Surgery - Block 2.4 Burns PDF

OUTLINE I. Burn overview I. Burn Overview Injury to the tissues caused by contact A. Moderate Burn with heat, flame, chemicals, electricity B. Major Burn or ra...

OUTLINE I. Burn overview I. Burn Overview Injury to the tissues caused by contact A. Moderate Burn with heat, flame, chemicals, electricity B. Major Burn or radiation. C. Criteria for Burn Center Referral D. Classification of Burns i. First Degree Moderate Burn ii. Second Degree 2nd degree burns of less than 25% of iii. Third Degree total body surface area (TBSA) in adults II. Effects of thermal Injury or less than 20% in children. A. Effects on the Skin B. Effects on the Vascular System and Blood Elements Major Burn III. First Aid A. Management 2nd degree >25% or 3rd degree >10% i. Airway Management Or involves hands, face, eyes, ears or IV. Extent of Burn Injury perineum A. Lund and Browder Chart (Not necessarily the TBSA, also the B. Rule of Nines by Pulaski and location is part of the presentation. Tennison Mentioned locations pose C. IV Fluid Resuscitation i. Parkland Formula complications). V. Burn Wound Management A. Sedation/Analgesics Criteria for Burn Center Referral B. Escharatomy and Fasciotomy C. Gastric Decompression Partial-thickness and full-thickness D. Burn Wound Care burns totaling greater than 10% TBSA E. Topical Chemotherapy in patients younger than 10 or older F. Synthetic Coverings than 50 years of age. VI. Complications Partial-thickness and full-thickness VII. Rabies A. Phases burns involving the face, hands, feet, B. Therapy genitalia, perineum or major joints. C. Recommended post-exposure Full-thickness burns greater than 5% prophylaxis TBSA in any age group. Electrical burns, including lightning Note: Text written in this color is injury. information from the book. - Be extra careful with electrical Text in this color is from Dr. Lozada. burns (major burn) - gamay itsura pero dako damage internally Chemical burns Inhalation injury 1  Burn injury in patients with pre-existing Erythema only, blanches in pressure medical disorders that could complicate Healing takes place uneventfully management, prolong the recovery Example: sunburn - heals by itself in period, or affect mortality. less than a week without scar Any burn with concomitant trauma in which the burn is the greatest risk. 2. Second Degree Burns ○ If the trauma is the greater Involves the epidermis and portion of immediate risk, the patient may be the dermis stabilized first in a trauma center Partial thickness burn – does not before transfer to a burn center. extend on both layers Burned children in hospitals without Blisters, subcutaneous edema, painful; qualified personnel for the care of surface is mottled red children Healing 10-14 days Burn injury in patients who will require Due to limited exposure to hot liquid, special social, emotional, or flame rehabilitative intervention Classification of Burns 3. Third Degree Burns Full-Thickness Burns Entire epidermis, dermis, subcutaneous 1. First Degree Burns destroyed by coagulation necrosis Involves only the epidermis Thrombosis of small blood vessels Erythema, pain, slight edema In 2-3 weeks; full thickness dead skin Healing takes place uneventfully (5-10 liquefies partially by autolysis and days) and epidermis peels off in small leukocytic digestion – suppuration scales 2  PAINLESS due to damage nerve Effects on the vascular system and endings (will not regenerate, dry, which blood elements is charred in appearance) A. Loss of vascular integrity - increase requires grafting capillary permeability prolonged exposure to flame, electrical → Increase fluid and protein burns loses into the interstitial space – edema → The amount of fluid lost is proportional to the extent and depth of burns → Capillary permeability returns to normal in 48 hours post injury Appear hard and leathery, may be B. Decrease in red cell mass white, brown or black, may see → Direct hemolysis of RBC by coagulated vessels heat Sensation and capillary refill will be → Trapping of RBC by absent thrombosis of blood vessels Little spontaneous healing will occur, → Alteration of RBC only from skin edges morphology – sequestration of RES Skin grafts are necessary; risks of → Sludging of RBC scarring and contractures Involvement of deeper tissues C. General Hemodynamic Changes and Metabolic Responses → Early