BURNS.pptx, comprehensive images of all burns

Burns

1. BURNS Dr.Kishan Rao

2. A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation. Among women in some areas, risk is related to use of open cooking fires or unsafe cook stoves. Among men, risk is related to the work environments. Alcoholism and smoking are other risk factors. Burns can also occur as a result of self-harm or violence between people.

3. Dupuytren’s Classification- First degree- Erythema then desquamation of superficial layer of epidermis Second degree- Blister formation Third degree- Destruction of epidermis Fourth degree- Destruction of whole thickness of skin Fifth degree- Destruction of muscles Sixth degree- Destruction of bone, nerve trunks etc.

4. TYPES OF BURNS Thermal injury -scald –spillage of hot liquid -Flame burns -Flash burns (natural gases, alcohol, combustible liquids) -contact burns (hot meals/objects/materials) Electrical injury Chemical injury -acid/alkali Cold injury -frost bite Ionising radiation Sun burns

5. First-degree burns injuries confined to the epidermis. painful and erythematous and blanch to the touch with an intact epidermal barrier. Examples include sunburn or a minor scald from a kitchen accident. These burns do not result in scarring, and treatment is aimed at comfort with the use of topical soothing salves and oral nonsteroidal anti-inflammatory agents

6. Second-degree burns two types: superficial and deep . erythematous and painful, blanch to touch, and often blister. Examples include scald injuries from overheated bathtub water and flash flame burns. These wounds spontaneously re-epithelialize from retained epidermal structures in the rete ridges, hair follicles, and sweat glands in 1 to 2 weeks. After healing, these burns may have some slight skin discoloration in the long term. Deep dermal burns into the reticular dermis appear more pale and mottled, do not blanch to touch, but remain painful to pinprick. These burns heal in 2 to 5 weeks by re-epithelialization from hair follicles and sweat gland keratinocytes, often with severe scarring as a result of the loss of dermis.

7. Third-degree burns full thickness through the epidermis and dermis and are characterized by a hard, leathery eschar that is painless and black, white, or cherry red. No epidermal or dermal appendages remain; thus, these wounds must heal by re-epithelialization from the wound edges. Deep dermal and full thickness burns require excision with skin grafting from the patient to heal the wounds in a timely fashion Fourth-degree burns involve other organs beneath the skin, such as muscle, bone, and brain.

8. PATHOPHYSIOLOGY OF BURN INJURY Local Changes thermal injury causes coagulative necrosis of the epidermis and underlying tissues; the depth of injury depends on the temperature to which the skin is exposed, the specific heat of the causative agent, and the duration of exposure .

9. The area of cutaneous or superficial injury has been divided into three zones: zone of coagulation, zone of stasis, and zone of hyperemia. The necrotic area of burn where cells have been disrupted is termed the zone of coagulation. This tissue is irreversibly damaged at the time of injury. The area immediately surrounding the necrotic zone has a moderate degree of insult with decreased tissue perfusion. This is termed the zone of stasis and, depending on the wound environment, can either survive or go on to coagulative necrosis. The zone of stasis is associated with vascular damage and vessel leakage. Thromboxane A2, a potent vasoconstrictor, is present in high concentrations in burn wounds, and local application of inhibitors improves blood flow and decreases the zone of stasis. Antioxidants, bradykinin antagonists, and sub atmospheric wound pressures also improve blood flow and affect the depth of injury .

10. The last area is the zone of hyperemia, which is characterized by vasodilation from inflammation surrounding the burn wound. This region contains the clearly viable tissue from which the healing process begins and is generally not at risk for further necrosis.

11. Burn Depth Accurate depth determination is critical to wound healing as wounds that will heal with local treatment are treated differently from those requiring operative intervention. Examination of the entire wound by the physicians ultimately responsible for their management then is the “gold standard” used to guide further treatment decisions. New technologies, such as the multi sensor laser Doppler flowmeter, hold promise for quantitative determination of burn depth.

12. Burn Size Determination of burn size estimates the extent of injury. Burn size is generally assessed by the “rule of nines” . In adults, each upper extremity and the head and neck are 9% of the total body surface area (TBSA), the lower extremities and the anterior and posterior trunk are 18% each, and the perineum and genitalia are assumed to be 1% of the TBSA. Another method of estimating smaller burns is to equate the area of the open hand (including the palm and the extended fingers) of the patient to be approximately 1% TBSA and then to transpose that measurement visually onto the wound for a determination of its size. This method is crucial in evaluating burns of mixed distribution .

