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Burn and wound management

Burn and wound management. C Balakrishnan, MD Associate Professor Division of Plastic Surgery Wayne State University Detroit, Michigan, USA. Burn care and Wound care. No financial interest

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Burn and wound management

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  1. Burn and wound management C Balakrishnan, MD Associate Professor Division of Plastic Surgery Wayne State University Detroit, Michigan, USA MOHC 2012, Grand Rapids, Michigan

  2. Burn care and Wound care • No financial interest • Aim: Principles of Wound care principles, Burn care and Reconstruction and rehabilitation following burn injuries MOHC 2012, Grand Rapids, Michigan

  3. Burn care and Wound care • Burn care and wound care – what is in common? • Skin is the largest organ in the body • Local and systemic changes are best studied for burns • American Burn Association, Am Academy of Wound management, American College of certified Wound specialists (CWS, FCCWS) MOHC 2012, Grand Rapids, Michigan

  4. Types of wounds Acute wounds: • Acute thermal injuries (Burns, Frostbite) • Traumatic injuries Chronic wounds: • Pressure sores • Radiation injuries MOHC 2012, Grand Rapids, Michigan

  5. Burns MOHC 2012, Grand Rapids, Michigan

  6. Frost bite Trench feet Cold injuries MOHC 2012, Grand Rapids, Michigan

  7. American Burn Association criteria for transfer to Burn unit • Major burns • Burns associated with inhalation injury • Burns of specific areas of the body – face, hand, feet, perineum • Chemical injuries • Electrical injuries MOHC 2012, Grand Rapids, Michigan

  8. Etiology of Burns Causes :  • Flame - damage from superheated, oxidized air     • Scald - damage from contact with hot liquids    • Contact - damage from contact with hot or cold solid materials    • Chemicals - contact with noxious chemicals    • Electricity - conduction of electrical current through tissues MOHC 2012, Grand Rapids, Michigan

  9. Etiology of Burns • Incidence of work related burn injuries – 26.4 per 10,000 workers (Islam et al J T 2000) • Male – Construction and mechanical • Women – Service industry MOHC 2012, Grand Rapids, Michigan

  10. Work force involved • Welders • Cooks • Laborers • Food service • Mechanics • Electrician • Fire fighters MOHC 2012, Grand Rapids, Michigan

  11. Area involved • Hand, wrist – hot liquid • Eyes – chemical • Face flame, hot liquid • Contact burns • Firefighters – face and posterior neck MOHC 2012, Grand Rapids, Michigan

  12. Etiology • Age groups - Younger cooks and food service personnel • Depth – 1.3 per 10,000 deep • Associated trauma – Inhalation injury, Fractures, Crush injuries MOHC 2012, Grand Rapids, Michigan

  13. Psychological problems associated with work related Burn injuries • Depression • PTSD • Anxiety disorders • Workers with electrical injuries had higher psychological sequlae (19%) JBCR 2011 MOHC 2012, Grand Rapids, Michigan

  14. Depth of injury • First degree - Injury localized to the epidermis    • Superficial second degree - injury to the epidermis and superficial dermis    • Deep second degree - injury through the epidermis and deep into the dermis    • Third degree - full-thickness injury through the epidermis and dermis into subcutaneous fat    • Fourth degree - injury through the skin and subcutaneous fat into underlying muscle or bone MOHC 2012, Grand Rapids, Michigan

  15. Depth of burn MOHC 2012, Grand Rapids, Michigan

  16. Incineration Fourth degree Depth of injury MOHC 2012, Grand Rapids, Michigan

  17. Physiology of depth of injury • Three zones: • zone of coagulation • zone of stasis • zone of hyperemia • This is similar for a pressure ulcer MOHC 2012, Grand Rapids, Michigan

  18. Aim of management • To limit the injure to zone of coagulation • To prevent injury to zone of stasis • Management actually aims at preventing a second degree or first degree burn to becoming a deeperinjury MOHC 2012, Grand Rapids, Michigan

  19. Rule of nine Charts Burn size MOHC 2012, Grand Rapids, Michigan

  20. Hydrofluoric acid Phenol Phosphorus - Calcium gluconate - Ethylene glycol - Copper sulfate Chemical burns MOHC 2012, Grand Rapids, Michigan

  21. Phenol – chemical peel Cardiac toxicity Monitor EKG Ethylene glycol Chemical burns MOHC 2012, Grand Rapids, Michigan

  22. Electrical injuries MOHC 2012, Grand Rapids, Michigan

  23. Electrical injuries • Muscle injury without skin damage • Myoglobinuria – treat to prevent renal failure • Cardiac arrhythmia • Tetany, rupture of tendons • Neurological deficit • Saliva good conductor of electricity MOHC 2012, Grand Rapids, Michigan