hypovolemia or shock phase – 48 hours → Intense catabolic phase prior to completion of closure of burn wound - Hypermetabolic state - Aggravated by infection → Final anabolic or restorative II. Effects of Thermal Injury phase - Open wound prevents Effects on the skin anabolic phase– can cause FUNCTION OF LOSS OF weight loss SKIN FUNCTION III. First Aid Prevent water and Dehydration heat loss Stop the cause of the thermal injury Burned person – horizontal position – Prevent invasive Infection rolled in a blanket or rug to smother the bacterial infection flames 3  Cover the wound – this minimizes contamination and inhibits pain by preventing air from coming in contact with injured surface CPR Management Quick history Estimation of extent and depth of burns Blood samples for crossmatching and baseline laboratory IV line Indwelling urinary catheter Determine the need for intubation or tracheostomy Antibiotics (controversial) Rule of Nines by Pulaski and Tennison Tetanus prophylaxis Planning fluid therapy Body Part BSA Head and Neck 9% Airway Management Anterior Trunk 18% → Upper airway obstruction in patient with Posterior Trunk 18% head, neck burns – 48 hours post injury due Each lower extremity 18% to edema of oral pharynx, and vocal cords Each upper extremity 9% following exposure to hot gasses Perineum 1% → Manifested by: - Increase respiratory rate - Progressive hoarseness - Difficulty in clearing bronchial secretions → Management - Endotracheal tube - Tracheostomy Rules of % Burn Rules of five* IV. Extent of Burn Injury nines (Child) 9 Head 20 Lund and Browder Chart 9 Each upper limb 10 More accurate method of estimating 18 Front trunk 20 percentage of burns 18 Back trunk 20 18 Each lower limb 10 1 Perineum 4 MINOR BURN PARKLAND FORMULA Aim of treatment 4mL x % of percentage of body water - Prevent infection surface area burned x weight in kilos; - Absorb exudate →give fluid requirements in mL. - Relieve pain → For the First 24 hours from the - Assess and reassess to time of burn (not arrival to the detect/anticipate problems with hospital) healing and need for plastics ○ 4cc/kg/2nd or 3rd degree involvement. burns - Achieve best possible → Crystalloid solution (LACTATE cosmetic/functional results RINGER) is given: ○ ½ first 8 hours First Aid measure ○ ¼ second 8 hours - Cold water lavage (temperature ○ ¼ third 8 hours -15C) for 20 minutes (caution in → Half in 1st 8 hours and remaining children) 16 hours from the time of the burn. - No value in lavage at or beyond → Maintain urine output of 30-70 3 hours ml/hour - Appropriate analgesia SAMPLE PROBLEM 1: 40yo male patient with a second IV Fluid Resuscitation degree burn on the anterior chest It is of little consequence which formula and whole left of the upper extremity. is used to begin fluid therapy as long as Weight is 60kg. What is the initial their modified according to patients order for fluid infusion in the first changing requirement 24hrs? IV requirement if burn is: - Anterior chest = 9% → >10% BSA child - Whole left extremity = 9% → >15% BSA adult = 9%+9%= 18% Adequacy of resuscitation best judged by frequent measurement of vital signs, → 4mLx18%x60kg= 4320mL is central venous pressure, hourly urine needed for the first 24hrs. output, mental and physical response Urine Output → Give the first half on the first 8 hrs → Is the most reliable guide to - 4320mL/2= 2160ml for the adequacy of fluid therapy first 8 hrs → 30-100ml/hour (use catheter - (order in chart as: 270mL/hr to monitor urine output) x 8 hrs) → Give the remaining ½ for the next second 16hrs =1080mL (order in chart as: 135mL/hr x 16 hrs) 5  SAMPLE PROBLEM 2: → Indicated unless actively 50yo male patient with a second immunized preceding 12 months degree burn on the anterior chest Escharatomy and Fasciotomy and abdomen, and whole left of the upper extremity. Weight is 50kg. In circumferential 3rd degree burns in What is the initial order for fluid peripheral extremities – edema infusion in the first 24hrs? beneath inelastic eschar – vascular - Anterior chest and abdomen compromise = 18% To prevent compartment syndrome - Whole left upper extremity = Ultrasonic flowmeter examination is the 9% most reliable non-invasive means of = 18% + 9% = 27% monitoring adequacy of the circulation in the circumferentially burned limb → 4mLx27%x50kg= 5400mL is needed for the first 24hrs. Signs and symptoms