BURNS

1. BURNS Dr. Eyad Baqain Plastic and Reconstructive Surgery

2. Epidemiology 0.5-1% of UK population suffer burn /year. 10% of these require admission Of these admissions, 10% are life threatening 75,000 Burn victims admitted to hospital every year in USA 45% of US admissions for the scald burn are in the children < 5years of age Flame burn are the largest group of patients admitted to a burn unit

3. High Risk Groups The very young The very old The very unlucky (21% are bystanders) The very careless ( �th from there own action)

4. THE VERY YOUNG

5. THE UNLUCKY

6. THE VERY CARELESS

7. TYPES OF BURNS Flame burns; fires Scold burns; hot liquids Electrical burns; lightening injuries Chemical burns; acids & alkali

8. FLAME BURN

9. SCOLD BURN

10. CHEMICAL BURN

11. CHEMICAL BURN

12. ELECTRICAL BURN

13. Burn wound ? Cell damage starts at 41 Deg Celsius Coagulation of Protein > 50 Deg Celsius Depth of wound: Temperature, Duration Chemicals: ph, strength Electricity: voltage, entry-exit points

14. Indications for admission to BU > 5% FT at any age > 10% PT in <10 yrs >50yrs > 20% PT in adults ,between 10 and 50 yrs Special areas: face, perineum, hands, feet Electrical ( including lightening) Chemical Inhalational injury

15. Indications for admission to BU Burns in patients with medical disorders Burns in patients with concomitant trauma Circumferential burns Suspected abuse Extremes of age

16. Organization of Burn Care

17. First Aid scene Extinguish flame, switch off power source, remove chemical soaked clothes, etc� Cool burn wound Dilute acid- alkali

18. First Aid Scene Cool burn wound: - reduce direct thermal trauma & stabilize mast cells, reducing release of histamine and other inflammatory mediators - pain relief - running water (15 degree C.) - worth considering for up to 2 hours

19. Treatment in the A&E A B C, Like all other trauma patients, should be evaluated systematically Intubation ?? Look for other injuries Assess burn wound

20. Intubation : Suspicion of inhalational injury Severe facial & neck burn � easy early intubation will become difficult and impossible later on�

21. Inhalational injury Fires Closed space Singed nasal hair Carbonaceous material in nose & mouth

22. INHALATIONAL INJURY

23. Inhalational injury Direct thermal injury (upper airway) Chemical injury ; products of combustion (lower airway) CO poisoning ; systemic effect

24. CO poisoning Toxic symptoms > 20%, death at 60% CO-Hb > 5% is indicative of inhalational injury but not severity 200 � 250 � greater affinity for Hb than oxygen Treatment ; 100% O2, hyperbaric oxygen

25. Assessment of burn wound Remove all clothes/ maintain warm temp. Remove all jewellery Check the back Estimate % BSA burn Estimate depth Recognize need for escharotomy

27. Large Burns (20 - 30%) Quantity of mediators is large : whole body oedema Hypovolaemic shock Fall in plasma volume Fall in cardiac output

28. Management of Major Burns Initial patient management Intravenous access established & I.V. fluids N/G tube ; ileus, enteral feeding Folley�s catheter Analgesia Tetanus vaccine Patient must be kept warm Dressing

29. Intravenous fluids Parkland formula : 4 ml R.L. � %TBSA � Wt (kg) half over 8 hrs half over 16 hrs 0.5 ml /kg /%TBSA of 5% albumin in RL 24 hrs after injury , over 8 hrs ( for > 30% burn) Children : 3ml R.L.� %TBSA � Wt + maintainance (G/S 0.45%)

30. Formula is a guideline U.O.P. of 0.5 ml/kg/hr in adults U.O.P. of 1 ml/kg/hr in children

31. Extra Fluid is Required in Children Inhalation injury Electrical injury Delayed resuscitation Dehydration Fire-fighters Intoxicated patients

32. Differences in Children Limited physiologic reserve Tendency to Hypoglycemia Greater surface area to mass ratio IV fluid required at a lower %TBSA Need higher volume per kilogram

33. Monitoring Resuscitation Urinary output Heart rate Blood pressure Central invasive haemodynamic Electrolytes Blood gases pH (<7.39 - lactic acidosis ?)

34. Burn wound depth Superficial (first degree) Partial thickness (second degree) superficial partial deep partial Full thickness (third degree)

35. Superficial (epidermal) Burn Redness Painful Dry Spontaneous scarless healing within 7 days

38. Partial Thicknesssuperficial Blister Redness Moist Painful Oedema Reepithelialisation within 14 days with minimal to no scarring

41. Partial thicknessdeep Grey-white Dry Little to no pain Reepithelialization with copious scarring over weeks (extensive collagen deposition)

43. Full thickness Dry No pain Clay like colour, white, charred Leathery No spontaneous wound closure possible (except very small wounds)

48. Burn Wound Management

49. Maximise Function and Appearance 1. Function - early reconstruction 2. Appearance - early reconstruction (particularly face)

50. FINGERS CONTRACTURE!!!!!

51. BURN DEFORMITY

56. FULL THICKNESS BURN

57. SKIN GRAFT

58. SIX MONTHS LATER

59. SIX MONTHS LATER

60. Functions of the Skin Protects against bacteria Prevents fluid loss Regulates temperature Initiates immune response Sensation Aesthetic & psychological importance

61. Escharotomy Chest: To allow respiratory movement Limb: To restore circulation in limb with excess swelling under rigid eschar

62. Limbs: Signs of Circulatory Obstruction Loss of distal circulation pallor coolness absent pulse loss capillary refill decreased oxygen saturation Pain on passive extension Deep pain at rest

64. Estimation of % TBSA burn

65. Rules of NinesAdults

66. Rules of NinesChildren

67. Lund and Browder Chart

69. OUTCOME PROGNOSIS Sum of Age in years Plus Area of burn in % TBSA < 80 good 80-100 life threatening >100 bad

70. OUTCOME In 1993 the LA 50 ( defined as burn size lethal to 50% of patients) in most burn units approached 75% total body surface area . Between 1971 and 1991, deaths attributed to flames and hot liquids dropped an estimated 40% while deaths from smoke inhalation decreased only 12%.

71. OUTCOME Causes of improvement Early and effective resuscitation Control of sepsis Improved management of inhalational injury, ventilation, ICU care. Early excision Development of alternative wound closure material Nutrition Team approach

72. INFECTION Infection is the leading cause of death in burn patients. Risk factors : 1.Burns > 30% TBSA 2.Deep partial / full thickness burns 3.Age: under 16 or over 60 years 4.Preexisting disease; DM, malnutrition,..

73. INFECTION During the past 15 years the primary cause of death has shifted from invasive burn wound infections to bronchopneumonia.

74. Wound Care Cleaning Debriding Topical Antimicrobial Protection Evaluation

75. Surgical Therapy Sharp Debridement (tangential, epifascial) Split Thickness Skin Grafts Alternative Wound Coverage

76. PRINCIPLES OF BURN RECONSTRUCTION Direct closure Adjacent tissue transfer Skin grafts; FTSG vs STSG Cultured epithelial autograts Flaps Tissue expansion

79. FULL THICKNESS BURN

80. 21 DAYS LATER

81. 21 DAYS LATER

82. ONE YEAR LATER