BURNS in Surgery part 1. Prof. Soria.pptx

Burns in Surgery

1. BURNS BY PROF. JORGE SORIA LA O

2. DEFINITION Coagulative destruction of the superficial layers of the body . Includes skin & any other tissues below it.

3. AETIOLOGY: Heat burns: Is the commonest cause of burns Two forms are known. Dry heat (Flames & hot objects). Wet heat (water, oil, porridge, etc ). Severity of burns depends on temperature & duration of contact as well as the size and depth of the burn

4. AETIOLOGY ( cont ): Electrical Burns: Electric currency is converted into heat Clinically electrical burns are deceptive Considered major burns Chemical Burns: Chemical reactions release heat ( exothermia ) They continue to cause burns even after withdrawal of the source . Friction Cold

5. PATHOPHYSIOLOGY: LOCAL EFFECTS: Other than epidermal injury, there is too dermal capillary damage They dilate and become permeable causing: F luid extravasation and formation of blisters locally or/and edema generally. This fluid contains protein (albumin), hence loss to tissues. Fluid movement peaks up 48hrs after burns, there after reabsorption resumes. Fluid lost in to tissue is proportional to the burnt area & capillaries damaged So, large burns can cause hypovolemia and shock!

6. Burns destroy the normal skin barrier, exposing it to infection Excessive wound colonization causes: Tissue destruction Delayed healing Interfere with skin graft take Absorption of toxins leading to toxic shock and death.

7. GENERAL EFFECTS: Loss of plasma causes, hypovolemia and haemoconcentration, hence increased blood viscosity Hypovolemic Shock develops later with the fall of BP & raise of pulse rate Burns damage RBCs, increasing their fragility and so decreasing their life span. Severe hypovolemia damages other organs like the kidneys, which may result into renal failure Urine out put of less than 0.5ml/kg/ hr suggests acute renal failure Persistent poor renal perfusion leads to irreversible renal damage.

8. Severe loss of body protein results into: Serious weight loss Pressure sores L ower resistance to infections Delayed wound healing Failure of skin graft take Causes of protein loss: Burns triggers cortisol release, to cause Protein catabolism Gluconeogenesis Impaired insulin release Insulin resistance This protein catabolism continues till healing is well advanced

9. A massive catabolic drive is initiated described as Autocannibalism . Characterized by : Increased metabolism Increased oxygen consumption Increased nitrogen loss Wasting of energy due to heat & water loss Energy demands increase due to: Infection/Sepsis Hypothermia Further trauma of surgery Pain & anxiety

10. INITIAL EVALUATION Involves four crucial assessments: Airway management. Evaluation of other injuries. Estimation of burn size and depth. Diagnosis of Co and cyanide poisoning (metabolic poisoning).

11. AIRWAY MANAGEMENT Asses for: Direct thermal injury to the upper airway Smoke inhalation R apid and severe airway oedema is a potentially lethal threat . Anticipating the need for intubation and establishing an early airway are critical.

12. SIGNS OF BURN INJURY TO THE UPPER AIRWAY Perioral burns and singed nasal hairs. Signs of impending respiratory compromise: hoarse voice wheezing stridor subjective dyspnea These are concerning symptoms and should trigger prompt endotracheal intubation.

13. EVALUATION OF OTHER INJURIES Burned patients should be first considered trauma patients. P rimary survey in accordance with ATLS guideline. Large-bore peripheral intravenous (IV) catheters. F luid resuscitation should be initiated. P atients with burns smaller than 15 % can be hydrated orally . S econdary survey must be performed on all burn patients. Deficits Hypothermia is a common prehospital complication that contributes to resuscitation failure. Patients should be wrapped with clean blankets in transport. A tetanus booster should be administered in the emergency room. Pain management and treatment of long-term anxiety (administer an anxiolytic such as a benzodiazepine).

14. ESTIMATION OF BURN SIZE Two criteria are in use: Wallace rule of nine (for adults ) Laud & Browder rule ( rule of seven) for children

15. WALLACE RULE OF NINE: Very useful in estimating fluid requirement in the management of burns. Considers : Head ---------------- 9% Trunk ---------------- 18% x 2 Upper limbs -------- 9 % x 2 Lower limbs --------- 18% x 2 Perineum -------------1%

16. RULE OF SEVEN: Considers children’s anatomy Head ------------- 28% Trunk --------------14 % x 2 Upper limb ------- 7 % x 2 Lower limb --------14 % x 2 Perineum ---------- 2%

