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Burns. General Considerations > than 1.2 m people are burned US every year> than 1.2 m people are burned US every year Approximately 50.000 burns per.

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Presentation on theme: "Burns. General Considerations > than 1.2 m people are burned US every year> than 1.2 m people are burned US every year Approximately 50.000 burns per."— Presentation transcript:

1 Burns

2 General Considerations > than 1.2 m people are burned US every year> than 1.2 m people are burned US every year Approximately burns per year in US are moderate to severe and require hospitalization for appropriate treatment.Approximately burns per year in US are moderate to severe and require hospitalization for appropriate treatment. Of these cases, more than 3900 people die of complications related to burns.Of these cases, more than 3900 people die of complications related to burns. Burns deaths generally occur immediately after the injury or weeks later from multiorgan failure.Burns deaths generally occur immediately after the injury or weeks later from multiorgan failure. 2/3 of all burns occur at home and commonly involve young adult men, children <15,and elderly.2/3 of all burns occur at home and commonly involve young adult men, children <15,and elderly. Morbidity and mortality rates are decreasing, this is the result of prevention efforts and improved clinical management.Morbidity and mortality rates are decreasing, this is the result of prevention efforts and improved clinical management.

3 Burns Units. Specialized units dedicated to the care of burned patients.Specialized units dedicated to the care of burned patients. The Units consist of experienced personnel : Experienced burns surgeons, Dedicated nursing personnel, Physical and occupational therapists, Social workers, Dietitians, Pharmacist, Respiratory therapists, Psychiatrists and clinical psychologists.The Units consist of experienced personnel : Experienced burns surgeons, Dedicated nursing personnel, Physical and occupational therapists, Social workers, Dietitians, Pharmacist, Respiratory therapists, Psychiatrists and clinical psychologists.

4 Burn Units cont… Criteria for referral to the burns center: Partial thickness burns >10% TBSAPartial thickness burns >10% TBSA Burns involving the face, hand, feet, genitalia, perineum, or major joints.Burns involving the face, hand, feet, genitalia, perineum, or major joints. Any full-thickness burn, electrical burns, chemical and inhalation injury.Any full-thickness burn, electrical burns, chemical and inhalation injury. Burns in patients with preexisting medical disorder that could complicate management.Burns in patients with preexisting medical disorder that could complicate management. Any patient with burns and concomitant trauma in which the burn injury poses the greater immediate risk.Any patient with burns and concomitant trauma in which the burn injury poses the greater immediate risk. Burned children in hospitals without qualified personnel.Burned children in hospitals without qualified personnel. Burn patient who will require rehabilitation.Burn patient who will require rehabilitation.

5 Pathophysiology :Local Changes Burns are classified into five different causal categories: Flame-Damage from superheated, oxidized air.Flame-Damage from superheated, oxidized air. Scald-Damage from contact with hot liquid.Scald-Damage from contact with hot liquid. Contact-Damage from with hot or cold solid materialsContact-Damage from with hot or cold solid materials Chemicals-Contact with noxious chemicals.Chemicals-Contact with noxious chemicals. Electricity-Conduction of electrical current through tissues.Electricity-Conduction of electrical current through tissues.

6 Depths of Burn

7 Burns Depth

8 Pathophysiology:Burn Size

9 Systemic Changes. Burns are associated with massive release of inflammatory mediators.Burns are associated with massive release of inflammatory mediators.

10 Hypermetabolism

11 Initial treatment of Burns: Prehospital. Remove patient from the source: Burning Clothing should be extinguished and removedRemove patient from the source: Burning Clothing should be extinguished and removed Inhalation injury should always be suspected and 100% o2 be given by face mask.Inhalation injury should always be suspected and 100% o2 be given by face mask. Care must be taking so that the rescuer does not become another victim.Care must be taking so that the rescuer does not become another victim. Room temperature water can be poured on the wound.Room temperature water can be poured on the wound.

12 Initial Assessment, wound care Primary Survey: immediate live-threatening conditions are identified and treated.Primary Survey: immediate live-threatening conditions are identified and treated. Secondary survey: Head-to-toe evaluation of the patient is undertakenSecondary survey: Head-to-toe evaluation of the patient is undertaken Progressive hoarseness is a sign of impending airway obstruction and endotracheal tube should be instituted earlyProgressive hoarseness is a sign of impending airway obstruction and endotracheal tube should be instituted early Wound care require clean dressing or sheet to cover the involved part from environment.Wound care require clean dressing or sheet to cover the involved part from environment.

