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BURNS

BURNS. DR. EDITH H. TERNA-YAWE MBBS,FWACS CONSULTANT PLASTIC AND RECONSTRUCTIVE SURGEON National Hospital Abuja. OUTLINE. INTRODUCTION CAUSES PATHOPHYSIOLOGY BURN CARE INHALATION INJURY WOUND CARE CHEMICAL BURN ELECTRICAL BURN COMPLICATIONS PREVENTION CONCLUSION. INTRODUCTION.

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BURNS

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  1. BURNS DR. EDITH H. TERNA-YAWE MBBS,FWACS CONSULTANT PLASTIC AND RECONSTRUCTIVE SURGEON National Hospital Abuja

  2. OUTLINE • INTRODUCTION • CAUSES • PATHOPHYSIOLOGY • BURN CARE • INHALATION INJURY • WOUND CARE • CHEMICAL BURN • ELECTRICAL BURN • COMPLICATIONS • PREVENTION • CONCLUSION

  3. INTRODUCTION Devastating trauma Largely PREVENTABLE Multidisciplinary treatment Requires proper understanding of pathology for treatment and good outcome

  4. ANATOMY /FUNCTIONS OF SKIN 1.Epidermis – outer layer 2.Dermis 3.Subcutaneous tissue FUNCTIONS -Protective Barrier -Regulation of Temperature -Sensation etc

  5. FUNCTIONS OF THE SKIN/BURN INJURY

  6. CAUSES OF BURN • HOT FLUIDS(SCALDS)- commonest in children • Hot water • Soups • Oils • Drinks • FLAME(NAKED FIRE)- commonest in adults • House fires- fuel, kerosene, gas explosion, electrical faults • Camp fires • Burning of trash, leaves

  7. CAUSES OF BURN • CONTACT BURN • Hot objects eg metals, plastics, coal • Usually deeper burns • ELECTRICAL BURN • CHEMICAL BURN

  8. PATHOPHYSIOLOGY OF THE BURN WOUND • Amount of tissue destruction is based on • Temperature • Time of exposure • Specific heat of the causative agent

  9. PATHOPHYSIOLOGY • Jackson(1953) described zones of injury • ZONE OF COAGULATION • No blood flow • Irreversible cell damage • Cellular death/necrosis • ZONE OF STASIS(oedema) • Decreased perfusion • Microvascular sludging and thrombosis of vessels results in progressive tissue necrosis • Cellular death in 24-48hr without proper treatment • N/B: factors favouring cell survival: moist, asceptic environment, rich blood supply • Zone where appropriate early intervention has most profound effect in minimizing injury

  10. PATHOPHYSIOLOGY • ZONE OF HYPERAEMIA • Vasodilatation from inflammation • Entirely viable • Cells recover within 7 days • Contributes to systemic consequences seen with major burns

  11. PATHOPHYSIOLOGY • SEVERE BURNS • Vascular permeability, oedema • Altered haemodynamics(decreased cardiac output, increased vascular resistance) • Hypermetabolism • Progressive pulmonary insufficiency • Increased gut mucosal permeability(GI bleed risk) • Immunosuppression • Renal failure(decreased renal blood flow)

  12. American Burn Association Burn Centre TRANSFER Criteria • 2nd or 3rd degree burns greater than 10% TBSA in patients younger than 10yrs or older than 50yrs • 2nd or 3rd degree burns greater than 20% TBSA in persons of other age groups • 2nd or 3rd degree burns that involve the face, hands, feet, genitalia, perineum or major joints • 3rd degree burns greater than 5% TBSA in persons of any age • Electrical burns including lightening injury • Chemical burns • Inhalational burns • Burn injury in patients of pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality • Any patient with burns or concomitant trauma (e.g. fracture) in which the burn injury poses the greatest risk or morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a Trauma Centre until stable before transfer to a Burn Centre • Lack of qualified personnel or equipment for the care of children (transfer to facility with these qualities) • Burn injury in patients who require social/emotional and/or long-term rehabilitative support, including cases involving suspected child abuse or substance abuse

