Management of burns.pptx

For surgical residents presentation

1. Principles of Management of Burns By Dr. Olofin K. E R egistrar Casualty Dept. UATH 2/4/2020 1

2. Outline Introduction/Definition Epidemiology Anatomy of the skin Pathology/Pathophysiology of burns Classification/wound estimation Management Complications Prognosis Prevention Conclusion References 2/4/2020 2

3. Introduction/Definition Definition : Injury to living tissue arising from exposure to heat, friction, electricity, radiation, chemicals or cold Non-fatal burn injuries are a leading cause of morbidity. 2/3 of all burns happen at home Burn injuries continue to be a major source of mortality and morbidity in low- and middle-income countries of the world, of which Nigeria is a part. 2/4/2020 3

4. Introduction Flame is emerging as the predominant cause of burns, and burn injury is occurring increasingly away from the domestic setting. The severity of the injuries is also increasing . Several challenges militate against optimal care for burn victims. Burn injuries continue to contribute significantly to the burden of disease in Nigeria. Avoidable complications are common and mortality remains high. 2/4/2020 4

5. Epidemiology 4.8 % of trauma deaths in Nigeria 6.7 % of surgically related deaths. In children, burns and scalds are the 4th commonest cause of trauma < road traffic accidents < accidental falls < bites. Over 95% of fatal fire-related burns occurred in low- and middle-income countries Chemical burns constitute 6.3% of burns in Enugu and 5% in Ibadan Electrical burn injuries have an incidence of less than 1% in children and 2.8-4.6% in all burn 2/4/2020 5

6. Epidemiology cont.… In India, over 1 000 000 people are moderately or severely burnt every year . In Bangladesh, Colombia, Egypt and Pakistan, 17% of children with burns have a temporary disability and 18% have a permanent disability. Burns are the second most common injury in rural Nepal, accounting for 5% of disabilities. In 2008, over 410 000 burn injuries occurred in the United States of America, with approximately 40 000 requiring hospitalization. 2/4/2020 6

7. A natomy of the skin 2/4/2020 7 The skin: Largest organ 15% of total body weight 1.7 m 2

8. Essential for: Thermoregulation Prevention of fluid loss by evaporation Barrier against infection Protection from environment provided by sensory information Others- social etc. 2/4/2020 8

9. Pathology of burns Fire/flames, Contact with hot liquids, hot/cold solid materials induce cellular damage via transfer of energy directly leads to coagulation necrosis . Chemical and electrical burns cause injury via cell membrane damage in addition to thermal injury. Depth of Injury depends on 3 factors Causative agents Temperature at which skin exposed Duration of Exposure. 2/4/2020 9

10. Pathology of burns 2/4/2020 10

11. Pathology cont.… 2/4/2020 11

12. Pathology cont.… 2/4/2020 12

13. Pathophysiology Systemic Effects of Burns Cardiovascular system Renal system Respiratory tract changes Gastrointestinal tract changes Central nervous system changes 6. Hematological changes 7 . Metabolic changes 8 . Endocrine changes 9 . Immune system changes 2/4/2020 13

14. Pathophysiology cont.… Post Burn Metabolic Phenomena Two Distinct phase of metabolic changes observed in post burns . Ebb phase It occurs within the first 48 hours of injury Characterized by decrease in cardiac output, oxygen consumption and metabolic rate, as well as impaired glucose tolerance T he flow phase These metabolic variables gradually increase within the first 5 days post injury to a plateau phase 2/4/2020 14

15. Pathophysiology cont.… Post Burn Squela Cardiac out put increases by 1.5 times Liver size increases by 225% Muscle protein is degraded much faster than it is synthesized . The net protein loss causes loss of lean body mass and severe muscle wasting. 10% loss – Immune Dysfunction 20% loss – Decrease wound healing 30% loss – Increased risk of Pneumonia & Pressure sores 40% loss – Death 2/4/2020 15

16. Pathophysiology cont.… 2/4/2020 16

17. Classifications - Depth -Types / Source of energy - Extent Depth Superficial Partial thickness Superficial Deep Full thickness Mixed 2/4/2020 17

