2.Burn.pptxvmncn mcbvnmcxnc ,m,cvb nmc c

educatinal purpose

1. Burn Management Biniam Moderator: Dr. Yohanes 1

2. ? 2

3. Outline Types Epidemiology Classification Pathophysiology Treatment Complications Prevention References 3

4. Burn A burn is an injury to the skin or other tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. 4 th most common type of trauma worldwide, following traffic accidents, falls, and interpersonal violence 4

5. Epidemiology Between 2 and 2.5 million persons each year sustain burns in the United States. Of these patients, 100,000 receive hospital treatment. SCALDS are the most frequent form of burn injury. Burn victims tend to reflect 4 general populations: The very young, The very old, The very unlucky, The very careless. Up to 75% of burn injuries result from the victim’s own action Unintentional…95% 5

6. Epidemiology Incidence of burns in this population was found to be 5-11 %. 6

7. Epidemiology The annual incidence of burns was 1.2 %. Burn had the highest incidence among children less than 5 years old (4.8%). Scald (59%) was the leading cause of burn followed by flame (34 %). Most burns occurred at home (81 %). Domestic burn injuries were common among women of reproductive age and work related burns were more common among men 7

8. Types of burn injuries Thermal: F lame S cald Contact Electrical A.C. – alternating current (residential) D.C . – direct current (industrial/lightening) Chemical Frostbite 8

9. Classification Burns are classified by depth, type and extent of injury Every aspect of burn treatment depends on assessment of the depth and extent 9

10. 1 st degree burn Involves only the epidermis Tissue will blanch with pressure Tissue is erythematous and often painful Involves minimal tissue damage Sunburn 10

11. 2 nd degree (partial-thickness) burn Involve the epidermis and portions of the dermis Often involve other structures such as sweat glands, hair follicles, etc . Blisters and very painful Edema and decreased blood flow in tissue can convert to a full-thickness burn 11

12. 3 rd degree (full-thickness) burn Charred skin or translucent white color Dry with leathery eschar until debridement; charred vessels visible under eschar Coagulated vessels visible Area insensate Complete destruction of tissue & structures 12

13. 4 th degree burn Involves subcutaneous tissue, tendons and bone Exposed bone, muscle, or tendon 13

14. Classification: Burn extent % BSA involved morbidity Burn extent is calculated only on individuals with second and third degree burns Palmar surface = 1% of the BSA 14

15. Measurement charts Rule of Nines: Quick estimate of percent of burn Lund and Browder: More accurate assessment tool Useful chart for children – takes into account the head size proportion. Rule of Palms: Good for estimating small patches of burn wound 15

16. BSA estimation Original Lund-Browder chart Modified Lund-Browder chart Rule of 9’s 16

17. Classification 17

18. Pathophysiology The Burn Syndrome Burn shock… 8 hrs Metabolic response… HMS Immune response,,, infln mediators continuously released Effect on vital organs 18

19. Pathophysiology … 1. Fluid and Electrolyte Imbalance ( burn shock )    microvascular changes induced by * direct thermal injury and *release of chemical mediators of inflammation systemic intravascular losses of water, sodium, albumin and red blood cells.  This process is maximum in the 1 st 8 hrs . 19

20. Pathophysiology … 2 . Hypermetabolic response   Due to neuro -endocrine mediator response ( Catecholamines are the major hormones) Metabolic changes : Increase gluconeogenesis Increased glycogenolysis Increased proteolysis This is evidenced by Increased resting oxygen consumption ( hypermetabolism ) An excessive nitrogen loss (catabolism) , Pronounced weight loss (malnutrition) 20

21. ! Pathophysiology… 3.   I mpaired immunity Lose their protective primary barrier (skin) to environmental microorganisms. Avascular necrotic tissue (eschar) provides a protein-rich environment favorable to microbial colonization and proliferation The avascularity of the eschar impairs migration of host immune cells and restricts delivery of systemically administered antimicrobial agents Toxic substances released by eschar tissue impair local host immune responses Inflammatory mediators that alter the baseline metabolic profile of the burn patient are continuously released, The baseline temperature is reset to approximately 38.5°C Tachycardia Tachypnea persist for months 21

