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Objectives Describe epidemiology of burn injury Discuss causes of burn Classify burn injury Discuss Pathophysiology of burn Assessment of burn patient Describe treatment plans for burn patient by using ATLS principles Discuss complications of burn Wednesday, May 24, 2017 BURN 2 Introduction Burn Tissue injury ○ thermal ( heat, cold) ○ electrical ○ Radiation ○ chemical coagulative necrosis Wednesday, May 24, 2017 BURN 3 Epidemiology 1% of the world population each year USA ~ 2.4 million burn injuries/ yr & 10,000 death/yr UK ~ 250,000 patients treated with burns & 700 deaths/yr. In Kenya 5,000 deaths/yr TZ(MNH) 10% of admission in pediatric surgical ward ??BMC Wednesday, May 24, 2017 BURN 4 epid…… Age Scald - < 5 year of age flame, electrical & chemical burn - adult Sex domestic burn - females occupational - males Race No race predilection exists in burn injuries Wednesday, May 24, 2017 BURN 5 Risks factors Diseases e.g. epilepsy, diabetes Children< 5years; Elderly > 75 years Cold weather Occupational – electricians/industrial Alcoholism ??Low socioeconomic status Wednesday, May 24, 2017 BURN 6 High morbidity and mortality emotional & psychological Wednesday, May 24, 2017 BURN 7 Anatomy Skin The epidermis derived from ectoderm it can regenerate. The dermis from mesoderm cannot re-generate, Wednesday, May 24, 2017 BURN 8 AETIOLOGY Thermal injuries Scald Flame Flash Contact Chemical injuries Electrical injuries Radiation injuries Cold injuries Wednesday, May 24, 2017 BURN 9 classification type /cause body site degree size/extent severity Wednesday, May 24, 2017 BURN 10 Class.. - type Thermal burn ○ Scald ○ Flame burn ○ Contact burn ○ Flash Electrical burn Chemical burn Radiation burn Cold burn Wednesday, May 24, 2017 BURN 11 Class.. site depth Facial burn Superficial burn Head & neck ○ Epidemal Trunk ○ Dermal Limbs Deep burn Perineal burn ○ Dermal ○ Full thickness Mixed burn Wednesday, May 24, 2017 BURN 12 Class.. degree of tissue injury First degree burn Second degree burn • 2nd Degree Superficial (superficial Dermal) • 2nd Degree Deep (deep Dermal) Third degree burn Fourth degree burn Wednesday, May 24, 2017 BURN 13 Class.. Size/Extent Total body surface area (TBSA) burned severity of burn • Minor burn • Moderate burn • Major burn Wednesday, May 24, 2017 BURN 14 PATHOPHYSIOLOGY Burn injuries result in: local response systemic Wednesday, May 24, 2017 response BURN 15 Pathophysiology…… LOCAL RESPONSE Inflammation Jackson zones (1947) coagulation /necrosis Stasis/ischaemia hyperemia Wednesday, May 24, 2017 BURN 16 Pathophysiology…… SYSTEMIC RESPONSE:Significant burn massive release of inflammatory mediators, both in the wound and other sites. Wednesday, May 24, 2017 BURN 17 Follow burn injury , neutrophils ,monocytes & platelets migrate into burn wound Capillary permeability locally & in distinct organs. ↓ Plasma oncotic pressure ↑ Interstitial oncotic pressure due to increased capillary permeability protein loss edema in burned & un-burned tissues Wednesday, May 24, 2017 BURN 18 Biochemical … ↓ tissue perfusion tissue hypoxia anaerobic resp Pyruvate ↑ lactic acid metabolic acidosis alter cellular enzymes activity Wednesday, May 24, 2017 BURN 19 Biochemical….. ↓ATP↓ Na+Ka+-ATPase ↑↑Na+ intracellular & ↑↑K+ extracellular cellular swelling hyperkalemia ↓ ECF vol. Cell death by necrosis or apoptosis Wednesday, May 24, 2017 BURN 20 CVS ♥ ↓Myocardial contractility TNF ♥ ↓ CO due to loss of intravascular vol, ↑ viscocity & ↓cardiac contractility. These changes, coupled with fluid loss from the burn wounds systemic hypotension & end organ hypotension MOD MOF Wednesday, May 24, 2017 BURN 21 Respiratory Inflammatory mediators →bronchoconstriction, → ARDS Pulmonary dysfunction Inhalation injury Aspiration Shock Circumferential thoracic eschar Wednesday, May 24, 2017 BURN 22 GIT mucosal atrophy changes in the digestive absorption