13. Children have a relatively larger portion of the body surface area in the head and neck, which is compensated for by a relatively smaller surface area in the lower extremities. Infants have 21% of the TBSA in the head and neck and 13% in each leg, which incrementally approaches the adult proportions with increasing age. The Berkow formula is used to accurately determine burn size in children

14. Systemic Changes Severe burns covering more than 20% TBSA in adults and 40% TBSA in pediatric patients are typically followed by a period of stress, inflammation, and hypermetabolism, characterized by a hyperdynamic circulatory response with increased body temperature, glycolysis, proteolysis, lipolysis, and futile substrate cycling. These responses are present in all trauma, surgical, and critically ill patients, but the severity, length, and magnitude are unique for burn patients

15. Hypermetabolic Response to Burn Injury Marked and sustained increases in catecholamine, glucocorticoid, glucagon, and dopamine secretion are thought to initiate the cascade of events leading to the acute hypermetabolic response with its ensuing catabolic state. Once these cascades are initiated, their mediators and byproducts appear to stimulate the persistent and increased metabolic rate associated with altered glucose metabolism seen after severe burn injury. The postburn metabolic phenomena occur in a timely manner, suggesting two distinct patterns of metabolic regulation after injury. The first phase occurs within the first 48 hours of injury and has classically been called the ebb phase, characterized by decreases in cardiac output, oxygen consumption, and metabolic rate as well as impaired glucose tolerance associated with its hyperglycemic state. These metabolic variables gradually increase within the first 5 days after injury to a plateau phase (called the flow phase), characteristically associated with hyperdynamic circulation and the hypermetabolic state

16. Inflammation and Edema Significant burns are associated with massive release of inflammatory mediators, both in the wound and in other tissues. These mediators produce vasoconstriction and vasodilation, increased capillary permeability, and edema locally and in distant organs .

17. Effects on Cardiovascular System Microvascular changes induce cardiopulmonary alterations characterized by loss of plasma volume, increased peripheral vascular resistance, and subsequent decreased cardiac output immediately after injury .

18. Effects on the Renal System Diminished blood volume and cardiac output result in decreased renal blood flow and glomerular filtration rate. Other stress induced hormones and mediators, such as angiotensin, aldosterone, and vasopressin, further reduce renal blood flow immediately after the injury. These effects result in oliguria, which, if left untreated, will cause acute tubular necrosis and renal failure.

19. Effects on the Gastrointestinal System The gastrointestinal response to burn is highlighted by mucosal atrophy, changes in digestive absorption, and increased intestinal permeability. Atrophy of the small bowel mucosa occurs within 12 hours of injury in proportion to the burn size and is related to increased epithelial cell death by apoptosis .

20. Effects on the Immune System Burns cause a global depression in immune function, which is shown by prolonged allograft skin survival on burn wounds. Burned patients are then at great risk for a number of infectious complications, including bacterial wound infection, pneumonia, and fungal and viral infections. These susceptibilities and conditions are based on depressed cellular function in all parts of the immune system, including activation and activity of neutrophils, macrophages, T lymphocytes, and B lymphocytes. With burns of more than 20% TBSA, impairment of these immune functions is proportional to burn size.

21. Which of the following statements regarding respiratory problems in burns are true ? A. Burn injury to this function may be lethal. B. Injury can be due to inhalation of hot or poisonous gases. C. Burn injury is more common in the supraglottic than in the lower airway. D. Haemoglobin combines with carbon monoxide less easily than with oxygen. E. Hydrogen cyanide interferes with mitochondrial respiration.

22. Ans:A , B, E Burns can damage the airway and lungs with life-threatening consequences. This can occur when the face or neck are burned, when the fire causing the burn is in an enclosed space, or when hot gases or poisonous vapours are inhaled. Burn injury is more common in the lower airway than in the supraglottic airway. Carbon monoxide has an affinity 240 times greater than oxygen for combining with haemoglobin and thus blocks the transport of oxygen. Blood gas measurement can be done to confirm the diagnosis. A concentration of carbon monoxide above 10 per cent is dangerous; 60 per cent is likely to be lethal. Hydrogen cyanide is a metabolic toxin produced in house fires, which interferes with mitochondrial respiration.

