Burn

Burn

1. BURNS Dr. Pranjal Rokaya Resident General Surgery KIST MCTH 5th Dec, 2022

2. CONTENTS INTRODUCTION CLASSIFICATION MANAGEMENT AND ROLE OF SURGERY SPECIAL CONSIDERATIONS SUMMARY

3. Introduction Burn injuries are a significant public health problem. Flame burns most common followed by scald burns. Scald burns among the pediatric population. Household injuries are most common. The average hospital stay : 13 to 60 days. Mortality: 4.5 to 23.5%, with the highest mortality among the flame burn patients.

4. Classification

5. Classfication according to % TBSA involved Mild - Partial thickness burns < 15 % in adult or < 10 % in children. - Full thickness burns < 2 % . Moderate - 2 nd degree of 15–25% burns ( 10–20% in children). - 3 rd degree between 2–10% burns. - Burns which are not involving eyes, ears, face, hand, feet, perineum Severe - 2 nd degree burns >25% in adults, in children >20%. - All 3 rd degree burns of ≥10% . - Burns involving eyes, ears, feet, hands, perineum. - All inhalation and electrical burns. - Burns with fractures or major mechanical trauma

6. Pathophysiology Thermal injuries cause coagulative necrosis of the tissues. Areas of injury: Zone of coagulation Zone of stasis Zone of hyperemia

7. Systemic changes in Burn

8. Managing burn injuries Pre-hospital care: Removing from the source and stopping the burning process, ensuring rescuer safety. Check for other injuries: ABC then rapid secondary survey. Cool the burn wound but avoid hypothermia. Oxygen supplementation. Elevate the limbs. Pre-hospital wound care: clean dry dressing

9. Hospital care With the same principle as any other trauma case: A- airway control B - Breathing and ventilation C - circulation D- disability assessment E - exposure with environmental control F- fluid resuscitation

10. Major determinants of outcome Burn surface area Depth of burn Presence of inhalational injury

11. Assessing Burn Size : Done in a controlled environment, remove any soot or debris, and avoid hypothermia. “ rule of nines ” as a rough guide. Open hand(palm + extended finger) Equal to 1% of TBSA

12. In pediatric population the rule of nine is too imprecise. “ The Lund- Browder chart ”

13. Assessing depth of burn : From history and examination

14. Resuscitation Start if >10% in ped, and >15% in adults. RL in >2ys old and add 5% dextrose in <2yr old. Delay in resuscitation directs to poor outcomes. Relys on the establishment of IV access – short peripheral catheters in normal skin preferred. Intraosseous access in children <6yr – if experience allows. Amount of fluids to be calculated by standard formulas.

15. Standard formulas for fluid resuscitation 50% fluid in first 8 hrs then remaining 50% in subsequent 16hr from injury. Monitoring resuscitation: Urine output 0.5- 1.0 ml/kg/ hr Tetanus prophylaxis is important in burns >10%.

16. Referral to burn center

17. Specific treatment of burns Inhalational injuries Dreaded injury in burn patients. Recognition History of being trapped in presence of smoke or hot gases. Burns on the palate or nasal mucosa; loss of hair in nose. Deep burns around mouth and nose T/t start with 100% O2 supplementation with facial mask.

18. Intubate if.. PaO2 Less than 60 mm Hg PaCO2 More than 50 mm Hg Pa02/Fi02 Less than 200 Respiratory or ventilatory failure Impending Upper airway edema Severe

19. Managing inhalation injuries Bronchodilators. Nebulization with: Heparin 5000-10000 units with 3ml NS every 4 hourly. N-acetylcysteine 20% , 3ml every 4 hours. Hypertonic saline – induces effective coughing. Epinephrine – decreases mucosal edema. Ventilatory support. Bronchoscopic removal of casts.

20. Suspect pneumonia clinically if (any 2): New and persistent infiltrate/ consolidation/ cavitation Sepsis Recent changes in sputum/ purulence in sputum/ culture positive Start treatment accordingly and should cover common hospital-acquired pathogens.

21. Wound care Consists of 3 stages: Assessment Management – thoroughly clean and debride then dressed with non occlusive dressing. First degree wound : No dressing; use topical salves with antimicrobials Use oral NSAIDS Second degree wound : Superficial wound: daily dressing and topical antimicrobials

22. …contd Deep second-degree and third-degree wounds : Require excision and grafting for sizable burns Choice of initial dressing should be aimed at holding bacterial proliferation in check and providing occlusion until the operation is performed.

23. Surgery for acute burn wounds Early debridement and grafting is the key. Early tangential skin excision and early grafting Decrease: hypertrophic scarring, joint contractures, stiffness Quicken rehabilitation. Excision: Skin graft knife or powered dermatome. Sharp excision with knife or electrocautery. Preserve as much viable dermis as possible. Remove all necrotic tissue in full-thickness burns.

24. Techniques of excision Tangential excision Repeated shaving off of deep dermal burns with dermatome until viable dermis reached. Depth : 0.005 – 0.010 inch Full thickness excision Depth: 0.015- 0.030 inch Fascial excision Reserved for 4 th degree/ infected wounds. Leaves permanent contour defects.