22. Pathophysiology: Summary Immunologic dysfunction is pleiotropic ( more zan 1 effect ) immunoglobulin levels depressed, B-cell response to new antigens blunted complement components activated, consumed normal T4/T8 ratios inverted impaired phagocyte function “immunologic dissonance ” 22

23. Pathophysiology: Effect on vital organs Pulmonary dysfunction results from multiple etiologies shock, aspiration, trauma, thoracic restriction inhalation injury; increases mortality 35-60% diffuse capillary leak reflected at alveolar level  Pulmonary edema  ARDS  bronchopneumonia.  CNS dysfunction may result from hypovolemia/ hypoperfusion , hypoxia, or CO exposure 23

24. Pathophysiology …   Renal insufficiency  H ypoperfusion or  N ephron obstruction with myoglobin and hemoglobin .  Gastrointestinal Ischemia & stasis promote bacterial translocation as a mechanism for endogenous infection.   Curling ulcer , & erosive gastritis Multi-system organ failure is a common final pathway leading to late burn mortality . 24

25. Pathophysiology … Factors Affecting Systemic Response to Burn Wounds Extent of the burn : systemic effects are proportional to the percentage of the BSA. Age of patient: prognosis for very young and elderly patients is worse   Depth: systemic response is greater in large, deep burns   Delay in resuscitation: established burn shock is difficult to treat 25

26. Initial evaluation Four crucial assessments : Airway management Evaluation of other injuries Estimation of burn size Diagnosis of CO and cyanide poisoning 26

27. Airway With direct thermal injury to the upper airway or smoke inhalation , rapid and severe airway edema is a potentially lethal threat! Perioral burns and singed nasal hairs further oral cavity and pharynx evaluation for mucosal injury Signs of impending respiratory compromise may include hoarse voice , wheezing , or stridor ; 27

28. II. Evaluation of other injuries Burned patients should be first considered trauma patients! A primary survey should be conducted in accordance with ATLS guidelines. Concurrently with the 1ry survey, large-bore peripheral intravenous (IV) catheters should be placed and fluid resuscitation should be initiated. IV placement through burned skin? Early and comprehensive 2ry survey must be performed on all burn patients 28

29. Inhalation injury Smoke inhalation causes injury in two ways: - direct heat injury to the upper airways -inhalation of combustion products into the lower airways Inhalation injury caused by products of combustion significantly increases burn mortality for a given percent skin burn . It decreases lung compliance and increases airway resistance work of breathing Increased fluid requirement during resuscitation! Diagnosis : patients who are trapped inside a burning room C ough , hoarse voice, and difficulty breathing ABG and Carboxyhemoglobin level 29

30. Inhalational injury: Mx Primarily of supportive care . Aggressive pulmonary toilet Nebulized bronchodilators such as albuterol are recommended. Aerosolized heparin aims to prevent formation of fibrin Steroids? Low tidal volume (6 cc/kg) or “lung-protective ventilation” 30

31. III . Carbon Monoxide Intoxication Carbon monoxide has a binding affinity for Hgb which is 210-240 times greater than that of O2. Results in decreased O2 delivery to tissues, leading to cerebral and myocardial hypoxia . Cardiac arrhythmias are the most common fatal occurrence. 31

32. Sx and Sn of Carbon Monoxide Intoxication Confused, irritable, restless Headache Tachycardia, arrhythmias or infarction Vomiting / incontinence Dilated pupils Bounding pulse Pale or cyanotic complexion Seizures Overall cherry red color – rarely seen Usually symptoms not present until 15% of the Hgb is bound to CO rather than to O2 , MR> 50%,if >60%. Early symptoms are neurological in nature due to impairment in cerebral oxygenation 32

33. Carboxyhemoglobin Levels/Symptoms 0 – 5 15 – 20 20 – 40 40 - 60 > 60 Normal value Headache, confusion Disorientation, fatigue, nausea, visual changes Hallucinations, coma, shock state, combativeness Mortality > 50% 33

34. Management of CO Intoxication Remove patient from source of exposure. Administer 100% high flow oxygen Half life of Carboxyhemoglobin in patients: Breathing room air 120-200 minutes Breathing 100% O2 30 minutes Patients who sustain a cardiac arrest as a result of their CO poisoning have an extremely poor prognosis! 34

