Burns Tasneem Anagreh - PowerPoint Presentation

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Burns

Tasneem Anagreh

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intro

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

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Burns are tissue injuries resulting from direct contact with

flames , hot liquids, gases, surfaces, caustic chemicals, electricity, or radiation. Most commonly, the skin is injured, which compromises its function as a barrier to injury and infection and as a regulator of body temperature and fluid loss. Like trauma, mortality

from burns occurs in

a

bimodal pattern

:

i

mmediately

after the injury or

weeks later

from sepsis and

multiorgan

failure.

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Burns are classified into:

A. Thermal burns:B. Non-thermal burns:1. Electrical injuries2. Radiation injuries3. Cold injuries4.Chemical burns

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1.THERMAL BURNS:

Heat causes coagulative necrosis of tissue, by coagulation of the cellular proteins, this type of necrosis is characterized by, preservation of the shape of the tissue involved , the temperature that causes burn is greater than 45 degrees. Thermal burns is classified into:

A

. Dry heat (direct flame burn) direct exposure to fire.

B

. Moist heat (scald burn), exposure to hot liquids,

C.Contact

burn. contact with hot metals.

D.Friction

burns.

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The burn wound and surrounding tissues classically have been described as a system of several circumferential zones

radiating from primarily burned tissues, as follows: 1. Zone of coagulation - A nonviable area of tissue at the "epicenter" of the burn. 2. Zone of ischemia or stasis

( Injury zone

): Surrounding tissues (both deep and peripheral to the coagulated necrotic areas), which are

not devitalized initially but, due to

microvascular

insult, can progress irreversibly to necrosis over several days if not resuscitated properly

.

3

. Zone of

hyperemi

a - Peripheral tissues that undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable.

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ASSESSMENT OF THE SEVERITY OF BURN ( depth and percentage):

1. The depth of burn damage (degree): depends on the quantity of heat (temperature and duration of exposure), determinns the local management and outcome of the burn wound 2.The surface area involved in burn, This is the

percentage of the burned area to the total body surface area

.

This

determins

the systemic management

,

complications,

and

prognosis

( mortality rate).

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Classification of the depth of burn injury:

1.First degree burn, thermal necrosis is limited to the epidermis, clinically there is pain, and erythema, it takes 1-6 days to heal and leaves no scars. 2.Second degree burn (

partial

thickness), necrosis of the

epidermis and varying depth of the dermis

, characterized clinically by

pain

( due to irritation of the dermal sensory nerves),

erythem

a,

blisters( bullae),

the burned area is wet with exudate (weeping), blanching denoting intact dermal vascularity, and preservation of skin elasticity. It takes 1-4 weeks to heal and leaves variable degrees of scarring.

3

.

Third

degree burn (

full

thickness), necrosis of the whole skin (

epidermis and dermis) and its skin appendages

, clinically there is an

eschar

which is simply -

the burned necrotic skin

,

it is

insensitive, leathery, hard, inelastic, and may show

thrombosed

dermal vessels

. It takes

months

to heal

and

leaves

significant scarring

, to avoid scarring it should be skin grafted.

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1st degree:

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Second-Degree:

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Second-Degree Burn with Sloughing:

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2nd:

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A) superficial partial-thickness scald 24 hours after injury. The dermis is pink and blanches to pressure.

(b) At 2 weeks,the wound is healed but lacks pigment. (c) At 3 months, the pigmentis returning.

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3rd:

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(a) A full-thickness burn on admission just prior toescharotomy. The wound is wrapped in cling film while in transit.

(b) Excision of the same full-thickness burn, down to healthy fat.

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2)ESTIMATION OF THE PERCENTAGE OF BURN:

This determines the prognosis, and the systemic management of burn, especially fluid management. There are three methods of TBSA estimation: 1. Rule of nines: the body is divided into 11 nines; Head &neck (9%), Upper limbs. (9% each), Anterior trunk (18%), Posterior trunk (18%), Lower limbs (18% each) and the remaining 1% for the genitals.

2. As the rule of nines is

not very accurate especially in children

, in whom the percentage of the surface area of the head (20% at birth) and decreases with age, while the percentage of the surface area of the lower limbs increases with age, it is more accurate to follow the

specially made charts available in the burns units and in the emergency rooms

.

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I. ASSESSMENT

Mechanism of injury Identify burn source, duration of exposure, time of injury, and environment.-----------------------------------------------------------------Primary survey (ATLS)

treated as victims of multisystem

trauma:

1)Airway

:

Supraglottic

tissue edema

progresses over the first 12 hours and can obstruct the airway rapidly.Inhalation injury should be suspected if the patient was burned in an enclosed structure or explosion.

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Physical signs include hoarseness, stridor, facial burns, singed facial hair, expectoration of carbonaceous sputum, and presence of carbon in the oropharynx

.minor inhalation injury humidified oxygen.

Major

injuries



endotracheal intubation

.(+ Bronchodilators can be given to treat bronchospasm whereas nebulized heparin and N-

acetylcysteine

can limit cast formation)

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Carbon monoxide poisoning :Carbon

monoxide exposure is suggested by a history of exposure in a confined space with symptoms of nausea, vomiting, headache, mental status changes, and cherry-red lips.The arterial carboxyhemoglobin level is obtained as a baseline.Mx supplemental oxygen (40-minute half-life with 100% oxygen via nonrebreathing

mask

).

oxygen

therapy should

continue until normal levels are achieved.

