The presentation is about Burns and hazards

The presentation is about burns

1. BURNS

2. Outline Anatomy of the skin Definition of burns Cause of burns Pathophysiology of burns Classification of burns Management

3. Definition A coagulative necrosis of tissues. Occurs in the young, the old, the careless, and the unlucky

4. Anatomy of skin( intergument )and epidermidis The skin is the largest organ in the body. It covers the bodies entire external surface, serving as a first-order barrier against pathogens, UV light, and chemicals, and provides a mechanical barrier to injury. It also regulates temperature and amount of water released into the environment.

5. Skin thickness Hairless skin of the palms of the hands and soles of the feet is thick skin, referring to thickness of epidermis. The thickest skin based on the thickness of the dermis is on the upper portion of the back. But it is considered “thin skin” histologically because of epidermal thickness.

6. The epidermis Stratum basale aka stratum germinativum – deepest layer, separated from dermis by basement membrane (basal lamina) and attached by hemidesmosomes. Cells are cuboidal to columnar and are mitotically active stem cells

7. The epidermis Stratum spinosum aka prickle cell layer - irregular, polyhedral cells with processes (“spines”) that extend out ward and contact neighboring cells by desmosomes.

8. Stratum granulosum - diamond shaped cells which contain keratohyalin granules; aggregates keratin filaments present in cornified cells

9. The epidermis Stratum lucidum - if present, thin clear layer consisting of eleidin (transformation product of keratohyalin ); usually seen in thick skin only. Stratum corneum - outermost layer, made up of keratin and horny scales which were once living cells; dead cells known as squamous ( anucleate ); layer which varies most in thickness, especially thick in callused skin

10. The dermis It consists of two layers of connective tissue which merge together, no clear demarcation. Papillary layer - Outer layer, thinner, composed of loose connective tissue and contacts epidermis. Reticular layer - Deeper layer, thicker, less cellular, and consists of dense connective tissue/ bundles of collagen fibers. The dermis houses the skin appendages (sweat glands and hairs), many sensory neurons and blood vessels

11. Hypodermis Also called subcutaneous fascia It is the deepest layer of the skin Contains adipose lobules along with some skin appendages (hair follicles), sensory neurons, and blood vessels.

12. Causes of burns Hot liquids – e.g. water, oils; also called scalds Flame or flash burns Contact burns – chemical burns (alkali and acids) electric burns ( high and low voltages Irradiation burns Friction burns – heat plus abrasion Cold injury – ice formation, tissue freezing, vasospasm Sun burn Burns from lightening strike

13. Contact burns Electrical burn Chemical burn

14. Pathophysiology Inflammatory mediators cause increased capillary permeability Leakage of fluids from vessels into interstitial tissues; causes oedema Fluid loss is rapid at first; reduced after 18 to 24 hours. Integrity of the vessel wall is restored

15. Systemic Effects Hypovolaemia Immunosuppression Catabolism Pulmonary oedema Loss of protective function of the skin Anaemia – due to (1) direct destruction of rbcs (2) haemolysis from initial injury (3) bone marrow depression (4) cutaneous loss from change of dressing

16. Classification 1 st Degree – epidermis 2 nd degree – epidermis and dermis{ deep dermal; from mid-dermis to subcutaneous tissue} 3 rd degree – epidermis, dermis and subcutaneous , muscle and bone involved also called deep burn or full thickness burn

17. Superficial partial burns. Range from 1st to second degree burns Presents a painful erythema. Without infection it heals by re – epitheliazation from epithelial linings of sweat duct, sebaceous glands and hair follicles.

18. Deep dermal burns Here the skin as far down as the dermis is involved . Also known as deep dermal or deep partial or second degree burns. Re- epithilization is not adequate.healed wound turned to have thin and unstable with a risk if hypertrophic scarring.

19. Full thickness burns Deep burns. whole skin is lost . Structures deeper than skin such as fat,fascia bone and muscle

20. Full thickness burns of trunk

21. Jackson’ Classification

22. Jackson’s Classification High temperature causes graded tissue injury radiating from point of contact Zone of coagulation and necrosis – cells in immediate area killed; proteins denatured Zone of stasis – characterised by vasoconstriction and ischaemia; cells viable but may convert to coagulation due to oedema, infection, decreased perfusion

23. Jackson’s Classification Zone of hyperaemia – vasodilatation from release of inflammatory mediators from cutaneous cells. Cells remain viable.

