Silver nitrate solution.
 Mupirocin.


2 . Antimicrobial soaks.

 0.5% silver nitrate.
 5% mefenide acetate.
 0.025% sodium hypochlorite.
 0.25% acetic acid .


3. Synthetic covering.

 Opsite .
 Biobrane.
 Transcyte.
 Integra.


4. Biological coverings.

 Xenograft (pig skin).
 Allograft (homograft, cadaver skin ).


Principles of dressings
for burns :
• Full thickness and deep dermal burns need
antibacterial dressings to delay colonisation
prior to surgery.
• Superficial burn will heal and need simple
dressing.
• An optimal healing environment can make a
difference to outcome in borderline depth burn.


Exposure versus Closed Management

1. Exposure therapy :
• Advantages –
a. Less bacterial growth.
b. Remains visible.
c. Readily accessible.
• Disadvantages-
a. Increased pain.
b. Heat loss.
c. Cross contamination.


2. Closed method :
Advantages –
- less pain .
- less heat loss .
- less cross-contamination .

Disadvantages –
- increases bacterial
growth .

The closed method is generally preferred .

Surgical treatment of deep burn :
• Deep dermal burns need tangential shaving and split-skin
grafting .
• All but the smallest full-thickness burns need surgery
• All burnt tissue needs to be excised .
• Stable cover , permanent or temporary , should be applied
at once to reduce burn load .
• Escharotomy – the tourniquet effect of full thickness burn
injury is easily treated by incising the whole length of burn
This should be done in the mid- axial line , avoiding major
nerves.


Tangential Excision
(TE)
• Done “early” (w/in 7 d)
• Various adjustable
knives
• Sequentially remove
only non-viable tissue
• Standard burn
operation
• BLOODY!!!
• Tourniquets on
extremities
• Speed is essential

Technique

Escharotomy
ANATOMIC POSITION!!
• Med & lat lines of extremities,
over lumbricals on dorsal
hands, ant or mid axillary
lines on chest, & lateral neck
lines
• Thru eschar only -- RELEASE
• Use cautery (knife OK)
• Not a sterile procedure
• Digits are controversial

After…


Electrical burn wound :
• Debribed to underlying healthy
tissue.
• Second debribement usually
indicated 24 - 48 hrs after injury.
• Microvascular flaps now used
routinely to replace large tissue
losses.

Fascial Excision (FE)

• Done “early”
(w/in 7 days)
• Used for deep FT
w/ dead subcut.
tissue
• Excise to fascia
• “Inferior”
cosmesis (?)
• Blood loss < TE


Chemical burn wound
Incident with chemical agent

Irrigate copiously water (several
liters )

Acid burns Alkali burn

Check surface PH Check surface PH

If <7 ,continue irrigating untill range ( 7- If >7.5, continue irrigating untill PH
7.5). Take care to direct the irrigant reaches the physiologic ranges (7-7.5) .
away from non-injures skin. Once theC PH should be checked again after
wound PH reaches a physiologic h range , debridement , as alkaki agents can
the injury process has finished. e penitrate through the surface . Thereafter ,
c treat the wound with standard techniques
k

Radiation burn wound :
• Local burns causing ulcerations
need excision and vascularised
flap cover – usually with free
flaps .
• Systemic overdose needs
supportive treatment .


Complications of Burn :
Infection
Bacteraemia .
Septecemia
Renal failure
Pulmonary complication
Inhalation injury.
Aspiration in unconscious pts.
Bacterial pneumonia.
Pulmonary edema.
Pulmonary embolism
Atelectasis
Brochiectasis
Post traumatic pulmonary insufficiency.


Complications of hyper metabolism and nutrition :

• A catecholamine mediated hyper metabolism is
manifested by tachycardia and hyper dynamic
cardiac activity with resultant increase in the
myocardial oxygen requirements .
• A syndrome of hyperglycemia , glycosuria, acute
dehydration , shock , coma and renal failure may
be seen .
• Combined with hyperglycemia resulting from the
necessary high calorie replacement of a major
burn a syndrome of pseudo-diabetis can occur .


Electrolyte imbalance :

- Hypokalaemia .
- Hyponatraemia .
- Seizure – a complication unique to
children which may result from
electrolyte imbalance .


Gastrointestinal complication :
Curling’s ulcer.
Hematemesis and melaena .
Diarrhoea

Cardiovascular :
Arrhythmia


Hematological & Immunological :
Anaemia
Immunosuppression increases the risk of septic
complications .

Multi-organ failure:
There may be progressive failure of renal ,
hepatic or heart failure .


Local complications:
Eschar formation
Scar formation :
Hypertrophic scar
Keloid .
Contracture :
a. Skin contracture
b. Muscle contracture ( fibrosis )
c. Joint contracture .
d. Tendon adherence to bones.
Marjolin’s ulcer .


Non specific complications :

UTI ( from catheterization ).

Deep vein thrombosis.

Pulmonary embolism .


Late management :
• Wound management :

 Skin graft :
- full thickness burns : require skin grafts.

 Transposition flaps .

 Free flaps .


Management of scar & contracture:
• Scar contracture –
Broad contracture require release and insertion of
skin grafts; such operations are particularly valuable in restoring the
range of motion of a joint
Where there is a localized linear contracture a better technique may
be Y- V plasty. Z-plasty is useful in the situation in which there is a
single band and a transposition flap is useful in wider bands of
scarring.


Tissue expansion
 This technique allows gradual stretching of
marginal skin by implanting expander balloons
under the adjacent normal skin .

 These are serially injected with saline through
a part , there by enlarging the expander &
stretching the over lying skin


Hypertrophic scar

Pressure garments ‍

Revision of hypertrophic scars is
appropriate where the scar cross skin
tension lines or where a specific
wound healing complication
occurred.


Pressure garments


Keloid scar
Some keloids will improve with
the application of pressure .

Intralesional injection of steroids .

Best cure by combination surgery and
postoperative interstitial radiotherapy.


Late management :

• Wound management :

 Skin graft .

 Trans position flaps .

 Free flaps .


Outcome of Burn :
Major determinants

1. Percentage of surface area
involved

2. Depth of burn

3. Presence of an inhalational
injury.

Percentage of burn+ age of patient
=100 indicates the bad prognosis.

Thanks!
Have a nice
day.


Burn rubel

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