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RAY RISNER C. OBENZA, MD, FPCS, FPSGS
EPIDEMIOLOGY • Quality of Burn Care Survival Long-term Function Appearance Surgeon’s Goal Well-healed, durable skin with normal function and near-normal appearance
BURNS *Depth of Injury is directly proportional to: Temperature applied Duration of contact Thickness of the skin .
Scald Burns .2nd most common mechanism .usually household from hot water .most common among civilians injuries especially children 2. Flame Burns . MVA .secondary to house fires.ETIOLOGY 1.
plastics. glass .common in industrial accidents .often 4th degree .ETIOLOGY 3.contact with hot metals.covers larger TBSA . Contact Burns .with thermal damage to upper airway 4.explosion of gases & other combustible liquids . Flash Burns .
ETIOLOGY 5.severity based on voltage. Chemical Burns .either occupational or household injuries . Electrical Burns .industrial accidents or assaults . duration of contact & resistance of the patient 6.due to strong acids or alkalis .
PHASES OF BURN INJURY • Acute Phase Fluids & Electrolytes Pain Control Burn Wound Care & Coverage Septic Complications Nutritional Management .
PHASES OF BURN INJURY • Chronic Phase Rehabilitation Reconstruction Psychological Support .
• Pathophysiology of Burn Injury 1. Hemolysis . Coagulation Necrosis 2. Increased Capillary Permeability 3.
remove source of heat .for burns more than 5 – 10% TBSA .Intubation if necessary Preparation for transfer to a burn facility .ABC’s take priority .CPR if necessary. O2 inhalation Assessment and Resuscitation = at the ER .ACUTE PHASE • Immediate Care Rescue and First Aid = on scene .
• Immediate first aid measures Cooling the burned area .wrap patient in clean blanket .application of cool water NOT iced water Removal of patient’s clothing .remove source of heat & exposure of injuries Prevention of hypothermia .
Feet.• Admission Criteria to a Burn Facility Partial Thickness Burns =/> 15% Full Thickness Burns =/> 5% Burns on Face. Hands & Perineum All Electrical & Chemical Burns Presence of Smoke Inhalation Injury Associated Injuries .
Patients w/ Associated medical illness All infected burns Dependent persons . & >50 y.o.o.• Admission Criteria Child Abuse Patients <10 y.
Age of the patient 2. Burn size 3.• Determinant Factors for Mortality 1. Smoke Inhalation Injury .
• Patient Assessment 1. Physical Exam Primary Survey = ABC’s 2ndary Survey = Other injuries . History Time of Injury Place of Injury Mechanism of Injury 2.
• Estimation of Burn Injury Severity Burn Size: Rule of Nines = massive burns Patient’s Palm = patchy burns Lund-Browder Chart = pediatrics .
Lower extremity Anterior trunk Posterior trunk Perineum % body surface 9 9 9 18 18 18 18 1 . Upper extremity Rt. Upper extremity Lt. Lower extremity Lt.• “Rule of Nines” for estimating TBSA Anatomic Area Head Rt.
Thickness of the skin c. Duration of contact d. Heat dissipating capability of skin . Temperature of burn source b.Estimation of Burn Injury Severity Burn Depth is dependent on: a.
Sunburn .relatively painful ex.do not blister but erythematous . Shallow Burns a) Epidermal Burns (1st Degree Burns) .Classification of Burn Depth 1.
b) Superficial PartialThickness Burns (2nd Degree Burns) - form blisters. pink & wet hypersensitive to pain blanch with pressure spontaneously heal < 3 weeks .
heals in 3 to 9 weeks . mottled pink and white .less sensitive to pain .Classification of Burn Depth 2.blisters. Deep Burns a) Deep Partial-Thickness Burns (2nd Degree) .capillary refill is slow to absent .
b) Full Thickness Burns (3rd Degree) .leathery.heal by contracture or skin grafting . dry white.all layers of dermis . firm & insensate .develop “ESCHAR” .
electrical.full thickness skin. contact. immersion burns in an unconscious patient . fascia & muscles . SQ fat.c) Fourth Degree Burns .
Evaluation of Physical Changes . Assessment of Change in Blood Flow 4.Assessment of Burn Depth Methods: 1.magnetic resonance imaging .biopsy. laser Doppler. Detection of Dead cells or denatured collagen 3. Analysis of Wound Color . use of vital dyes .fluorometry. ultrasound. Clinical observation – only 70% accurate 2. thermography 5.light reflectance method .
hypermetabolism. endothelial & epithelial permeability .Physiologic Response to Burn Injury SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) . increased cellular. gastrointestinal and coagulation systems .pathologic alterations in metabolic.extensive microthrombosis . cardiovascular.
circulatory dysfunction .Physiologic Response to Burn Injury BURN SHOCK . Eicosanoids – increase levels of vasodilator PG’s . Histamine – release mast cells which disrupts venular endothelial junctions 2. Serotonin – increase pulmonary vascular resistance 3.increase in vascular permeability & microvascular hydrostatic pressure Mediators: 1.