35. Electrical Injuries Can take several forms, including injury from the electrical current itself, flash burns, flame burns, contact burns H igh/ Low voltage ( 1000 volts) All patients who sustain electrical injuries should have an ECG in the emergency room . No formula for fluid management of electrical burn patients If myoglobinuria is present, intravenous fluids should be titrated to a goal urine output of 100 mL/ hr until the urine clears. 35

36. Electrical If myoglobinuria persists despite fluid resuscitation, mannitol can be administered Early surgical management of electrical injuries should focus on the need for fasciotomy or compartment release Monitor for compartment syndrome! Neurologic deficits , including peripheral and CNS disorders, can develop weeks to months following electrical injury. 36

37. Chemical Injuries Severity depends on the composition of the agent, concentration of the agent, duration of contact with the agent Alkaline burns cause more severe injury than acid burns because they can cause a liquefaction necrosis that allows penetrate deeper The 1 st step in managing a chemical injury is removal of the inciting agent. Clothes , including shoes, that have been contaminated should be removed. Areas of affected skin should be copiously irrigated with water 37

38. IV. Burn size determination & Mx Depth determination: most effective ways to determine burn depth is full thickness biopsy Laser Doppler can measure skin perfusion to predict burn depth Noncontact ultrasound Serial examination by experienced burn surgeons! 38

39. Initial Mx: Fluid resuscitation Goal: Maintain perfusion to vital organs Based on the TBSA, body weight and whether patient is adult/child Fluid overload should be avoided – difficult to retrieve settled fluid in tissues and may facilitate organ Hypoperfusion 39

40. Fluid resuscitation Lactated Ringers - preferred solution Contains Na+ - restoration of Na+ loss is essential Free of glucose – high levels of circulating stress hormones may cause glucose intolerance 40

41. Fluid resuscitation Burned patients have large insensible fluid losses Fluid volumes may increase in patients with co-existing trauma Fluid requirement calculations for infusion rates are based on the time from injury , not from the time fluid resuscitation is initiated. 41

42. Parkland Formula 4 cc R/L x % burn x body wt. In kg. ½ of calculated fluid is administered in the first 8 hours Balance is given over the remaining 16 hours. Maintain urine output at 30 mL/h in adults & 1 - 1.5 mL/kg/h in pediatric patients. 42

43. Galveston Formula Used for pediatric patients Based on body surface area rather than weight More time consuming 5000cc/m2 x % BSA burn plus 2000cc/M2/24 hours maintenance. ½ of total fluid is given in the 1 st 8 hrs and balance over 16 hrs . Urine output in pediatric patients should be maintained at 1 cc/kg/hr. 43

44. Assessing adequacy of resuscitation Peripheral blood pressure: may be difficult to obtain – often misleading Urine Output: Best indicator unless ARF occurs A-line: May be inaccurate due to vasospasm CVP: Better indicator of fluid status Heart rate: Valuable in early post burn period – should be around 120’ > HR indicates need for > fluids or pain control Invasive cardiac monitoring: Indicated in a minority of patients (elderly or pre-existing cardiac disease) 44

45. Resuscitation: complications Abdominal compartment syndrome Extremity compartment syndrome Intraocular compartment syndrome Pleural effusions Monitoring bladder pressures can provide valuable information about development of intra-abdominal hypertension. 45

46. Histopathology of burns 1 . Zone of coagulation: dead, avascular tissue that must be débrided . 2. Zone of stasis : injured tissue in which blood flow is impaired. Desiccation, infection, or mechanical trauma may lead to cell death . 3. Zone of hyperemia: minimally injured, inflamed tissue that forms the border of the wound. The hyperemia usually resolves within 7 to 10 days but may be mistaken for cellulitis. 46

47. Treatment of the burn wound Escharotomy : indications Full thickness circumferential burns of the extremity Full thickness burns of the chest wall when the eschar compromises ventilation of the patient The incision should go through only eschar, not fascia. An Escharotomy is not a fasciotomy! 47

48. Airway compromise? Respiratory distress? Circulatory compromise? Intubation, 100% O 2 IV access, fluids Multiple trauma? Yes No Evaluate & treat injuries Burns >15%, or complicated burns? Yes No Burn care, tetanus prophylaxis, analgesia IV access; fluid replacement Circumferential full thickness burns? Escharotomy Yes Yes No No 48