13 Resuscitation Resuscitation Venous access: Venous access is best attained through short peripheral in unburned skin.Venous access: Venous access is best attained through short peripheral in unburned skin. Saphenous vein cutdowns are useful in case of difficult access, and are used in preferences to central vein canulation.Saphenous vein cutdowns are useful in case of difficult access, and are used in preferences to central vein canulation. LR solution without dextrose is the fluid of choice except in children younger than 2 years, who should receive D5LR.LR solution without dextrose is the fluid of choice except in children younger than 2 years, who should receive D5LR. Resuscitation formulas included:Resuscitation formulas included:

14 Resuscitation formulas included: Formulas Crystalloid Volume Colloid Volume Free Water Parkland 4 mL/kg per % TBSA burn NoneNone Brooke 1.5 mL/kg per % TBSA burn 1.5 mL/kg per % TBSA burn 0.5 mL/kg per % TBSA burn 2.0 L 2.0 L Galveston (pediatric) 5000 mL/m2 burned mL/m2 total NoneNone

15 Escharotomies Deep second and third degree burn encompass the circumference of an extremity, peripheral circulation to the limb can be compromised.Deep second and third degree burn encompass the circumference of an extremity, peripheral circulation to the limb can be compromised. These patients will present with numbness, tingling and increased pain in the digits. These patients will present with numbness, tingling and increased pain in the digits. Arterial flow can be assessed with Doppler signals, capillary refill. Tissue pressures will be greater than 40mm Hg.Arterial flow can be assessed with Doppler signals, capillary refill. Tissue pressures will be greater than 40mm Hg. Troncal eschar will decrease ventilation by limiting chest excurtion.Troncal eschar will decrease ventilation by limiting chest excurtion.

16 Escharotomies cont…

17 Inhalation Injury One of the major factor contributing to the death in burn injury patient.One of the major factor contributing to the death in burn injury patient. Increase the amount of time spent on mechanical vent which is a predictor of mortIncrease the amount of time spent on mechanical vent which is a predictor of mort Damage is caused by inhaled toxins. Heat is dispersed in the upper airways, cooled particles of smoke and toxins go into bronchiDamage is caused by inhaled toxins. Heat is dispersed in the upper airways, cooled particles of smoke and toxins go into bronchi Smoke inhalation induce increase in blood flow to the bronchi with edema formation and increase lung neutrophils.Smoke inhalation induce increase in blood flow to the bronchi with edema formation and increase lung neutrophils.

18 Inhalation injury cont… Inhalation injury is also associated with separation of ciliated epithelial cells from basement membrane with exudates formation which coalesces to form fibrin cast.Inhalation injury is also associated with separation of ciliated epithelial cells from basement membrane with exudates formation which coalesces to form fibrin cast. Often seen in close space smoke exposure.Often seen in close space smoke exposure. Bronchoscopy can reveal erythema, ulceration, infraglotic soot.Bronchoscopy can reveal erythema, ulceration, infraglotic soot.

19 Inhalation injury cont… The clinical course of patients with inhalation injury is divided into three stages:The clinical course of patients with inhalation injury is divided into three stages: The first is acute pulmonary insufficiency with asphyxia, CO poisoning, bronchospasm, and upper airway obstruction.The first is acute pulmonary insufficiency with asphyxia, CO poisoning, bronchospasm, and upper airway obstruction. The second stage occur 72-96Hrs after injury, and associated with hypoxia, and diffuse lobal infiltrates (ARDS).The second stage occur 72-96Hrs after injury, and associated with hypoxia, and diffuse lobal infiltrates (ARDS). In third stage, bronchopneumonia dominates, it occurs 3-10 days after injury. Early by staph,after 5- 7 days by pseudomonas.In third stage, bronchopneumonia dominates, it occurs 3-10 days after injury. Early by staph,after 5- 7 days by pseudomonas.

