burns management and burns etiology of burns

Burns

1. Burns grafts flaps Subtitle

2. Burns is defined as a wound caused by an exogenous agent leading to coagulative necrosis of the tissue

3. causes ™. 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 : xrays , gamma rays ™. Sun burns

4. So what temperature ? Human skin can tolerate temperatures up to 42-44 C (107-111 F) but above these, the higher the temperature the more severe the tissue destruction Below 45 C (113 F), resulting changes are reversible but >45 C, protein damage exceeds the capacity of the cell to repair

5. Assessment of the burn

6. Assessing the size Burn size needs to be formally assessed in a controlled environment. This allows the area to be exposed and any soot or debris washed off. In the case of smaller burns or patches of burn, the best measurement is to cut a piece of clean paper the size of the patient’s whole hand (digits and palm), which represents 1% TBSA, and match this to the area. Another accurate way of measuring the size of burns is to draw the burn on a Lund and Browder chart , which maps out the percentage TBSA of sections of our anatomy. It also takes into account different proportional body surface area in children according to age. The ‘rule of nines’, which states that each upper limb is 9% TBSA, each lower limb 18%, the torso 18% each side and the head and neck 9%, can be used as a rough guide to TBSA outside the hospital environment

7. Lund and Browder chart

8. Assessing the depth The first indication of burn depth comes from the history. The burning of human skin is temperature- and time-dependen t. It takes 6 hours for skin maintained at 45°C to suffer irreversible changes, but a surface temperature of 70°C for 1 s is all that is needed to produce epidermal destruction. hot water at 65°C: exposure for 45 s will produce a full-thickness burn, for 15 s a deep partial-thickness burn and for 7 s a superficial partial-thickness burn.

9. DEGREE OF BURN

10. 1 st degree burns Here the epidermis looks red and painful, no blisters, heals rapidly in 5–7 days by epithelialisation without scarring. It shows capillary filling Eg sun burn

11. 2 nd degree burn Superficial partial thickness burns The damage in these burns goes no deeper than the papillary dermis. The clinical features are blistering and/or loss of the epidermis. The underlying dermis is pink and moist. The capillary return is clearly visible when blanched. Pinprick sensation is normal. Superficial partial-thickness burns heal without residual scarring in 2 weeks. The treatment is non-surgical

12. Deep partial-thickness burn These burns involve damage to the deeper parts of the reticular dermis. Clinically, the epidermis is usually 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 does not blanch with pressure under the examiner’s finger. Sensation is reduced, and the patient is unable to distinguish sharp from blunt pressure when examined with a needle. Deep dermal burns take 3 or more weeks to heal without surgery and usually lead to hypertrophic scarring

13. 3 rd degree burns / full thickness burns The whole of the dermis is destroyed in these burns. Clinically, they have a hard, leathery feel. The appear- ance 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.

14. Pathophysiology of burns

15. Effects of Burn Injury Hypovolemic shock Renal failure. Respiratory complications -Pulmonary oedema , respiratory infection, ARDS, respiratory failure. Infections- by Staphylococcus aureus , Pseudomonas, Klebsiella etc GIT complications- Erosive gastritis— Curling’s ulcer (seen in burns > 35%). Fluid and electrolyte imbalance.

16. 7. Eschar formation and its complications-defective circulation, ischaemia when it is circumferential. 8. Electrical injuries often cause fractures, major internal organ injury, convulsions. 9. Development of contracture - leads to ectropion, microstomia, disability of different joints, defective hand functions, growth retardation causing shortening

17. 10 . Complications of burns contracture itself like hypertrophic scar, keloid formation and Marjolin’s ulcer DEATH

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

19. 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

20. MANAGEMENT OF BURNS Definitive Treatment • Admit the patient.(Patient should be in burns unit ideally airconditioned ) • Maintain Airway, Breathing, Circulation. • Assess the percentage, degree, and type of burn. • Sedation and proper analgesia. • Fluid management

21. MANAGEMENT OF BURNS • Chemoprophylaxis – tetanus toxoid ; antibiotics; local antiseptics • Covering with dressings by different methods . • Total Parenteral Nutrition (TPN) is required for faster recovery, using carbohydrates, lipids, vitamins (through a CVP line). • Tracheostomy /intubation tube may be required in impending respiratory failure

22. MANAGEMENT OF BURNS Local Management • Dressing at regular intervals under general anaesthesia • Tangential excision of burn wound with skin grafting can be done within 48 hours in patients with less than 25 % burns. It is usually done in deep dermal burn wherein dead dermis is removed layer by layer until fresh bleeding occurs. Later skin grafting is done. • Slough excision is done regularly.