49. Rx : Minor burns FIRST AID Remove the person from further danger. Remove clothing . Irrigate the areas with water in copious amounts  scald ,flame for 5min .  chemical injuries for 20-30 min Cover the wound with clean towel. Management of associated injuries Analgesia Burn dressing Appropriate tetanus prophylaxis mandatory 49

50. Minor burn: dressing The hair in the burn itself or around the wound should not be shaved. Debride sloughed skin In the absence of infection, intact blisters are often left alone at the first visit A fine-mesh gauze applied to the dry burn wound The burn is covered with loose gauze fluffs. The web spaces are padded and the digits are individually wrapped and separated with strips of gauze. Antibiotic creams or ointments may be used as an option with this dressing The topical antibiotic may be applied to the burned skin directly or impregnated into the gauze. 50

51. Blisters If Treated < 48 Hr after the Burn Leave all intact blisters alone. If blisters have ruptured, treat them as dead skin and débride them completely . Needle aspiration is generally not advised but may be used to decompress large burn blisters that appear ready to burst. On Follow-up, or > 48–72 Hr after the Burn Débride large (>5 cm in diameter) intact blisters and all blisters that have ruptured. Large, firm blisters of the palms and soles may be left intact longer. Do not aspirate blisters! Do not débride small or spotty blisters until they break, or until 5–7 days after the burn. Five to 7 Days after the Burn Débride all blisters completely . Note : Intact blisters provide significant pain relief. Be prepared for an exacerbation of pain immediately after débridement . Prophylactic analgesia is recommended. 51

52. Topical Wound Agents Choice of topical burn wound treatment is contingent on the depth of burn injury and the goals of management Superficial burn wounds (such as sunburns) require soothing lotions such as aloe vera Partial thickness burn wounds need coverage with agents that keep the wound moist and provide antimicrobial protection . Prophylactic systemic antibiotics have no role in the management of burn wounds ! 52

53. Topical Wound Agents Silver sulfadiazine: Leukopenia has broad-spectrum antimicrobial coverage, excellent staphylococcus and streptococcus coverage . does not penetrate an eschar ; less useful in the management of an infected burn wound. Leukopenia ?? part of SIRS Mafenide : MA , treating burn wound infections has a broad anti microbial spectrum, including gram-positive and gram-negative organisms . readily penetrates burn eschar , excellent agent for treating burn wound infections. commonly used on the ears and the nose because of its ability to protect against suppurative chondritis potent carbonic anhydrase inhibitor that can cause a metabolic acidosis, can be painful , which may limit its use in partial-thickness burn 53

54. Topical Wound Agents… Silver nitrate electrolyte monitoring is needed broad-spectrum coverage against gram-positive and gram-negative organisms. needs to be applied every 4 hours to keep the dressings moist. it stains everything it touches black , prepared in water at a relatively hypotonic solution (0.5%), osmolar dilution can occur, resulting in hyponatremia & hypochloremia Consequently, frequent electrolyte monitoring is needed . Bacitracin , Neomycin Polymyxin B ointments 54

55. Surgery Early excision and grafting results in Increased survival decreased infection rates decreased length of hospital stay If feasible, early staged excision should begin on post-burn day 3 for major burns that are clearly full thickness. Operations can be spaced 2 to 3 days apart until all eschar is removed 55

56. Surgery: Techniques of Excision Tangential excision : sequential removal of layers of eschar & necrotic tissue until a layer of viable, bleeding tissue, which can support a skin graft, is reached . Carried out using a Watson or Goulian ( Weck ) knife Disadvantages When excising a large surface area there can be substantial blood loss ; It may be difficult to accurately assess the viability of the excised wound bed. Fascial excision : For patients with clearly deep burns and concern for excessive blood loss Electrocautery is used to excise the burned tissue &the underlying subcutaneous tissue down to muscle fascia. markedly decreases blood loss Disadvantages R esults in a cosmetically inferior appearance due to the loss of subcutaneous tissue 56

57. Techniques of Excision… Pressurized Water dissector: For excision of burns in difficult anatomic areas such as the face, eyelids, or hands, Offer more precision Disadvantages Time consuming , Very expensive Regardless of which technique: Extremity excisions should be performed under tourniquet control to minimize blood loss! Risks of blood loss and probable need for transfusion should be clearly communicated to the anesthesia 57