20 Inhalation cont… Management is directed at maintaining open airways and maximizing gas exchange while the lung heals.Management is directed at maintaining open airways and maximizing gas exchange while the lung heals. Patient presenting respiratory failure should be intubated with frequent chest physiotherapy, suction, and bronchoscopy.Patient presenting respiratory failure should be intubated with frequent chest physiotherapy, suction, and bronchoscopy. Mechanical ventilation should be used to provide gas exchange with little barotrauma.Mechanical ventilation should be used to provide gas exchange with little barotrauma. Use inhalation treatments to increase clearance of tracheobronchial secretion, and decrease bronchospasmUse inhalation treatments to increase clearance of tracheobronchial secretion, and decrease bronchospasm

21 Wound Care After airway is assessed, and resuscitation is underway, attention must be turned to the burn wound.After airway is assessed, and resuscitation is underway, attention must be turned to the burn wound. Therapy is divided into three stages: assessment, management, and rehabilitation.Therapy is divided into three stages: assessment, management, and rehabilitation. First-degree wounds are treated with topical salves, and NSAID.First-degree wounds are treated with topical salves, and NSAID. Second degree are treated with daily dressing change, and topical ABx. Second degree are treated with daily dressing change, and topical ABx. Deep-second and third degree require excisionDeep-second and third degree require excision

22 Antimicrobials Topical ABx can be divided into two: Salves and Soaks.Topical ABx can be divided into two: Salves and Soaks. Salves are applied directly to the wound with cotton dressing,need to be apply twice a day and this can result in loss of grafts.Salves are applied directly to the wound with cotton dressing,need to be apply twice a day and this can result in loss of grafts. Soaks are poured into cotton dressing on the wound, no need for remove dressing but underlying skin can become macerated.Soaks are poured into cotton dressing on the wound, no need for remove dressing but underlying skin can become macerated.

23 Antimicrobials salves Silver sulfadiazine: broad-spectrum, painless, does not penetrate eschar, may inhibit epitheliazation.Silver sulfadiazine: broad-spectrum, painless, does not penetrate eschar, may inhibit epitheliazation. Mefenide acetate: Broad-spectrum, penetrate eschar, may cause pain and metabolic acidosis, mild inhibition of epitheliazation.Mefenide acetate: Broad-spectrum, penetrate eschar, may cause pain and metabolic acidosis, mild inhibition of epitheliazation. Bacitracin, neomycin, polymyxin B: Ease application, painless, antimicrobial not wide.Bacitracin, neomycin, polymyxin B: Ease application, painless, antimicrobial not wide. Nystatin: Inhibit most fungal growthNystatin: Inhibit most fungal growth Mupirocin (bactroban): effective in staph coverage, expensiveMupirocin (bactroban): effective in staph coverage, expensive

24 Antimicrobial Soaks 0.5%silver nitrate: Broad-spectrum, leaches sodium from wounds, may cause methemoglobinemia.0.5%silver nitrate: Broad-spectrum, leaches sodium from wounds, may cause methemoglobinemia. 5%Mafenide acetate:Broad-spectrum,no fungal coverage, painful in application, can be associated with metabolic acidosis.5%Mafenide acetate:Broad-spectrum,no fungal coverage, painful in application, can be associated with metabolic acidosis. Dakin’s solution: Broad-spectrum,mostly Gram+, mildly inhibits epitheliazation.Dakin’s solution: Broad-spectrum,mostly Gram+, mildly inhibits epitheliazation. 0.25% Acetic acid: Effective against most organisms, particularly Gram-,may inhibits eptheliazation0.25% Acetic acid: Effective against most organisms, particularly Gram-,may inhibits eptheliazation

25 Synthetic and Biological Dressing They are an alternative to antimicrobial dressingThey are an alternative to antimicrobial dressing They provide Stable coverage without painful dressing change, provide barrier to evaporative losses, do not inhibit epithelialization.They provide Stable coverage without painful dressing change, provide barrier to evaporative losses, do not inhibit epithelialization. These include: allograft, xenograft, trancyte, biobrane, and Integra. These should be apply within 72hrs of injury.These include: allograft, xenograft, trancyte, biobrane, and Integra. These should be apply within 72hrs of injury. They are used to cover second-degree wound while epithelium heals, full-thickness for which autograft is not available.They are used to cover second-degree wound while epithelium heals, full-thickness for which autograft is not available.