BUN & Serum Creatinine Baseline electrolytes Arterial blood gas determination X-rays (Chest.• Diagnostic Work-up Complete Blood Count Urinalysis. other areas) Electrocardiography Etc .
• Fluid Resuscitation Recommended Fluids: Plain Lactated Ringer’s Solution = 1st 24 hours Colloids or D5Water = after 24 hours .
• Fluid Computation & Administration a) 1st 24 hours “Parkland Formula” TFR = BW x TBSA x 4 mg/kg/%burns (1/2 given in1st 8H. 1/2 next 16H) D5W replace evaporative losses Colloids maintain plasma volume Maintenance Fluids = 30-40 cc/kg/day b) 2nd 24 hours c) After 48 hours .
Vital Signs Blood pressure & Heart rate Central Venous Pressure 3. Urine Output Adults: 0. Sensorium .5 cc/kg/hour Pedia : 1 cc/kg/hour 2.• Parameters for Monitoring Fluid Therapy 1.
• Reasons for Failed Resuscitation 1. Coronary artery disease . Presence of electrical burns 3. Delayed resuscitation 2. Smoke inhalation injury 4.
Ancillary Management Measures 1. Antibiotics 4. Pain control & sedation 3. Gastric decompression 2. Tetanus prophylaxis .
Compartment Syndrome a) Clinical Manifestations 6 P’s: Pulselessness Pallor Pain Paresis/Paralysis Paresthesia Poikilothermia b) Definitive Treatment: ESCHAROTOMY FASCIOTOMY .
Inhalation Injury 1. Carbon Monoxide Poisoning Effects: a) prevents reversible displacement of O2 b) decrease O2 unloading at tissue level c) less effective intracellular respiration d) directly toxic to cardiac & skeletal muscles Treatment: Hyperbaric Oxygen ??? .
Inhalation Injury 2.mucosal & submucosal erythema . hemorrhage & ulceration .edema. Thermal Airway Injury Manifestations: .potential for upper airway obstruction Treatment: Endotracheal Intubation .
Smoke Inhalation Factors: a) Type and amount of smoke inhaled b) Size of particulates c) Duration of Toxic Exposure d) Magnitude of thermal injury Clinical Manifestations: a) dyspnea b) burned vibrissae c) carbonaceous sputum .Inhalation Injury 3.
Inhalation Injury Diagnosis: a) Chest X-ray b) Bronchoscopy c) Arterial blood gas Management: a) Endotracheal intubation b) Mechanical ventilation .
000 volts Mechanisms of injury: a) Direct contact b) Conduction arc c) Secondary ignition .000 volts High voltage: >1.Electrical Burns Classification: Low voltage: <1.
Electrical Burns Physiologic Alterations: a) Arrhythmias b) Acute Renal Failure c) CNS & PNS Deficits d) Hemorrhage & Hematomas
Chemical Burns Factors to consider: a) Contact time b) Chemical involved Primary Management: Rapid termination of burning process
Burn Wound Care Salient Aspects: Debridement of necrotic tissue Daily dressing of burn wound Surgical Management: a) Tangential excision b) Fascial excision
Burn Wound Care Topical Antimicrobials a) Aqueous silver nitrate b) Mafenide acetate c) Silver sulfadiazine d) Povidone-iodine .
massive nitrogen loss Formula: TCR = 25 kcal/kg BW + 40 kcal/%TBSA Route: Total Enteral Nutrition (TEN) Adv: maintain integrity of GI tract reduce bacterial translocation & sepsis .exaggerated energy expenditure .Nutritional Support State of hypermetabolism .
Neo-eschar formation 4. Dark-brown/blackish discoloration 3. Violaceous wound margins 6. Metastatic septic lesions . Conversion from partial to full thickness 2. Rapid eschar separation 5.Burn Wound Infection Clinical Manifestations 1.
Suppurative chondritis 5. Pneumonia 2.Burn Complications A) Distant infections 1. Vascular Catheter-Related Infection . Bacterial Endocariditis 3. Urinary Tract Infection 4.
Burn Complications B) Other complications 1. Myocardial Infarction . Curling’s ulcer 2. Acute Acalculous Cholecystitis 3.
Hydrocolloid dressings . Biologic wound coverings Allograft Xenograft Amnion 2.Burn Wound Coverage a) Temporary 1.
Burn Wound Coverage b) Permanent 1. Skin Grafting a) Split-thickness b) Full-thickness 2. Skin Flaps 3. Cultured Skin a) Apligraf b) Epicel . Skin Substitutes a) AlloDerm b) INTEGRA 4.
Depression. Denial Withdrawal. Psychological Support: Anxiety. Rehabilitation: Range of motion exercises Ambulation training Return to functional status 2.Chronic Phase 1. Regression .
Chronic Phase 3. Reconstruction: Burn contractures Keloids Hypertrophic scars Marjolin’s ulcer .
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