23. Which of the following statements regarding smoke inhalation are true ? A. Inhaled smoke particles can cause a chemical alveolitis and subsequent increased gaseous exchange. B. Inhaled smoke particles may be suspected with a specific situation in an enclosed space. C. Early elective intubation is contraindicated. D. Symptoms can take 24 h or up to 5 days to develop. E. The result of carbon monoxide poisoning is a metabolic alkalosis best treated by low inspired oxygen.

24. Ans : B, D Inhaled smoke particles can cause a chemical irritation or alveolitis . This results in interference with gaseous exchange. Early elective intubation is important and is definitely not contraindicated. Symptoms may not be immediately evident and can take up to 5 days to develop. Carbon monoxide poisoning causes a metabolic acidosis and is treated by inhalation of pure oxygen

25. IMMEDIATE CARE OF THE BURN PATIENT The principles of pre-hospital care are: •Stop the burning process . •Check for other injuries. A standard ABC (airway, breathing, circulation) check followed by a rapid secondary survey will ensure that no other significant injuries are missed. •Cool the burn wound. This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury. Cooling should occur for a minimum of 10 minutes and is effective up to 1 hour after the burn injury. It is a particularly important first aid step in partial-thickness burns, especially scalds. In temperate climates, cooling should be at about 15°C, and hypothermia must be avoided. •Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen, especially if there is an altered consciousness level. •Elevate. Sitting a patient up with a burned airway may prove life-saving in the event of a delay in transfer to hospital care. Elevation of burned limbs will reduce swelling and discomfort.

26. Hospital care • A, Airway control • B, Breathing and ventilation • C, Circulation • D, Disability – neurological status • E, Exposure with environmental control • F, Fluid resuscitation. Major determinants of the outcome of a burn ■ Percentage surface area involved ■ Depth of burns ■ Presence of an inhalational injury

27. Airway The burned airway creates problems for the patient by swelling and, if not managed proactively, can completely occlude the upper airway. The treatment is to secure the airway with an endotracheal tube until the swelling has subsided, which is usually after about 48 hours. The symptoms of laryngeal oedema , such as change in voice, stridor, anxiety and respiratory difficulty, are very late symptoms. Intubation at this point is often difficult or impossible owing to swelling, so acute cricothyroidotomy equipment must be at hand when intubating patients with a delayed diagnosis of airway burn. Because of this, early intubation of suspected airway burn is the treatment of choice in such patients.

28. Initial management of the 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

29. Breathing Time is also a factor; anyone trapped in a fire for more than a couple of minutes must be observed for signs of smoke inhalation. Other signs that raise suspicion are the presence of soot in the nose and the oropharynx and a chest radiograph showing patchy consolidation. The clinical features are a progressive increase in respiratory effort and rate, rising pulse, anxiety and confusion and decreasing oxygen saturation. These symptoms may not be apparent immediately and can take 24 hours to 5 days to develop. Treatment starts as soon as this injury is suspected and the airway is secure. Physiotherapy, nebulizers and warm humidified oxygen are all useful. The patient’s progress should be monitored using respiratory rate, together with blood gas measurements. If the situation deteriorates, continuous or intermittent positive pressure may be used with a mask or T-piece. In the severest cases, intubation and management in an intensive care unit will be needed.

30. Metabolic poisoning Any history of a fire within an enclosed space and any history of altered consciousness are important clues to metabolic poisoning. Blood gases must be measured immediately if poisoning is a possibility. Carboxyhaemoglobin levels raised above 10 percent must be treated with high inspired oxygen for 24 hours to speed its displacement from haemoglobin . Metabolic acidosis is a feature of this and other forms of poisoning. Once again, the key to diagnosing these injuries is suspicion from the history. Blood gas measurement will confirm the diagnosis. The treatment is oxygen.

