Burns.pptx

Burns

1. Burns Dr Janai A. M. Ondieki For Clinical Medicine Diploma Class yr 2

2. Definitions Burns are caused by transfer of energy from a heat source to the body. Heat may be transferred through conduction or electromagnetic radiation. Burns are defined as a wound caused by exogenous agent leading to coagulative necrosis of tissue Tissue destruction results from coagulation, protein denaturation , or ionization of cellular contents.

3. Aetiology Thermal Burns Dry Heat Contact Burn Flame Burn Moist Heat-Scald Burn Smoke and Inhalation Chemical Burns Acids and Alkali Electrical Burns -High & Low Voltage Cold Burns - Frost bIte Radiation

4. Thermal Burns Heat changes the molecular structure of tissue causing denaturing of proteins The extent of burn damage depends on Temperature Amount of heat Duration of contact For example, in the case of scald burns in adults, 1 second of contact with hot tap water at 68.9°C (156°F) may result in a burn that destroys both the epidermis and the dermis , causing a fullthickness (third-degree) injury. Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar full-thickness injury.

5. The effects of thermal burns are influenced by Intensity of the energy the duration of exposure the type of tissue injured

6. Pathophysiology of burns Burns that do not exceed 25% TBSA produce a primarily local response. Burns that exceed 25% TBSA may produce both a local and a systemic response and are considered major burn injuries. The incidence, magnitude, and duration of pathophysiologic changes in burns are proportional to the extent of burn injury, with a maximal response seen in burns covering 60% or more TBSA These systemic responses are due to the release of cytokines and other mediators into the systemic circulation

7. Fluid shift period of inflammatory response Vessels adjacent to burn injury dilate, increased capillary hydrostatic pressure and permeability Continous leak of plasma from intravascular space into interstitial space associated imbalences in fluids, electrolytes and acid-base occur Haemoconcentration Lasts 24-36 hours

8. Fluid mobilization capillary leak ceases and fluid shifts back into the circulation Restores fluid balance and renal perfusion increased urine formation and diuresis continued electrolyte imbalances hypokalaemia Hyponatremia Haemodilution

9. Systemic Changes Cardiac decreased cardiac output Pulmonary Respiratory insufficiency as a secondary process can lead to respiratory failure Gastrointestinal Decreased or absent motility Stress Ulcer formation ( Curlings Ulcer)

10. Metabollic Hypermetabolic state increased oxygen and calorie requirements increased in core body temperature Immunological loss of protective barrier increased risk of infection suppression of humoral and cell-mediated immune responses

11. Acute Phase Clinical issues External loss of Plasma Loss ofd circulating red cells Burn oedema

12. Sub Aute Phase Diuresis Clinical Anaemia Accelerated metabolic rate Nitrogen Disequilibrium Bone and joint changes Endocrine disturbances Electrolyte and chemical imbalance circulatiry derangements loss of function of skin as an organ

13. Body's response to Burns Emergent Phase (stage 1) Pain response Catecholamine release tachycardia, tachypnoea , mild Hypertension, mild anxiety Fluid Shift Phase (stage 2) Length 8-24 hours Begins after emergent phase reaches peak in 6-8 hours damaged cells initiate inflammatory response increased blood flow to cells Shift of fluid from intravascular to extra vascular space MASSIVE OEDEMA

14. Hypermetabolic Phase (stage 3) Lasts for days to weeks Large increase in the body's need for nutrients as it repairs itself Resolution phase(stage 4) scar formation general rehabilitation and progression to normal function

15. Jackson's theory of Thermal Burns Zone of coagulation Area nearest to the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels Zone of Stasis Area surrounding zone of coagulation characterized by decreased blood flow Zone of Hyperemia Peripheral area around burn that has increased blood flow

16. Severity of burns is determined by depth of the burn Extent of the burn/total Burn Surface A (TBSA) Location of the burn Patient risk factors

17. Grading of burn according to depth First Degree - Injury to the Epidermis Superficial Second Degree - injury to epidermis and Superficial Papillary dermis Deep secondary Degree - Injury from epidemis to reticular dermis Third degree -full thickness burn through epidermis and all layers of dermis Fourth degree - injury trhough skin, subcutaneous fat into underlying muscle or bone

