Management Of Burn

Undergraduate presentation about management of burn injury based on Bailey and Loves Short practice of Surgery

1. Management of burn injury Dr.noushin nowar Intern doctor, Department of surgery,jnnhah,noakhali .

2. Burns In children- SCALDS caused by accidents with kettles, pans, hot drinks and bath water In young males - E xperimenting with matches and inflamable liquids In adults- Electrical and chemical injuries. Associated conditions such as mental disease,epilepsy,alcohol and drug abuse may present with burn.

3. Etiology Dry heat Flame Electric contact Chemical Frost bite Ionizing radiation

4. Classification Depending on the thickness of skin involved Superficial (first degree ) Partial-thickness (second degree ) Superficial partial-thickness Deep partial-thickness Full-thickness burns (third degree) Fourth degree

5. Classification Depending on the percentage of burns (Burn severity classification) Mild Partial thickness burns <15% in adults or <10% in children Full thickness burns <2% Can be treated on outpatient basis

6. Classification Depending on the percentage of burns ( Burn severity classification) Moderate S econd degree of 15 -25% (10-20 in children) Third degree 2-10% Not involving eyes, ears, face, hand, feet, perineum

7. Classification Depending on the percentage of burns (Burn severity classification) Major ( Severe ) Second degree burns more than 25% (>20%in children) All third degree burns of 10%or more Burns involving eyes, ears, face, hand, feet, perineum All inhalational and electrical burns Burns with fractures and major mechanical trauma

8. Classification First degree Epidermis looks red and painful No blisters Heals rapidly within 5 to 7 days by epithelialization without scarring First degree burn

9. Classification Second degree Affected area looks red ,mottled and painful Blister formation Heals within 14 to 21 days by epithelialization with scarring

10. Classification Third degree Affected area is painless and insensitive with thrombosis of superficial vessels Requires grafting Fourth degree Involves underlying tissues, muscles, bones

11. Degrees of burns

12. Assessment Assessing size Assessing the depth of a burn

13. Assessment Assesing size Should be assessed in a controlled environment to avoid hypothermia In smaller burns, Just cut a piece of a clean paper of a size of patients whole hand (digit and palm) which present 1% TBSA and match this to the area burnt Another accurate way of measuring the size of burns is to draw the burn on a LUND AND BROWDER CHART

14. The LUND AND BROWDER CHART

15. Assessment Rule of 9 ( W allace’s rule of 9) Each upper limb is 9% TBSA Each lower limb is 18% TBSA Torso 18 % each side Head and neck 9% Perineum 1% In children head and neck is 18% and lower limb is 13.5%each = 27%

16. Assessment Rule of 9 (wallace’s rule of 9) Each upper limb is 9% TBSA Each lower limb is 18% TBSA Torso 18 % each side Head and neck 9% Perineum 1% In children head and neck is 18% and lower limb is 13.5%each = 27%

17. Assessment Assessing the depth from the history and time A.Superficial partial-thickness burns No deeper than the papillary dermis. Clinical features Blistering and/or loss of the epidermis. Underlying dermis is pink and moist. When blanched, capillary return is clearly visible Pinprick sensation is normal. Heal without residual scarring in 2 weeks. Treatment is non-surgical

18. Assessment Assessing the depth from the history and time B.Deep partial-thickness burns damage to the deeper parts of the reticular dermis . Epidermis is usually lost. The exposed dermis is not as moist as that in a superficial burn. Fixed capillary staining Colour does not blanch with pressure Sensation is reduced and the patient is unable to distinguish sharp from blunt pressure Takes 3 or more weeks to heal without surgery Leads to hypertrophic scarring

19. Assessment Assessing the depth from the history and time B.Deep partial-thickness burns damage to the deeper parts of the reticular dermis . Epidermis is usually lost. The exposed dermis is not as moist as that in a superficial burn. Fixed capillary staining Colour does not blanch with pressure Sensation is reduced and the patient is unable to distinguish sharp from blunt pressure Takes 3 or more weeks to heal without surgery Leads to hypertrophic scarring

20. Assessment Assessing the depth from the history and time C. Full-thickness burns The whole of the dermis is destroyed Hard and leathery feel 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

21. Assessment Assessing the depth from the history and time C. Full-thickness burns The whole of the dermis is destroyed Hard and leathery feel 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

22. Causes of death in burns Hypovolaemia and shock Renal failure Pulmonary edema and ARDS Septicaemia Multi organ failure

23. Management of burns IMMEDIATE CARE OF THE BURN PATIENT Pre-hospital care Ensure rescuer safety Stop the burning process. Check for other injuries. A standard ABC (airway, breathing, circulation) check followed by a rapid secondary survey Cool the burn wound with tap water by continuous irrigation for 20 minutes Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen Elevate

24. Management of burns 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

25. Management of burns Hospital care A, Airway control B, Breathing and ventilation C, Circulation D, Disability – neurological status E, Exposure with environmental control F, Fluid resuscitation.

