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Presentation on theme: "IN THE NAME OF GOD."— Presentation transcript:


2 Burns

3 Be sure to keep hot liquids out of reach of small children.
Looks and tastes great, right? You should see what a hot liquid will do to a child’s skin when the two come into contact. Be sure to keep hot liquids out of reach of small children.

4 The Skin The skin, the largest organ of the body, consists of two layers-the epidermis and dermis. The depth or degree of burn depends on which layers of skin are damaged or destroyed. The epidermis is the outer layer that forms the protective covering. The thicker or inner layer of the dermis contains blood vessels, hair follicles, nerve endings, sweat and sebaceous glands. When the dermis is destroyed, so are the nerve endings that allow a person to feel pain, temperature, and tactile sensation.

5 The burn/wound center includes an expanded reception area for children receiving outpatient care.

6 BSA estimation: “Rule of 9s”

7 Mechanism/Type: Chemical Burn

8 Mechanism/Type:Electrical Burn
- direct contact with electrical current                 ®  entry & exit wounds

9 Superficial Burn

10 Deep Burn

11 Burn Assessment Lund & Browder Chart

12 Typical burns from hot water in a child
Welcome to the burns module! Burns constitute a major global problem and are a leading cause of trauma deaths in children. Minor burns, if poorly treated, cause devastating complications with lifelong morbidity. Understanding how burns cause tissue damage and how the skin heals is vitally important in ensuring that the right diagnosis is made and the right treatment given. Typical burns from hot water in a child

13 Anatomy of skin (1) Epidermis basement membrane Dermis Subcutaneous layer The skin is made up of two layers, the outer layer (epidermis) and inner layer (dermis). Between the epidermis and dermis is the basement membrane which is semi permeable and acellular. It provides support, flexibility and regulates the transfer of substances across the dermal-epidermal junction. Under the skin is the subcutaneous layer which allows the skin to be loosely attached to the underlying fascia. It increases mobility and is especially important over joints.

14 Anatomy of skin – Epidermis (1)
A protective barrier of stratified squamous epithelium consisting of 5 layers Stratum corneum: rows of dead cells continually shed Stratum lucidum: 3-4 layers clear flat dead cells Stratum granulosum: Cells degenerating with production of keratin Stratum spinosum: 8-10 rows of cells that produce protein but can not duplicate Stratum basale: Columnar cells continually dividing, gradually migrating to surface EPIDERMIS There are three other cell types within the epidermis: melanocyte, Langerhan and Merkel cells

15 Anatomy of skin – Dermis (1)
The dermis consists of 2 layers: Papiliary dermis: The upper layer of dermis. It has extensions protruding into the epidermis called Rete pegs which also contain small capillary loops Reticular dermis: The lower layer of dermis. It is made up of collagen, elastin and ground substance as well as hair follicles, sweat and sebaceous glands Fibroblasts are the predominant cell type in the dermis and produce collagen and elastin which provide strength and flexibility to the skin. In addition, there are blood vessels, sebaceous glands, sweat glands, hair follicles, sensory receptors and fat cells.

16 Functions of the skin Physical barrier Vitamin D production Immunity
Sensation Identity Temperature control

17 Local effects of burn injury (1)
Summary of local effects: Cell death/disturbed function Release of inflammatory mediators Increased capillary permeability Microvascular thrombosis 1. Cell death/disturbed function Cellular function is disturbed when the temperature rises above 43oC. The higher the temperature and more prolonged the contact, the more cells die. An instantaneous full thickness burn occurs at a temperature of 700C or greater. Due to differences in skin thickness with age, at 55C, severe damage occurs after 10 seconds in a child and 30 seconds in an adult. Skin thickness is also reduced in older people and in certain conditions (e.g. steroid therapy).