17. Based on %age surface burned, burns can be classified into : Major burns TBSA of 15% and above for adults & 10% and above for children . Managed as in patient & treated with I/V fluids Minor burns This can be managed as out patient with oral fluids

18. DEPTH OF BURNS Difficult to assesses due to mixed picture. Includes: Superficial partial thickness b urns The clinical features are blistering and/or loss of the epidermis . The damage goes no deeper than the papillary dermis. The underlying dermis is pink and moist. The capillary return is clearly visible when blanched. Pinprick sensation is normal. H eal without residual scarring in 2 weeks . The treatment is non-surgical

19. Deep partial-thickness burn I nvolve damage to the deeper parts of the reticular dermis. The epidermis is lost. The exposed dermis is not as moist as that in a superficial burn. There is often abundant fixed capillary staining, especially if examined after 48 hours. The colour is pink pale and does not blanch with pressure. Sensation is reduced, patient is unable to distinguish sharp from blunt pressure when examined with a needle. Take 3 or more weeks to heal without surgery and usually lead to hypertrophic scarring

20. Full-thickness burns The whole of the dermis is destroyed in these burns. Clinically , they have a hard, leathery feel. The appearance can vary from that similar to the patient’s normal skin to charred black, depending upon the intensity of the heat. There is no capillary return. Often , thrombosed vessels can be seen under the skin. These burns are completely anaesthetised: a needle can be stuck deep into the dermis without any pain or bleeding. Difficult to heal without surgical treatment

21. DIAGNOSIS OF CO AND CYANIDE POISONING (METABOLIC POISONING). It is provoked by inhalation of carbon monoxide and other toxic gases H istory of a fire within an enclosed space. History of altered consciousness. Blood gases must be measured immediately. Carboxyhaemoglobin levels raised above 10% must be treated with high inspired oxygen for 24 hours. Metabolic acidosis is a feature of this and other forms of poisoning. Blood gas measurement will confirm the diagnosis. The treatment is oxygen.

22. Other problems to asses in burn patients Inhalational injury Provoked by inhalation of minute particles dissolved in the thick smoke A nyone trapped in a fire for more than a couple of minutes must be observed for signs of smoke inhalation . Signs that raise suspicion: soot in the nose and the oropharynx and patchy consolidation in chest x-ray . C linical features: P rogressive increase in respiratory effort and rate R ising pulse A nxiety and confusion Decreasing oxygen saturation.

23. S ymptoms can take 24 hours to 5 days to develop. Treatment starts as soon as this injury is suspected and the airway is secured. Physiotherapy , nebulisers and warm humidified oxygen are all useful. The patient’s progress should be monitored using respiratory rate, together with blood gas measurements. In the severest cases, intubation and management in an intensive care unit will be needed. The key, therefore, in the management of inhalational injury is to suspect it from the history, institute early management and observe carefully for deterioration.

24. Mechanical block to breathing Full-thickness burn on the chest wall creates an eschar which impedes breathing. The treatment is to make some scoring cuts through the burned skin to allow the chest to expand ( escharotomy ). The nerves have been destroyed in the skin, and this procedure is not painful for the patient. Compartmental syndrome Limb threatening

25. TREATMENT: First Aid: Remove patient from source of burns Flash the patient with copious amount of water Avoid breaking blisters early Cover wounds with clean & dry material Relief pain with I/V analgesics

26. General treatment: Major burns must be admitted for I/V fluid management Always start with crystalloids: RL, NS, HS, etc . If a patient presents with hypovolemia, best fluid should be colloids; blood, plasma or dextran. Caution : fluid extravasation

27. FLUID CALCULATIONS: Parkland formula 4ml x kgBwt x %BSA = fluid needed in 24hours ½ in first 8hrs ¼ in next 8hrs ¼ in last 8hrs After 48hrs, fluid loss decreases, fluid infusion should decrease too The formula helps to estimate fluid requirement, but rest should be in accordance to patient response. So monitor: Haematocrit . Urine out put ( e.g in a 20% burns, U.O of 35 – 60mls/ hr in an adult is enough)

28. Monitor the following: Physical signs: Pallor, coldness, restlessness & collapsed peripheral veins These suggest hypovolemia Give colloids Serum electrolytes Should be assessed regularly especially for potassium ion concentration

29. LOCAL TREATMENT: Aims : Minimise infection Prevent further tissue loss Restore the burnt surfaces Wound dressing Promote wound healing Rehabilitation.

30. Bibliography: Bailey and Love’s Short Practice of Surgery Schwartz’s Principle of Surgery