18. Superficial burns old 1st degree Epidermis only Resembles Sunburn No blistering Capacity to heal completely 2/4/2020 18

19. Superficial partial thickness Epidermal and papillary layers of dermis involved Blister formation Rupture causes weeping moist injury 2/4/2020 19

20. Deep Partial Thickness old 2nd degree through epidermis, into reticular dermis Pale or Pink , moist, blisters, very painful Some capacity to heal 2/4/2020 20

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22. Full thickness burn old 3rd degree (and 4th) Through epidermis, dermis and connective tissue Appears waxy white, leathery gray or charred black and dry and is not painful Has various colours 2/4/2020 22

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24. Classification cont.… Types/source Thermal: Contact, flame, Scald, Electrical- AC,DC Chemical Sun burn Lightening Radiation Laser Frostbite 2/4/2020 24

25. Classification cont .… Extent Assessment of extent of burn wound Rule of Nines: Quick estimate of percent of burn Lund and Browder: More accurate assessment tool Useful chart for children – takes into account the head size proportion. Rule of Palms: Good for estimating small patches of burn wound 2/4/2020 25

26. Rule of Nines 2/4/2020 26

27. Lund Browder Chart 2/4/2020 27

28. American Burn Association Severity Classification 2/4/2020 28

29. Management Prehospital care Principles Ensure rescuer safety Stop the burning process Check for other injuries Cool the burn Give oxygen Elevate 2/4/2020 29

30. Management ATLS protocol Primary survey A irway: Early recognition of airway compromise, intubation. B reathing: Pattern of breathing. Breathing? C irculation: vascular access, monitor device, blood pressure. D isability: other injuries; fractures, abdominal injury or neurological deficit. E xposure: out of clothes, exposure of all orifices. F luid resuscitation: 2/4/2020 30

31. Management cont.… Secondary survey Full history Biodata Cause of the burn Time of injury Place of the occurrence (closed space, presence of chemicals, noxious fumes) Likelihood of associated trauma (explosion,…) Pre-hospital interventions 2/4/2020 31

32. Management cont.… Detection of the mechanism of injury. Consideration of abuse Possibility of carbon monoxide intoxication Full examination TBSA, Burn depth, inhalational injury Concomitant injury, deformity, dx habitus Height and weight. 2/4/2020 32

33. Management cont.… Indications For admission Major Burns Special areas- face, hand, perineum, joints, inhalational Poly-trauma Co- morbidities- DM, SCD, CVA Domestic abuse (slightest suspicion) 2/4/2020 33

34. Management cont.… I nvestigations Electrolytes Blood gases Glucose Protein Haemoglobin (must be kept >12 g %) Bronchoscopy, X-rays 2/4/2020 34

35. Management cont.… Goals of management 4Rs: revive , restore, repair and rehabilitate Maintaining body fluids & electrolytes Relieving pain Preventing/Treating infection Nutrition Early wound cover/ healing/surgery Rehabilitation 2/4/2020 35

36. Management cont.… Fluid Resuscitation Goal- Maintain tissue perfusion Burns > 10% TBSA for children Burns > 15% TBSA for Adults Parkland, Brookes, Galveston, Shriners Crystalloids or colloids? Fluid monitoring Urine output , blood pressure ,central venous pressure, heart rate Urine output- 30-50ml/hr . 0.5 - 1.0 ml/kg/hr. Input/ output chart recorded hourly!!! 2/4/2020 36

37. Management cont.… Resuscitation Formula’s total area FORMULA CRYSTALLOID COLLOID Parkland 4 mL/kg per % TBSA burn None None Brooke 1.5 mL/kg/% TBSA burn 0.5 mL/kg per % TBSA burn Galveston (pediatric) 5000 mL/m 2 burned area + 1500 mL/m 2 2/4/2020 37

38. Management cont.… Parklands Commonest 1/2 in first 8hrs post burn 1/2 in next sixteen hrs. Subsequently, Daily requirements plus ongoing losses after 24hrs Ongoing losses = 1cc/kg x TBSA Monitor urinary output!!! As determinant of adequate resuscitation (except in ARF) 2/4/2020 38