18 Local effects of burn injury (3)
3. Increased capillary permeability When capillaries are damaged, they leak protein-rich fluid which results in oedema. Normal skin; normal capillary permeability Burn wound oedema with increased capillary permeability and protein leakage

19 Local effects of burn injury (4)
4. Microvascular Thrombosis Release of thrombogenic factors such as thromboxane, together with a hypovolaemic state cause sludging in the smallest blood vessels. This in turn leads to further tissue ischaemia, increased cell death and can cause extension of the depth and surface area of the burn. Area of burn increases due to sludging in blood vessels and ischaemia

20 Systemic effects of burn injury (2)
Click each box Psychological system Respiratory system Cardiovascular system Immune system Renal system Gastrointestinal system Haematological system

21 Assessing TBSA - Rule of Nines
This method divides the body into areas each of which equates to 9% of the total body surface area: the whole of one arm (anterior and posterior surfaces including the hand) is 9%, therefore 2 arms = 18% the entire head including face, scalp and neck is 9% anterior trunk is 18% posterior trunk including buttocks is 18% the whole lower limb (anterior and posterior surfaces, including the thigh, leg and foot) is 18%; therefore both lower limbs = 36%. This totals 99% with the perineum making the final 1%. Beware: this method is unreliable in young children.

22 Assessing TBSA in children
Why might the “rule of 9’s” be unreliable in children? Click to Reveal Answers Body proportions change with age. In a child, the head represents a much greater proportion of the total body surface area.

23 Assessing TBSA - Lund and Browder charts
These take account of the patient’s age and provide a more detailed mapping system for the burnt area AREA AGE 0 1 5 10 15 ADULT A = ½ OF HEAD 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ 3 ½ B = ½ OF ONE THIGH 2 ¾ 3 ¼ 4 4 ¾ C = ½ OF ONE LEG 2 ½ 3

24 Assessing TBSA - Palm size
Another useful way, especially for small burns is to use the palm of the patient’s hand (with fingers extended). This equates to approximately 1% of the body surface area.

25 Assessing TBSA - Unburnt area
In very large burns, it is often easier to measure the area of skin that is unburnt and then subtract this from 100%.

26 Area of the body involved
Not only is the surface area or size of burn important, but also the specific part of the body affected Eyes: Burns to the eyes (especially chemical) can cause blindness. Face: Facial oedema can lead to airway obstruction. Scarring can cause significant psychosocial problems Feet: Mobility problems Hands: Problems with feeding and hygiene Perineum: problems with urogenital function and psychosexual Circumferential burns of the limbs can cause distal ischaemia; of the chest, can compromise breathing

27 Depth of burn - Superficial (erythema)
Involves epidermis only: Painful Red No blistering Heals rapidly (reversible injury) No permanent scars Note that erythema is NOT included when assessing TBSA

28 Depth of Burn – superficial partial thickness
Typical hot water scald Involves epidermis and upper dermis: Red Blistering, moist Painful Heals by epithelialization Healing complete within 14 days Minimal or no permanent scars but can leave discolouration Glistening moist red/pink appearance typical of superficial injury Patches of skin that would come off on cleaning

29 Depth of Burn - superficial partial thickness
Pin-point bleeding Pink surface; blanches on pressure Blister

30 Depth of Burn – deep partial thickness
Involves epidermis, upper dermis and varying degrees of lower dermis: Pale, mottled appearance Fixed staining (no blanching) May be painful or insensate (depending on depth) Heals by combination of epithilialization and wound contracture May take weeks to heal Can leave significant scars and contractures over joints depending on time taken to heal Deep dermal area, reddish with fixed staining

31 Depth of Burn – full thickness
Involves all of epidermis and all of dermis Dry, leathery (white, dark brown or charred) Insensate Heals by contraction Delayed healing Hypertrophic or keloid scars Leads to contractures Dry, leathery, charred appearance of a full thickness burn

32 Circumferential full thickness burn
Black, charred skin Typical position of hand in full thickness burns with metacarpophalangeal joints extended and interphalangeal joints flexed

