Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences Subspecialty Surgery Plastic Surgery (Burns and Wounds) Ali Jassim Alhashli

2. Burns • What are the causes of burn? • Thermal injury (most common): • Dry: • Fire: • If fire occurs in a closed space this will produce hot fumes and CO which result in inhalation injury (determined by the presence of black spots in oral cavity with black sputum). Patient must be intubated immediately to secure his airway before laryngeal edema occurs. • Inhalation of carbon monoxide (CO) impairs tissue oxygenation. • Signs and symptoms: cough, wheeze, carbonaceous sputum, head and neck burns and burnt nose hairs. • Diagnosis: bronchoscopy and measurement of carboxyhemoglobin with ABG. • Mild injury: humidified oxygen + incentive spirometer. • Moderate injury: repeated bronchoscopy when there is continued mucosal sloughing and the patient is unable to clear it. • Severe with progressive hypoxemia: intubation. • Hot objects. • Moist: • Hot oil. • Hot water. • Chemical burn: • Acid. • Alkali (more severe than acidic burns because the body cannot buffer it!). • Remove contaminated cloths which are in contact with patient’s body. Use runny water when washing chemicals from body parts for 30 minutes with acidic burns and longer time for alkali burns (do NOT use saline to avoid any possible reactions because it contains electrolytes).

3. What are the causes of burns? (continued) • Electrical burn: signs and symptoms include the following • Charring متفحم at point of contact. • Myoglobinuria (with muscle damage). To prevent renal failure, think about “HAM”: • Hydration with IV fluids. • Alkalization of urine with IV bicarbonate. • Mannitoldiuresis. • Hyperkalemia (with tissue necrosis). • High-voltage or lightening injury may cause cardiac arrest. • Neuropathy (immediately following the injury and is likely to resolve over time). • Compartment syndrome. • Physical burn: • Sunlight → it is important to moisturize the skin. • Radiation. • Special burns: • Friction burn (mechanical): it is a form of abrasion caused by the friction of skin rubbing against a surface. This is often uncomfortable and even painful but rarely results in bleeding. The risks of a friction burn include infection and temporary or permanent scarring. Treatment usually involves application of anti-inflammatory cream and analgesics. Burns

4. Burns Electrical burn Sunburn Friction burn

5. Classification of burns according to the depth of skin which is involved: • 1st degree: only involves the epidermis. Skin is painful, red but with NO blisters. • 2nd degree: epidermis and varying levels of the dermis. Skin is painful, swollen WITH blisters. • 3rd degree: epidermis and the entire dermis. Skin is painless (nerve endings are destroyed), white and looks like a dried leather. • 4th degree: burn injury reaching into bones/muscles. Burns

6. Pathophysiology of burn: • There are 3 zones within a burn: • Zone of coagulation: most intimate contact with the heat source; composed of dead and dying cells. • Zone of stasis: initially intact circulation, often ceases within 24 hours and becomes non-viable. • Zone of hyperemia: intact circulation which usually heals • How to determine the extent of burn? • Rough stimulation → rule of the palm → surface area of patient’s palm represents approximately 1% of his Total Body Surface Area (TBSA). • Rule of nines: notice that it is not very accurate as there are differences in percentages representing the head of a child with different ages. Therefore, burn chart was established. Burns

7. Burns

8. Burns • Diagnosis of burn is made through: • History. • Physical examination. • Don’t forget to look for other diseases/ conditions (fractures, diabetes, HTN, arrhythmias… etc). • American Burn Association criteria for referral to a burn center: • Partial thickness burns > 10% of TBSA in pediatrics and > 15% of TBSA in adults (due to higher risk of shock). • Burns which involve: face, hands, genitalia/ perineum or major joints. • 3rd degree burns in any age group: it requires skin grafting for healing and has higher risk for dehydration and infection. • Electrical burns (including lightening injury). • Chemical burns. • Inhalation injury. • Burn injury in patients with pre-existing medical disorders (such as diabetes or HTN). • Any patient with burns and concomitant trauma (such as fractures).

9. Treatment outline: • ABCDE: • A: Airway (intubate patient if indicated especially with inhalation injury). • B: Breathing. • C: Circulation • There has to be a rapid access to circulation. • Type of fluid: Ringer lactate. • Amount of fluid (Parkland’s formula): (%) of burn x body weight (Kg) x 4 cc • ½ of this amount is administered in first 8 hours of burn. • Other ½ of the amount is administered within next 16 hours. • Maintain urine output –by placing Foley’s catheter- at: 0.5 – 1 ml/ kg/ hour to prevent renal failure. • D: Disability. • E: Exposure with avoidance of hypothermia. • Determine the extent of burn. • Analgesia: use narcotics (IV morphine) with partial thickness burns. • Cover burns with silver sulfadiazine (has an action of antibiotic) then closed dressing is applied. • Elevate burned areas when possible to minimize edema. • Give prophylaxis for tetanus (except for those actively immunized within the past 12 months). • GI prophylaxis (for Curling ulcers). • Patients with high-voltage electrical injury require cardiac monitoring (ECG). • What are the complications of burns? • Early: • Shock. • Acute renal failure. • Laryngeal edema (with inhalation injury of thermal burns). • Arrhythmias with electrical burns. • Late: • Infection (S.aureus, Pseudomonas, Streptococcus and Candida albicans are common organisms). • Curling ulcer. • Post-burn contractures. Burns

10. What is the definition of a wound? • It is a break in the continuity of the skin which can be of different types: • In a form of a line: surgical incision. • Skin loss: in burns. • Irregular wounds: traumatic. • Notice that most wounds of the skin will heal without any problems/ complications, but some of them might express delayed process of healing and require special interventions. • What are the steps of wound healing? Wounds

11. Wounds

12. There are 4 levels for the assessment of an injury: • Assessment of the patient: check for factors which might delay the process of healing (DM, HTN, renal failure or being immunocompromised). • Patient and event assessment: immediate causes of the wound and any underlying pathophysiology. • Wound assessment: local conditions at the wound site (infection, foreign bodies… etc). • Assessment of possible outcomes (is it improving? if not, why?). • When assessing a wound, you must consider the following: • Site, size, shape, depth, color, (amount, type and color of exudates), odor, presence of an infection, wound-related pain, condition of the surrounding skin and any evidence of wound healing. • Classification of wounds: Wounds

13. What are the types of wound healing? • Wound infections (Surgical Site Infections SSIs): Wounds

14. Wounds

15. Incisions • If a patient has an old incision at the same location through which you need to do your operation, it is better to enter through this old incision. • Both epidermis and dermis are incised with a scalpel. • Incisions: • Kocher: incision in right subcostal area – for open cholecytectomy. • Midline laparotomy: incision through linea alba in midline of abdomen. • McBurney’s: small, oblique incision in RLQ for appendectomy. • Pfannensteil: transverse incision in lower abdomen (with retraction of rectus muscles) for caesarian section. • Mercedes-Benz incision: for liver transplantation. • Midline sternotomy: incision made through the sternum for heart procedures. • Thoracotomy: usually in 4th/5th ICS; it can be anterior, lateral or posterior. • What are Langer’s lines? • They are natural skin lines of minimal tension (e.g. lines across the forehead). Incisions perpendicular to Langer’s lines result in larger scars than incisions parallel to the lines.

16. Incisions