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2. Breathing is evaluated for effort, depth of respiration, and auscultation of breath sounds.

Wheezing or rales suggest either inhalation injury or aspiration of gastric contents.3. Circulation. Circulatory support in the form of aggressive and prompt fluid resuscitation.4.Exposure. -------------------------------------------------------------------------

2) Burn-specific secondary

survey

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When to transfer to a burn center?1.

Partial-thickness burns greater than 10% BSA. 2. Any full-thickness burn. 3. Burns that involve the face, hands, feet, genitalia, perineum, or major joints. 4. Any inhalation, chemical, or electrical injury.5. Burn injury in patients with

pre-existing medical

conditions that could complicate management, prolong recovery, or affect

mortality

6.

Burned

children in hospitals without qualified personnel

or equipment for the care of children.

8

. Patients

requiring specialized rehabilitation, psychological suppor

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Management :

A. Emergency room 1. Resuscitation in patients with major injury. a. Oxygen: A 100% oxygen high-humidity facemask for those with possible inhalation injury .b. Intravenous access:

All patients with burns of

15% or greater

BSA require intravenous fluids.

Two 16-gauge

or larger peripheral venous catheters should be started immediately to provide circulatory volume support

.

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Fluids :hemodynamically, the depletion of the intra-vascular compartment will cause hypovolemic shock, and its severity depends on the percentage of burn.

Practically, burn shock is seen in adults with burns greater than 15-20% and in children with burn more than 10-15% .

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a. Consensus formula(Parkland formula):-

The estimated crystalloid requirement for the first 24 hours after injury is calculated on the basis of patient weight and BSA burn percentage.Lactated Ringer solution volume in the first 24 hours = 2 to 4 mL × %BSA (second-, third-, and fourth-degree burns only) × body weight (kg).One-half of the calculated volume is given in the first 8 hours after injury, and the remaining

volume is

infused over the next 16 hours

with

adjustments being made as clinical conditions

and size/depth of burns evolve

.

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Example: An adult weighing 70 Kgm

, with 50% burn, should receive : 4x 70x 50= 14000 ml of Ringer lactate (Half of this amount is administered in 8 hours , and the remaining half over the next 16 hours).b. Colloid-containing solutions for resuscitation remains an ongoing debate. Some studies show they should be avoided as an intravenous therapy until after the first 24 hours postburn

,

at which time

capillary leak

diminishes. Some providers

option

for a compromise,

augmenting resuscitation with albumin later in the first 24 hours and in patients with large

burns

.

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B. Additional Management:1. Foley

catheter(hourly monitored) : a minimum urine production rate of 1 mL/kg/hr in children (weighing ≤30 kg) and 0.5 mL/kg/hr in adults is the guideline for adequate intravenous infusion.2. Nasogastric tube

:

insertion

with low suction

is performed if patients are

intubated or develop nausea, vomiting, and abdominal distention consistent with

adynamic

ileus

.

3. Continuous pulse oximetry .4. Laboratory evaluation : baseline CBC, type and crossmatch, electrolytes and renal panel,

β-

human chorionic

gonadotropin (in women),

arterial

carboxyhemoglobin

,

ABG

,

and

urinalysis

,

ECG.

5.

Tetanus prophylaxis

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C. Wound Care :1.

Early irrigation and debridement are performed using normal saline and sterile instruments to remove all loose epidermal skin layers. Nonviable tissue in the burn wound should be debrided early because the dead tissue provides a bacterial medium putting the patient at risk for both local and systemic infections2.Topical antimicrobial agents

:

gram-negative organisms

, particularly

Pseudomonas

aeruginosa

, and fungi

are the most common causes of invasive burn wound

sepsis.

(note:

Systemic antibiotics are not administered prophylactically)A biopsy of suspicious eschar and underlying unburned tissue is required to diagnose an invasive infection.

Wound

infection is defined by

more than

10^

5 organisms per gram of tissue.

Treatment

requires infected

eschar

excision and appropriate topical/systemic

antibiotic therapy

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3. Dressings:a. Biologic dressings include

allograft (cadaver skin) and xenograft (pig skin).B. Synthetic dressings (Biobrane , Trancyte , Integra)-----------------------------------------------------------------------

D. Operative

Management:

Escharotomy



may

be necessary in

full

-thickness

circumferential burns of the neck, torso, or extremities when increasing tissue edema impairs peripheral circulation or when chest involvement restricts respiratory efforts.

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E. Nutrition. Severe burns induce a hypermetabolic

state proportional to the size of the burn up to 200% the normal metabolic rate.The daily estimated metabolic requirement (EMR) in burn patients can be calculated from the Curreri formula: EMR = [25 kcal × body weight (kg)] + (40 kcal × %BSA) Note  supply

1.5 to 2

g/kg of

protein per

day

.

1.

Enteral

feedings

2. Total parenteral nutrition3. Daily vitamin supplementation(ascorbic acid, nicotinamide,riboflavin,thiamine,zinc)

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F. Critical Care Considerations:1. Stress ulcer

prophylaxis (e.g., H2 blockers or proton-pump inhibitors).2. Venous thromboembolism (VTE).3. Sepsis. In patients who survive the first 24 hours after injury, burn sepsis is the leading cause of mortality!!!

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Thank you ^^

*Reference: ( bailey &love + The Washington manual of surgery)