Burns and Plastic & Reconstructive Surgery Management PDF

# Burns and Plastic & Reconstructive Surgery Management ## By ## Ass-Prof Dr Nagwa Ragab ## Intended Learning Outcomes Upon the completion of these lectures the learner should be able to: * Identify types and classifications of burns * Describe appearance of different type of burns * List thre...

# Burns and Plastic & Reconstructive Surgery Management ## By ## Ass-Prof Dr Nagwa Ragab ## Intended Learning Outcomes Upon the completion of these lectures the learner should be able to: * Identify types and classifications of burns * Describe appearance of different type of burns * List three signs of burned airway * Given a description of the extent, calculate the percent using rule of nines and Lund and Browder chart * Identify signs and symptoms of burned airway * Analyze the pathophysiologic changes as a basis of signs and symptoms as well as complications * Draw plan of nursing care to manage burned patients in all phases of care ## 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 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 life threatening, disfiguring and disabling * Critical burns requires 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 was 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 ## II - 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 ## The Severity of Burns - **Epidermis** - **Dermis** - **Subcutaneous** - **Muscle** - **Superficial (first degree) burn** - **Partial thickness (second degree) burn** - **Full thickness (third degree) burn** ## III - According To Burn Depth: The Burns Can Be Classified into Three Degree | Depth | Histology | Appearance | Sensation | Healing | |---|---|---|---|---| | First-degree: | Epidermis only | Erythema; blanches with pressure | Intact; mild to moderate pain | 3-6 days without scarring | | Second degree: - Superficial | Epidermis and superficial dermis; skin appendages intact | Erythema, blisters, moist, elastic; blanches with pressure | Intact, severe pain | 1-3 weeks; scaring unusual | | - Deep | Epidermis and most dermis; most skin appendages destroyed | White appearing with erythematous areas, dry, waxy, less elastic; reduced blanching to pressure | Decreased; may be less painful | >3 weeks; often with scarring and contractures | | Third-degree: | Epidermis and all of dermis; destruction of all skin appendages | White, charred, tan, thrombosed vessels; dry and leathery, does not blanch | Anesthetic, not painful (although surrounding areas of second-degree burns are painful) | Does not heal; severe scarring and contractures | ## The Body's Response To a Burn Burn injuries result in both local and systemic responses. ## Clinical Image of Burn Zones There is central necrosis, surrounded by the zones of stasis and of hyperemia. ## Physiology/Pathophysiology - **Cell lysis** - **Hemolysis** - **Hemoglobin/ myoglobin in urine** - **Hyperkalemia** - **Concentration of red blood cells** - **Blood viscosity** - **Capillary permeability** - **Possible inhalation injury** - **Loss of skin barrier** - **Sodium, H₂O and protein shift from intravascular to interstitial spaces** * **Circulating Blood Volume (up to 50%)** - **Hyponatremia** - **Thermo-regulation problems** - **Inflammatory response** - **Impaired immune response** ## Major Burns >30% TBSA - **Burn shock** * **Myocardial depressant factor** * **Massive stress response. Sympathetic nervous system activation** - **Adrenal corticoid hormones and catecholamine release** * **Blood pressure** - **Peripheral vasoconstriction** - **Tachycardia** - **Hyperglycemia** - **↑ Catabolism** * **Risk of Curling's ulcer** - **Afterload** - **Cardiac output** - **Risk of acute renal failure** - **Risk of ileus** - **↑ Metabolism (after burn shock resolves)** ## Tissue Perfusion - **Renal blood flow** - **Gl blood flow** - **Anaerobic metabolism** - **Metabolic acidosis** - **Tissue damage** - **Potential tissue necrosis** - **Cellular dysfunction** - **Cell swelling** ## Pathophysiology of Smoke Inhalation Burns - **Pulmonary alveolar macrophage activated** * **Chemotactic factors released** * **Aggregation/activation neutrophils** * **Release of oxygen radicals, proteases** - **Thromboxane released** * **Increased pulmonary artery pressure** - **Tracheobronchial epithelial injury** * **Airway exudate case formation small airway obstruction** * **Atelactasis, Air trapping** - **Increased pulmonary endothelial permeability** - **Pulmonary edema** - **Pneumonia** - **Pulmonary fibrosis** ## Burn Extent (Size) - **The Rule of Nines** - **Palm for Scattered burns** - **Rule of five for pediatric patients** - **Lund and Browder Rule** ## The Rules of Nines - **Head 9%** - **Neck 9%** - **Ant. trunk 18%** - **Post. trunk 18%** - **Right arm 9%** - **Left arm 9%** - **Buttocks 1%** - **Genitalia 1%** - **Right leg 18%** - **Left leg 18%** ## Lund Bowder Chart | **REGION** | **PT %** | **FT %** | |----|----|----| | Head | 4.5% | 4.5% | | Neck | 9% | 9% | | Ant. trunk | 13 | 13 | | Post. trunk | 13 | 13 | | Right arm | 9 |9 | | Left arm | 9 | 9 | | Buttocks | 1.5% | 1.5%| | Genitalia | 1 | 1 | | Right leg | 15 | 15 | | Left leg | 15 | 15 | ## Burn Centers: What Are Burn Centers? Burn centers are specialized facilities that maintain a team of healthcare professionals that are highly trained and qualified to manage the care of patients with serious burns. ## Guidelines & Criteria For a Burn Center ## Referral * All third-degree and forth-degree burns * Burns to the hands, face, genitals, or joints * Partial thickness burns that affect more than 10% TBSA * Electrical burns, chemical burns, or inhalation injury * Pediatric patients with a serious burn injury * Burn injuries that occur with concomitant trauma * Any burn injury that requires a special form of treatment that extends beyond the expertise of the facility ## 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 ## Notice Three hyperbaric oxygen treatments within a 24 hours period appeared to reduce the risk of cognitive sequlae 6 weeks and 12 months after acute carbon monoxide poisoning. ## Phases of Burn Care ## Four Phases ## Assessment of Pain is Crucial Using Numeral or Visual Analogue Scale ## Figure 3: Wong-Baker FACES Pain Rating Scale - **0 No hurt** - **2 Hurts little bit** - **4 Hurts little more** - **6 Hurts even more** - **8 Hurts whole lot** - **10 Hurts worst** ## Blister ## Bulla ## Nutritional Support * The nutritional requirement of burn wound depends on * 1. Patient preburn nutrition status 2. Extent of body surface areas * Daily caloric requirement of burned patient increases from normal of 1,700-3,000 calories * The ideal caloric intake for an adults patient can determined by using the following equation : * **25 x kg body weight + 40 calories x % of burn** * The daily protein requirement is greater than normal because of negative nitrogen balance post burn * **1 gm x Kg + 3gmx % of burns** * The recommended daily intake for burned Patient is * **1 gm x Kg + 3gmx % of burns**