31. FLUID RESUSCITATION The principle of fluid resuscitation is that the intravascular volume must be maintained following a burn in order to provide sufficient circulation to perfuse not only the essential visceral organs such as the brain, kidneys and gut, but also the peripheral tissues, especially the damaged skin . Intravenous resuscitation is appropriate for any child with a burn greater than 10 per cent TBSA, 15 per cent TBSA for adults. If oral resuscitation is to be commenced, it is important that the water given is not salt free. It is rarely possible to undergo significant diuresis in the first 24 hours in view of the stress hormones that are present. Hyponatraemia and water intoxication can be fatal. The resuscitation volume is relatively constant in proportion to the area of the body burned and, therefore, there are formulae that calculate the approximate volume of fluid needed for the resuscitation of a patient of a given body weight with a given percentage of the body burned. These regimens follow the fluid loss, which is at its maximum in the first 8 hours and slows, such that, by 24–36 hours, the patient can be maintained on his or her normal daily requirements

32. There are three types of fluid used. The most common is Ringer’s lactate or Hartmann’s solution; some centres use human albumin solution or fresh-frozen plasma, and some centres use hypertonic saline. Perhaps the simplest and most widely used formula is the Parkland formula. This calculates the fluid to be replaced in the first 24 hours by the following 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 16 hours.

33. Crystalloid resuscitation Ringer’s lactate is the most commonly used crystalloid. Crystalloids are said to be as effective as colloids for maintaining intravascular volume. They are also significantly less expensive. Another reason for the use of crystalloids is that even large protein molecules leak out of capillaries following burn injury; however, non-burnt capillaries continue to sieve proteins virtually normally. In children, maintenance fluid must also be given. This is normally dextrose–saline given as follows: • 100 mL /kg for 24 hours for the first 10 kg; • 50 mL /kg for the next 10 kg; • 20 mL /kg for 24 hours for each kilogram over 20 kg body weight. Hypertonic saline effective in treating burns shock for many years. It produces hyperosmolarity and hypernatraemia . This reduces the shift of intracellular water to the extracellular space. Advantages include less tissue oedema and a resultant decrease in escharotomies and intubations

34. Colloid resuscitation Plasma proteins are responsible for the inward oncotic pressure that counteracts the outward capillary hydrostatic pressure. Without proteins, plasma volumes would not be maintained as there would be oedema . Proteins should be given after the first 12 hours of burn because, before this time, the massive fluid shifts cause proteins to leak out of the cells. The most common colloid-based formula is the Muir and Barclay formula: • 0.5 × percentage body surface area burnt × weight = one portion; • periods of 4/4/4, 6/6 and 12 hours, respectively; • one portion to be given in each period.

35. Monitoring of resuscitation The key to monitoring of resuscitation is urine output. Urine output should be between 0.5 and 1.0 mL /kg body weight per hour. If the urine output is below this, the infusion rate should be increased by 50 per cent. If the urine output is inadequate and the patient is showing signs of hypoperfusion (restlessness with tachycardia, cool peripheries and a high haematocrit ), then a bolus of 10 mL /kg body weight should be given. It is important that patients are not overresuscitated , and urine output in excess of 2 mL /kg body weight per hour should signal a decrease in the rate of infusion. Other measures of tissue perfusion such as acid–base balance are appropriate in larger, more complex burns, and a haematocrit measurement is a useful tool in confirming suspected under- or overhydration . Those with cardiac dysfunction, acute or chronic, may well need more exact measurement of filling pressure, preferably by transoesophageal ultrasound or with the more invasive central line

36. TREATING THE BURN WOUND Escharotomy Circumferential full-thickness burns to the limbs require emergency surgery . One should remember that an escharotomy can cause a large amount of blood loss; therefore , adequate blood should be available for transfusion if required. .

37. Full-thickness burns and obvious deep dermal wounds

38. ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia Small burns, especially superficial burns, respond well to simple oral analgesia, paracetamol and non-steroidal anti-inflammatory drugs. Topical cooling is especially soothing. Large burns require intravenous opiates. Intramuscular injections should not be given in acute burns over 10 per cent of TBSA, as absorption is unpredictable and dangerous. In patients with large burns, continuous analgesia is required, beginning with infusions and continuing with oral tablets, such as slow-release morphine. Powerful, short-acting analgesia should be administered before dressing changes. Administration may require an anaesthetist , as in the case of general anaesthesia or midazolam and ketamine, or less intensive supervision, as in the case of morphine and nitrous oxide.

