management of small burns - spitalzentrum biel...management of small burns biennovation, 14....
TRANSCRIPT
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Management ofSmall Burns
B I E N N O V A T I O N , 1 4 . S e p t e m b e r 2 0 1 8
D r . m e d . K a t h r i n N e u h a u s , U n i v e r s i t y C h i l d r e n ` s H o s p i t a l Z u r i c h , P e d i a t r i c B u r nU n i t , D i v i s i o n o f P l a s t i c a n d R e c o n s t r u c t i v e S u r g e r y
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Main Topics
• Pre-hospital care for thermal injuries
• Repetition of basic (burn) wound assessment
• Conservative management: options for dressings
• Decision making conservative vs operative treatment
• Surgical treatment of small burns
• Principles of rehabilitation and after care
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Epidemiology of Burns
Type of Injury Temperature Frequency in Children
Scald burn 60 - 100 º C 65%
Flame burn 1000 º C 25%
Contact burn 250 - 500 º C 8%
Electrical burn/electric arc
1000 º C 1%
Chemical burn 0.5%
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First Aid
• Disruption of heat contact + cooling
• Scald burns may be cooled with clothing on
• Do not cool the entire body, only body parts
• Cool first, then warm up/wrap, and then call for help!!!!
Tap water 20-25 degree Celsius for 10 (-15) min.
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Transfer to the Hospital
• rough estimation of BSA (in steps of 10%)
• rough estimation of burn depth (1st/2nd/3rd degree)
• keep the patient warm and monitor body temperature
• analgesia (opioids, ketamin), keep NPO
• dressings: isolating rescue blankets, simple petroleum gauzedressing, leave blisters intact no wet gauzes!!
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Transfer to the Hospital
• Peripheral iv line:
≥ 10% BSA or ≥ 5-10% BSA + expected transfer time ≥ 60min:
formula based fluid rescuscitation only for burns >20% BSA AND transfer time ≥ 2-3h (contact pediatric burn center)
• difficult venous access consider intraosseous access
cristalloides (e.g. lactated ringer` s solution): 10 ml/kg (bolus) + 10 (-15) ml/kg/h continously
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Transfer Criteria to Pediatric Burn Centers
• 2nd degree burns > 10-15 % BSA
• 3rd degree burns
• Face, hand, feet, genitalia burns, burns crossing large joints
• Electrical injuries
• Chemical burns
• Inhalation trauma
• Children with significant comorbidities
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Assessment of BSA Involved
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14 months
14 years
Assessment of BSA involved
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14 Monate
Assessment of BSA Involved
Rule of nine by Wallace for the age of 14 or older!
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Assessment of BSA Involved
1 %
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Burn Case 3D
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Skin Anatomy and Burn Depth
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Skin Anatomy and Burn Depth
1st degree = sun burnOnly epidermis involved erythema, no blistering, swelling and pain
Heals within a few days, no scars
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Skin Anatomy and Burn Depth2a = superficial partial thicknessepidermis and papillary dermis involved, but basal cell membrane partially intact blisters, wound pink and blanching, moist, moderate pain
Heals within 5-14 days, no scars, possiblepermanent changes in pigmentation
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Skin Anatomy and Burn depth2b = (deep) partial thicknessComplete involvement of basal layer ofepidermis and main parts of dermis (reticulardermis)± blisters, wound white/pinkish withhemorrhagic staining, minimal to no blanching, dry, minimal pain
Heals within 3-5 weeks, usually with severescar formation, usually requires grafting
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Skin Anatomy and Burn Depth
3rd degree = full thicknessComplete epidermis and dermis involvedincluding skin appendagesand sometimes subcutanous fat
wound white, dry, eschar formation, insensate, no blanching, hair can be pulled out
Heals from the edges only, over weeks andmonths with scar formation, requires grafting
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Skin Anatomy and Burn Depth
4th degreeComplete epidermis, dermis and subcutanousfat, muscle, tendons and bones may beinvolved
Black eschar, insensate, no pain
No healing potential, may require flap
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Wound Assessment
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Wound Assessment
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Wound Assessment
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Wound Assessment
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Wound Assessment
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„Restrain yourself to give any earlyprognosis“
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„Restrain yourself to give any earlyprognosis“
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Day 3 Day 8
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Assessment of microvascular dermal perfusionin the wound – allows non invasive objectiveburn depth assessment
- Window of assessment: 48h to 5d post burn- accuracy 90 - 98%- pos. predictive value for deep dermal to full
thickness burns (HP >21 Tage) 85-98%Moor LDI
Laser Doppler Imaging
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Moor LDI
Laser Doppler Imaging
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Zurich Management of Small Burns (< 15-20% BSA)
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Zurich Management of Small Burns (< 15-20% BSA)
The care of a burned child and his family should be done from the day of injury till transition to adult medicine by one team
at one single location.