intestinal permeability Thromboxane A2 prominent mesenteric vasoconstriction ↓gut blood flow compromise gut mucosal intergrity & ↓ immune fxn Stress (Curling’s) ulcer ( stomach & duodenum). Acute pseudo-obstruction of the colon (Adynamic ileus) Acute dilatation of the stomach & colon. Acalculous cholecystitis Wednesday, May 24, 2017 BURN 23 Renal Changes BV &↓ CO RBF GFR ATN ARF Wednesday, May 24, 2017 BURN 24 CNS Changes CNS dysfunction in up to 14% of burn patients Delirium, disorientation Hypoxia smoke inhalation, pulmonary edema, pneumonia Wednesday, May 24, 2017 BURN 25 Haematological Haemoconcentration Anaemia Destruction of RBC Continual loss of RBC for 1 wk Mild thrombocytopenia (sequestration) early, followed by thrombocytosis (2-4x > normal) by end of the 1st week Persistant thrombocytopenia associated with poor prognosis suspect sepsis DIC with generalized bleeding can occur shock, sepsis, hypoxia, reperfusion injury Wednesday, May 24, 2017 BURN 26 Immunological Innate immunity Skin Cellular Immune Function lymphocyte function Humoral Immune Function IgG & IgA Wednesday, May 24, 2017 BURN 27 Metabolic Ebb phase Flow phase Catabolic phase Anabolic [recovery phase] Wednesday, May 24, 2017 BURN 28 Ebb phase Occurs during the 1st 24 hours hypothermia CO & O2 consumption Wednesday, May 24, 2017 BURN 29 Catabolic Phase Occurs after 24 hours of burn injury Mediated through release of catabolic hormones [ eg, catecholamines, glucocorticoids, glucagon ] and other chemical mediators e.g. cytokines, lipid mediators. ↑ Cardiac output ↑ Oxygen consumption ↑ Heat production [hyperthermia] ↑ BMR Hyperglycemia Proteolysis Peripheral lipolysis Wednesday, May 24, 2017 BURN 30 BURNSTRE SS CORTISOL Catecolamines GLUCAGO N Gluconeogenes is Peripheral Lipolysis GLUCOSE FREE FAT ACIDS Wednesday, May 24, 2017 BURN Proteolysis AMINO ACIDS 31 Anabolic / recovery phase Characterized by:This phase continues for weeks to months after injury Slow re-accumulation of protein and fat Wednesday, May 24, 2017 BURN 32 ASSESSMENT OF BURN INJURY Remember Establish cause. Associated injuries During escape from fire. Explosions throw patient a distance causing internal injuries. Electrical muscular spasms can cause fractures. Burns in enclosed space suggest inhalational injury. Pre-existing disease states, medication, allergies, lung sensitivities. Establish tetanus immunization status. Wednesday, May 24, 2017 BURN 33 Clinical assessment History Physical examination General Local Systemic Wednesday, May 24, 2017 BURN 34 history Patient characteristics age , occupation History of injury Time of burn Place of burn Nature of injury ○ Intentional ○ Unintentional ○ Undetermined Wednesday, May 24, 2017 BURN 35 History…. Type of burn Thermal Chemical Electrical Radiation Cold Mechanism of injury Associated injuries Associated inhalation injuries Associated clothing ignition Whether first aid measures was done at the site of accident Wednesday, May 24, 2017 BURN 36 ROS PMHx ?? Epilepsy, DM, Psychosis FSHx ??alcohol Wednesday, May 24, 2017 BURN 37 General Exam Body weight Shock Level of consciousness Dyspnoea In pain Restless ± gasping Anaemic Dehydration Wednesday, May 24, 2017 BURN 38 Physical examination Local examination [assessment of burn wound] Examine the wound Body region burned Extent of burn Burn depth Severity of burn Systemic examination Cardiovascular system Respiratory system PA May CNS Wednesday, 24, 2017 BURN 39 Local exam Body region Head / neck Upper limbs Trunk Lower limbs Genitalia / Perineal areas Wednesday, May 24, 2017 BURN 40 Extent of burn Size of a Burn Injury Total Body Surface Area (TBSA) Burned Palmar Method A quick method to evaluate scattered or localized burns Client’s palm = 1 % TBSA Rule of Nines (Wallace’s) A quick method to evaluate the extent of burns Major body surface areas divided into multiples of nine Modified version for children and infants (Rule of Sevens ) Lund-Browder Method Most Accurate; based on age (growth) Can be used for the adult, children & infants Wednesday, May 24, 2017 BURN 41 Wednesday, May 24, 2017 BURN 42 Wednesday, May 24, 2017 BURN 43 Wednesday, May 24, 2017 BURN 44 Burn depth Superficial (1st Degree) Partial Thickness Superficial (2nd Degree) Deep ( 2nd Degree) Full Thickness (3rd Degree) Deep-Full Thickness (4th degree) Wednesday, May 24, 2017 BURN 45 Superficial first degree burn Epidermis Wound Appearance: Red to pink (light skin) Mild edema Dry and no blistering Pain / hypersensitivity to touch ○ i.e. Classic sunburn Desquamation occurs 2-3 days Wound Healing Wound Healing spontaneous Duration 3 to 5 days No scarring / other complications Wednesday, May 24, 2017 BURN 46 46 Superficial second degree burn 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 Wednesday, May 24, 2017 BURN 47 Deep second degree burn deep dermis layer Wound Appearance Mottled: Red, pink, to white surface Moist Moderate edema Painful; usually less severe than superficial 2nd Degree superficial. No blisters Wound Healing May heal spontaneously 2-6 weeks If so Hypertrophic scarring / formation of contractures Wound Management: Treatment of choice surgical excision & skin grafting Wednesday, May 24, 2017 BURN 48 Full thickness third degree burn entire epidermis and dermisSubcutaneous fat Wound Appearance Dry, leathery and rigid + Eschar (hard and in-elastic) Red, white, yellow, brown or black Severe edema Painless & insensitive to palpation Wednesday, May 24, 2017 BURN 49 Wound Healing No spontaneous healing; No epidermal or dermal appendages remain, thus must heal by reepithelialization from the wound edges. Wound Management: Surgical excision & skin grafting Cx severe scarring/contracture Wednesday, May 24, 2017 BURN 50 Deep full thicknesss burn Extends beyond the skin to include muscle, tendons & possibly bone. Wound Appearance: Black (dry, dull and charred) Eschar tissue: hard, inelastic No edema Painless & insensitive to palpation Wednesday, May 24, 2017 BURN 51 Deep full thickness…… Wound Healing No spontaneous healing Wound Management: Surgical excision & skin grafting Frequently requires amputation if extremity involved Wednesday, May 24, 2017 BURN 52 Severity classified as follows:- Minor Moderate Major Wednesday, May 24, 2017 BURN 53 Severity of burn is determined by Type of burn Depth of burn injury Total body surface (TBSA) burned Location of burn( face, hands, feet and perineum are considered severe !! ) Patient’s Age Presences of other preexisting medical conditions Presence of associated injuries Complications ( Inhalation , Hypothermia , Shock ) Wednesday, May 24, 2017 BURN 54 Minor burn Characterized by: <10% in adult < 5% <10 yrs or >50 yrs < 2% full thickness No associated injuries, no complications, no pre- morbid illness, no circumferential burns, not involving the hands, face, perineum Minor burns needs outpatient Mnx. Wednesday, May 24, 2017 BURN 55 Moderate burn 10 - 20 % in adult 5 - 10 % <10 yrs >50 yrs High voltage, suspected inhalation, circumferential or susceptibility to infection Admit Wednesday, May 24, 2017 BURN 56 Major burn 2nd & 3rd Degree burns >10% (BSA) in patients <10 or > 50 yrs of age 2nd & 3rd Degree burns >20% BSA in pts btn 10 and 50 yrs of age 2nd & 3rd Degree burns with serious threat to functional and cosmetic impairment that involve the face, hands, feet, genitalia, perineum, and other major joints 3rd Degree burns >5% BSA Specialized injuries such as electrical burns, including lightning and chemical burns, with serious threat of functional or cosmetic impairment Wednesday, May 24, 2017 BURN 57 Major burn… Significant inhalation injuries Circumferential burns of the extremities or the chest Pre-existing medical disorders that complicate management, prolong recovery, or affect mortality Concomitant trauma in which the burn injury poses the greatest risk of mortality