Download Burns and Thermal Injuries

Burns and Thermal Injuries
K. John Hartman MD FACS
ACS-IA Chapter COT Vice Chair
Trauma Medical Director
Co-Director Surgical ICU
Genesis Davenport
10JAN16
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Provides several essential functions that are
lost with burn injury.
Functions include immunologic defense,
fluid conservation, and temperature
regulation.
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Important elements of skin include
melanocytes and glands.
Sweat-producing exocrine glands may
become hypersecretory in healed areas after
thermal injury.
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Injuries to tissues caused by contact with
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Dry heat
Moist heat
Electricity
Chemicals
Friction
Radiant and electromagnetic
energy.
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Thermal injuries are those burns caused by
flame, hot objects, or hot liquids.
Hypothermia and frostbite are other forms of
thermal injury.
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Burns damage or destroy skin cells and may
involve the subcutaneous tissues including,
fat, muscle, and bone.
The depth of injury is determined by the
cause of the burn, chemical vs. electric vs.
thermal, the temperature or energy to which
the skin was exposed, and the duration of
exposure.
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Depth combined with the extent of the burn,
based on total body surface area (TBSA)
burned and the patient's body weight,
determine the severity of the injury
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More than 1.2 million people are burned in the United
States every year
Up to 75% are treated as out patients.
From 2006 to 2012, 175,099 patient were admitted to
Burn Centers
Only motor vehicle collisions cause more trauma-related
deaths
Burn deaths occur after the injury or weeks later as a
result of multisystem organ failure
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Seventy-two percent of all burns occur at home.
Sixty-nine percent of burn patients are men.
The mean age is 32 years old.
Children under 5 years old account for 20% or cases.
Adults over 60 years old account for 12% of cases.
Seventy-five percent of all burn-related deaths occur in
house fires.
Other risk factors include low socioeconomic class and
unsafe environments.
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Nonflammable children’s sleepwear.
National Electrical Code decreasing oral
commissure burns.
Elevation of hot water heaters from the ground.
Increased smoke alarm use.
Mortality rate has improved for patients
sustaining severe injuries.
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In 1949, in the United Kingdom first reported a 50%
mortality rate for children 14 years old and younger with
burns of 49% TBSA
◦ 50% mortality was reached for those 15 to 44 years
old with burns of 46% TBSA,
◦ 45 to 64 years with burns of 27% TBSA, and those 65
years and older with burns of 10% TBSA.
Latest studies reporting a 50% mortality rate for 98%
TBSA burns in children 14 years old and younger, and
75% TBSA burns in other young age groups.[9]
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Flame—damage from superheated, oxidized air
Scald—damage from contact with hot liquids
Contact—damage from contact with hot or cold
solid materials
Chemicals—contact with noxious chemicals
Electricity—conduction of electrical current
through tissues
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First degree—injury localized to the epidermis
Superficial second degree—injury to the epidermis
and superficial dermis
Deep second degree—injury through the
epidermis and deep into the dermis
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Third degree—full-thickness injury through the
epidermis and dermis into the subcutaneous fat
Fourth degree—injury through the skin and
subcutaneous fat into underlying muscle or bone
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Destroys only superficial layers of skin
(epidermis).
Physiologic functions of the skin remain
intact.
Manifestations include local pain, blistering,
and erythema.
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The injury heals in 3 to 5 days without
scarring.
For large burns, hydration and symptom relief
with non-narcotic analgesics may be
recommended.
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Second-degree burns include two subtypes:
superficial and deep partial thickness
Superficial partial-thickness burns involve the
epidermis and dermis.
Pain and blistering occur.
Heals in 21 to 28 days, and scarring may
occur, depending on genetic tendency. Hair
follicles remain intact.
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Deep partial-thickness burns involve the
entire dermis.
The injury is mottled, has dry blisters, and is
relatively painless.
Healing occurs in about 30 days
spontaneously.
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Third-degree full-thickness burns involve the
epidermis, dermis, and underlying
subcutaneous tissue.
Skin is charred and may appear black, white,
or cherry-red.
The wound is painless to touch.
 Skin
grafting is indicated for
wounds greater than 2 inches
in diameter
 The wound is painless to
touch.
 Fourth-degree
full-thickness
burns are rare.
 When they do occur, they are
often fatal.
 The injury extends beyond the
dermis and involves muscle, bone,
or both.
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Safe distance
STOP the burning
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The initial evaluation of the burned patient is
the same as any trauma patients and follows
the ABC of airway, breathing, and, circulation.
