Burns Lecture Notes PDF

Burns Ass.Prof.Dr. Burak Kankaya Istanbul Aydin University Department of General Surgery  Burn? Tissues encounter energy beyond what they can absorb Skin and subcutaneous tissue -hot -a hot substance -caustic chemicals -damage due to a reason such as electric c...

Burns Ass.Prof.Dr. Burak Kankaya Istanbul Aydin University Department of General Surgery  Burn? Tissues encounter energy beyond what they can absorb Skin and subcutaneous tissue -hot -a hot substance -caustic chemicals -damage due to a reason such as electric current or radiation Loading…  Skin Loss of fluids and electrolytes through evaporation Prevents bacterial invasion.  Burn Risk Groups Under 15 (4 years and under) Physically disabled children Danger and taking necessary precautions and Loading… avoiding are not yet developed Old Usually at home Active working age group (18-45 years old) Accidents at work Workplaces - in open areas Fatal - disabling  Age Burn type Width Depth Anatomical localization Comorbidity  Burn Types Thermal Burns Inhalation Burns Electrical Burns Chemical Burns  💀 Burn of Wounds Classification Degree Color View Pain Recovery time First degree Light red Dry Painful 3-10 days erythema Second Red Blister Extremely 7-21 days degree Abundant painful superficial exudate Second Dark red Blister Painful More than 3 degree deep Little weeks exudate Third degree White gray Dry Painless Debridement Black Graft Loading…  Physiopathology Edema Respiratory system Metabolism Erythrocyte loss Paralytic ileus  Edema Short periodical temporary local vasoconstriction Local ischemia All in the body vasodilation General from microcirculation interstitial into the void liquid and protein leakage  Respiratory system Histamine, serotonin, thromboxane A 2 under the influence vasoconstriction and bronchoconstriction Chest wall burns results formed contractures Burning in the environment air O 2 pressure up to 10% to fall results developing hypoxia Carboxyhemoglobin, which is formed when CO passes into the blood distrupts the transport of O2 to the tissues CO cell stockchrome oxidase to the system by connecting mitochondria functions spoils and ATP production decreases Respiratory of your ways direct irritation result oral, nasal , broncheal secretion increases , mucosa irritation , edema , flat eyebrow contraction results spasm develops  Metabolism Ebb period Hypermetabolic period  Ebb period To the tissues transported O2 amount with the decrease metabolism decreases Catecholamines released from the adrenal medulla and autonomic nervous system increase vasoconstriction peripheral vascular resistance by causing vasoconstriction. With the increase in corticosteroids and glucagon, glycogenolysis in the liver increases , glycogen stores decreases , hyperglycemia occurs. Burn from your wounds formed heat loss, hypothermia glucose use increases Meeting the O2 requirement with anaerobic metabolism increases the lactate level. Inflammation and infection increase metabolic rate. Metabolic rate is high in large wounds and young patients.  Hypermetabolic period Protein catabolism increases O2 consumption increases Body temperature increases as IL1 and Gram (-) bacterial endotoxins increase the release of PGE2 from the fever center. As stress hormones (cortisol, glucagon, growth hormone and catecholamines) increase, gluconeogenesis increases and hyperglycemia occurs. Due to tissue resistance to insulin, insulin cannot show its effect even though it increases.  Erythrocyte Loss It occurs as a result of direct heat hemolysis, thrombosis in the vessels, destruction of damaged cells in the RES, and coagulation due to fluid loss. Htc initially rises due to plasma loss, then decreases with fluid replacement. Amount of hemoglobin in urine increases. When treatment is necessary, transfusion is given after 72 hours.  