  13. EXTENT OF BURNS(TBSA) • Wallace’s rule of nines • Lund and Browder chart • Patient’s palm = 1%

  14. BURN EXTENT Rule of Nines

  15. The Lund and Browder Chart

  16. Lund and Browder chart

  17. BURN DEPTH • DETERMINATION OF BURN DEPTH • Inspection – most reliable by experienced burn surgeon • Fluorescein dyes • Ultrasound • Laser Doppler • Magnetic Resonance Imaging

  18. Burn depth

  19. MANAGEMENT • Pre-hospital care • First aid • Primary Survey/Assessment - Airway - Breathing - Circulation • Secondary Survey • Mechanism of injury • Evaluation for presence/absence of inhalation injury/carbon monoxide poisoning • Consider possibility of abuse • Detailed assessment of burns wound • Detailed history documented

  20. MANAGEMENT • Prevent and/or treat burn shock – 2 wide bore IV cannula • Identify and treat immediate life-threatening conditions eg inhalation injury, CO poisoning • Determine TBSA affected • Depth – difficult to determine initially, easier to determine after 24hrs • Tetanus prophylaxis – 0.5ml IM, also give 250 units of tetanus Ig if prior immunization absent or unclear or last booster >10yrs ago • Baseline lab studies: FBC, urinalysis, EUC, RBS, GXM • Cleanse, debride and apply antimicrobial dressing • Early excision and grafting important for good outcome in deeper burns

  21. FLUID THERAPY • Parkland formula: 4ml Ringers lactate/kg/%TBSA • ½ of total in 0-8hrs • ½ of total next 16hrs • EXTRA FLUID IS REQUIRED IN THE FOLLOWING • Burn>80%TBSA • 40 burns • Associated traumatic injury • Inhalational injury • Electrical injury • Delayed start of resuscitation • Paediatric burns

  22. MONITORING • Urine output – best measure for adequate fluid resuscitation. Maintain at 0.5ml/kg/hr for adults, then 1ml/kg/hr for children <12yrs • Maintain a clear sensorium, • HR<120/min, mean BP>70mmHg

  23. INHALATIONAL INJURY • Closed-space fire incidents • Soot in the nares and mouth • Facial burns • Singed nasal hairs • Cough, hoarseness of voice, difficulty in breathing • Carbon monoxide intoxication • Probable in persons injured in structural fires, particularly if they are obtunded

  24. INHALATION INJURY 2 • Bronchoscopy • Carbonaceous debris • Ulceration/erythema • Clinical consequences • Upper airway oedemia • Bronchospasm • Small airway occlusion • Increased dead space and intrapulmonary shunting • Decreased lung and chest wall compliance • Infection • Management - Largely supportive - Oxygen - Intubation and ventilation - Airway toileting - Vasodilators - Pneumonia/tracheobronchitis occur in 30% of these patients

  25. BURN WOUND MANAGEMENT • Out-patient (Majority) • In-patient • FOUR PHASES • Initial evaluation & resuscitation • Initial wound excision & biologic closure • Definitive wound closure • Rehabilitation & reconstruction

  26. MEDICATION AND MEMBRANE • MEDICATIONS • Silver sulfadiazine • Aqueous 0.5% silver nitrate • Mafernide acetate • Petrolatum • Various debriding enzymes • Honey • Various antibiotic ointments

  27. SKIN COVER SUBSTITUTES • Split thickness human allograft • Epidermal • Amniotic membrane • Dermal analogues • Intergra R • Alloderm

  28. MEMBRANES • Porcine xenograft • Amniotic membrane • Split thickness allograft • Various hydrocolloid dressings • Various impregnated gauzes • Various semi-permeable membrane • Acticoat • Biobrane • Transcyte • Alloderm R • Intergra R