26 Synthetic and Biological Dressings. Biobrane: consists of collagen-coated silicone,provides painless wound bed, easily peeled off when epithelium is complete. Used in superficial 2 nd degree and split-thickness graft donor site.Biobrane: consists of collagen-coated silicone,provides painless wound bed, easily peeled off when epithelium is complete. Used in superficial 2 nd degree and split-thickness graft donor site. Transcyte: Similar to biobrane with the addition growth factors from lyses fibroblast. They had advantages of stimulating wound healing. Can be used in deeper 2 nd degree wound.Transcyte: Similar to biobrane with the addition growth factors from lyses fibroblast. They had advantages of stimulating wound healing. Can be used in deeper 2 nd degree wound. Integra: Product that combine a collagen matrix with silicone sheet outside layer. The collagen engrafts into the wound and two weeks later silicone layer is removed and replace with autograft. Can be used in full-thickness burns to close the wound.Integra: Product that combine a collagen matrix with silicone sheet outside layer. The collagen engrafts into the wound and two weeks later silicone layer is removed and replace with autograft. Can be used in full-thickness burns to close the wound.

27 Dressings cont… Biological dressings include xenografts from swine and allograft from cadavers donorsBiological dressings include xenografts from swine and allograft from cadavers donors They are optimal wound coverage in the absence of normal skin. They will be rejected by immune system later on.They are optimal wound coverage in the absence of normal skin. They will be rejected by immune system later on. Indication is for massive partial-thickness injuries >50%TBSA.Indication is for massive partial-thickness injuries >50%TBSA. Disadvantages include possible transmission of viral diseases with allograft and the possibility that a residual mesh from engrafted cadaver.Disadvantages include possible transmission of viral diseases with allograft and the possibility that a residual mesh from engrafted cadaver.

28 Excision and Grafting Deep-second and third-degree burn do not heal in timely fashion without autografting.Deep-second and third-degree burn do not heal in timely fashion without autografting. Excision is usually performed immediately after stabilization of the patient. Blood lost diminishes if the operation can be done after the first day of the injury.Excision is usually performed immediately after stabilization of the patient. Blood lost diminishes if the operation can be done after the first day of the injury. Wounds covering 20-30% TBSA can be closed at one operation with split-thickness skin graft.Wounds covering 20-30% TBSA can be closed at one operation with split-thickness skin graft. Allograft skin can be used in massive burn wound in preparation for autografting.Allograft skin can be used in massive burn wound in preparation for autografting.

29 Excision and grafting cont… Lost of skin grafts may be due to fluid under the graft, sharing force, infection causing graft lysis, or presence of necrotic tissue in the wound bed.Lost of skin grafts may be due to fluid under the graft, sharing force, infection causing graft lysis, or presence of necrotic tissue in the wound bed. Alternative to split-thickness: cultured keratinocytes from the patient own skin, GH.Alternative to split-thickness: cultured keratinocytes from the patient own skin, GH. Full-thickness skin graft includes the entire dermal and epidermal layer, and provide the best outcomes in wound coverage, with diminished contracture.Full-thickness skin graft includes the entire dermal and epidermal layer, and provide the best outcomes in wound coverage, with diminished contracture.

30 Nutrition Hypermetabolism occurs after severe burns.Hypermetabolism occurs after severe burns. This response can be as high as 200% of the normal metabolic rate and return to normal after wound closure.This response can be as high as 200% of the normal metabolic rate and return to normal after wound closure. Metabolic requirement are met by mobilization of carbohydrate, fat, and protein stores; leading to the lost of active muscle tissue and malnutrition.Metabolic requirement are met by mobilization of carbohydrate, fat, and protein stores; leading to the lost of active muscle tissue and malnutrition. Malnutrition can be subverted by delivery of adequate exogenous nutritional support.Malnutrition can be subverted by delivery of adequate exogenous nutritional support.

31 Nutrition cont… Several formulas are used to calculate calories requirements:Several formulas are used to calculate calories requirements: Basal energy expenditure time 2 in burns 40% TBSA, assuming 100% increases in total energy expenditure.Basal energy expenditure time 2 in burns 40% TBSA, assuming 100% increases in total energy expenditure. Curreri formula 25Kcal/kg/day+40Kcal/% TBSA.Curreri formula 25Kcal/kg/day+40Kcal/% TBSA. Dietary composition contain 1-2g/kg/day of protein.Dietary composition contain 1-2g/kg/day of protein. Non-protein calories can be given as carbohydrate or as fat.Non-protein calories can be given as carbohydrate or as fat. Diet may be delivered either through enteric tubes or through TPN.Diet may be delivered either through enteric tubes or through TPN.