39. Energy balance and nutrition One of the most important aspects in treating burns patients is nutrition. Any adult with a burn greater than 15 per cent (10 per cent in children) of TBSA has an increased nutritional requirement. All patients with burns of 20 per cent of TBSA or greater should receive a nasogastric tube. (Feeding should start within 6 hours of the injury to reduce gut mucosal damage.) A number of different formulae are available to calculate the energy requirements of patients Nutrition in burns patients ■ Burns patients need extra feeding ■ A nasogastric tube should be used in all patients with burns over 15 per cent of TBSA ■ Removing the burn and achieving healing stops the catabolic drive

40. Monitoring and control of infection

41. Nursing care Physiotherapy All burns cause swelling, especially burns to the hands. Elevation, splintage and exercise reduce swelling and improve the final outcome. The physiotherapy needs to be started on day 1, so that the message can be reinforced on a daily basis. Psychological A major burn is an overwhelming event, outside the normal experience, which overwhelms the patient’s coping ability, suspends the patient’s sense of safety and causes post-traumatic reactions. These are normal and usually self-limiting, receding as the patient heals. The features of this intensity of experience are of intrusive reactions, arousal reactions and avoidance reactions.

42. SURGERY FOR THE ACUTE BURN WOUND Any deep partial-thickness and full-thickness burns, except those that are less than about 4 cm2, need surgery. Any burn of indeterminate depth should be reassessed after 48 hours. This is because burns that initially appear superficial may well deepen over that time. Delayed microvascular injury is especially common in scalds. The essence of burns surgery is control. In deep dermal burns, the top layer of dead dermis is shaved off until punctate bleeding is observed and the dermis can be seen to be free of any small thrombosed vessels .

43. MINOR BURNS/OUTPATIENT BURNS Local burn wound care Blisters Whether to remove blisters or leave them intact has been the subject of much debate. Proponents of blister removal quote laboratory studies which show that blister fluid depresses immune function, slowing down chemotaxis and intracellular killing and also acting as a medium for bacterial growth. Conversely, other authors advocate leaving blisters intact as they form a sterile stratum spongiosum. Leaving a ruptured blister is not advised. Initial cleaning of the burn wound Washing the burn wound with chlorhexidine solution is ideal for this purpose.

44. Dressing the minor burn wound The aims of dressing are to decrease wound pain and to protect and isolate the burn wound. The small superficial burn requires Vaseline gauze or another non-adherent dressing, such as Mepitel , as the first layer. Following this, gauze or Kerlix® is wrapped around with sufficient tightness to keep the dressing intact, but not to impede the circulation. This is further wrapped with bandage. It is important to realise that bulkiness of dressings in the minor burn wound depends upon the amount of wound discharge. A special case is burns of the hands where dressings should be minimised so as not to impede mobilisation and physiotherapy. Synthetic burn wound dressings are popular as they: • decrease pain associated with dressings; • improve healing times; • decrease outpatient appointments; • lower overall costs. Biobrane is a bilaminar dressing made up of an inner layer of knitted nylon threads coated with porcine collagen and an outer layer of rubberised silicone impervious to gases, but not to fluids and bacteria. Wounds to be dressed with Biobrane should be carefully selected. Burn wounds should be fresh (less than 24 hours), sensate, show capillary blanching and refill. Biobrane ® should be applied to the wound after removal of all blisters. It should be checked at 48 hours for adherence and any signs of infection. It should be removed if any sign of infection is found. Duoderm or hydrocolloid dressings are not bulky, help in healing and can be kept in place for 48–72 hours. They provide a moist environment, which helps in re- epithelialisation of the burn wound. Healing of burn wounds Burns that are being managed conservatively should be healed within 3 weeks. If there are no signs of re- epithelialisation in this time, the wound requires debridement and grafting.

45. Infection Infection in the minor burn should be tackled very aggressively as it is known to convert a superficial burn to a partial-thickness burn and a partial- to a deep partial-thickness burn, respectively. It should be managed using a combination of topical and systemic agents. Debridement and skin grafting should also be considered. Itching Most burn patients have itchy wounds. Histamine and various endopeptides are said to be the causative factors of itching. Antihistamines, analgesics, moisturising creams, aloe vera and antibiotics have all been tried with varying degrees of success. Traumatic blisters The healed burn wound is prone to getting traumatic blisters because the new epithelium is very fragile. Non-adherent dressings usually suffice; regular moisturisation is also useful in this condition.