39. Management cont.… Pain management Pain- Hyperalgesia develops from exposed viable and growing nerve endings Pain with time becomes learned and is psychological and difficult to manage Pain is REAL to the patient IV injections not advised when burns exceeds 10% TBSA 2/4/2020 39

40. Management cont.… Analgesics- Opioids- morphine(adults). Pethidine , PCM NSAIDS- Oral ketamine Anesthesia for dressings Psychotherapy, encouragement Good dressing techniques Soak dressings-shower Products- Non Adherent, Fewer intervals Early mobilization 2/4/2020 40

41. Management cont .… Surgery Debridement Fasciotomy For compartment syndrome Escharoctomy Tangential excision + STSG Others as indicated 2/4/2020 41

42. Management cont.… 2/4/2020 42

43. Management cont.… Burn Wound dressings Principles: Full-thickness and deep-dermal burns need antibacterial dressings to delay colonization prior to surgery Superficial burns will heal and need simple dressings An optimal healing environment can make a difference to outcome in borderline-depth burns 2/4/2020 43

44. Management cont.… wound dressing Regular intervals as determined by the need (not by staffing) Give analgesics I.V 30 mins before procedure ( or proceed with psychotherapy) Layered removal of dressing Debride when required Clean with normal saline Dab dry Apply topical antibiotic Layered dressings applied systematically 2/4/2020 44

45. Management cont.… Dressings can be occlusive or open Benefits of occlusive dressing Protects against infection Reduces pain- nerve endings exposed to air is painful Providers a moist environnent for re-epithelisation Nursing care is easier/ not messy like open dressing Reduces need for frequent dressings with pain and pressure on nursing personnel 2/4/2020 45

46. Management cont.… Benefits of Open Dressings Easy , Quicker Dressing procedure less painful Cheaper Easy access to assess wounds for infection Great for hot tropical weather Difficult to move patient if extensive Messy on beddings More difficult to control hypothermia Requires strict control of environment, visitors 2/4/2020 46

47. Management cont.… Dressing agents Full-thickness burns and obvious deep dermal wounds Nanocrystalline silver Silver sulphadiazine cream: 1%broad spectrum, not painful, yellow pseudo eschar. Self limiting leucopenia Silver nitrate solution (0.5%) Mafenide asetate cream or 5% soln. Painful. Permeates eschars. Carbonic anhydrase inhibitor causes acidosis Cerium nitrate 2/4/2020 47

48. Management cont.… Superficial partial-thickness wounds and mixed –depth wounds Exposure Mefix mepitel Hydrocolloid Biobrane A mniotic membrane Bacitracin: chlorhexidine Povidone iodine Bactroban:Mupirocin – MRSA 2/4/2020 48

49. Management cont.… Skin Substitutes Transcyte - cultured human fibroblasts in semi- permiable membrane on nylon matrix Alloderm Integra CEA – cultured epithelial autograft 2/4/2020 49

50. Management cont.… Blisters To rupture or to leave? Controversial Blister fluid contains vasoactive mediators-progression of the ischemic zone, and inhibit healing. The intact blister also serves as a physiologic dressing Blisters larger than several inches in diameter are most likely to rupture and should be removed. Small blisters- Can leave Large blister- Rupture Blisters over joints- Rupture 2/4/2020 50

51. Management cont.… Hydrotherapy Cart Shower 2/4/2020 51

52. Management cont .… Nutrition Aim- Achieve a positive nitrogen balance Correct deficit Premorbid, pre referral Correct on-going losses Chronic catabolic state Maintenance Daily requirements 2/4/2020 52

53. Management cont.… Commence oral feeds as soon as possible Enteral feed superior to parenteral NGT in burns > 20% TBSA in children and > 30% TBSA in adults Manage Ileus Tight glucose control – esp ICU pts Protein – 2g/kg body wt /day 2/4/2020 53

54. Curreri formula Sutherland Davies 2/4/2020 54

55. Management cont.… Infection control Wash down on arrival Anti Tetanus prophylaxis Meticulous protocol in the burn unit Disciplined antibiotic use Early debridement and wound closure Nutrition Topical antibiotic dressing 2/4/2020 55

