BURN.pptx important surgery topic answer pdf

Burn formula, management, complications

1. BURN Dr. GOVIND KUSHWAH M.S. (GENERAL SURGERY) ASSISTANT PROFESSOR DEPT. OF GEN. SURGERY ABVGMC VIDISHA(M.P.)

2. BURN 1.Typesof burn 2.Classification of burn 3.Pathophysiology of burn 4.Management of burn 5.Complication of burn

3. Types of Burns • Thermal injury – Scald – spillage of hot liquids – Flame burns – Flash burns due to exposure of natural gas,alcohol , combustible liquids – Contact burns – contact with hot metals/objects/materials • Electrical injury • Chemical burns – acid/alkali • Cold injury — frost bite • Ionising radiation • Sun burns

4. Classification of Burns I. Depending on thickness of skin involved a. First degree :Here the epidermis looks red and painful, no blisters, heals rapidly in 5-7 days by epithelialization without scarring. b. Second degree: The affected area is mottled, red, painful, with blisters, heals by epithelialization in 14-21 days. c. Third degree: The affected area is charred, parchment like, painless and insensitive, with thrombosis of superficial vessels. It requires grafting. Charred, denatured, insensitive, contracted full thickness burn is called as eschar . These wound must heal by reepithelialization from wound edge. d. Fourth degree: Involves the underlying tissues— muscles, bones

5. II. Depending on thickness of skin involved a.Partial thickness burns: It is either first or second degree burn which is red and painful, often with blisters b. Full thickness burns: It is third degree burns which is charred, insensitive, deep involving all layers of the skin.

6. Depending on the Percentage of Burns 1.Mild (Minor): • Partial thickness burns < 15% in adult or <10% in children. Full thickness burns less than 2%. • Can be treated on outpatient basis. 2.Moderate: • Second degree of 15-25% burns (10-20% in children). • Third degree between 2-10% burns. • Burns which are not involving eyes, ears, face, hand, feet, perineum.

7. 3.Major (severe): • Second degree burns more than 25% in adults, in children more than 20%. • All third degree burns of 10% or more. • Burns involving eyes, ears, feet, hands, perineum. • All inhalation and electrical burns. • Burns with fractures or major mechanical trauma.

8. Assessment of Burns • Wallace’s rule of nine is used for early assessment . • Using the Lund and Browder chart is better method for assessing the burns wound. Clinical Features • H/o burn. • Pain, burning, anxious status, tachycardia, tachypnoea , fluid loss. • In severe degrees features of shock.

9. Pathophysiology of burn Heat causes coagulation necrosis of skin and subcutaneous tissue. ↓ Release of vasoactive peptides ↓ Altered capillary permeability ↓ Loss of fluid ↓ Severe hypovolaemia ↓ Decreased cardiac →→ → Decreased myocardial output function ↓ Decreased renal blood flow (Renal failure ) →→ → Oliguria Decreased cardiac ↓ Altered pulmonary resistance causing pulmonary oedema ↓ Infection ↓ Systemic Inflammatory Response Syndrome (SIRS) ↓ Multi Organ Dysfunction Syndrome (MODS)

10. Effects of Burn Injury 1. Shock due to hypovolaemia . 2. Renal failure. 3. Pulmonary oedema , respiratory infection, adult respiratory distress syndrome (ARDS),respiratory failure. 4. Infection . 5. GIT: Hypovolaemia , ischaemia of mucosa, erosive gastritis—Curling’s ulcer (seen in burns > 35%). 6. Fluid and electrolyte imbalance. 7. Postburn immunosuppression predisposes to severe opportunistic infection. 8. Eschar formation and its problems like defective circulation, ischaemia when it is circumferential. 9. Electrical injuries often cause fractures, major internal organ injury, convulsions. 10. Development of contracture is a late problem. 11. Inhalation burn causes pulmonary oedema , respiratory arrest, ARDS. 12. Chemical injury causes severe GIT disturbances like erosions, perforation, stricture oesophagus (alkali), pyloric stenosis (acid), mediastinal injury. 13. Other problems commonly seen are DVT, pulmonary embolism, urinary infection, bed-sores, severe malnutrition with catabolic status, respiratory infection. 14. Complications of burns contracture itself like hypertrophic scar, keloid formation. 15. Toxic shock syndrome: It is a life-threatening exotoxin mediated disease caused by Staphylococcus aureus .

11. Causes of death in burns a. Hypovolaemia and shock b. Renal failure c. Pulmonary oedema and ARDS d. Septicaemia e. Multiorgan failure

12. MANAGEMENT OF BURNS First Aid • Stop the burning process and keep the patient away from the burning area. • Cool the area with tap water by continuous irrigation for 20 minutes (not cold water as it can cause hypothermia). Indications for admission in burns • Any moderate and severe burns •Airway burns of any type • Burns in extremes of age • All electrical/deep chemical burns Initial management •Clothing should be removed •Cooling of the part by running water for 20 minutes •Cleaning the part to remove dust, mud etc •Chemoprophylaxis – tetanus toxoid ; antibiotics; local antiseptics •Covering with dressings by different methods •Comforting with sedation and pain killer

13. Definitive Treatment • Admit the patient. • Maintain Airway, Breathing, Circulation. • Assess the percentage, degree, and type of burn. • Keep the patient in a clean environment. • Sedation and proper analgesia. • Patient should be in burns unit(ideally air conditioned) with barrier nursing, sterile clothes, bed sheets with all aseptic methods.

14. Fluid Resuscitation Formulas to calculate the fluid replacement: a. Parkland regime : Commonly used 4 ml/% burn/kg body weight/24 hours. Maximum percentage considered is 50%. Half the volume is given in first 8 hours, rest given in 16 hours. b. Muir and Burclay regime: c. Galveston regime (pediatric) d. Modified Brooke formula e. Evan’s formula

15. -Fluids used are normal saline, ringer lactate, Hartmann fluid, plasma. - Ringer lactate is the fluid of choice . First 24 hours only crystalloids should be given. (Crystalloids are one which can pass through capillary wall like saline either hypo, iso or hypertonic, dextrose saline, ringer lactate.) -After 24 hours up to 30-48 hours, colloids should be given to compensate plasma loss. (colloids are one which are retained in intravascular compartment). Plasma, haemaccel (gelatin), dextrans , hetastarch are used. Blood is transfused in later period (after 48 hours). • Urinary catheterization to monitor output; 30-50 ml/ hour should be the urine output. • Tetanus toxoid .

16. Local Management :- Dressing Open method with application of silver sulfadiazine without any dressings, used commonly in burns of face, head and neck. Closed method is with dressings done to soothen and to protect the wound, to reduce the pain, as an absorbent Tangential excision of burn wound with skin grafting can be done within 48 hours in patients with lessthan 25 % burns. • Slough excision is done regularly. • After cleaning with povidone iodine solution silver sulfadiazineointment is used. It is an antiseptic and soothening agent. It causes neutropenia.Other agents used are Sulfamylon ( Mafenide acetate) and Silver nitrate.

17. Regular culture and sensitivity for bacteria is required, to see for streptococcal growth which should be less than 1,00,000 per gram of tissues. • Once the area granulates well, in 3 weeks usually, split skin grafting is done (SSG, Thiersch graft). • For wider area MESH split skin graft is used. • If there is eschar , escharotomy is required to prevent compression of vessels. • In certain areas like face and ear, full thickness graft (Wolfe graft) or flap is required.

18. Thank you Dr. GOVIND KUSHWAH M.S. (GENERAL SURGERY) ASSISTANT PROFESSOR DEPT. OF GEN. SURGERY ABVGMC VIDISHA(M.P.)