46. NON-THERMAL BURN INJURY Electrical injuries Electrical injuries are usually divided into low- and high-voltage injuries, the threshold being 1000 V

47. Low-tension injuries Low-tension or domestic appliance injuries do not have enough energy to cause destruction to significant amounts of subcutaneous tissues when the current passes through the body. The main danger with these injuries is from the alternating current interfering with normal cardiac pacing. This can cause cardiac arrest. The electricity itself does not usually cause significant underlying myocardial damage, so resuscitation, if successful, should be lasting.

48. High-tension injuries High-tension electrical injuries can be caused by one of three sources of damage: the flash, the flame and the current itself. When a high-tension line is earthed, enormous energy is released as the current travels from the line to the earth. It can arc over the patient, causing a flash burn. The extremely rapid heating of the air causes an explosion that often propels the victim backwards. The key here is that the current travelled from the line to the earth directly and not through the patient .

49. The flash , however, can go on to ignite the patient’s clothes and so cause a normal flame burn.The damage to the underlying muscles in the affected limb can cause the rapid onset of compartment syndrome. The release of the myoglobins will cause myoglobinuria and subsequent renal dysfunction. Therefore, during the resuscitation of these patients, efforts must be made to maintain a high urine output of up to 2 mL /kg body weight per hour. Severe acidosis is common in large electrical burns and may require boluses of bicarbonate. These patients are also at risk of myocardial damage as a result of direct muscle damage rather than by interference with cardiac pacing. This gives rise to significant electrocardiogram changes, with raised cardiac enzymes . In the case of a severe injury through a limb, primary amputation is sometimes the most effective management.

50. Chemical injuries T here are two aspects to a chemical injury. The first is the physical destruction of the skin and the second is any poisoning caused by systemic absorption. The initial management of any chemical injury is copious lavage with water. There are only a handful of chemicals for which water is not helpful, for example phosphorus, which is a component of some military devices, and elemental sodium, which is occasionally present in laboratory explosions. These substances need to be physically removed with forceps.

51. Alkalis are usually the more destructive and are especially dangerous if they have come into contact with the eyes. After copious lavage , the next step in the management of any chemical injury is to identify the chemical and its concentration and to elucidate whether there is any underlying threat to the patient’s life if absorbed systemically. One acid that is a common cause of acid burns is hydrofluoric acid. The initial management is with calcium gluconate gel topically; however, severe burns or burns to large areas of the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10 per cent. If the patient has been burnt with a concentration greater than 50 per cent, the threat of hypocalcaemia and subsequent arrhythmias then becomes high, and this is an indication for acute early excision. It is best not to split-skin graft these hydrofluoric acid wounds initially, but to do this at a delayed stage

52. Ionising radiation injury The management of localised radiation damage is usually conservative until the true extent of the tissue injury is apparent. Should this damage have caused an ulcer, then excision and coverage with vascularised tissue is required. A patient who has suffered whole-body irradiation and is suffering from acute desquamation of the skin has received a lethal dose of radiation, which can cause a particularly slow and unpleasant death. Non lethal radiation has a number of systemic effects related to the gut mucosa and immune system dysfunction .

53. Cold injuries Cold injuries are principally divided into two types: acute cold injuries from industrial accidents and frostbite. Exposure to liquid nitrogen and other such liquids will cause epidermal and dermal destruction. The tissue is more resistant to cold injury than to heat injury, and the inflammatory reaction is not as marked. The assessment of depth of injury is more difficult . Frostbite injuries affect the peripheries in cold climates. The initial treatment is with rapid rewarming in a bath at 42°C. The cold injury produces delayed microvascular damage similar to that of cardiac reperfusion injury. The level of damage is difficult to assess, and surgery usually does not play a role in its management, which is conservative, until there is absolute demarcation of the level of injury.

54. References 1.Bailey and love’s short practice of surgery 2.Sabiston’s textbook of surgery 3.Schwartz principles of surgery 4.Textbook of plastic surgery- grabbe and smith