As part of the initial resuscitation, vascular
access is obtained through unburned tissue if
possible, if not place the iv through burned
tissue.
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Remove all clothing and jewelry to stop the
burning process and prevent injury from
edema.
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Inhalation injury
◦ One third of all major burns
◦ Mortality is more than double that of cutaneous
burns.
◦ Isolated inhalation injuries do not result in high
mortality.
◦ Combination of inhalation injury and cutaneous
thermal injury creates a double insult.
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Suspect Inhalation injury if:
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Face or Neck burns
Singeing of facial hair
Carbonaceous sputum
Oralpharynx erythema
Hoarseness
Closed space blast or fire
Carboxyhemoglobin greater than 10%.
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Upper airway rather than in the lower airway
because the oropharyngeal cavity has a
substantial capacity to absorb heat
Constitutes an important indication for
intubation
Mandatory to control the airway before airway
edema develops during resuscitation
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Diagnosis is achieved with direct
laryngoscopic visualization of the
oropharyngeal cavity
Upper airway thermal burns usually
manifest within 48 hours after injury,
Airway swelling can be expected to peak at
12 to 24 hours after injury.
True upper airway burn will likely require
airway protection for 72 hours
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Injury to the tracheobronchial tree and the
lung parenchyma results from combustion
products in smoke and, under unique
conditions, inhaled steam
Irritants in smoke can cause direct mucosal
injury, leading to mucosal slough and
bronchial edema, bronchoconstriction, and
bronchial obstruction.
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May progress to pulmonary edema,
pneumonia, and acute respiratory distress
syndrome (ARDS)
Can be confirmed by bronchoscopy or
xenon-133 ventilation-perfusion scan
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Inhalation injury is identified and treated as
necessary with intubation and or
bronchoscopy.
Other traumatic injuries are identified and
treated appropriately
In burns greater than 20% TBSA, a nasogastric
tube is place to decompress the stomach and
eventually begin early enteric feedings.
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Fluid resuscitation follows based on one of
several formulas that calculate the fluid
needed for the first 24 hours based on the
TBSA burned and the patient's body weight.
After the acute management, pain
management, wound management, nutrition,
and rehabilitation are addressed.
1. Partial thickness burns greater than 10% TBSA
2. Burns involving the face, hands, feet, genitalia,
perineum, or major joints
3. Any full-thickness burn
4. Electrical burns, including lightning injury
5. Chemical burns
6. Inhalation injury
1. Burns in patients with preexisting medical disorders that
could complicate management, prolong recovery, or affect
outcome
2. Any patient with burns and concomitant trauma (such as
fractures) in which the burn injury poses the greater
immediate risk of morbidity and mortality.
3. Burned children in hospitals without qualified personnel or
equipment to care for children
4. Burns in patients who will require special social, emotional, or
long-term rehabilitative intervention.
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History: 36 y/o female with 57%TBSA, mostly third degree
thermal burns of face, neck, both hands, forearms, arms,
shoulders; both legs and thighs, buttocks and anterior
abdominal wall. TOI ~1015L 4 Oct. MOI - Patient a Social
Scientist embedded in 2/2. Unit attacked and petrol poured over
patient and set alight. Extinguished in stream contaminated with
sewage. Evidence of upper airway burn on intubation. No
radiological evidence yet of true inhalation injury. Rewarming
and fluid resuscitation ongoing using Parkland formula.
Intubated and ventilated. Right subclavian central venous access
and left long saphenous peripheral venous access. Admitted to
ITU. Surgery: 1200L 4 Oct. Debridement and dressing of burns.
Bilateral escharotomies of digits, hands, and forearms.
Recommend URGENT aeromedevac to closest burn facility able to
handle this level of injury. Specific Blood Pressure not obtainable
currently due to nature of injuries but is deemed stable per
physician on duty. Good urine output. Arterial cannulation will be
attempted following rewarming. Blood gases are venous sample.
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Burn shock is a life-threatening process
that occurs in the acute phase after major
burn injury.
Massive fluid leak from capillaries results in
intravascular hypovolemia, extensive
edema, hemoconcentration, and reduced
urine output.
Capillary leak resolves about 24 hours after
injury. Fluid replacement is the primary
treatment objective during burn shock.