23. MANAGEMENT OF BURNS Prevention of development of contracture • Joint exercise in full range during recovery period of burns • Pressure garments for a long period • Topical silicon sheeting • Saline expanders for scars

24. Management Contractures Scar excision Scar release Z plasty Tendon release Flaps Skin grafting

25. Principles of physiotherapy Range of Motion (ROM) Muscle strength Mobility status General functional status Respiratory assesment Education Rehabilitation

26. PLASTIC AND RECONSTRUCTIVE SURGERY

27. GRAFTS Definition: Grafts are tissues that are transferred without their blood supply Types of Grafts: (Based on donor origin) Autograft - both donor and recipient are same Allograft- different individuals of same species Isograft - identical twins Xenograft - different species

28. TYPES OF SKIN GRAFT Split-thickness skin grafts ( Thiersch grafts) . Full-thickness skin grafts (Wolfe grafts) Composite skin grafts (usually skin and fat, or skin and cartilage).

29. Graft anatomy Split-thickness skin grafts Harvested by taking all of the epidermis together with some dermis, leaving the remaining dermis behind to heal the donor site.

30. Graft Anatomy Full-thickness skin grafts Harvested to incorporate the whole dermis, with the underlying fat trimmed away Full-thickness and composite grafts require the most careful handling and postoperative nursing to help ensure that they ‘take’ in their transplanted site.

31. How does a skin graft survive? Initially by imbibition of plasma from the wound bed; after 48 hours, fine anastomotic connections are made, which lead to inosculation of blood. Neovascularisation : Capillary ingrowth then completes the healing process with fibroblast maturation. Skin grafts inevitably contract , with the extent of contracture determined by the amount of dermis taken with the graft and the level of postoperative splintage and physiotherapy applied to the grafted site.

32. INDICATIONS FOR SKIN GRAFT Well granulated ulcer Clean wound or defect which can not be apposed After surgery to cover and close the defect created For example: After wide excision in malignancy After mastectomy After wide excision in squamous cell carcinoma

33. CONTRAINDICATIONS SSG can not be done over bone, tendon, cartilage, joint Infection with B hemolytic streptococcus-causes graft lysis Collagen vascular disease

34. ADVANTAGES OF SSG Technically easier. Wide area of recipient can be covered. Graft take up is better. Donor area heals on its own.

35. Disadvantages Contracture of graft Seroma and haematoma formation will prevent graft take up. Infection. Loss of hair growth, blunting of sensation. Dry, scaling of skin due to nonfunctioning of sebaceous glands. Cosmetically not same color and texture

36. FULL THICKNESS (WOLFE) GRAFT It includes both epidermis + full dermis. It is used over the face, eyelid, hands, fingers and over the joints. Common sites of donor area 1. Post auricular area 2. Supraclavicular area 3. Groin crease area

37. Advantages Colour match is good. Especially for face. No contracture Sensation, functions of sebaceous glands, hair follicles are retained better compared to SSG. Functional and cosmetic results are better 1..

38. Disadvantages 1. It can be used only for small areas. 2. Wider donor area has to be covered with SSG to close the defect

39. FLAPS Definition Flaps are tissues that are transferred with a blood supply. Types of flaps Random flaps. Axial flaps. Pedicled /islanded flaps. Free flaps- Composite flaps- Various tissues are transferred together, often skin with bone or muscle ( osseocutaneous or myocutaneous flaps, respectively).

40. FLAPS

41. Flaps Local flaps A local flap is raised next to a tissue defect in order to reconstruct it. Types: Transposition flap. Z- plasty . For lengthening scars or tissues; Rhomboid flap. Rotation flap. Advancement flap. Bilobed flap. For convex surfaces, especially the nose Bipedicle flap. For eyelids, rarely elsewhe

42. FREE FLAPS Here the blood supply of the flap is disconnected from its donor site and reconnect it in a distant place using the operating microscope. Advantages Able to select exactly the best tissue to move Only takes what is necessary Minimises donor site morbidity Disadvantages More complex surgical technique Failure involves total loss of all transferred tissue Usually takes more time

43. Advantages of Flaps 1. Good blood supply, good take up. 2. Gives bulk, texture, colour to the area. 3. Allows required movements in the recipient area. For example, jaw movements after pectoralis major flap after wide excision with hemimandibulectomy for carcinoma cheek. 4. Cosmetically better.

44. Disadvantages of Flaps 1. Long-term hospitalisation . 2. Infection. 3. Kinking, rotation and flap necrosis. 4. Staged procedure.

45. Causes of flap failure: poor anatomical knowledge when raising the flap (such that the blood supply is deficient from the start) flap inset with too much tension local sepsis or a septicaemic patient; the dressing applied too tightly problems with surgical technique tobacco smoking by patient

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