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BURN

BURN. Objectives. Describe epidemiology of burn injury Discuss causes of burn Classify burn injury Discuss Pathophysiology of burn Assessment of burn patient Describe treatment plans for burn patient by using ATLS principles Discuss complications of burn. Introduction. Burn

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BURN

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  1. BURN

  2. Objectives • Describe epidemiology of burn injury • Discuss causes of burn • Classify burn injury • Discuss Pathophysiology of burn • Assessment of burn patient • Describe treatment plans for burn patient by using ATLS principles • Discuss complications of burn BURN

  3. Introduction Burn Tissue injury • thermal ( heat, cold) • electrical • Radiation • chemical • coagulative necrosis BURN

  4. Epidemiology • 1% of the world population each year • USA ~ 2.4 million burn injuries/ yr & 10,000 death/yr • UK ~ 250,000 patients treated with burns & 700 deaths/yr. • In Kenya 5,000 deaths/yr • TZ(MNH) 10% of admission in pediatric surgical ward • ??BMC BURN

  5. epid…… Age Scald - < 5 year of age flame, electrical & chemical burn - adult Sex domestic burn - females occupational - males Race No race predilection exists in burn injuries BURN

  6. Risks factors Diseases e.g. epilepsy, diabetes Children< 5years; Elderly > 75 years Cold weather Occupational – electricians/industrial Alcoholism ??Low socioeconomic status BURN

  7. High morbidity and mortality emotional & psychological BURN

  8. Anatomy Skin The epidermis • derived from ectoderm • it can regenerate. The dermis • from mesoderm • cannot re-generate, BURN

  9. AETIOLOGY Thermal injuries Scald Flame Flash Contact Chemical injuries Electrical injuries Radiation injuries Cold injuries BURN

  10. classification • type /cause • body site • degree • size/extent • severity BURN

  11. Class.. - type • Thermal burn • Scald • Flame burn • Contact burn • Flash • Electrical burn • Chemical burn • Radiation burn • Cold burn BURN

  12. Class.. site • Facial burn • Head & neck • Trunk • Limbs • Perineal burn depth • Superficial burn • Epidemal • Dermal • Deep burn • Dermal • Full thickness • Mixed burn BURN

  13. Class.. degree of tissue injury • First degree burn • Second degree burn • 2nd Degree Superficial (superficial Dermal) • 2nd Degree Deep (deep Dermal) • Third degree burn • Fourth degree burn BURN

  14. Class.. Size/Extent Total body surface area (TBSA) burned severity of burn • Minor burn • Moderate burn • Major burn BURN

  15. PATHOPHYSIOLOGY Burn injuries result in:- local response systemic response BURN

  16. Pathophysiology…… LOCAL RESPONSE • Inflammation • Jackson zones (1947) • coagulation /necrosis • Stasis/ischaemia • hyperemia BURN

  17. SYSTEMIC RESPONSE:- Significant burn  massive release of inflammatory mediators, both in the wound and other sites. Pathophysiology…… BURN

  18. Follow burn injury , neutrophils ,monocytes & platelets migrate into burn wound • Capillary permeability  locally & in distinct organs. • Plasma oncotic pressure • Interstitial oncotic pressure due to increased capillary permeability  protein loss  edema in burned & un-burned tissues BURN

  19. Biochemical … ↓ tissue perfusion tissue hypoxia anaerobic resp Pyruvate↑ lactic acid metabolic acidosis alter cellular enzymes activity BURN

  20. Biochemical….. ↓ATP↓ Na+Ka+-ATPase ↑↑Na+ intracellular & ↑↑K+ extracellular cellular swelling hyperkalemia ↓ ECF vol. Cell death by necrosis or apoptosis BURN

  21. CVS • ↓Myocardial contractility  TNF • ↓ CO due to loss of intravascular vol, ↑ viscocity & ↓cardiac contractility. These changes, coupled with fluid loss from the burn wounds systemic hypotension & end organ hypotension  MOD  MOF BURN

  22. Respiratory Inflammatory mediators →bronchoconstriction, → ARDS Pulmonary dysfunction • Inhalation injury • Aspiration • Shock • Circumferential thoracic eschar BURN

  23. GIT • mucosal atrophy • changes in the digestive absorption •  intestinal permeability Thromboxane A2  prominent mesenteric vasoconstriction  ↓gut blood flow compromise gut mucosal intergrity & ↓ immune fxn • Stress (Curling’s) ulcer ( stomach & duodenum). • Acute pseudo-obstruction of the colon (Adynamic ileus) • Acute dilatation of the stomach & colon. • Acalculous cholecystitis BURN

  24. Renal Changes  BV &↓ CO  RBF GFR ATN ARF BURN

  25. CNS Changes CNS dysfunction in up to 14% of burn patients • Delirium, disorientation Hypoxia • smoke inhalation, • pulmonary edema, • pneumonia BURN

