Burns and Plastic & Reconstructive Surgery Management PDF

# Burns and Plastic & Reconstructive Surgery Management ## 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 the appearance of different types of burns * List thre...

# Burns and Plastic & Reconstructive Surgery Management ## 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 the appearance of different types of burns * List three signs of burned airway * Given a description of the extent, calculate the percent using the 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 a 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 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 into different types: * Thermal / scald * Chemical * Electrical * Ionising radiation * Inhalation injury ### Critical Burns * Critical burns are potentially life-threatening, disfiguring and disabling. * Critical burns require the attention of a qualified nursing and medical professional. * Burns from chemicals or electrical sources or inhalation. * Has full-thickness burn younger than 5 years and/or older than 50. * Has manifestations of trouble breathing burn around the mouth, head, neck, hands and feet, or genital organs. * 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 ### III - According to Burn Depth: The burns can be classified into three degrees | 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; scarring unusual | | Deep | Epidermis and most. Dermis. Most. Skin appendages destroyed. | White appearing with erythematous areas, dry and 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 hyperaemia. ### Physiology/Pathophysiology #### Major Burns > 30% TBSA | | | | | | | | ------------------------------- | ------------------- | --------------------- | ------------------------ | ---------------------- | -------------------------- | | Cell lysis | Hemolysis | Hemoglobin/Myoglobin in urine | Capillary Permeability | Possible inhalation injury | Loss of skin barrier | | Hyperkalemia | | | | | Thermo regulation problems | | Concentration of red blood cells | Blood viscosity | | | Impaired immune response | Inflammatory response | | | | | | | Hyponatremia | | | | **Circulating Blood Volume (up to 50%)** | | | | | | Burn shock | | | | | | | Myocardial depressant factor | Massive stress response. Sympathetic nervous system activation | Blood pressure | Hypoxemia | | #### Adrenal corticoid hormones and catecholamine release | | | | | | | | ------------------------- | ---------------------------------- | --------------------------- | ---------------------- | ------------------- | ---------------------------------------- | | Peripheral vasoconstriction | Tachycardia | Hyperglycemia | Catabolism | Risk of Curling's ulcer | Metabolism (after burn shock resolves) | | Afterload | ↓ Cardiac output | Tissue Perfusion | | | | | | Renal blood flow | Gl blood flow | Anaerobic metabolism | Tissue damage | Cellular dysfunction | | | Risk of acute renal failure | Risk of ileus | | | Potential tissue necrosis | | | | Metabolic acidosis | | | Cell swelling | ### Pathophysiology of Smoke Inhalation Burns | | | | | | | ------------------------------ | ----------------------------- | ------------------------------------------------------------------ | ------------------------------------------------ | -------------------------------------------- | | Pulmonary alveolar macrophages | Chemotactic factors released | Aggregation/activation neutrophils | Thromboxane Released | Increased pulmonary artery pressure | | Release of oxygen radicals, proteases | Increased pulmonary endothelial permeability | Tracheobronchial epithelial injury | Airway exudate/cast formation/small airway obstruction | Atelactasis, Air trapping | | | | | | 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 Nine * **Front** * Head - 4.5% * Neck - 4.5% * Right Arm - 4.5% * Left Arm - 4.5% * Trunk - 18% * Right Leg - 9% * Left Leg - 9% * Genitals - 1% * **Back** * Head - 4.5% * Neck - 4.5% * Right Arm - 4.5% * Left Arm - 4.5% * Trunk - 18% * Right Leg - 9% * Left Leg - 9% * Genitals - 1% ### Lund Bowder Chart | Region | PT % | FT % | | -------- | ---- | ---- | | Head | 1 | 2 | | Neck | 2 | 2 | | Ant. Trunk | 13 | 2 | | Post. Trunk | 13 | 2 | | Right Arm | 1.5 | 1.5 | | Left Arm | 1.5 | 1.5 | | Buttocks | 25 | 25 | | Genitalia | 1 | 1 | | Right Leg | 1.75 | 1.75 | | Left Leg | 1.75 | 1.75 | | Area | Age 0 | Age 1 | Age 5 | Age 10 | Age 15 | Adult | | ------------ | ------ | ------- | ------- | ------- | ------- | ------ | | A: half of head | 9.5 | 8.5 | 6.5 | 5.5 | 4.5 | 3.5 | | B: half of one thigh | 2.75 | 3.25 | 4 | 4.5 | 4.5 | 4.75 | | C: half of one leg | 2.5 | 2.5 | 2.75 | 3 | 3.25 | 3.5 | ### 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 fourth-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 * Pediatiric 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-hour period appeared to reduce the risk of cognitive sequelae 6 weeks and 12 months after acute carbon monoxide poisoning. ### Phases of Burn Care #### Four Phases ### Assessment of Pain is Crucial Using Numerical 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 | * *From Hockenberry MJ: Wong's Essentials of Pediatric Nursing, ed 7, St. Louis, 2005, Mosby, P. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.* ### Blister ### Bulla ### Nutritional Support * The nutritional requirement of burn wounds depends on: 1. Patient preburn nutrition status. 2. Extent of body surface areas. * Daily caloric requirement of burned patients increases from normal of 1,700-3,000 calories. * The ideal caloric intake for an adult patient can be determined by using the following equation: $25 \times kg \: body \: weight + 40 \: calories \times \%\: of\: burn$ * The daily protein requirement is greater than normal because of negative nitrogen balance post-burn. $1 \: gm \times Kg + 3gmx \% \: of \: burns$ * The recommended daily intake for burned patients is: $1 \: gm \times Kg + 3gmx \% \: of \: burns$