Burn Injury, Plastic & Reconstructive Surgery Management PDF

# Burn Injury, Plastic & Reconstructive Surgery Management ## Definition of Burns Burn is a special kind of soft tissue injury. Burn is a destruction of skin layers resulting in physical and psychological damage of the human being. Burns account for about 25 percent of all soft tissue injuries. #...

# Burn Injury, Plastic & Reconstructive Surgery Management ## Definition of Burns Burn is a special kind of soft tissue injury. Burn is a destruction of skin layers resulting in physical and psychological damage of the human being. Burns account for about 25 percent of all soft tissue injuries. ## Classifications of Burns - **According to causes and sources of burns:** It can be classified to different types - Thermal/scald - Chemical - Electrical - Ionizing radiation - Inhalation injury ## Critical Burns - Critical burns are potentially the life-threatening, disfiguring, and disabling. - Critical burns require the attention of a qualified nursing and medical professionals. - Burns from chemicals or electrical sources or inhalation. - Has full thickness burn younger than 5 years and or older than 50. - Has manifestation of trouble breathing burn around mouth, head, neck, hands, and feet, or genital organ. - Associated with other trauma or diseases. ## Inhalation Injury: Smoke inhalation suspected in: 1. Hypoxemia 2. All cases especially enclosed spaces of the victim were unconscious. 3. Exposure of airways and lungs to toxic chemicals. 4. Tracheobronchitis, epithelial fibrin casts. 5. Airway obstruction. 6. Pulmonary edema within 2-3 days ## According to Burn Severity: - The burns can be classified into three types: **minor, moderate, and severe** ## The severity of burns depends on: - The temperature of the sources. - The length of exposure to the sources. - Location of burn. - The extent of the burns. - The victim’s age and medical condition. - A diagram showing the relationship and flow of different factors of smoke inhalation: - Pulmonary alveolar macrophages activated - Chemotactic factors released - Aggregation/activation neutrophils - Release of oxygen radicals, proteases - Increased pulmonary endothelial permeability - Pulmonary edema - Thromboxane released - Increased pulmonary artery pressure - Tracheobronchial epithelial injury - Airway exudate/cast formation/small airway obstruction - Atelactasis/Air trapping. - Pneumonia - Pulmonary fibrosis ## Burn Extent (Size) - The Rule of Nines - Palm for Scattered burns. - Rule of five for pediatric patients - Lund and Browder Rule # Burn Management ## Goals of Burn Management - Prevention - Institution of life-saving measures of burned persons - Prevention of disability and disfigurement through early specialized individualized treatment ## Medical Management - **Endotracheal intubation:** Indications of endotracheal intubation - Rapid progressive airway edema. - Tachypnea with use of accessory muscles. - Arterial hypoxemia <70 despite oxygen. - Ratio of partial pressure of arterial oxygen to fraction of inspired oxygen less than 200. - Consider awake intubation with massive airway edema and spontaneous respiration. - Mechanical ventilation. - Monitoring cardiovascular status. ## Phases of Burn Care - **Immediate prehospital phase/first aids** - **Four phases** - **Rehabilitation phase** - **Acute intermediate phase** - **Emergent phase** # Wound Care ## Goals of Wound Care - Control microbial colonization and prevent wound infection - Prevent wound progression - Achieve wound coverage as early as possible - Promote functions of healing skin - Provide for comfort - Reduce scarring and deformity ## Wound Care - This encompasses methods of dressing techniques, escharotomy and fachiotomy, hydrotherapy. - **Indications for eschrotomy** - Deep circumferential burns over neck, chest, limbs - Compromised airway, breathing or circulation - May be life threatening for any parts of the body ## Hydrotherapy - Refers to placing the patient in a large tank which enables him to perform wound care, range of motion exercise and total body bathing. Various types of tubs or tanks may be used including regular bath tub, Hubbard tank, whirlpool. - Hydrotherapy has become the most highly utilized treatment approach to manage burns. - Duration of time for hydrotherapy 20-30 minutes prior to wound care, an opioid analgesic is administered. ## Hydrotherapy and Wound Care - Topical antimicrobial agents are applied to the wound such as silver