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Burn Management

Burn Management. Tad Kim, M.D. Connie Lee, M.D. UF Surgery. Skin. Epidermis: barrier Dermis: durable & elastic. Burn Pathophysiology: Tissue Repair. Initial hemostatic response = coagulation and microvascular constriction Resuscitative phase = vasodilatation and capillary leak

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Burn Management

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  1. Burn Management Tad Kim, M.D. Connie Lee, M.D. UF Surgery

  2. Skin • Epidermis: barrier • Dermis: durable & elastic

  3. Burn Pathophysiology: Tissue Repair • Initial hemostatic response = coagulation and microvascular constriction • Resuscitative phase = vasodilatation and capillary leak • Epithelialization = restoration of fluid maintenance, temperature regulation, and microbial barrier function • Fibrogenesis = a/w wound appearance and strength

  4. Burn Pathophysiology: Systemic Response • Accelerated intravascular volume depletion • Inadequate tissue perfusion • Risk of multiorgan dysfunction

  5. Burn Pathophysiology: Metabolic Response Hypermetabolism:  glucose metabolism, lipolysis, and proteolysis Neuroendocrine response:  catecholamines,  thyroid hormones,  cortisol

  6. Burn Pathophysiology: Zones of Tissue Injury • Central zone of coagulation (full-thickness) • Zone of stasis (partial-thickness) • Zone of hyperemia (superficial partial-thickness)

  7. Zones of Injury Orgill D. NEJM 2009;360:893-901

  8. Burn Classification Superficial (1°): epidermis (sunburn) Partial-thickness (2°): Superficial partial-thickness: papillary dermis Blisters with fluid collection at the interface of the epidermis and dermis. Tissue pink & wet. Deep partial-thickness: reticular dermis Blisters. Tissue molted, dry, decreased sensation. Full-thickness (3°): dermis Leathery, firm, insensate. 4th degree: skin, subcutaneous fat, muscle, bone

  9. Classification of Burn Depth

  10. Criteria for Referral to a Burn Center Orgill D. NEJM 2009;360:893-901

  11. Initial Assessment • Airway • Breathing • Circulation • Disability • Exposure • Initial burn treatment: remove burn source

  12. Assessment: Airway Airway at risk secondary to: Direct injury Fluid resuscitation Edema from inflammatory response Clues to airway injury: history, facial burn, carbonaceous sputum, hoarseness, stridor, wheezing Intubate based on respiratory and mental status

  13. Inhalation Injury • Carbon monoxide poisoning • Upper airway thermal injury • Lower airway burn injury • ARDS

  14. The Rule of Nines and Lund–Browder Charts Orgill D. N Engl J Med 2009;360:893-901

  15. Fluid Resuscitation Resuscitation based on burn size Parkland formula 4 x Wt(kg) x %TBSA = mL/24 hours Deliver 1/2 volume over 1st 8hrs Deliver 2nd half over next 16 hours

  16. Fluid Resuscitation Complications • Overresuscitation complications: Poor tissue perfusion Compartment syndrome Pulmonary edema Pleural effusion Electrolyte abnormalities

  17. General Management • Neuro • CV • Respiratory • GI • FEN • HEME/ID • Activity

  18. Wound Management: General • Clean & debride wound • Prophylactic systemic abx unnecessary • Topical abx delay wound colonization and infection • Escharotomy/fasciotomy may be required (circumferential burns, deep burns, compartment syndrome)

  19. Wound Management: Topical Antibiotics Mafenide acetate (Sulfamylon) for ears Good at penetrating eschar & is painful Broad spectrum Side effect: metabolic acidosis via carbonic anhydrase inhibition Bacitracin for face Gram-positive bacteria Silver sulfadiazine (Silvadene) for trunk & extremities Broad spectrum, esp. Pseudomonas Does not penetrate eschar very well Side effects: neutropenia/thrombocytopenia

  20. Excision and Grafting Orgill D. N Engl J Med 2009;360:893-901

  21. Wound Management: Burn Excision & Grafting • Early excision & grafting improved burn patient mortality & functional outcome • Initial excision should occur soon after resuscitation • Full-thickness skin grafts (FTSG) • Split-thickness skin grafts (STSG) • Human allograft • Porcine xenograft • Dermal substitutes: Integra

  22. Electrical Burns Categories: high voltage (>1000 volts), low voltage, lightning High voltage: requires trauma evaluation Local injury, deep injury, fractures, blunt injuries Risk of rhabdomyolysis, compartment syndrome, cardiac injury Low voltage: common in children Local injury Late complications: cataracts, progressive demyelinating neurologic loss

  23. Chemical Burns Empirical treatment End the exposure ABCDE Alkalis generally cause worse damage Initial treatment for acid or alkali: irrigation with water Dry powder should be brushed off Hydrofluoric acid: can cause severe hypoCa

  24. Take Home Always start with ABCDE for trauma/burns The airway is at risk in burn patients Parkland formula for initial resuscitation Rule of Nines Keep burns clean with soap & topical abx Early burn excision & grafting saves lives

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