18. Burn Depth Burn depth determines whether epithelialization will occur. Determining burn depth can be difficult even for the experienced burn care provider. The following factors are considered in determining the depth of the burn: How the injury occurred Causative agent, such as flame or scalding liquid Temperature of the burning agent Duration of contact with the agent Thickness of the skin

19. 1st Degree Burn Involves only the epidermis Reddening/Darkening of the skin Pain at burn site Blanch to touch Have an intact epidermal barrier Do not result in scarring Examples: Sun Burn, Minor Scald from Kitchen accident Treatment aimed at comfort

20. 2nd degree Superficial Burn Involves the epidermis and papillary dermis Intense pain Blisters reddening/darkening Spares hair follicles , sweeat glands etc erythematous & blanch to touch Very painful/sensitive No/Minimal Sacrring Spontaneously re- epithelialize from retained epidermal structures in 7-14 days

21. 2nd degree deep burn Involves the epidermis and reticular dermis less pain, remain painful to pin prick Appears pale and mottled do not blanch to touch capillary return sluggish or absent takes 14-35 days to heal by epithelialisation from hair follicles & sweat glands often with severe scaring Contractures possible may require excision & skin grafting

22. 3rd degree burns dry, leathery skin(white, dark, brown or charred) Loss of sensation All dermal layers are invovled will require surgery

23. 4 Th degree Burn Involves underlying tissue e.g. bone, tendons, muscle etc..

24. Assessing Total Burn Surface Area Rule of Nines best used for large surface areas Expedient tool to measure extent of burn Modified to Rule of S evens for pediatric age group Rule of palms best used for burns< 10% BSA Lund and Browder Chart

25. Rule of Sevens for children

26. 98% 94% 45% 65%

27. Criteria for Classifying the Extent of Burn Injury(American Burn Association) Minor Burn Injury Second-degree burn of less than 15% total body surface area(TBSA) in adults or less than 10% TBSA in children Third-degree burn of less than 2% TBSA not involving special care areas (eyes, ears, face, hands, feet, perineum, joints ) Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients ( eg , extremes of age, concurrent disease) 31

28. Criteria for Classifying the Extent of Burn Injury(American Burn Association) Moderate, Uncomplicated Burn Injury Second-degree burns of 15%–25% TBSA in adults or10%–20% in children Third-degree burns of less than 10% TBSA not involving special care areas Excludes electrical injury, inhalation injury, concurrent trauma, all poor-risk patients ( eg , extremes of age, concurrent disease) 32

29. Criteria for Classifying the Extent of Burn Injury(American Burn Association) Major Burn Injury Second-degree burns exceeding 25% TBSA in adults or 20% in children All third-degree burns exceeding 10% TBSA All burns involving eyes, ears, face, hands, feet, perineum, joints All inhalation injury, electrical injury, concurrent trauma, all poor-risk patients 33

30. Pre Hospital care for burn victims Ensure rescuer safety Stop the burning process: Stop, drop and roll Check for other injuries Standard ABC (airway, breathing, circulation)followed by a rapid secondary survey Cool the burn wound Analgesia Slows the delayed microvascular damage minimum of 10 min effective up to 1 hour after the burn injury give oxygen elevate

31. Management of the Patient With a Burn Injury 35 Burn care must be planned according to the burn depth and local response , the extent of the injury , and the presence of a systemic response . Burn care then proceeds through three phases: Emergent/resuscitative phase (on-the-scene care), Acute/intermediate phase, and Rehabilitation phase. Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.

32. Table: phases of burn care 36 Phase Duration Priorities Emergent or immediate resuscitative From onset of injury to completion of fluid resuscitation First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Wound assessment and initial care Acute From beginning of diuresis to near completion of wound closure Wound care and closure Prevention or treatment of complications, including infection Nutritional support Rehabilitation From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment Prevention of scars and contractures Physical, occupational, and vocational rehabilitation Functional and cosmetic reconstruction Psychosocial counseling