58. Wound coverage Split-thickness sheet autografts: Areas of cosmetic importance such as the face, neck, and hands In larger burns, meshed autografted skin provides a larger area of wound coverage Donor sites : Thighs- easily harvested and relatively hidden from an aesthetic standpoint . T hicker skin of the back is useful in older patients Buttocks: are an excellent donor site in infants and toddlers The scalp: is also an excellent donor site; the skin is thick and the many hair follicles allow rapid healing, Patients with limited donor sites: Human cadaveric allograft (temporary) Permanent synthetic skin substitute: Integra, Alloderm, cultured epithelial autografts 58

59. Pain Control Typically have two types of pain: background & procedural Background pain : is best treated with longer-acting agents. Methadone can be used for patients who are going to have a long hospital course .. Oxycodone or morphine Procedural pain : shorter-acting agents are probably best, short acting benzodiazepines can also be used. NSAID: not for inpatients to undergo surgery but can be used as an outpatient analgesia 59

60. Nutrition Hypermetabolism and hypercatabolism both occur following burn injury The Curreri formula differs for children and adults as follows: Adult : 25 kcal × weight (kg) + 40 kcal × %TBSA Children : 60 kcal × weight (kg) + 35 kcal × % TBSA The Harris-Benedict formula provides an estimate of basal energy expenditure (BEE): Men : 66 . 5 + 13 . 8 × weight (kg) + 5 × height (cm ) − 6 . 76 × age ( years) Women: 65 . 5 + 9 . 6 × weight (kg) + 1 . 85 × height (cm )− 4 . 68 × age (years) 60

61. Nutrition … Calorimetric formula is less reliable at FiO2 levels above 50 %. Protein requirements: Patients with normal renal function should receive 2 g of protein per kilogram per day 61

62. Gastrointestinal Prophylaxis Histamine receptor blockers , Sucralfate PPI have minimized the incidence of stress (Curling) ulcers . The best protection against stress ulcers is feeding the patient ! Stress ulcer prophylaxis is only necessary in patients, Not taking oral diet or enteral feeds Patients with previous history of PUD 62

63. Deep venous thrombosis Risk factors: Injuries to an extremity occasional need for prolonged bed rest indwelling catheters Prophylaxis is required in burn patients who are hospitalized and unable to regularly ambulate S equential compression devices and antiembolism stockings may not be practical for use in patients with lower-extremity burns. These patients should receive subcutaneous heparin 63

64. Late effects of burn injury Hypertrophic Scarring Marjolin’s Ulcer Heterotopic Ossification 64

65. Survival Data: BSA and age BSA involved 65

66. Burn reconstruction Burn reconstruction is fundamentally about the release of contractures and the correction of contour abnormalities . Contracture releases can be carried out with local tissue rearrangement such as Z- plasties Transposition flaps Releases and skin grafting of the resulting defects 66

67. Timing of reconstruction The timing of burn reconstruction falls into three distinct phases : acute, intermediate, and late Acute : during the early months following burn injury when urgent procedures are necessary to facilitate patient care, to close complex wounds such as open joints , or to prevent acute contractures from causing irreversible secondary damage The intermediate phase : of burn reconstruction is best described as scar manipulation designed to favorably influence the healing process 67

68. Timing… Late-phase: reconstructive surgery includes all post burn deformities that are essentially stable and consist of mature scars and grafts Operations directed at relief of the tension will usually cure the chronic open wounds. 68

69. Burn Injury: Prevention Education : very little data on the effectiveness of fire prevention educational programs Engineering: Smoke detectors and alarms Water temperature Fireworks  Low ignition propensity cigarettes Enforcement:   Smoke detector legislation Water temperature regulation  Fireworks legislation Flammable Fabrics Act Fire-safe cigarette legislation 69

70. References Grabb and smith’s plastic surgery , 6 th e d i t i o n Practical Plastic Surgery , Zol B. Kryger , Mark Sisco H andbook of plastic surgery , steven e.greer The epidemiology of burns in rural Ethiopia , Paul Courtright , Demka Haile, Elaine Kohls , Journal of Epidemiology and Community Health Epidemiology of burn injuries in Mekele Town, Northern Ethiopia: A community based study , Kidanu Estifanos Nega , Bernt Lindtjørn Management of Burns , WHO Schwartz’s Principles of Surgery 10 th Edition Bailey & Love’s S hort practice of surgery 25 th edition 70