24. CLASSIFICATION Jackson’s Classification Zone of stasis stabilises over 36 to 48 hours and all cells survive under favourable conditions In hypoxic and ischaemic conditions, e.g. due to inadequate fluid resuscitation, cells will die; zone of coagulation will extend to include zone of stasis An initial superficial burn may progress to a deeper burn injury during resuscitation phase

25. Estimation of Burn Size Wallace’s Rule of Nines Adults: Head and neck – 9% Upper limb – 9% Anterior trunk – 18% Posterior trunk – 18% Each lower limb – 18% Genitalia – 1% Palm Estimation – 1% Minor & major burns: major>15% in adults; >10% in children

26. Lund & Browder Charts – corrected for the different body proportions in children

27. Major burn Fluid exudation is mainly in the burnt tissue therefore the body surface area affected determine the amount of fluid loss. Classify a burn as major when a superficial burn occupies 15% of TBSA in an adult and 10% TBSA for children. In Major because the risk if shock and overwhelming septicemia increases exponentially . Burns of the face,hand, feet, flexion crease and genitalia are considered serious.

28. Management Management : first aid – put out flame; pour cold water by placing under running water for 10 minutes to cool the tissue. Then cover with clean sheet; transfer to hospital . The principles of management of burns include revival, repair,restoration,and rehabilitation.

29. Emergency Room – history/ABC/history assess burn size; weigh patient; start i.v. resuscitation- calculate using Parkland Formula (4ml/Kg/%TBSA); fluid of choice is Ringer’s lactate; ½ in first 8 hours; next half in16 hours Monitor urine output – 1.2ml/Kg body weight/%TBSA adequate Wound swab for C/S; tetanus prophylaxis

30. Wound Management Dressing – open or closed Wound toileting under sedation; savlon; then saline; apply dermazine; gauze, thick layer of cotton wool; crepe bandaging If dressing not soaked, leave for one week; if soaked change immediately

31. Drugs Antibiotics - <24 hrs burn wound is sterile; no antibiotics; if contaminated give antibiotics Extensive burns > 50% risk of Gram negative septicaemia Analgesia - for pain; beware of NSAIDS Prophylaxis for GIT bleeding

32. Topical management of major burn three agents have proven efficacy for major burns: 11.1 percent mafenide acetate cream, 1 percent silver sulfadiazine cream, and 0.5 percent silver nitrate solution. Silver sulfadiazine is the mostly widely used of the three for routine prophylaxis because of its relatively low toxicity and ease of use. 

33. Surgical Management Wound excision and grafting Skin grafting of acute burns Tangential excision Escharotomy Secondary surgery for contractures, revision of scars

34. Escharotomy for circumferential burns to the lower limbs Escharotomy done Escharotomy

35. Non-surgical management Positioning of burnt extremity Splinting of joints Active and passive movements Others - oral feeding, high protein, high calorie

36. Inhalation Injury Inhalation injury is a broad term that includes pulmonary exposure to a wide range of chemicals in various forms including smoke, gases, vapors , or fumes. Inhalation injury from smoke exposure is commonly seen in patients exposed to fires Carbon monoxide inhalation Thermal injury to respiratory tract Inhalation of products of combustion – aldehydes, ketones, organic acids from combustion of synthetic products

37. Inhalation injury affects the respiratory system through damage to the airways (including nasal passages, posterior oropharynx, larynx, trachea, bronchi) or parenchymal damage (alveoli). The location where damage occurs is complex. Thermal injury often affects only to the level of the larynx The effect caused by tissue edema narrowing the passageways and mucus/blood/fluid impeding airflow.

38. C linical presentation History of fire in an enclosed space; patient lying unconscious in a fire Symptoms: hoarse voice, increasing stridor, respiratory difficulty Signs: soot around mouth, singed facial and nasal hair, carbonaceous sputum Treatment: intubation; 100% oxygen; antibiotics

39. Patient with inhalation injury

40. Patient with inhalation injury in BICU

41. Treatment of inhalational burns The simplest and probably the best treatment for carbon monoxide poisoning is ventilation with 100 percent oxygen, which decreases the half-life of carboxyhemoglobin from 4 1/4 hours to about 50 minutes. Hyperbaric-oxygen therapy has been recommended, but credible evidence of its superiority is sparse. Moreover, the logistics of initiating and delivering care to patients with extensive burns within the confines of most hyperbaric-oxygen chambers are formidable.

42. Summary Most minor burns can be managed in primary care  Appropriate first aid limits progression of burn depth and influences outcome Assessment of area and depth is crucial to formulating a management plan Burn depth may progress with time, so re-evaluation is essential All major burns require fluid resuscitation, which should be guided by monitoring of the physiological parameters

43. Thank you