Paralytic ileus Gastric dilatation develops, leading to vomiting and aspiration. Nasogastric decompression is applied and oral food is not given for approximately 2 days. Rule of nines  Minor burns < 15% I. and II. degree ( adult ) < 10% I. and II. degree ( child ) < 2% III. degree ( eye , ear, face , genital area not containing burns )  Moderate burns 15-25% II. degree burns ( adult ) 10-20% II. degree burns ( child ) 2-10% III. degree burns ( eyes, ears , face) and genital area not containing burns )  Major burns > 25% II. degree burns (adult) > 20% II. degree burns (child) > 10% III. degree burns Eyes, ears, face, hands, feet or genital area Inhalation burns Electrical burn Burns associated with a major trauma such as a fracture or head injury Burns associated with diseases such as cerebrovascular disease, psychiatric disorder, lung disease, cancer, DM  American Burn Association (ABA) hospitalization criteria < 10 years and > 50 years, > 10% 2nd and 3rd degree burns > 15% 2nd degree burns, > 5% 3rd degree burns at any age Significant burns involving the face, hands, feet, genital area, perineal area, and major joints Significant infected burns Significant inhalation burns Significant chemical burns Burns associated with diabetes , cardiopulmonary disease , cancer, cerebrovascular disease Burns associated with major traumas ( fracture, head trauma, penetrating injuries , etc. ) Burns associated with private, social and emotional reasons ( suspected child neglect and abuse, etc. )  Considerations in treatment-I The patient is completely undressed ( in the case of chemical burns, clothing can aggravate the burn). The patient is covered with clean, warm and dry clothes to avoid hypothermia. Wounds are washed with sterile water (ideally) or tap water for 60 minutes for alkali chemical burns and 30 minutes for acid burns. The patient is placed in a 30 degree sitting position to reduce edema in the neck and chest areas. Moisturized O2 is given to clear secretion from respiratory tract. Betasympathomimetics such as metaprotorenol are given by inhalation to prevent bronchospasm.  Considerations in treatment-II Gastric dilatation is a common complication in large burns, nasogastric decompression is applied in burns exceeding 15% in children and 20% in adults and oral feeding for 48 hours not given Urine monitoring with foley catheter to monitor fluid balance. Prophylactic antibiotic and steroid use is unnecessary. Tetanus prophylaxis should be performed with only 0,5ml of toxoid for those who have been vaccinated more than 5 years ago, and toxoid and tetanus immunoglobulin (TIG) together for those who have been vaccinated more than 5 years ago. Escharotomy should be performed in burns involving the thorax. Analgesics such as morphine and mepheridine should be used to relieve the patient’s pain.  Resuscitation principles Fluid therapy is administered through peripheral veins (especially from the upper extremity where there is no burn). Central venous catheter (CVC) should not be used unless necessary due to the risks of hypercoagulation and thromboembolism due to infection and burn. Catheters in peripheral veins should be replaced every 3-4 days. CVC is changed at the same place on the 4th day. The location is changed on the eighth day. If these rules are not followed, the risk of infection and sepsis due to CVC increases by 1% for each day after the 4th day. The ideal type of fluid is isotonic and glucose-free (especially neutral (pH= 6.5: Lactated Ringer's sol.) In 20% of burns in adults and 15% in children, fluid replacement is administered intravenously due to fluid loss and gastric ileus.  