33 Depth of Burn – mixed thickness
(A) Assess the depth of the burn in areas A, B and C

34 Depth of Burn – Mixed thickness
Full thickness, dry white leathery appearance Deep dermal with pale pink and white patches, non blanching Superficial partial thickness showing pink blanching

35 Zones of Burn Injury Zone of Coagulation Zone of Stasis
Inner Zone Area of cellular death (necrosis) Zone of Stasis Area surrounding zone of coagulation Cellular injury: decreased blood flow & inflammation Potentially salvable; susceptible to additional injury Zone of Hyperemia Peripheral area of burn Area of least cellular injury & increased blood flow Complete recovery of this tissue likely.

36 Superficial-Thickness Burns
Involves the epidermis Wound Appearance: Red to pink Mild edema Dry and no blistering Pain / hypersensitivity to touch i.e. Classic sunburn Desquamation (peeling of dead skin) occurs 2-3 days post-burn Wound Healing: In 3 to 5 days (spontaneous) No scarring / other complications

37 Superficial, Partial-Thickness Burns
Involves 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

38 Full-Thickness Burns Involves the entire epidermis and dermis
Wound Appearance: Dry, leathery and rigid + Eschar (hard and in-elastic) Red, white, yellow, brown or black Severe edema Painless & insensitive to palpation Wound Healing: No spontaneous healing; weeks to months with graft Wound Management: Surgical excision & skin grafting

39 The Rule of Nines

40 Lund-Browder Method

41 A Child Suffering From Marasmus.
The word marasmus is derived from a Latin word meaning to decay. Marasmus is seen when an individual (a child or adult) is essentially starving, typically energy intake would fall short of energy usage - Notice the absence of body fat and looseness of skin (e.g. over the surface of the arms) which can indicate sudden or extreme weight loss.

42 Kwashiorkor Produces Characteristic Oedematous
Protruding Abdomen In Children.

43 A Badly Infected Deep Burn Wound (Streptococcus faecalis & Pseudomonas aeruginosa) In An Elderley Patient. Necrotic Tissue May Have To Be Removed/Excised To Treat The Infection.

44 Burn Wound Infected With Pseudomonas spp. After Application Of A Graft.
Pseudomonal infections frequently produce a green discolouration.

45 Burn Wound Infected With Staphylococcus spp.
In hospital environments Staphyloccoccus spp. maybe resistant to one, or several, antibiotics. Burned regions may therefore be regularly swabbed and screened for antibiotic resistance/susceptibility should an infection occur.

46 A Chronic Non-Healing Burn Wound Due To A Protein Dietary Deficiency.
Pale Granulating Areas Are Becoming Larger. Surrounding Epithelium Is Becoming White (*), Macerated & Non-Adherent. Clarke John. A colour atlas of burns injuries. Chapman & Hall Medical. P60 (*) This individual is white.

47 Inadequate Nutrition In A Patient With Extensive Burns.
One Year After The Injury. One year after the injury gross emaciation is evident (i.e. severe muscle wasting & stiffening at the joints) in addition to the large areas of unhealed areas of skin that were previous damaged by this thermal injury.

48 Inadequate Nutrition In A Patient With Extensive Burns
Inadequate Nutrition In A Patient With Extensive Burns. One Year After The Injury. Wounds Have Become Over-Granulated And Epithelialisation Is Not Seen At The Wound Margins. Spontaneous healing is expected if adequate levels of nutrition are introduced & maintained.

49 Appearance After Three Months Of Nasogastrc Feeding
Wounds Have Healed Without The Need For Grafts – Though There Has Not Been Any Significant Increase In Body Mass.

50 Appearance Of The Patient One Month Later.
Adequate Nutrition & Healing Allow The Person To Support Their Own Weight Though Joint Deformity Remains. Clarke John. A colour atlas of burns injuries. Chapman & Hall Medical. P60

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