burn care amit mitra md,ms,frcs,facs. burn statistics ranks 2 nd in cause death in childhood (1 st...
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Burn care Burn care
Amit MitraAmit Mitra
MD,MS,FRCS,FACSMD,MS,FRCS,FACS
Burn statisticsBurn statistics
• Ranks 2nd in cause death in childhood (1st being trauma)
• 50% occur < age 20 yrs (peaks between age 2-4 and 17-25 yrs)
• 50% occurs at home and 2/3rd are preventable• 50% needs medical attention and 25% becomes
bedridden• 1% of US population is burned each year• 8000-12000 deaths/yr• Cost > 100 million/yr
Physiology of skinPhysiology of skin
• Consists of epidermis (.06-.8mm) and dermis (20-30 times thicker than epidermis)
• Protects from injury• Maintains water balance• Protects again solar exposure• Receives environmental stimulus• Excretory functions• Synthesizer of Vit D• Immunity• Maintains temperature• Slow thermal conductivity (heats and cools slowly)
Local changesLocal changes
• Increased vascular permeability
• Increased burn tissue osmolarity
• Fluid and protein shift – leads to edema
• Hypovolemia
• Hypoproteneimia
• Decreased tissue O2 tension
• Increased tissue pressure
Systemic changesSystemic changes
• Decreased cardiac output• Increased vascular resistance• Decreased cardiac contractility ( due to
circulating myocardial depressant factors)• Decreased CVP/PCWP• Hemoconcentration• Leucocytosis• Hypercoagulable state (platelets, PT, PTT)
Evolving zone of injuryEvolving zone of injury
From central to peripheral
zone of coagulation
zone of stasis
zone of hyperemia
Classification of burnClassification of burn(classification is based on depth)(classification is based on depth)
• 1st degree or Superficial– Painful and red. Does not need fluid correction
• 2nd degree or Partial thickness– Epidermis and part of the dermis– Hair follicles sweat glands are not destroyed and thus
heals with conservative management– Commonest type – Red, painful, blisters, intact hairs
• 3rd degree or deep/full thickness – Gray/white, leathery, non elastic, anesthetic
Initial evaluationInitial evaluation
• History of the injury– Mechanism of injury (flames, scald, electrical
or chemical contact)
• Exact time of the injury
• Duration of the exposure
• Any extrication/resuscitation problems
• Any associated in juries
• Depth of burn
Patient historyPatient history
• Past significant medical/surgical history
• Use of medications
• Drug abuse/suicidal history
• Allergies
• Socio economic status
Initial management Initial management
• Stop the burning process, remove clothes
• Cool the area
• Do not break blister
• Keep the patient warm
• Clean dry dressings
Acute care in the ERAcute care in the ER
• Never stray from ABC’s• History• Establish and maintain airway• Large bore IVs• Other injuries (failure to recognize other injuries is
possibly the biggest error)• Estimate the severity and size of the burn• Calculate the fluid management• Accurate measurement of I/O• Plan the local wound care• Evaluate the possibilities of inhalation injuries• Assess the need for escharotomy
Specific careSpecific care
• Calculate fluid requirement• NG suction (20% BSB)• Foley cath• Tetanus prophylaxis• Sedation (IV only)• ABG’s• CBC, Electrolytes, glucose, BUN, Creatinine• Chest Xray
How to calculate BSBHow to calculate BSB
• Rule of 9 (9 or its multiplier)– Head and neck - 9– Anterior trunk - 18– Post. Trunk - 18– Each arm - 9– Each leg - 18
• Measurement by patients palm size – 1%• Lund-Browder chart – relative adjustment
of BSB according to the pts age
Calculations of fluid managementCalculations of fluid management(most important in extensive burn)(most important in extensive burn)
Parkland formula (this is only for 1st.24 hrs)
4 cc of LR/ % of BSB/ Kg of pt.