33. Criteria for admission to hospital/Burns Unit suspected airway/inhalational injury any burn requiring fluid resuscitation (>15% in adults and 10% in children) any burn requiring surgery burns to special areas; face, hands, feet perineum pts with psychiatric or social circumstance making it inadvisable to send them home any suspicion of non-accidental Injury Any burn in a patient at extremes of age any burn associated with potentially serious sequelae high tension electrical burns Chemical burns

34. Emergent/resuscitative phase mgt Emergency Medical Management A : Airway Control B: Breathing and ventilation C: Circulation D: Disability - neurological status E: Exposure with environmental control F: Fluid resuscitation 38

35. Airway Recognition of the potentially burned airway A history of being trapped in the presence of smoke or hot Gases Burns on the palate or nasal mucosa, or loss of all the hairs in the nose burns around the mouth and neck

36. Burned airway Early elective intubation is safest Delay can make intubation very difficult because of Swelling Be ready to perform an emergency cricothyroidotomy if intubation is delayed

37. Upper Airway Injury Injury above the glottis Results from direct heat (hot air) or edema Manifested by mechanical obstruction of the upper airway, including the pharynx and the larynx Assess patients for facial burns, erythema , swelling, tachypnea , dyspnea, hoarsness , and singed nasal hairs. Treatment: early endotracheal or nasotracheal intubation

38. Lower Airway Injury Injury below the glottis Results from inhaling toxic gases and chemical contained in inhaled smoke When these substances come in contact with pulmonary mucosa, irritation and inflammation reaction occurs, resulting in hypersecretion, severe mucosal edema, ciliary action , and possibly bronchospasm Pulmonary surfactant is reduced, causing atelectasis Assess patient for expectoration of sputum with carbon particles

39. Carbon Monoxide (CO) Poisoning CO is a colorless, odorless gas that is a by-product of the combustion of organic materials. The affinity of hemoglobin for CO is 200X greater than that for O₂ CO combines with hemoglobin to form carboxyhemoglobin and blocks the uptake of O₂ and causing tissue hypoxia Treatment: early intubation and mechanical ventilation with 100% O₂

40. Fluids for resuscitation In children with burns over 10% TBSA and adults with burns over 15% TBSA, consider the need for intravenous fluid resuscitation Fluids needed can be calculated from a standard formula Parkland Formula : Total percentage body surface area × weight(kg) × 4 = volume (ml ) Half this volume is given in the first 8 hours, and the second half is given in the subsequent 16hours.

41. Crystalloid : Ringer’s lactate Hypertonic saline Human albumin solution Colloid resuscitation Not Routinely Used in Our set up !!

42. Management of fluid loss and shock Fluid Replacement Therapy: The total volume and rate of intravenous fluid replacement are gauged by the patient’s response. The adequacy of fluid resuscitation is determined by: urine Output totals of 30 to 50 mL /hour systolic blood pressure exceeding 100 mm Hg and/or pulse rate less than 110/minute. 46

43. Conditions Leading to Burn Shock 47

44. Acute Phase management Hemodynamically stable through diuresis Capillary permeability is restored 48-72 hours after injury Goal is restorative therapy Focus on infection control, wound care and closure, nutritional support, pain management, PT Concluded when the burned area is completely covered by skin grafts or when the wounds are healed 48

45. Full to deep partial thickness HWB Skin graft Day 1 3 weeks Day 12

46. Acute Phase management Pathophysiology Diuresis from fluid mobilization occurs, and the patient is no longer grossly edematous Bowel sounds return Healing begins Formation of granulation tissue A partial-thickness burn wound will heal from the edges Full-thickness burns must be covered by skin grafts 50

47. Acute Phase management • Wound Care Daily observation Assessment Cleansing Debridement Appropriate coverage of the burn 51

48. TREATING THE BURN WOUND Escharotomy Circumferential full-thickness burns to the limbs require emergency surgery . The tourniquet effect of this injury is easilytreated by incising the whole length of full-thickness burns .. Escharotomy • Incise along medialand /or lateral surfaces . Avoid bonyprominences . Avoid tendons, nerves,major vessels.