  24. Impaired attention span Memory problems (especially for short-term anterograde verbal information Persistent distress and frustration Mood disorders - often characterized by psychosocial difficulty and violent behavioral outbursts, accompanied by a background of generalized depression Electrical Injuries MOHC 2012, Grand Rapids, Michigan

  25. Electrical injuries • Survivors of severe electrical injury have been noted to exhibit abnormal neuropsychologic findings several years after trauma. • Late evaluation of patients with significant electrical injury has suggested a common constellation of symptoms involving both cognitive and affective disturbances. MOHC 2012, Grand Rapids, Michigan

  26. Systemic response to Burns • Inflammation and edema • Altered hemodynamics • Immunosuppression • Hyper metabolism • Decreased renal flow • Increased gut mucosal permeability MOHC 2012, Grand Rapids, Michigan

  27. Principles of management • Burn Resuscitation • Early management • Wound care • Surgical management • Management of complications • Management of Psychosocial issues MOHC 2012, Grand Rapids, Michigan

  28. Parkland formula • Parkland 4 ml/kg per % TBSA burn Total fluid =4 x body wt x BSA • ½ of which is given in first 8 hours from the point of injury • Next half is given in the next 16 hours MOHC 2012, Grand Rapids, Michigan

  29. Wound management • Escharotomy • Excision • Skin grafts • Flaps • Others MOHC 2012, Grand Rapids, Michigan

  30. Indications - Improve circulation Escharotomy MOHC 2012, Grand Rapids, Michigan

  31. Fasciotomy MOHC 2012, Grand Rapids, Michigan

  32. Wound care • Silver sulfadiazine • Mefenate acetate • Silver dressings MOHC 2012, Grand Rapids, Michigan

  33. Biological dressings Allograft (cadaver skin) Xenograft Placental membrane Bilayered Cultured epidermal cells Wound care MOHC 2012, Grand Rapids, Michigan

  34. Wound healing Principles • Burn wounds are potentially contaminated and needs debridement. • Clean wound with out coagulum heals faster. • Epithlialization occurs from the cells remaining in the dermis. MOHC 2012, Grand Rapids, Michigan

  35. Wound therapy • Management of burn wounds can be divided into three stages: assessment, management, rehabilitation. • Rehabilitation starts early in management • Positioning and splinting • Stretching of joints MOHC 2012, Grand Rapids, Michigan

  36. Surgical management • Primary excision • Early excision • Excision with Skin grafting • Excision with allograft • Excision with skin substitutes • Excision – Integra – Skin grafting • Excision with flap coverage MOHC 2012, Grand Rapids, Michigan

  37. Surgical management • Immediate excision • Primary excision • Early excision • Delayed excision MOHC 2012, Grand Rapids, Michigan

  38. Excision and grafting of the Burn wound • Early excision vs delayed MOHC 2012, Grand Rapids, Michigan

  39. Outcome in Burns • Early, aggressive resuscitation regimens including early excision and wound coverage have improved survival rates dramatically. • By decrease in Sepsis and Multi organ failure MOHC 2012, Grand Rapids, Michigan

  40. Outcome • Hypertrophic scar • Burn contractures • Amputations MOHC 2012, Grand Rapids, Michigan

  41. Prevention of contractures!!!! • Think neck and chest are a single unit when it comes to contracture • Hand splints • Position elbows and axilla • Knee brace • Prevent foot drop MOHC 2012, Grand Rapids, Michigan

  42. Pressure garments Pressure garments appear to help in : • reduce scar thickness/lumpiness • reduce scar redness • reduce swelling • relieve itching • protect newly healed skin/graft • prevent contractures/ maintain contours MOHC 2012, Grand Rapids, Michigan

  43. Silicone gel sheets • The exact mechanism of action of silicone in the prevention and management of hypertrophic scars is unclear. • Influences the collagen remodeling phase of wound healing • Soften, flatten and blanch the scar, making it comfortable and improves appearance MOHC 2012, Grand Rapids, Michigan

  44. Custom Compression Garments • 25 mm of Hg • Constant use • Clear masks for face MOHC 2012, Grand Rapids, Michigan

  45. Management of contractures • Serial casting • Surgical release • Post operative splinting MOHC 2012, Grand Rapids, Michigan

  46. Lip deformity secondary to neck contracture MOHC 2012, Grand Rapids, Michigan

  47. Complications of Hand Burns • Burn associated neuropathy • Reflex sympathetic dystrophy • Pain syndrome • Amputations and loss of parts MOHC 2012, Grand Rapids, Michigan

  48. Hand burns - Principles • Early excision and wound coverage • Excision and skin grafting • Flap coverage of exposed bones and joints MOHC 2012, Grand Rapids, Michigan

  49. Cross finger flap MOHC 2012, Grand Rapids, Michigan

  50. Radial forearm flap MOHC 2012, Grand Rapids, Michigan

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