thermal injuries -plastic surgery
TRANSCRIPT
Mahajna MohammadSackler’s faculty of medicine , Tel-Aviv Uni; 2017
Thermal injuries
INTRODUCTION
“ Concentrate all your thoughts upon the work at hand. The sun's rays do not burn until brought to a focus”
500K >50% 4K66%
33% 44% 26% 17%
Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.
American Burn Association White Paper. Surgical management of the burn wound and use of skin
Scalded :contact with hot liquids
Flame: superheated, oxidized air
Thermal
Chemical
Electrical
Inhalation
Radiation
Cold exposure (frostbite)
Depe
nds on
:
Jackson's thermal wound theory- 1947
ABC of burnsShehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10; 329(7457): 101–10; doi: 10.1136/bmj.329.7457.101
Lund-Browder — is the most accurate for adults and children (larger heads and smaller lower extremities) It takes into account the relative percentage of BSA affected by growth
Rule of Nines — For adult assessment, the most expeditious method :
Each leg =18 % TBSA
Each arm =9 %TBSA
The anterior and posterior trunk each =18 % TBSA
The head =9 %TBSA
Palm method — used for irregular ,small or patchy burns
The palm, excluding the fingers, =0.5 % TBSA
the entire palmar surface including fingers is 1 % TBSA in children and adults Superficial burns are not included in the TBSA
burn assessment.
Determination of burn size estimates the extent of injury. Burn size
is generally assessed by the “rule of nines”
Burn assessment
“Understanding is the first step to acceptance, and only with acceptance can there be recovery.” J.K. Rowling, Harry Potter and the Goblet of Fire
Stage 1 : Emergent phase
Stage 2 : Fluid shift-<24hr , peak at 8hr
Stage 3 : Hypermetabolic phase :days-weeks
Stage 4: Resolution phase : healing / scar formation
Initial assessment / treatment
basic
Pre-hospital / initial treatment hospitalization
Specific injury
e.g. inhalation
Airway and breathing support
Administer humidified oxygen at a rate of 10-12 L/min if signs of inhalation injury are present
A patient who is not breathing should be intubated and ventilated with 100% oxygen
Cooling : ↓ lactate production +acidosis,promoting catecholamine function and cardiovascular homeostasis
Remove clothing
Immerse wound in cold (1-5°C) water for 30m
Do not use ice water / ice directly to the burn wound
Local cooling of burns of < 9% of TBSA can for > 30 min relieve pain
Fluid resuscitation –burns >15% of TBSA may produce shock as a result of hypovolemia
Maintain IV access
In children <6 years : intraosseous access in the proximal tibia until IV access is accomplished
Begin immediately with warmed fluid if possible
Cannulate burned skin if unburned skin is unavailable
In adults: solution can be without glucose.
In children <2 yr should receive 5%dextrose in lactated Ringer solution
Insertion of nasogastric tube (e.g Levin ,salem-sump,Andersen, Dobhof) is crucial :
• Reduce intestinal ileus
• Prevent patient from air swallowing
• Alleviates distention
Dobhof tube should be placed into the fist part of the duodenum to maintain caloric
intake
Recommendations for tetanus prophylaxis :
All patients >10% TBSA should receive 0.5 mL of tetanus toxoid. 250 units of tetanus immune globulin are also given If:
1. prior immunization is absent or unclear 2. the last booster dose was more than 10 years ago
Karyoute SM1, Badran IZ Tetanus following a burn injury.Burns Incl Therm Inj. 1988 Jun;14(3):241-3.
Admission to burn unit Assets the need for intensive
care unit
Wound care
Excision Escharotomies Coverage \ dressing
Basic support
Nutritional support Resuscitation
Consider location :e.g.
Fingers and toes should be wrapped individually
separating the digits in order to prevent maceration
and adherence
Wash + debride any open blisters
Steroids have no role in treating burn wounds.
The World Health Organization (WHO) recommends
debridement of all bullae and excision of all adherent
necrotic tissue
Decompressive escharotomy :Extremities at risk are identified either on clinical examination or on
measurement of tissue pressures > 40 mm Hg.
