Joseph Hardwicke SpR Burns & Plastic Surgery West Midlands Deanery BURN INJURY Joseph Hardwicke SpR Burns & Plastic Surgery West Midlands Deanery
TIMELINE OF BURN CARE THEN GREAT WAR WWII FALKLANDS NUTRITIONAL SUPPORT ANTI-SEPSIS FLUID RESUSCITION BURN EXCISION "BURN TOXINS" SKIN GRAFTS MESHED GRAFTS MULTI-DISCIPLINARY APPROACH
? TIMELINE OF BURN CARE NOW REHABILITATION ORGAN SUPPORT SKIN CELL CULTURE SKIN SUBSTITUTES SCAR MANAGEMENT PSYCHOLOGICAL SUPPORT
FIRE DISASTER
AIMS Causes of burns and the demographics of UK burn injury The anatomy of the skin, depth of burn and the Jackson burn wound model Estimation of burn % total body surface area (%TBSA) and fluid resuscitation Inhalation injury
CAUSES OF BURNS AND THE DEMOGRAPHICS OF UK BURN INJURY
CAUSES OF BURNS THERMAL HOT COLD Hot or cold HOT COLD Liquid - scald - Freezing - frostbite / nip Solid - contact - Non-freezing - trench foot Gas - flame Direct cellular destruction Freeze-thaw Embolic/thrombotic
CAUSES OF BURNS ELECTRICAL Conduction through tissues Low voltage < 1,000V High voltage > 1,000V Superhigh voltage > 10,000V Conduction through tissues
CAUSES OF BURNS Deep tissue destruction Myoglobinuria Compartment syndrome Cardiac dysrhythmias
CAUSES OF BURNS CHEMICAL ACID ALKALI IRRIGATION Acid Alkali Coagulative necrosis - Liquifactive necrosis Painful - Non-painful tissue destruction IRRIGATION Copious water to correct pH
CAUSES OF BURNS RADIATION UVB Ionising radiation
UK BURN DEMOGRAPHICS 250,000 burns/year 175,000 A&E attendances 13,000 hospital admissions 1,000 resuscitation burns 50% < 16 yrs 300 deaths/year Majority > 60 yrs
CAUSES OF BURNS BURNS FIRST AID THERMAL ELECTRICAL CHEMICAL RADIATION Stop the burning process Cool the burn Cool running water 10-30 minutes Cover the burn A&E if area of SKIN LOSS bigger than palm of hand KEY POINT THERMAL ELECTRICAL CHEMICAL RADIATION Extremes of age Non-accidental injury Psychiatric co-morbidity Industrial / workplace
THE ANATOMY OF THE SKIN, DEPTH OF BURN AND THE JACKSON BURN WOUND MODEL
SENSORY BARRIER METABOLIC ANATOMY OF THE BURN Functions of the skin SENSORY BARRIER METABOLIC THERMO- REGULATION PSYCHO- SOCIAL
DEPTH OF BURN SUPERFICIAL ERYTHEMA PARTIAL THICKNESS FULL THICKNESS No skin loss Not included in burn %TBSA PARTIAL THICKNESS Superficial Deep FULL THICKNESS
BURN ZONE OF STASIS Adequate fluid resuscitation may preserve zone of stasis Infection may cause burn extension Early burn excision reduces necrotic load Prognosis determined by the size of the burn unburnt skin zone of coagulation zone of hyperaemia
INITIAL BURNS MANAGEMENT KEY POINT A : AIRWAY + C-SPINE CONTROL OXYGEN B : BREATHING + VENTILATION C : CIRCULATION IV ACCESS, STOP BLEEDING D : DISABILITY GCS E : EXPOSURE TEMPERATURE CONTROL %TBSA F : FLUID CALCULATION
ESTIMATION OF BURN % TOTAL BODY SURFACE AREA (%TBSA) AND FLUID RESUSCITATION
ESTIMATION OF %TBSA BURN Average adult TBSA 1.7m2 Distribution changes with age
BODY WEIGHT Important to calculate fluid requirements Measure or estimate MEASURE ESTIMATE Under 10 yrs (age + 4) x 2 = kg Over 10 yrs age x 3 = kg
FLUID RESUSCITATION Hartman's solution / Ringer's lactate Then titration of fluids depending upon urine output etc. KEY POINT Higher value for: Inhalation injury Electrical burns Paediatric burns 2 - 4 mls/kg/%TBSA From time of burn Half given in first 8h Half given in next 16h
INHALATION INJURY
INHALATION INJURY Mortality increased by 40% Early airway management KEY POINT POINTERS TO INHALATION INJURY Enclosed space Delayed extraction Facial burns Singed facial hair Carbonaceous sputum Hoarse voice / stridor
SITE OF INJURY Supraglottic Infraglottic Bronchoalveolar lavage Thermal injury from inhaled gases Airway spasm Infraglottic Chemical burns from products of combustion Bronchoalveolar lavage
Oxygen-dissociation curve TOXINS Products of combustion CARBON MONOXIDE Preferential binding to Hb (200x) Arterial blood gas <10% normal >60% fatal HYDROGEN CYANIDE Synthetic rubber, polyurethane Inhibits cytochrome C oxidase Antidote and oxygenate Oxygen-dissociation curve shifts to the left
OVERVIEW Causes of burns and the demographics of UK burn injury The anatomy of the skin, depth of burn and the Jackson burn wound model Estimation of burn % total body surface area (%TBSA) and fluid resuscitation Inhalation injury
WOUND HEALING
BASICS OF WOUND HEALING Sequential process Driven by cellular and matrix components
BURN WOUNDS Superficial partial thickness wounds heal by re-epithelialisation Keratinocyte reserve in "epidermal derivatives" Hair follicles Sweat glands Should heal by 2 weeks Minimal scarring
DEEPER BURNS Loss of keratinocyte reserve Loss of epidermal derivatives Hair follicles Oil / sweat glands May heal by contraction from wound edge Myofibroblasts New matrix formed Fibroblasts SCAR FORMATION
SCARS End stage of normal wound healing NORMAL PATHOLOGICAL contracture hypertrophic keloid
IMPAIRED WOUND HEALING PATIENT FACTORS Medications Nutrition Mobility Systemic disease Continence Smoking LOCAL FACTORS Infection Skin loss Pressure necrosis Wound tension Tissue maceration
WOUND DRESSINGS …don't need to be confusing Adequate cleaning or surgical debridement Aim for: Controlled wound environment Moist wound healing Infection control Analgesia
THREE COMPONENTS When putting a dressing on, consider who will be taking it off (and when)…. All (nearly!) are made of 3 things: A NON-ADHERENT LAYER ± antimicrobials AN ABSORBANT LAYER depending on exudate AN ADHESIVE LAYER depending on anatomy Tailor-made for each patient
BURN DRESSINGS After initial assessment and stabilisation If the burn is suitable for treatment in primary care Clean wound, deroof large blisters Definitive dressing Review at 48h If transfer is needed to burns centre Temporary wound cover Minimal interference Reduce need for analgesia
SKIN GRAFTS The ideal wound dressing? Supplies cellular and matrix components and is incorporated into the wound Speeds up wound healing Reduces pathological scarring in large burn wounds BUT… Limited resource Donor site
SPLIT THICKNESS SKIN GRAFT
QUESTIONS? Joseph.Hardwicke@uhcw.nhs.uk
FURTHER READING