26. Management of burns Initial Management C lothing should be removed C ooling of the part by running water for 20 minutes C leaning the part to remove dust, mud, etc C hemoprophylaxis—tetanus toxoid; antibiotics; local antiseptics C overing with dressings by different methods C omforting with sedation and pain killer

27. Management of burns Definitive Treatment Admit the patient. Maintain airway, breathing, circulation (ABC). Emergency endotracheal intubation may be required in early period 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.

28. Fluid resuscitation IV volume must be maintained following a burn in order to provide sufficient circulation to perfuse not only the organs but also the peripheral tissues,especially damaged skin IV resuscitation is appropriate for any child with a burn greater than 10% and 15% for TBSA for adults If oral resuscitation is to be commenced then water is given should not be salt free It is appropriate to give oral rehydration with a solution such as DIORALYTE

29. Fluid resuscitation Formulas to calculate the fluid replacement Parkland formula (commonly used) This calculates the fluid to be replaced in the first 24 hours 4ml x TBSA (%) x body weight (kg) = volume (ml) Half of this volume is given in first 8 hours Second half is given in the subsequent in 16 hours Other formulas are Evan’s formula,Muir and Barclay formula,Modified brook formula

30. Fluids used Crystalloid As effective as colloids for maintaining intravascular volume Less expensive Ringer lactate -most commonly used In children- Dextrose saline is given for maintainance 100ml/kg for 24h for first 10kg 50ml/kg for 24 hrs for next 10 kg 20ml/kg for 24 hrs for each kg above 20kg body weight

31. Fluids used Hypertonic saline Human albumin solution (HAS) is a commonly used colloid. Effective in treating burns shock for many years. Produces hyperosmolarity and hypernatremia Reduces shift of intracellular water to extracellular space Advantages Include less tissue oedema and a resultant decrease in escharotomies and intubation

32. Fluids used Colloid resuscitation Plasma proteins are responsible for the inward oncotic pressure that counteracts the outward capillary hydrostatic pressure. Without proteins, there will 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.

33. 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 % 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. Urine output in excess of 2 mL/kg body weight per hour should signal a decrease in the rate of infusion. Haematocrit measurement is a useful tool in confirming suspected under- or overhydration.

34. Local management Dressings Paraffin gauze, Hydrocolloids, plastic films, vaseline impregnated gauze or fenestrated silicone sheet or biological dressings like amniotic membrane or synthetic biobrane . Open method Silver sulfadiazine application without dressings commonly used in burns of face, head and neck Closed method with dressings . Done to soothen and to protect the wound, reduce the pain, as an absorbent

35. Treating the burn wound Principles of dressings for burns Superficial burns will heal and need simple dressings Full-thickness and deep dermal burns need antibacterial dressings to delay colonisation prior to surgery An optimal healing environment can make a difference to outcome in borderline depth burns The choice of dressing can make the difference between scar and no scar and/ or operation and no operation.

36. Dressings Options for topical treatment of deep burns 1% silver sulphadiazine cream 0.5% silver nitrate solution Mafenide acetate cream Silver sulphadiazine and cerium nitrate 1% silver sulphadiazine cream Broad-spectrum prophylaxis against bacterial colonisation such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. It cause s neutropenia.

37. Dressings 0.5% silver nitrate solution Highly effective as a prophylaxis against Pseudomonas colonisation, not as active as silver sulphadiazine cream It needs to be changed or the wounds resoaked every 2–4 hours. Causes staining of burnt area. Mafenide acetate cream/sulfamylon Popular especially in the US, but is painful to apply. Causes acidosis. Silver sulphadiazine and cerium nitrate. Cerium nitrate forms a sterile eschar ,when a conservative treatment option has been chosen. To boost cell-mediated immunity in these patients.