32 Electric burn Represent 3-5% of all admitted burn patientsRepresent 3-5% of all admitted burn patients Electric current enter a part of the body and proceed through tissue with the lowest resistance to the current: nerves, blood vessel and muscle.Electric current enter a part of the body and proceed through tissue with the lowest resistance to the current: nerves, blood vessel and muscle. The current leave the body at a grounded area, the foot.The current leave the body at a grounded area, the foot. The muscle is the major tissue through which the current flow, and thus sustains most damage.The muscle is the major tissue through which the current flow, and thus sustains most damage.

33 Electric Burn cont… Injuries are divided into high and low voltageInjuries are divided into high and low voltage Low voltage injury is similar to thermal injury without transmission to the deeper tissue. Most household current produce this type of injury.Low voltage injury is similar to thermal injury without transmission to the deeper tissue. Most household current produce this type of injury. High voltage injury consist of various degree cutaneous burn at the entry and exit sites, combined with hidden destruction of deep tissue.High voltage injury consist of various degree cutaneous burn at the entry and exit sites, combined with hidden destruction of deep tissue. Those patients are at risk for other injury: Fallen from high, titanic muscular contraction with fractures, and dislocations.Those patients are at risk for other injury: Fallen from high, titanic muscular contraction with fractures, and dislocations.

34 Electric Burn management Obtain an EKG, Lab, cardiac monitoring if necessary.Obtain an EKG, Lab, cardiac monitoring if necessary. Assessment should include circulation to distal vascular bed with escharotomy and fasciotomy if required. Amputation if extensive injury and necrosis.Assessment should include circulation to distal vascular bed with escharotomy and fasciotomy if required. Amputation if extensive injury and necrosis. Vigorous hydration with infusion of sodium bicarbonate and mannitol to solubilize the myoglobin, and maintain UOP.Vigorous hydration with infusion of sodium bicarbonate and mannitol to solubilize the myoglobin, and maintain UOP.

35 Chemical Burn Most are accidental from mishandling of household cleaners.Most are accidental from mishandling of household cleaners. The degree of tissue damage is determined by the chemical nature of the agent, concentration and duration of skin contact.The degree of tissue damage is determined by the chemical nature of the agent, concentration and duration of skin contact. They cause injuries by protein denaturation, oxidation, and desiccation of the tissue.They cause injuries by protein denaturation, oxidation, and desiccation of the tissue. Lavage with copious quantity of clean water should be done immediately after removing all clottingLavage with copious quantity of clean water should be done immediately after removing all clotting

36 Chemical burn: Alkali Includes limes, KOH, bleach, and NaOH.Includes limes, KOH, bleach, and NaOH. Mechanism of alkali burn saponification of fat, massive extraction of water from cell, formation of alkaline proteinates which contain ions OHMechanism of alkali burn saponification of fat, massive extraction of water from cell, formation of alkaline proteinates which contain ions OH Do not neutralize alkaline agent with weak acid because heat released will induce further injuryDo not neutralize alkaline agent with weak acid because heat released will induce further injury

37 Chemical Burns: acid Acid induce protein breakdown by hydrolysis, which result in hard eschar.Acid induce protein breakdown by hydrolysis, which result in hard eschar. Formic acid injury are relatively rare. Concern includes metabolic acidosis, renal failure, intravascular hemolysis, and pulmonary complications.Formic acid injury are relatively rare. Concern includes metabolic acidosis, renal failure, intravascular hemolysis, and pulmonary complications. Hemodialysis may be required for extensive absorption, and mannitol for sever hemolysis.Hemodialysis may be required for extensive absorption, and mannitol for sever hemolysis. Formic acid wound has greenish appearance and is deeper than what is initially appearFormic acid wound has greenish appearance and is deeper than what is initially appear

38 Cont… Hydrofluoric acid is a toxic agent used in both industrial and domestic setting.Hydrofluoric acid is a toxic agent used in both industrial and domestic setting. It produces dehydration and corrosion of tissue with free H ion.It produces dehydration and corrosion of tissue with free H ion. Fluoride ion complexes with Ca and Mg, and can induce intravascular calcium chelation, and hypocalcemia. Fluoride ion complexes with Ca and Mg, and can induce intravascular calcium chelation, and hypocalcemia. Treatment includes irrigation, 2.5%Ca gluconate gel, intradermal injection of 10% Ca gluconate.Treatment includes irrigation, 2.5%Ca gluconate gel, intradermal injection of 10% Ca gluconate. All patients should be admitted for cardio monitor with attention to QT interval.All patients should be admitted for cardio monitor with attention to QT interval.

39 Treatment of acid and alkali burn

40 THE END !


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