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Main Patient Population < 4yScald Burns
• map like pattern of variable depth within one anatomic region
• ”deepen” within 24-48h
• 2a/2b (3), some require grafting
Contact Burns• mainly palm burns• 2b/3, frequently require
grafting• difficult to rehabilitate
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Key Points of Management
1. Minimal and “atraumatic” dressing changes: every 5-7 days, under analgosedation
2. Precise assessment of burn depth: clinical experience : + Laser-Doppler-Imaging
3. Specific dressing concept for different burn depths
4. Decision conservative vs surgical management not later than day 9-12 for scald burns and day 14-21 for palm burns
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The Ideal Wound Dressing ?
maximum support of wound healing
maximum protection against infection
long acting low frequency of dressing changes
minimum pain during dressing changes
minimum costs
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The Ideal Wound Dressing ?
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Dressing Algorithm
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Dressing AlgorithmDay of injury Day 2-5 Day 8-12
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Dressing Algorithm
Woundcleaning anddebridment
undersedation in
the EDMepilexAg®
Day of injury Day 2-5 Day 8-12
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Dressing Algorithm
Woundcleaning anddebridment
undersedation in
the EDMepilexAg®
Day of injury Day 2-5 Day 8-12
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Dressing Algorithm
Woundcleaning anddebridment
undersedation in
the EDMepilexAg®
2a: Suprathel®
Dressing changeunder
sedation + Laser
Doppler-Imaging
Outpatient, dressingchange without sedation
Day of injury Day 2-5 Day 8-12
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Dressing Algorithm
Woundcleaning anddebridment(sedation) in
the EDMepilexAg®
2a: Suprathel®
Dressing changeunder
sedation + Laser
Doppler-Imaging
2a/2b:Polymem Ag®
outpatient dressingchange without sedation
Inpatient or outpatient, w/o sedation, definitive decision cons vs surgical
Day of injury Day 2-5 Day 8-12
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Dressing Algorithm
Woundcleaning anddebridment(sedation) in
the EDMepilexAg®
2a: Suprathel®
Dressing change
(sedation) + Laser
Doppler-Imaging
2a/2b:Polymem Ag®
2b/3: Acticoat®
Outpatient, dressingchange without sedation
Inpatient or outpatient, definitive decision cons
vs surgical
inpatient or outpatient, sedation, definitive
decision cons vs surgical
Day of injury Day 2-5 day 8-12
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Dressing Algorithm
Woundcleaning anddebridment(sedation) in
the EDMepilexAg®
2a: Suprathel®
Dressing change
(sedation) + Laser
Doppler-Imaging
2a/2b:Polymem Ag®
2b/3: Acticoat®
outpatient dressingchange without sedation
Inpatient or outpatient, w/o sedation, definitive decision cons vs surgical
inpatient or outpatient, dressing change under
sedation, definitive decision cons vs surgical
Day of injury Day 2-5 Day 8-12
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…if Surgery is Needed: STSG
5 important rules
1. Prevent any unnecessary blood loss!
2. Do not sacrifice vital dermis
3. Go for the scalp!
4. Do not mesh, use sheet grafts!
5. Invest time and passion into your dressings!
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Tangential Necrosectomy
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Tangential Necrosectomy1. thoroughly mark the area that requires excision
2. inject the area with epinephrine (or use a tourniquet)
3. wait prepare the next step , chat with your colleagues
4. score the edge of the area with a scalpel
5. excise tangentially using a weck (goulian) or watson knife until woundbed is vital
6. achieve hemostasis (epinephrine soaked telpha non adhesive pads, electrocautery)
7. prepare and harvest your donor site
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Harvesting the Scalp
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Harvesting the Scalp
• Favourable size relation in children
Up to 350cm2 per harvest
Lower rate of complication (CAVE dark skin types)
• ”hidden donor site”
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Harvesting the Scalp
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Harvesting the Scalp
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Do not mesh!
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Sheet Grafting
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Outcome
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Post STSG• POD 5-7: graft take down removal of suture material under sedation simple, thin
dressing
Measurements for pressure garments
Physiotherapy/occupational therapy
• POD 6-10: no more dressing mobilisation
daily baths and moisturizing (Bepanthen/Dexeryl)instruction of parents
garment fit test
• POD 9-12: discharge home
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...When Things Go Wrong
Wound Bed Related
• Wound bed not vital, insufficientnecrosectomy
• Wound bed infection
Graft Related
• Mechanical forces (insufficient dressingan/or incompliant patient/parents
• STSG too thin
• STSG applied upside down
5 Reasons for Graft Loss
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Rehabilitation
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Rehabilitation/Follow up
Multidisciplinary outpatient burn clinic every 3 months (6 weeks) in thefirst year:
assessment of scar quality/hypertrophic scarring siliconesheets/gel?
assessment of pruritus
ROM need for pyhsiotherapy/occupational therapy?
need for splints
fit of garments and need for further garments (± 12 months)
Keep pressure garments as long as needed and as short as possible!
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Rehabilitation
• Early surgery: rarely needed, usually no reconstructive surgerywithin first 12 months of the injury, await scar maturization
• New option: Laser therapy: pulse dye and fractional CO2 Laser
• Reconstructive Surgery during growth: Local flaps, Scar Incision andrelease
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Questions????