of compromised distal flow → Give the first half on the first 8 hrs cyanosis - 5400mL/2= 2700ml for the impaired capillary refilling first 8 hrs = (2700/8=337.5) progressive neurologic deficits - (order in chart as: 337.5mL/hr x 8 hrs) Escharotomy → Give the remaining ½ for the next - Circumferential full-thickness burns second 16hrs to the chest, which mechanically =2700mL/16 = 168.75 constrict and compromise respiration - (order in chart as: 168.75 - Circumferential of electrical burns to mL/hr x 16 hrs) the extremities causing loss of distal pulses, impaired capillary filling, NOTE: Other formula used in paresthesias or motor weakness, estimation for the first 24hr requirement cyanosis of distal uninjured skin, or for fluid is Modified Brooke’s Formula tense edema with rigid muscle → Formula = 2ml/kg -- 2nd or 3rd ○ Eschar - skin of 3rd degree degree burns burns → Not popularly used V. Burn Wound Management Sedation/Analgesics Kept at absolute minimum to prevent depression of CP function and allow evaluation of sensation Antibiotics – controversial Tetanus Prophylaxis 6  Fasciotomy - linear incision through deep fascia Prepared as 10% sulfamylon acetate (mafenide acetate) Water soluble Effective gm+ gm- anaerobics Locally nontoxic Burning sensation upon application Carbonic anhydrase inhibitor – decrease bicarbonate production – metabolic acidosis Increase potassium loss in urine Skin allergy No dressing Gastric Decompression 20% burns – reflex paralytic ileus in 2. Silver sufadiazine (silvadene ) first 24 hours NGT Broad-spectrum antimicrobial; gm – Antacid Prophylaxis – to prevent stress or gm +, candida albicans ulcers Less pain on application Does not penetrate eschar Burn Wound Care Skin allergy 1. Debridement and Excision No dressing Clean burn wounds with surgical Painless and easy to use antiseptics May leave black tattoos from silver Excise big bullae ion Excise eschar 3. Silver nitrate soaks (0.5%) 2. Dressings Occlusive Required dressing stains clothing Absorptive to keep the wound surface Disadvantage – electrolyte depletion dry Hyponatremia, hypochloremia, Bulky methemoglobinemia Gm+ pseudomonas 3. Exposure method Increase potassium loss from the Initial cleansing of the burn wound, wounds along with sodium, Cl and place patient in bed on clean sheets Ca Exudate dries in 48-72 hours and forms hard crust 4. Povidone Iodine (Betadine) Topical Chemotherapy Gm+ and gm - Disadvantage: ○ Pain in application 1. Sulfamylon Cream ○ Excessive drying of eschar 7  None of the currently used topical exudate risking invasive wound antimicrobial chemotherapeutic infection; no antimicrobial properties agents sterilize the burn wound but do limit proliferation of Burn Wound Coverage microorganisms Thus prevent bacterial conversion of second degree burns to full Split thickness skin graft applied to thickness injury 3rd degree burned areas as soon as eschar is removed and recipient site prepared OTHER TOPICAL CHEMOTHERAPY a. Preparation of recipient site AGENTS Aim: to obtain wound surface on which an excellent graft Neomycin take is expected ○ Ease of application; painless; Clean granulation tissue antimicrobial spectrum not as b. Grafting – transplant skin wide dermatome -- split thickness Nystatin (Mycostatin) mesh dermatome ○ Effective in inhibiting most occlusive dressing, changed fungal growth; cannot be at 4-5x per day used in combination with autograft -.012 -.015 inches mafenide acetate Mupirocin (Bactroban) Early burn wound excision and ○ More effective staphylococcal immediate skin grafting coverage; does not inhibit ○ reduce length of hospital stay epithelialization; expensive ○ attended by impressive blood loss ○ extend of burn excised a Synthetic Coverings single sitting should be limited to 20% of body 1. OpSite surface Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate requiring removal; no antimicrobial properties 2. Biobrane Provides a wound barrier; associated with decreased pain; use complicated by accumulation of 8  3. Curlings ulcer acute ulceration in stomach and duodenum prophylactic antacid treatment Management; ○ iced saline lavage, antacids, volume replacement vagotomy, hemigastrectomy if medical treatment fail 4. Pulmonary progressive pulmonary failure is VI. Complications smoke inhalation syndrome 1. Infection - burn wound sepsis 5. Miscellaneous Signs and Symptoms ○ increase fever, clouding of UTI - mindwelling catheter sensorium, paralytic ileus decubitus ulcer Invasion infection contracture ○ focal dark discoloration of the suppurative thrombophlebitis burn wound on conversion of an area of partial thickness injury to full thickness VII. Rabies necrosis. Diagnosis - Cultures ○ Wound biopsy cultures - Incidence – 2 M animal bites per reveal more than 10 to 5th year organisms per gram tissue Rabies virus – large non filtrable Management particle measuring 75 x 180 mu ○ massive antibiotics Infected nervous tissue or salivary ○ subeschar clysis with gland tissue is the source of the antibiotics virus Transmitted through a break in the 2. Acute gastic dilatation skin or by direct contact with mucous membrane vomiting abdominal distension, dyspnea 9  Airborne infection is possible – soap and water, benzalkonium exploring areas inhibited by rabid chloride bats antibiotics Incubation period – 6 days to 23 suturing as necessary months or ave 10 days to one year Virus travels in association with ❖ Circumstances of the bite nervous structures – those areas Provoked attack --- domestic rich in nerve endings (fingers and animal face) Unprovoked attack --- likely rabid Phases ❖ Extent and location of bite wound Severe--- multiple or deep 1. Prodromal phase punctured wounds, ites on non specific --- fever, head, face neck or fingers headache, malaise, anorexia, Mild --- scratches, lacerations sore throat or single bites other than violent, painful contraction of head, face, neck or fingers muscles of deglutition 2. Acute excitement phase increasing nervousness, insomnia, anxiety, Recommended post-exposure apprehension prophylaxis for rabies infection unusual behavior convulsive seizures Category of Post-exposure exposure to measures 3. Paralytic ileus due to neuronal suspect rabid death animal hypoxia, cardiac arrhythmias, Category I – None hemparesis, coma touching or feeding death in 4 -10 days animals, licks on intact skin (i.e. no ❖ Autopsy – dark inclusion bodies – exposure) Negri bodies – found in the brain – Category II – Immediate thalamus and lentiform nucleus nibbling of vaccination and uncovered skin, local treatment of minor scratches or the wound abrasions without Therapy bleeding Category III – Immediate soft tissue injuries – cleansing, single or multiple vaccination and antisepsis, debridement if necessary transdermal bites or administration of 10  Category III scratches, licks on rabies broken skin; immunoglobulin; contamination of local treatment of Single or multiple transdermal bites, mucous membrane the wound scratches or contamination of with saliva from mucous licks, exposures to membrane with saliva (i.e. licks) bats use immunoglobulin plus vaccine Rabies Immune Globulin (RIG) or Antirabies Serum (ARS). 20 iu/kg IM Rabies post-exposure treatment Five 1.0 mL doses are given modalities intramuscularly on Day 0, 3, 7, 14 and 28 World Health Organization Imogam® Rabies –is supplied in 2 Department of Communicable mL and 10 mL vials with minimal Diseases Surveillance and potency of 150 International Units Response per milliliter (IU/mL). Vial, 2 mL contains 300 IU which is sufficient for a child weighing 15 kg Category I (33 lb).. Vial, 10 mL contains a total of 1, 500 Touching, feeding of animals or licks IU which is sufficient for an adult on intact skin weighing 75 kg (165 lb). no exposure therefore no treatment if history reliable History of Rabies Vaccines Category II Virtually every infection with rabies Minor scratches or abrasions without resulted in death, until the two bleeding or licks on broken skin and French scientists Louis Pasteur and nibbling of uncovered skin Emile Roux developed the first use vaccine alone rabies vaccination in 1885. Five 1.0 mL doses are given nerve tissue-derived vaccines - intramuscularly on Day 0, 3, 7, 14 cheaper - but risk of neurological and 28 complications Imovax® Rabies Vaccine The human diploid cell rabies ○ (rabies) Vaccine WISTAR vaccine (H.D.C.V.) was started in RABIES VIRUS STRAIN 1967 PM-1503-3M GROWN IN less expensive purified chicken HUMAN DIPLOID CELL embryo cell vaccine, and purified CULTURES Vero Cell rabies vaccine are now available. References 11  Dr. Lozada’s PPT Burn Injury: Initial Management of the Burn patient (https://www.brighamandwomens.or g/assets/BWH/surgery/pdfs/burn-inju ry-manual2010.pdf) 12