TABLE 22-2 -- Resuscitation Formulas
Formula
Crystalloid Volume
Colloid Volume
Free Water
Parkland
4 mL/kg per % TBSA burn
None
None
Brooke
1.5 mL/kg per % TBSA burn
0.5 mL/kg per % TBSA burn
2.0 L
Galveston (pediatric)
5000 mL/m2 burned +1500
mL/m2 total
None
None
These are used as guidelines for the initial fluid management after burn. The response to fluid resuscitation should be continuously monitored,
and adjustments in the rate of fluid administration should be made accordingly.
TBSA, total body surface area.
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The emergent phase is the time between the
end of burn shock and closure of the wound
to less than 20% TBSA.
Wound management, nutritional support, and
surgical grafting of full-thickness wounds are
the priorities of treatment during the
emergent phase.
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Cardiovascular: Low cardiac output may
occur in response to unknown myocardial
depressant factors.
Respiratory: Inhalation injury can cause
airway obstruction, carbon monoxide
poisoning, and hypoxia. Acute respiratory
distress syndrome is a serious complication
of burn injury characterized by refractory
hypoxemia.
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Metabolic: Release of catecholamines in
response to burn stress is associated with
an increased heart rate, increased oxygen
consumption, and increased serum glucose.
A hypermetabolic state is maintained by
hypothalamic thermoregulation.
Gastrointestinal: Adynamic ileus lasts for
about 3 days after burn injury. The liver
may increase production of clotting factors.
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Immune: Inflammation is initiated by burned
tissue and results in the release of cytokines
that mediate increased capillary permeability
and vasodilatation. In general, immune
system depression is predominant with
decreased leukocyte migration and poor
opsonization.
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Cellular: Dysfunction of energy-requiring
cellular processes, such as pumping of ions,
results in widespread cellular swelling and
altered membrane potentials.
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Electrical shock is associated with injury
deep within the body, particularly injury
involving low-resistance tissue such as
blood vessels and nerves.
Cardiac arrest, coagulation of blood within
the vessels, and renal damage secondary to
myoglobinuria are serious consequences of
electrical injury.
Severe short-term memory loss, ataxia, and
sensory deficits may occur as a result of
neuronal damage.
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Carbon monoxide (CO) poisoning,
Upper airway thermal burns,
Inhalation of products of combustion.
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Most common cause of death in inhalation
injury
Carbon monoxide has a 200 times greater
affinity to hemoglobin than oxygen
Oxygen–hemoglobin dissociation curve loses its
sigmoidal shape and shifts to the left
Levels of CO greater than 60% are usually fatal
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80 minutes for a person breathing room air to
reduce the CO level of 60% to a safer level of
20%.
The addition of 100% oxygen can reduce that time
to 20 minutes
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Wound management is necessary to prevent
bacterial colonization of the wound and
subsequent septicemia.
Early surgical wound management is
essential.
Topical antibiotics are used because systemic
antibiotics cannot reach the wound because
of a lack of blood supply.
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Early surgical excision and skin grafting are
the treatment of choice for deep burns.
Excision procedures result in significant
blood loss requiring blood transfusions.
Skin grafts are taken from a healthy portion
of the patient's own skin.
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Temporary grafts (e.g., cadaver skin,
synthetics, pig skin) may be used to cover the
wound until an autograft can be completed.
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Silver Sulfadiazine
Mafenide
Bacitracin
Neomycin
Polymixin
Mupirocin
 0.5%
Silver nitrate
 5% Mafenide acetate
 0.025% Sodium hypochlorite
 0.25% Acetic acid
 OpSite
 Biobrane
 Trancyte
 Integra
 Xenograft
(pig skin)
 Allograft (homograft, cadaver
skin)
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The rehabilitation phase begins when the
burn is reduced to less than 20% TBSA.
Problems during this phase include skin
contracture and excessive scarring.
Healing is complete at 6 months to 1 year.
Positioning in extension and range-ofmotion exercises are important to prevent
contracture
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Mildest form of cold injury.
Pain, Pallor, Numbness or effected area.
Reversible with warming.
Does NOT result in tissue loss.
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Injury due to freezing of tissue.
Intracellular ice crystal formation.
Get reperfusion injury with warming of the
tissue.
Leads to tissue loss.
Degree of injury same as for burns
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Trench foot, long term exposure to wet
conditions with temperature just above
freezing
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Put on dry socks
Drink warm fluids
Rewarm body part in 40Degree C (104 degree
F) water until pink color and perfusion return.
Avoid dry heat
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Save as much tissue as possible.
Do NOT open blisters.
Prevent infection.
Elevate the extremity.
Leave open to the air.
Avoid pressure spots.
Wait several weeks prior to debridement to
determine viability of tissues.