56. Electrical Burn Of all burns patients admitted, 3% to 5% are injured from electrical contact. Electrical current enters a part of the body, such as the fingers or hand, and proceeds through tissues with the lowest resistance to current, generally the nerves, blood vessels, and muscles. The skin has a relatively high resistance to electrical current and is therefore mostly spared. Heat generated by the transfer of electrical current and passage of the current itself then injures the tissues. 2/4/2020 56

57. Electrical Burn cont.… The muscle is the major tissue through which the current flows, and thus it sustains the most damage . Injuries are divided into high- and low-voltage injuries. Threshold being 1000v Low-voltage injury is similar to thermal burns without transmission to the deeper tissues . 2/4/2020 57

58. Electrical Burn cont.… The syndrome of high-voltage injury consists of varying degrees of cutaneous burn at the entry and exit sites, combined with hidden destruction of deep tissue . Address Cardiac derangement. The key to managing patients with an electrical injury lies in the treatment of the wound. 2/4/2020 58

59. Chemical Burns 2/4/2020 59

60. Management cont … Nursing care Physiotherapy Psychological care 2/4/2020 60

61. Complications Early Hypovolemia/ Shock Acute renal failure Acute gastric erosion Compartment syndrome Gastric paralysis Anemia Sepsis Immunocompromised Severe weight loss Tetanus 2/4/2020 61

62. Complications Late Scarring Hypertrophic scars Keloids Contractures Myositis ossificans Cataracts (electric) Chronic Pruritus Chronic/ recurrent ulcers Malignancy – Marjolin's Ulcer 2/4/2020 62

63. Prognosis Baux score Expressed as % TBSA + Age The score is a comparative indicator of burn severity, with a score over 140 considered as being un-survivable , depending on the available treatment resources   Modified Baux score = body area affected  +  age of patient  + 17 2/4/2020 63 .

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65. Prevention According to the WHO, Improve awareness Develop and enforce effective policy Describe burden and identify risk factors Set research priorities with promotion of promising interventions Provide burn prevention programs Strengthen burn care Strengthen capacities to carry out all of the above. 2/4/2020 65

66. First aid What to do Stop the burning process by removing clothing and irrigating the burns. Extinguish flames by allowing the patient to roll on the ground, or by applying a blanket, or by using water or other fire-extinguishing liquids. Use cool running water to reduce the temperature of the burn. In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water. Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate facility for medical care. 2/4/2020 66

67. What not to do Do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals etc.) Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn. Do not apply ice because it deepens the injury . Avoid prolonged cooling with water because it will lead to hypothermia. Do not open blisters until topical antimicrobials can be applied, such as by a health-care provider. 2/4/2020 67

68. Do not apply any material directly to the wound as it might become infected. Avoid application of topical medication until the patient has been placed under appropriate medical care. 2/4/2020 68

69. Conclusion The treatment of burns is complex and require a multidisciplinary approach Minor injuries can be treated in the community by knowledgeable physicians. Moderate and severe injuries, however, require treatment in dedicated facilities. Burn injury treatment depends on the depth and total body surface area affected . 2/4/2020 69

70. Conclusion cont.… Early fluid resuscitation with adequate fluids and addressing inhalation injury saves lots of life . Addressing wound comes second after initial resuscitation with adequate covering of wound. Main aim of wound care is to protect body from infection and hypothermia. Early wound excision and grafting prevents wound contracture . Primary prevention- Best bet. Prevent burns from occurring at all 2/4/2020 70

71. References Burns in Nigeria: a Review A.O . Oladele  and  J.K. Olabanji Ann Burns Fire Disasters . 2010 Sep 30; 23(3): 120–127. Published online 2010 Sep 30 . Bailey & Love's Short Practice of Surgery, 27th Edition 27th Edition Overview of the management of burns, Dr. Dafieware O.R Https://www.Who.Int/news-room/fact-sheets/detail/burns Ann burns fire disasters . 2010 sept 30; 23(3): 120–127. Grabb and Smith's plastic surgery seventh edition Principles and practice of surgery including pathology in the tropics 4 th edition Principles and practice of burn care editor - in-chief sujata sarabahi 2/4/2020 71

72. Thank you 2/4/2020 72