With deep dermal and full thickness burns, the dermis can become stiff
and unyielding, and this tissue is referred to as an eschar.
escharotomy
Fluid selection
• Resuscitation• Maintenance• Over-resuscitation
Desired fluid amount
Monitoring fluid status
Over-resuscitation
Fluid selectionHypertonic saline Colloids (e.g, albumin solution, dextran) Crystalloids or volume expanders
↓ net fluid intake ↓ edema, ↑ lymph flow
• significantly more expensive• should not be used in the fist 24 hours until
capillary permeability returned closer to normal
• Ringer lactate is typically used• lactate may reduce the incidence of
hyperchloremic acidosis
Hypernatremia !!! Na <160 mEq/dL ↑ renal failure ↑ acute tubular necrosis ↑ hyper-chloremic metabolic
acidosis
• Albumin use is controversial• The Cochrane group showed in a meta-
analysis of 31 trials that the risk of death was higher in burned patients receiving albumin compared with those receiving crystalloid. RR=2.40 : (cl 95% ,1.11 - 5.19).
5% Dextrose =D5W 0.45% NaCl = half formal saline 0.9% NaCl = normal saline Ringer lactate Hartmann’s 5% dextrose, normal saline = D5NS
Authors’ conclusions:
Whether Hypovolemic or hypoalbuminemic
there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline.
Human albumin solution for resuscitation and volume expansion in critically ill patients.Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi: 10.1002/14651858.CD001208.pub3.
Recommended amount
Another alternative method is the Rule of Tens depending on patient size: Estimate (TBSA) to the nearest 10 percent.
Multiply the percent TBSA x 10 = initial fluid rate in mL/hour for adults 40 to 80 kg.
> 80 kg, increase the rate by 100 mL/hour for every additional 10 kg of body weight.
Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.
Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE ;Burns. 2009 Feb; 35(1):4-1
Burn severity
Associated injury
comorbidities
age
Burn depthTBSALocation
Calculate amount needed
Start initial resuscitation
50% of the calculated fluid requirement is administered in the
first 8 hours
50% is given over the remaining 16 hours Evaluate response adequate resuscitation
achieved stabilized
Change crystalloid to 5 % dextrose in (ie, 0.45%Nacl) +20 mEq of KCl per liter
Monitoring fluid status - Non-invasive methods
0.5 mL/kg / hr in adults
1.0 mL/ kg/ hr in children
If urine output drops below 0.5 mL/kg/hr a bolus of IV crystalloid (500 -1000 mL)
↑infusion rate by approximately 20 to 30 percent
Clinical signs of volume status: monitored every hour for the first 24 hours: heart rate
blood pressure
pulse pressure
distal pulses
capillary refill
color and turgor of uninjured skin are
edema
Monitoring fluid status invasive methods (CVP/ Swan-ganz / Arterial BP /
SVV)
Evaluate response stabilizedChange crystalloid to 5 % dextrose in (ie, 0.45%Nacl) +20 mEq of KCl per
liter
unresponsive to resuscitation1) > 6 mL/kg X (X%) TBSA per 24 hours
2 )impending cardiac failure are present
Evaluate response
Invasive / non-invasive
Swan-Ganz
Measure Co
If adeq Vol. but ↓ urine output
dopamine (5 µg/kg/min) may be used to increase renal perfusion.
Resuscitation related complication
CONCLUSIONS:Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.
13 trials have indicated that as much as 50% of the edema observed in non-burned tissues.
In burns > 25% TBSA , capillary permeability is increased also in non-burned areas
Symptoms : Unproportioned Pain (early ,common finding)
burning pain
Paresthesia (30m-2 hr;)
Examination findings Pain
Tense compartment with a firm "wood-like" feeling
Pallor (uncommon)
Diminished sensation
Muscle weakness (onset 2-4hr)
Paralysis (late finding)
ACS ∆ pressure = diastolic BP measured compartment ‒pressure
ACS ∆ pressure <20 to 30 mmHg indicates need for fasciotomy
(we use <30 mmHg)
J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture.Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD
References
Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.
American Burn Association White Paper. Surgical management of the burn wound and use of skin
ABC of burnsShehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10; 329(7457): 101–10; doi: 10.1136/bmj.329.7457.101
Karyoute SM1, Badran IZ Tetanus following a burn injury.Burns Incl Therm Inj. 1988 Jun;14(3):241-3.
Human albumin solution for resuscitation and volume expansion in critically ill patients. Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1.Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi: 10.1002/14651858.CD001208.pub3.
Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.
J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture.Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD
Overview of the management of the severely burned patientAuthors:Gerd G Gauglitz, MMS, MDFelicia N Williams, MDSection Editor:Marc G Jeschke, MD, PhDDeputy Editor:Kathryn A Collins, MD, PhD, FACS
Sabiston textbook of surgery 19th;chapter19 : burns; David C Sabiston; Courtney M Townsend, Jr.; Philadelphia, PA : Elsevier Saunders, ©2012.
Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE; Burns. 2009 Feb; 35(1):4-1