nitrate, neomycin, and bacitracin. - Selection is determined by the physician, and is based on **many factors** such as - The location. - The injuring agent. - The severity of the burn. - The amount of cream or ointment that is applied depends upon the needs of the wound and the manufacturer’s directions. - **Escharotomy, and fasciotomy** may be included as part of the treatment so wound care considerations must be adjusted for specific needs. ### Advantages - Allow for easier removal of topical agent. - Soften the eschar and thus allow easier less painful removal and range of motion exercise. ### Disadvantages - Loss of body heat. - Sodium loss in water because water is hypotonic. - Possible cross contamination ## Wound Debridement - Wound debridement can be performed through one of these methods: - Surgical debridement - Chemical - Mechanical methods - Enzymatic - For whom you perform or not debridement? - Dry dead tissues burned - Debride bullae (blisters more than 2.5 cm in diameter). - **Avoid debridement of blisters less than 2 centimeters in diameter.** ## Technique of Wound Care/Methods of Dressing ### Open/Exposed Method - More often used with burns affecting face, neck, perineum and broad areas of trunk. - Partial thickness burn exudates dries in 48-72 hours forming a hard crust that protect the wound. - Full thickness dead skin is dehydrated and converted to black leathery eschar in 48-72 hours. Loose eschar is gradually removed with hydrotherapy or debridement. - The burn wound initially cleansed with saline solution, or chlorhexidine gluconate solution. Once rinsed, drying with square gauze and an antibacterial cream is applied and then wrapped with a gauze and dressing or allowed to be open. ### Closed/Occlusive Method - Wound is washed and sterile dressing changes may be one time per day. - Dressing consists of gauze and or ace wraps impregnated with topical ointment and after that wrapped with several layers of dressing and bandaged. ### Semi-Open - Covering the wound with topical antimicrobial agents and gauze after cleansing and deriding it without applying layers of dressing materials. #### Advantages: - Speed debridement. - Develop granulation tissue faster. - Skin grafting possible sooner. ## Graft and Skin Substitute - **Types of Graft**: - Temporary or - Permanent. - **Another Classification for Types of Graft** - **Homograft** from the same species (cadver skin). - **Auto graft** permanent coverage from patients’ own skin. - **Heterograft** temporary coverage from another species (pig skin). - **Genetic engineering skin cell culture** - **Indications for Grafting** - Full thickness burn and deep partial-thickness wounds - Priority areas - Wound bed pink - Bacterial count <100,000/gram of tissue. ## Nutritional Support - The nutritional requirement of burn wound depends on - Patient preburn nutrition status. - Extent of body surface areas. - Daily caloric requirement of burned patient increases from normal of 1,700-3,000 calories. ## Complications of Burn Injuries ### Early Complications 1. A major complication that can occur with a flame burn in an enclosed space is **inhalation injury**. 2. **Circulation**: Cardiac arrhythmias 3. **Cardiac arrest** due to hyperkalemia (can affect the heart) 4. **Shock** (cardiogenic, neurogenic, hypovolemic) 5. **Acute tubular necrosis** 6. **Exposure**: Hypothermia is a common complication that poses immediate risks to survival (from coagulopathies and cardiac arrhythmias) ### Late Complications of Burns (Secondary) - **Septic shock**: Infection is a common secondary complication of burn injuries. Once the patient is stable, this is one of the most common events that can threaten survival in the patient with a burn injury. - Septecaemia - Pneumonia - Renal failure - Adrenocortical insufficiency - Stress Diabetes - Metabolic acidosis may not present until later on. Dramatic alterations in fluid, electrolyte, and oxygenation status predispose the patient to metabolic acidosis. - **➤Depression.** # Heath Teaching For Patient Before Discharge From Hospital: - Care of healing skin - wash daily, cover with cocoa butter - Teach the patient and his family about the following: - Avoid using brushing burned area or scratch it - Avoid expose burned area to sun rays - Avoid using soap with corrosive substances - Minimize traumatization - Use cotton clothes and use acrylic ones. - Promote mobility, positioning, exercise splinting, ADL - Wear Pressure garments, ace wraps to prevent contracture