25. Escharotomy Deep 2 nd degree or 3 rd degree burns– circumferential burns  compartment syndrome. Longitudinal incision -- lateral and medial aspects. Improves venous outflow e dema under the unyielding eschar decrease. Reperfusion injury may occur after escharotomy – ultimately may require fasciotomy .

26. WOUND COVERAGE Autografts are the mainstay– split-thickness or full thickness. Various biologic and synthetic substrates: Integra, Alloderm . If full thickness burn >40% TBSA  consider allograft and cadaveric skin too.

27. Preventing multiorgan failure Optimal resuscitation Early excision and early surgical management reduce chances of wound infection. Perioperative antibiotics in severe burns. Timely replacement of IV sites. Observing closely for pneumonia and aggressive treatment. Early enteric feeding reduces septic morbidity and prevents gut barrier dysfunction. DVT prophylaxis in patients not at risk of hemorrhage.

28. Attenuating hypermetabolic response Hypermetabolism directly proportional to the size of burn. O2 consumption Metabolic rate Urinary nitrogen excretion Lipolysis Weight loss 200% of the normal metabolic rate. Quick depletion of energy reserves– malnutrition– delayed recovery.

29. Nonpharmacologic modalities Nutritional support– high protein and carbohydrate diet. Environmental supports– preventing hypothermia. Exercise and adjunctive measures– balanced physiotherapy for optimal recovery and rehabilitation. Pharmacologic modalities Recombinant growth hormone Insulin-like growth factors. Testosterone analog oxandrolone

30. Treating late complications Hypertrophic scars Pruritus, erythema, pain, thickened tight skin, and even contractures Treatment Nonsurgical therapies compression garment, and corticosteroid . Surgical excision and scar revision Pulsed dye laser (PDL) and the ablative carbon dioxide (CO2) laser.

31. Joint Contractures Both wound contracture and scar contracture prevent the range of motion of a particular joint. Treatment Nonsurgical and surgical options ranging from pressure garments and splints to laser therapy and contracture excision.

32. Electrical burn ELECTRICAL BURNS Low voltage (<1000V) Similar to thermal burn with less transmission to deeper tissue and local damage. High voltage (>1000V) Various degrees of cutaneous burns Hidden destruction of deeper tissue Muscle sustains the most damage. Can be lethal immediately with associated cardiac arrhythmias Can also be associated with blunt traumatic injuries and fractures.

33. Lichtenberg figures

34. Initially  acute trauma management. Continuous cardiac monitoring is required with pharmacological management. Treatment of wound is the key component. Early exploration and debridement of necrotic muscle may be required. Areas of questionable viability may need re-exploration after 48hrs. Early fasciotomy, sometimes nerve decompression and in some cases early amputation of the affected limb. Injuries to vessels may be delayed and thus extend the necrosis even after initial debridement. Management

35. Closure of the wound is paramount. Skin graft may suffice but may require flaps if bones and tendons are exposed. Vigorous fluid replacement diuresis is required to prevent acute kidney injury due to myoglobin released in the circulation after muscle injury  obstructive nephropathy. Urine output: 2ml/kg/ hr Delayed complications: Neurologic deficits– cortical encephalopathy, hemiplegia, aphasia brainstem dysfunction. Development of cataracts even years after injury. …Continued

36. Chemical burns Extent depends upon : Chemical nature of the agent Concentration Duration of contact Denaturation of proteins; formation of protein esters, Desiccation of tissue Early intervention is very important. A large amount of water required, Eg : 10ml of 98% H2SO4 dissolves in 12 litresof water

37. Alkali burns Usual chemicals: lime, KOH, NaOH, bleach, cement Usually deeper than acid burns. Cause burns by: Saponification of fat Massive extraction of water from cells Treatment Removal of the caustic agent and lavage with a large amount of water. Consider debridement in the operating room. Tangential removal until tissue iremoved is in at normal pH.

38. Acid burns Protein breakdown by hydrolysis: eschar , but the heat generated can still cause further soft tissue damage. Treatment Lavage with a large amount of water Wound management is like any thermal burn, but wounds are deeper than the initial appearance. Large amounts of industrial acid can cause electrolyte abnormalities, renal failure, intravascular hemolysis, and pulmonary complications. Acidemia  from ABG  may require treatment with NaHCO3 Hemodialysis

39. Summary Carry a significant burden as a public health problem. Injury is usually by coagulative necrosis and denaturation of tissue proteins. Initial management starts with same principle of acute trauma management. Early debridement and closure of the wound plays key role in the successful management of burn injuries Proper nutritional, environmental and physical rehabilitation is very important for the optimal recovery of patients.

40. References Williams NS, O‘Connell PR, McCaskie A, editors. Bailey & Love's Short Practice of Surgery: 27 th edition. CRC press; 2018. Townsend CM, Beauchamp RD, Evers MB, Mattox KL. Sabiston Textbook of Surgery. 20 th Edition Schwartz’s Principles of Surgery. 11 th Edition. SRB’s Manual of Surgey . 5 th Edition.