  26. Haematological • Haemoconcentration • Anaemia • Destruction of RBC • Continual loss of RBC for 1 wk • Mild thrombocytopenia (sequestration) early, followed by thrombocytosis (2-4x > normal) by end of the 1st week Persistant thrombocytopenia associated with poor prognosis  suspect sepsis • DIC with generalized bleeding can occur shock, sepsis, hypoxia, reperfusion injury BURN

  27. Immunological Innate immunity Skin Cellular Immune Function lymphocyte function Humoral Immune Function IgG & IgA BURN

  28. Metabolic • Ebb phase • Flow phase Catabolic phase Anabolic [recovery phase] BURN

  29. Ebb phase Occurs during the 1st 24 hours • hypothermia • CO &  O2 consumption BURN

  30. Catabolic Phase Occurs after 24 hours of burn injury • Mediated through release of catabolic hormones [ eg, catecholamines, glucocorticoids, glucagon ] and other chemical mediators e.g. cytokines, lipid mediators. • ↑ Cardiac output • ↑ Oxygen consumption • ↑ Heat production [hyperthermia] • ↑ BMR • Hyperglycemia • Proteolysis • Peripheral lipolysis BURN

  31. BURNSTRESS Catecolamines CORTISOL GLUCAGON Proteolysis Peripheral Lipolysis Gluconeogenesis AMINO ACIDS GLUCOSE FREE FAT ACIDS BURN

  32. Anabolic / recovery phase Characterized by:- This phase continues for weeks to months after injury Slow re-accumulation of protein and fat BURN

  33. ASSESSMENT OF BURN INJURY Remember • Establish cause. • Associated injuries • During escape from fire. • Explosions throw patient a distance causing internal injuries. • Electrical muscular spasms can cause fractures. • Burns in enclosed space suggest inhalational injury. • Pre-existing disease states, medication, allergies, lung sensitivities. • Establish tetanus immunization status. BURN

  34. Clinical assessment History Physical examination General Local Systemic BURN

  35. history Patient characteristics age , occupation History of injury Time of burn Place of burn Nature of injury Intentional Unintentional Undetermined BURN

  36. History…. • Type of burn • Thermal • Chemical • Electrical • Radiation • Cold • Mechanism of injury • Associated injuries • Associated inhalation injuries • Associated clothing ignition • Whether first aid measures was done at the site of accident BURN

  37. ROS • PMHx ?? Epilepsy, DM, Psychosis • FSHx ??alcohol BURN

  38. General Exam Body weight Shock Level of consciousness Dyspnoea In pain Restless ± gasping Anaemic Dehydration BURN

  39. Physical examination Local examination [assessment of burn wound] • Examine the wound • Body region burned • Extent of burn • Burn depth • Severity of burn Systemic examination • Cardiovascular system • Respiratory system • PA • CNS BURN

  40. Local exam Body region • Head / neck • Upper limbs • Trunk • Lower limbs • Genitalia / Perineal areas BURN

  41. Extent of burn Size of a Burn Injury Total Body Surface Area (TBSA) Burned Palmar Method A quick method to evaluate scattered or localized burns Client’s palm = 1 % TBSA Rule of Nines (Wallace’s) A quick method to evaluate the extent of burns Major body surface areas divided into multiples of nine Modified version for children and infants (Rule of Sevens ) Lund-Browder Method Most Accurate; based on age (growth) Can be used for the adult, children & infants BURN

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  45. Burn depth • Superficial (1st Degree) • Partial Thickness Superficial (2nd Degree) Deep ( 2nd Degree) • Full Thickness (3rd Degree) • Deep-Full Thickness (4th degree) BURN

  46. Superficial first degree burn Epidermis Wound Appearance: • Red to pink (light skin) • Mild edema • Dry and no blistering • Pain / hypersensitivity to touch • i.e. Classic sunburn • Desquamation occurs 2-3 days Wound Healing • Wound Healing spontaneous • Duration 3 to 5 days • No scarring / other complications BURN 46

  47. Superficial second degree burn upper 1/3 of dermis • Wound Appearance • Red to pink • Wet and weeping wounds • Thin-walled, fluid-filled blisters • Mild to moderate edema • Extremely painful • Wound Healing • In 2 weeks (spontaneous) • Minimal scarring; minor pigment discoloration may occur BURN

  48. BURN Deep second degree burn deep dermis layer • Wound Appearance • Mottled: Red, pink, to white surface • Moist • Moderate edema • Painful; usually less severe than superficial 2nd Degree superficial. • No blisters • Wound Healing • May heal spontaneously 2-6 weeks • If so Hypertrophic scarring / formation of contractures • Wound Management: • Treatment of choice surgical excision & skin grafting

  49. Full thickness third degree burn entire epidermis and dermisSubcutaneous fat • Wound Appearance • Dry, leathery and rigid • + Eschar (hard and in-elastic) • Red, white, yellow, brown or black • Severe edema • Painless & insensitive to palpation BURN

  50. Wound Healing • No spontaneous healing; • No epidermal or dermal appendages remain, thus must heal by re-epithelialization from the wound edges. • Wound Management: Surgical excision & skin grafting Cx severe scarring/contracture BURN

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