Calculation starts at the time of injury, exact time of burn injury must be notedHalf of fluid amount to be given in 1st 8 hrs of the injury and next half over next 16 hrsD5 needs to be added in children
Other formulaeOther formulae
Evan’s formula1 ml of colloid/ % of BSB / Kg1 ml of LR/ %/ % of BSB / kg2000 ml of D5W Brooke’s formula0.5 ml of colloid/ % of BSB /Kg1.5 ml of LR/ % of BSB /kg2000 ml of D5W
( this is only for 1st 24 hours)
On the second 24 hrsOn the second 24 hrs
• In parkland formula 0.5 ml/ % /kg of colloid gets added. Other fluid and electrolytes as needed based on I/O and electrolyte levels
• In Evan and Brooke the calculations are different• Maintenance of Euvolumia based on urine
output is the most important criteria• On average 0.35 ml of colloid/ % /Kg +
maintenance of fluid is the common practice
Other considerations and fluid Other considerations and fluid management after 48 hrsmanagement after 48 hrs
• After 48 hrs maintenance of electrolytes and fluid balance is the goal
• Patients with cardiac failure or pulmonary edema is managed by less fluid and hypertonic saline may be indicated
• Patients who need more fluid than the BSB calculations are– Massive burns, electrical burns, pre burn hypovolumia
as seen in intoxicated patients, patients with other associated injuries, inhalation injuries, 4th degree burn when bones are involved
monitormonitor
• Urine output ( most important)
• CBC, Electrolytes
• ABG
• Cardiac parameter if CVP, Swan Gantz catheter is in place
Adequacy of resuscitationAdequacy of resuscitation
1. Urine output 30 – 50 cc/hr I adult and 1 cc/kg an hr. in
children
2. Sensorium : clear and lucid
3. Pulse : 100 -120 / min
4. BP : Normal to slightly high
5. Lack of nausea and ileus
Special considerations in childrenSpecial considerations in children
• Decreased glucose stores
• Decreased buffering capacity
• hypothermia
Problems to look forProblems to look for
• Acidosis – Inadequate resuscitation
• Hyperkalemia– Acidosis, electrical injury
• Hypernatremia– Inadequate resuscitation
• Hyponatremia– Over fluid resuscitation
• Hypoglycemia– Seen in children due to limited glycogen reserve and poor glucose
mobilization• Dehydration
– Usually seen in patients on air fluidized bed due to evaporative loss
Topical wound careTopical wound care
• Reduction of burn wound infection and mortality by 50 -60%
• Loose necrotic skin should be debrided• Blisters can be aspirated, do not need to be
debrided immediately• Likely organisms for BW infections are
– 1st. Wk : strep– 2nd wk : pseudomonas– 3rd wk : fungi ( most common cause of death after 24 hrs)
Common source of infectionCommon source of infection
• Burn wound
• Canulated arteries or veins
• pulmonary
Topical agentsTopical agents
• Silver nitrate 0.5% solution
• Silver sulfadiazine (Silvadene)
• Betadine
• Nitrofurazone (Furacene)
• Mafendine acetate 10% ( sulfamylon)
Biologic dressingsBiologic dressings
• Xenograft ( pig skin )
• Allograft ( human cadaver)
• Bio synthetics
• Synthetics (biobrane, integra)
• Cultured epithelial auto graft
Operative wound managementOperative wound management
• Early debridement
• Skin grafting
• Escharotomy
• Release of compartment syndrome
NutritionNutrition
• All burn patients are in hypermetabolic state and needs to be supported– Hosp. diet– Oral supplement– Tube feed– Peripheral intravenous supplements– TPN
Goal is 1-2 gm protein/kg/day in adult and 2-3 gm /kg /day in children.
Carb : 5 mg/kg/minute
Complications besides burn wound Complications besides burn wound sepsis and pulmonary complication sepsis and pulmonary complication• Ileus• Curling's ulcer• Pancreatitis• Acalculus cholecystitis• Ischemic enterocolitis• SMA syndrome• Otitis media in children• Osteomyelitis, chondritis specially in ear• Burn scar, contracture, keloid as a long term sequelle• Burn scar carcinoma (marjolins ulcer)
Be mindful ofBe mindful of
• Inhalation injury ( mostly due to CO)– Doubles mortality rate– Occurs in 50% of cases in closed space injury
• Difficult to diagnose initially• Closed space fire• Carboxy hgb 10%• Carbonaceous sputum• Confused, lethargic, head ache, nausea, vomiting,
decreased manual dexterity
Also rememberAlso remember
• Electrical burn• Chemical burns specially HFA (water ignites,
calcium gluconate and zephiran neutralises)• Frost bite• Radiation burns• Alkali burn• Acid burn• Phosphorus( ignites on air contact and copper
sulfate can identify the retained particles)• tar
PrognosisPrognosis
• Age• BSB• Inhalation injury• Other associated medical issues and
injuries
SPLINTS, THERAPY,COMPRESSION, REHABILITATION
Who are plastic surgeonsWho are plastic surgeons
• Presently almost anyone• To be board certified in plastic surgery one needs to
have training in either General Surgery (most of plastic surgeons) or ENT and two to three years in Plastic surgery residency in an ACGME approved program
• Plastic surgery training is regarded as residency not a fellowship
• As plastic surgery covers almost all areas of the body a broad based residency in general is helpful
• Plastic surgery is regarded, at the present time, as the “last bastion” of general surgery
Plastic surgery now Plastic surgery now encompasses over 12 encompasses over 12
subspecialtiessubspecialties
Skin CancersSkin Cancers
Abdominal wall Abdominal wall ReconstructionReconstruction
Breast ReconstructionBreast Reconstruction
Back ReconstructionBack Reconstruction
Lower ExtremityLower Extremity
Microvascular SurgeryMicrovascular Surgery
ReplantReplant