New York Hospital Method Erişkin Çocuk (30Kg’ın altında) İlk 24 saat LR 4ml/Kg/%yanık LR 4ml/Kg/%yanık + İlk 10 kg için 100 ml/kg + İkinci 10 kg için 50 ml/kg + Üçüncü 10 kg için 20 ml/kg İkinci 24 saat %5 DextrozH2O +kolloid % 5 Dextroz % 0.45Nacl + O.5ml/Kg/%yanık kolloid 0.5ml/kg/% yanık % 50’den fazla yanıklar % 50 olarak hesaplanır  Fluid resuscitation in burns first 48 hours First 24 hours Ringer’s Lactate sol. 4 ml/kg/% burn Half is given in the first 8 hours , the other half in the next 16 hours. Urine should not fall below 0.5 ml/Kg/ hour in adults , 1 ml/Kg/ hour in children In the second 24 hours, 5% Dextrose H 2 O or R. Lactate ( in children under 30 kg, solutions with electrolytes (especially 5% Dextrose 0.5% NaCl ) are used 1.5 ml/kg/% burn In patients with unstable hemodynamics , 5% Albumin can be given as colloid in extensive II. and III. degree burns. Colloid is given by calculating 0.3 ml/kg/% burn for 30-50% burns , and 0.5 ml/kg/% burn in burns over 50%. Modified Baxter formula  Fluid resuscitation after the first 48 hours Fluid lost through evaporation (25 x % burn xm 2 body surface ) Nasogastric loss Daily urine output the day before The sum of these constitutes the daily fluid recirculation. Since glycogen stores are depleted in the first 48 hours and sodium loss is high, 5% Dextrose NaCl solutions are used.  Patients with special features in fluid therapy in burn patients Requiring more fluid Requiring less fluid High voltage electrical Patients under 2 years old burns Patients over 50 years old Inhalation burns Presence of Patients with delayed cardiopulmonary disease resuscitation Presence of renal failure Patients who were severely intoxicated at the time of the burn. Clinical Types of Inhalation Burns 1. Acute Asphyxia Usually results in death 2. Upper respiratory tract damage Progressive airway edema and causes obstruction 3. ARDS in the early period (2-5 days) Late bronchopneumonia  CO Poisoning % 0-5 Normal değer % 15-20 Baş ağrısı, konfüzyon, hafif dispne % 20-40 Disorientansiyon, yorgunluk, bulantı, görme bozuklukları, ajitasyon, ataksi % 40-60 Kollaps, koma > % 60 Mortalite %50  Intubation criteria in patients with burns ( Inhalation ) 1. The burn occurs in a closed area 2. The patient is unconscious 3. Severe burns in the perioral region, neck and oropharynx 4. Tar colored sputum (most common external finding) 5. Burns on nose hair 6. Hoarseness 7. Bronchoscopic and laryngoscopic mucosal damage detection (definitive diagnosis) 8. Blood COHb > 40% Treatment of Inhalation Burn 1. They require intensive care 2. Postural drainage and bronchospasms are treated 3. Head is raised 30 ° to facilitate venous return 4. Using high PEEP 0 2 saturation > 90% 5. Steroids are useless Treatment of Electrical Burns 1. Urine color is normal. 0.5-1 ml/kg of urine is provided with 0.9% NaCl 2. Urine color is red ( Myoglobulinuria ) osmotic with 20% Mannitol and 44 mEq NaHCO3 diuresis is provided Then add 15.5 g/ lt to liquids. amount of urine by adding mannitol It is ensured that it is > 1 ml/kg 3. Ventricular fibrillation is monitored by ECG  Burn Complications 1. Burn wound infections 2. Suppurative thrombophlebitis 3. Curling ulcer 4. Contractures Late comp. Physiotherapy Burn Wound Infections Gr (+) infections in the early period Late (>5th day) Gr (-) especially in the pseudomonas aeruginosa infections Opportunistic infections in later stages The Most Common Microorganisms in Burn Wound Infection Microorganism Frequency of Staphylococcus aureus Incidence Beta- hemolytic 85% Streptococci 5% Pseudomonas Aeroginosis 25% Enterococci 55% E. coli 40% Candida albicans 40%  Suppurative thrombophlebitis In about 4% of burns IV catheters should be changed every < 72 hours Generally, signs of systemic infection, bacteremia or hematogenous pneumonia (Lobar pneumonia) occur. The vein is explored. If there is no pus, the vein is excised until bleeding occurs, the wound is left open and the wound is covered with a biological graft. When the infection passes, the wound is closed with delayed primary repair.  Curling Ulcers Ulcerations seen in the upper GIS (Stomach, Duodenum ) Treatment antacid, H2 blockers  Thanks …