49. Debridement• Types of debridement : 1 . Auto debridement . 2 . Tangential excision (at the end of 1st week ) 3 . Staged primary debridement (1-3 days postburn ). This early debridement of dead tissue interrupts and attenuates the systemic inflammatory response and normalize immune function .4. For deep circumferential burn , urgent escharotomy is done

50. Superficial burns expected to heal by epitheliaization are managed by either Exposure Method or by Closed Dressing

51. Acute Phase management Excision and Grafting Eschar is removed down to the subcutaneous tissue or fascia and skin grafts done 55

52. Acute Phase management Surgeon Harvesting Skin 56

53. Acute Phase management Donor Site After Harvesting 57

54. Acute Phase management Healed Split-Thickness Skin Graft 58

55. Acute Phase management Pain Management Opioids Several drugs in combination ( MULTIMODAL ANALGESIA) Non pharmacologic strategies • Relaxation tapes • Visualization, guided imagery • Meditation 59

56. Acute Phase management Nutrition Burns patients need extra feeding A nasogastric tube should be used in allpatients with burns over 15% of TBSA Removing the burn and achieving healing stops the catabolic drive. Nutrition Sutherland formula Children : 60 kcal/ kg + 35 kcal% TBSA Adults : 20 kcal /kg + 70 kcal% TBSA Protein20 % of energy1.5 to 2 g/kg protein/day

57. Acute Phase management Infection Prevention T etanus prophylaxis Tetanus toxoid , 0.5 mL intramuscularly, if thelast booster dose was more than 5 years beforethe injury . If immunization status is unknown,human tetanus immunoglobulin 250 to 500units, I.M. plus tetanus toxoid in opposite side Monitoring and control of infection Burns patients are immunocompromised They are susceptible to infection from manyroutes Sterile precautions must be rigorous Swabs should be taken regularly A rise in white blood cell count,thrombocytosis and increased catabolism are warnings of infection

58. Topical treatment of deep burns 1% silver sulphadiazine cream • 0.5% silver nitrate solution Mafenide acetate cream• Serum nitrate, silver sulphadiazine and ceriumnitrate

59. Rehabilitation Phase The rehabilitation phase is defined as beginning when the patient’s burn wounds are covered with skin or healed and the patient is able to resume a level of self-care activity Complications Skin and joint contractures Hypertrophic scarring 63

60. Rehabilitation Phase Both patient and family actively learn how to care for healing wounds Cosmetic surgery is often needed following major burns Role of exercise (physiotherapy) cannot be overemphasized Constant encouragement and reassurance Address spiritual and cultural needs Maintain a high-calorie, high-protein diet Occupational therapy 64

61. Complications of Burns Emergent phase Shock and multi organ failure Renal failure Respiratory failure (inhalational Injury) Hypothermia

62. Acute phase Infection Wound infection, hypostatic pneumonia Curling’s (stress ulcers) Anaemia Hypoproteinaemia Deep Venous Thrombosis Paralytic ileus

63. Long term complications Contractures Hypertrophic scars Keloids Marjolin’s Ulcers Psychological problems

64. Contractures 68

65. Chemical Burns Chemical Burns Acids • Protein injury by hydrolysis . • Thermal injury is made with skin contact . Alkali • Saponification of fat • Hygroscopic effect- dehydrates cells • Dissolves proteins by creation of alkaline proteinates (hydroxide ions)

66. Electrical Burns Greatest heat occurs at the points of resistance –Entrance and Exit wounds –Dry skin = Greater resistance – Wet Skin = Less resistance Longer the contact, the greater the potential of injury Increased damage inside body Smaller the point of contact, the more concentrated the energy, the greater the injury .

67. Electrical Current Flow –Tissue of Less Resistance • Blood vessels • Nerve –Tissue of Greater Resistance • Muscle • Bone Results in……….. –Serious vascular and nervous injury –Immobilization of muscles –Flash burns Late complications: cataracts, progressive demyelinating neurologic loss

68. Assess patient Entrance & Exit wounds Remove clothing, jewelry , and leather items Treat any visible injuries– Thermal burns ECG monitoring– Bradycardia , Tachycardia, VF or Asystole – Treat cardiac & respiratory arrest– Aggressive airway, ventilation, and circulatory management . Consider Fluid bolus for serious burns– 20 ml/kg Look out for compartment syndrome – prohylactic fasciotomy Myoglobinuria – leads to renal failure