38. Dressings Synthetic dressings in burn wound Vaseline impregnated gauze dressing prevents stiffness of eschar. Hydrocolloid dressing ( duoderm ) helps moist environment, proper epithelialisation. It is useful in mixed deep burns. It is changed once in 3 days. Opsite -less expensive, less pain, creates moist barrier,no antimicrobial effect,causes accumulation of exudates. Biobrane is collagen coated silicone sheet which gets adherent to wound acting as barrier without any pain. No antimicrobial effect ,causes accumulation of exudates. It is used for 2nd degree burns. Transcyte has similar features of biobrane. It contains growth factor derived from cultured fibroblasts which promotes wound healing. Integra contains deeper collagen matrix as dermal substitute; Provides complete wound cover. Scarring is reduced.

39. Treating the burn wound Tangential excision of burn wound with skin grafting can be done in 48 hours in patients with less than 25% burns. Usually done in deep dermal burn Dead dermis is removed layer by layer until fresh bleeding occurs. Later skin grafting is done. Reduces the chance of secondary infection, the hospital stay, and formation of hypertrophic scar or contracture, the cost.

40. Surgical treatment of deep burns Deep dermal burns need tangential shaving and split-skin grafting All but the smallest full-thickness burns need surgery The anaesthetist needs to be ready for significant blood loss Topical adrenaline reduces bleeding All burnt tissue needs to be excised Stable cover, permanent or temporary, should be applied at once to reduce burn load

41. 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.

42. TREATING THE BURN WOUND Escharotomy Circumferential full-thickness burns to the limbs require emergency surgery The tourniquet effect of this injury is easily treated by incising the whole length of full-thickness burns. This should be done in the mid-axial line, avoiding major nerves , adequate blood should be available for transfusion if required. Management of the burn wound remains the same, irrespective of the size of the injury. Full thickness burns and deep partial-thickness burns that will require operative treatment will need to be dressed with an antibacterial dressing to delay the onset of colonisation of the wound.

43. ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Analgesia Paracetamol/NSAIDs in superficial burns IV opiates for large burns IM shouldn’t be used in burns over 10% Short acting analgesia before dressing Energy balance Burns patients need extra feeding. It should start within 6 hours of the injury to reduce gut mucosal damage Nasogastric tube -in burns over 15 % of TBSA Burn injuries are catabolic in the acute episode.

44. ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Monitoring and control of infection Patients with major burns are immunocompromised They are susceptible to infection from many routes 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 Control of infection begins with policies on hand-washing and other cross-contamination prevention measures.

45. ADDITIONAL ASPECTS OF TREATING THE BURNED PATIENT Nursing care Physiotherapy Psychological

46. MINOR BURNS/OUTPATIENT BURNS Local burn wound care Blisters Whether to remove blisters or leave them intact has been the subject of much debate. Some says it acts as a medium for bacterial growth.blister fluid depresses immune function, slowing down chemotaxis and intracellular killing Conversely, other authors advocate leaving blisters intact as they form a sterile stratum spongiosum.

47. MINOR BURNS/OUTPATIENT BURNS Local burn wound care Initial cleaning of the burn wound Washing the burn wound with chlorhexidine solution is ideal Dressings with a non-adherent material, such as Vaseline-impregnated gauze ,left in place for 5 days. Silver sulphadiazine 1% is most commonly used Healed after 7–10 days. Avoid in pregnant women, nursing mothers and infants <2 months of age because of the increased possibility of kernicterus in these patients.

48. MINOR BURNS/OUTPATIENT BURNS Local burn wound care The aims of dressing -decrease wound pain ,protect and isolate the burn wound. First layer is Vaseline gauze or another non-adherent dressing . Then, gauze is wrapped around with sufficient tightness to keep the dressing intact, but not to impede the circulation. This is further wrapped with bandage . Bulkiness of dressings depends upon the amount of wound discharge. Burn of Hands - dressings should be minimised so as not to impede mobilisation and physiotherapy.

49. MINOR BURNS/OUTPATIENT BURNS Local burn wound care Synthetic burn wound dressings are popular 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.

50. 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 Infection - use combination of topical and systemic agents. Consider Debridement and skin grafting . Itching - Antihistamines, analgesics, moisturising creams, aloe vera and antibiotics Traumatic blisters - Non-adherent dressings usually suffice; regular moisturisation is also useful

51. Thank You