  29. CHEMICAL BURNS • Acid • Alkaline • Phosphorus • Chemical injection injuries • COMMON AGENTS • Cement • Hydrofluoric acid • Phenol • Tar

  30. CHEMICAL BURNS • MECHANISM OF INJURY • Chemical solutions coagulate tissue leading to necrosis • ACIDS – coagulative necrosis • ALKALI – saponification followed by liquefactive necrosis • SEVERITY DEPENDS ON • Type of chemical • Temperature • Volume • Concentration • Contact time • Site affected • Mechanism of chemical reaction • Degree of tissue penetration • N/B: burns are deeper than they initially appear and may progress with time

  31. CHEMICAL BURNS • Immediate removal of clothes and chemical • First responders need to protect themselves from injury • Copious irrigation with tap water for at least 30mins • Some agents are associated with irritating fumes which can result in airway compromise • Inspect and irrigate eyes if affected with normal saline • Correct metabolic abnormalities and tetanus prophylaxis if necessary

  32. CHEMICAL BURN • HYDROFLUORIC ACID • Water irrigation • Topical Calcium gel • +/- subcutaneous injection of Calcium gluconate • +/- 10% IV Calcium gluconate depending on amount of exposure and pain • SULFURIC ACID • Treat with soap/lime prior to irrigation as direct water exposure produces heat

  33. ELECTRICAL BURNS • Low voltage • Mid-voltage (200 to 1,000V) • Can have destructive injuries • High voltage (> 1,000V) • Associated with cardiac arrhythmias, myoglobinuria, loss of consciousness, falls, fractures

  34. ELECTRICAL BURN • System-specific damages associated with electrical burns • Abdominal – intraperitoneal damage • Bone – fractures and dislocations • Cardiopulmonary – anoxia, ventricular fibrillation, arrhythmias • Muscle – myoglobinuria indicates significant muscle damage/compartment syndrome • Neurological – seizures, spinal cord damage • Ophthalmic – cataract formation • Renal – acute tubular necrosis • Vascular – vessel thrombosis

  35. ELECTRICAL BURNSTreatment • Primary and secondary survey • Treat associated injuries • Monitor colour of urine, compartment syndrome and urine output • WOUND MANAGEMENT • Topical agents with good penetrating ability(Silver sulfadiazine or Mafenide acetate) • Debride non-viable tissues early and repeat PRN(every 48hrs) to prevent sepsis • Amputations frequently required

  36. BURNS REHABILITATION • Physiotherapy should commence from a critical care setting • Range of motion exercise • Splinting • Anti-deformity positioning • Minimize oedema • Reconstructive surgeries • Scar management • Compression garments • Topical silicon • Steroid injections • Management of pruritus

  37. PROGNOSIS • TBSA • Age • Depth • Location • Inhalation injury • Associated injuries • Comorbid factors

  38. PREVENTION • Patients, personnel and community education • Speed limits • Not carrying inflammable substances in passenger vehicles • Fire extinguishers in vehicles, etc

  39. REFERENCES 1. Robert L. Sheridan MD et al. Initial evaluation & management of the burn. Emedicine.medscape.com (2015) 2. Matthew B. Klein. Thermal, chemical and electrical injuries. Chapter 17 Grab & Smith’s plastic surgery. 6th edition (2007) 3. Brett D. Amolda et al. Electrical Injuries. Chapter 38. Total Burns Care 4th edition (2012) 4. Ronald P. Mlcak et al. Pre-hospital Management, transportation and emergency care. Chapter 7. Total Burns Care 4th edition (2012) • Nigerian Burn Society. Handbook on Prevention of Burns in our Environment/Society. • Charles H. Thorne: Grabb and Smith’s Plastic Surgery. 6th Ed.(2007). Lippincott Williams and Wilkins. • Ryan Austin et. al. Toronto notes of Plastic Surgery. 2011

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