Wednesday, May 24, 2017 BURN 58 Management aim prevent fluid and electrolyte imbalance rapid and painless healing prevent complications rehabilitation Wednesday, May 24, 2017 BURN 59 Burn team Surgeons –reconstructive (plastic), General or Wednesday, May 24, 2017 trauma surgeon, Paediatric surgeon Nurses Anesthetist ICU team Physiotherapist Occupational therapist Social workers Psychologists Psychiatrist Dietitians BURN 60 Criteria for admission Type of burn Electrical Chemical Lightining %TSBA >15% in adult >10% in children Body site affected: face, hands, perineum, genitalia Complications- inhalation burn Pre-existing illness – renal diseases, Diabetes mellitus, respiratory diseases Circumferential burns of the limbs or chest Wednesday, May 24, 2017 BURN 61 Phases of management ATLS (Advanced Trauma Life Support) Phase I: Primary survey phase Phase II: Resuscitation phase Phase III :Secondary survey phase Phase IV: Supportive care phase Phase V: Definitive treatment phase Wednesday, May 24, 2017 BURN 62 Fluid Resuscitation maintain tissue perfusion to the zone of stasis and so prevent the burn from deepening Indication= ped 10%, adult 15% Fluid resuscitation formula not ideal guidelines success relies on adjusting the amount of resuscitation fluid ↔ against monitored physiological parameters hypoperfusion VS oedema Wednesday, May 24, 2017 BURN 63 Resuscitation cont….. Parkland formula 4mls x KgBwt x %TBSA1st 24hrs crystalloid formula For burn >50% TBSA, use 50% for calculation (to prevent fluid overload) ½ given in 1st 8 hrs & ½ next 16hrs. In children add the maintenance fluid Wednesday, May 24, 2017 BURN 64 Resuscitation cont…. After 1st 24 hrs, colloid infusion is started at a rate of:0.5 ml× (%TBSA)×(Bwt in kg) and Maintenance crystalloid (usually DNS) is continued at a rate of 1.5mlsx%TBSAxBwt End point to aim is a urine output of:0.5-1.0 ml/kg/hr in adults 1.0-1.5 ml/kg/hr in children Wednesday, May 24, 2017 BURN 65 Resuscitation cont….. Colloid use is controversial: ○ some units start colloid after 8 hrs( as the capillary leak begins to shut down) ○ whereas others wait until 24 hrs FFP is often used in children, albumin or synthetic high molecular weight in adults. Wednesday, May 24, 2017 BURN 66 Resuscitation cont… The Modified Brooke formula RL: 2 mls x % BSA x Bwt (kg) Replacement reassessed on an hourly basis. Urine output< 0.7ml/kg/hr. If urine output is inadequate, increase infusion by 200ml next hour 2nd. 24 hours Colloid (Albumin, Dextran 70) (0.3-0.5ml/kg/%BSA) Dextrose to maintain urinary output Wednesday, May 24, 2017 BURN 67 Phase III :Secondary survey phase History Physical examination Investigations Wednesday, May 24, 2017 BURN 68 Secondary survey cont… Baseline investigation for major burn. Blood ○ Hb ○ Grp & x-match ○ CoHb ○ Serum glucose ○ Electrolytes ○ Arterial blood gases X-rays Wednesday, May 24, 2017 BURN 69 Phase IV: Supportive care phase Analgesics Haematenics PPI Systemic antibiotics against ß- hemolytic streptococcus Tetanus toxoid NGT for pts with > 20%TBSA Urethral catheterization Monitor vital signs Input /output Maintain body Temp Nutrition support Elevate limbs Wednesday, May 24, 2017 BURN 70 Phase V: Definitive treatment phase (Wound care) Wednesday, May 24, 2017 Escharotomy Fasciotomy skin grafting Dressing Debridement Application of autograft Splinting Contractures Mnx. BURN 71 Complications Can be classified as: Early Complications Late Complications Wednesday, May 24, 2017 BURN 72 a. Early Complications Fluid / Electrolyte imbalance Hypovolaemic shock Thermoregulation dysfunction Acute renal failure Inhalation injury Infections Wednesday, May 24, 2017 BURN 73 b. Late Complications Contractures Keloids Hypertrophic scars Marjolin’s ulcer Wednesday, May 24, 2017 BURN 74 ‘‘Once you start studying medicine, you never get through with it’’ Charles H. Mayo (1865-1939) Wednesday, May 24, 2017 BURN 75 Wednesday, May 24, 2017 BURN 76