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Thermal injuries

The loss of integrity of the skin loss of body temperature loss of proteins loss of fluid and electrolytes ingress of the foreign materials and invasion by the microbes.

Examination of the patient

Extend of burn injury (the surface area involved and the depth of injury) is necessary to know. It influences further fluid resuscitation and plan of care. 1. Involved area: the rule of nines or the rule of palms (surface area of the palm = roughly 1%).

Lund-Browder chart and burn diagram. This enables the practitioner to estimate
burn size more accurately based on the relative contribution of anatomic body parts and patient age to body surface area. Second-degree burns should be shaded in blue on the body map and third-degree burns are shown in red.

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2) The depth of injury: partial- and full-thickness burns. Partial-thickness

burns (first- and second-degree) damage variable amounts of the dermis and dermal appendages. Full-thickness (third-degree) burns result in complete epidermal and dermal destruction.

Partial thickness burn involves the outer layer of the skin and may extend to

the dermis (first and second degree burns): blistering the skin is red and moist painful to touch sensation is intact

First degree burn

Partial thickness burn is further subdivided into superficial and deep partialthickness injury. The clinical differentiation is difficult (by the time of healing, laser doppler flowmetry). superficial partial-thickness burn should heal within 2 weeks (minimal cosmetic and functional consequence). deep partial-thickness wound (cosmetic deformity and disturbance of function) takes 3 weeks to reepithelize. In this case skin g ) p grafting will g improve the outcome and is preferred approach in this depth of injury.

Partial-thickness burn

Burned buttocks in a child (scold)

Second degree burn

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Full-thickness wound
leathery white or charred dry insensate. All dermis is destroyed. During healing a contraction occurs decreasing the area but leading to poor cosmetic results and joint stiffness. Except for small surface area wounds, full-thickness wound should be either excised and closed primary or grafted with the patients skin.

Types of wound Thermal burn results in superficial area of coagulation necrosis. The depth of the necrosis is related to

temperature duration of exposure thickness of tissue blood supply of the tissue

Third degree burn

Types of wound Chemical burns cause denaturation of proteins.

The degree of injury depends on: time of exposure p strength of the agent solubility of the agent in tissue Alkali tends to penetrate deeper into tissue then does an acid. Ingestion of chemical agent leads to esophageal injury (later consequences include development of strictures). Beside local effects of chemicals they also may exert systemic effects (especially phenol, mustard gas). Phenol burns can be treated with lipophylic solvents such as polyethylene glycol or glicerol.

Types of wound
In the local area of injury a subcutaneus tissue, muscle, and bone may be damaged. Electrical current passes through the path of least resistance between the entrance and exit point (nerves and blood vessels) Injury of the heart: arrhythmias or cardiac arrest. Resuscitation must be initiated immediately (ECG monitoring). Fluid resuscitation as in burned patients.

Electric injury: the surface injury is often not indicative of the extend of injury.

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At the small point of contact the skin is charred. It may overlie extensive areas of devitalized muscles: liberation of mioglobin ARF (if an adequate UO is not maintained). Nephron structure. Myoglobinuric renal failure. Renal biopsy of a patient who had rhabdomyolysis and myoglobinuric ARD. Coarse eosinophilic casts of p myoglobin are evident in the tubular lumen.

Edema formation in injured tissue beneath fascia may increase muscle compartment pressure and compromise blood supply. Fasciotomy should be performed.

Fasciotomy. The anterior and lateral compartments are decompressed through a lateral incision. The skin incision is placed just anterior to the fibula and the skin is undermined anteriorly and posteriorly to expose these two separate compartments. The incision on the medial side of the leg opens the superficial posterior compartment. At a deeper plane, the deep compartment is then released.

Etiology: aldehydes, carbon monoxide and cyanide. Pathology: erythema, edema, blistering, ulceration, erosion, and sloughing in the airway endobronchial cast and obstruction of the bronchioles obstruction and accumulation of the necrotic debris (due to injury of the mucocilliary transport mechanism) poor ventilation and ground for infection (70% within a week of injury).

Inhalation injury Diagnosis: based on the history, signs and symptoms. Assume inhalatory injury in: injury in closed space has burns above the clavicle singeing of n in in f nasal vibrissae l ibri hoarseness carbonaceous sputum

Inhalation injury

Pathologic response of the lung to inhalation of smoke.

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Inhalation injury management

Airway evaluation (at emergency department) using flexible bronchoscopy. It confirms diagnosis and helps to insert an endobronchial tube if necessary (tube is passed over the bronchoscope before the endoscopy).

Inhalation injury management

Therapy is not specific (the injury is not quantified by testing - X-ray, respiratory tests are not helpful) aggressive pulmonary toilet use of mucolytics early identification and treatment of infection prophylaxis with AB i not used h l i ith is t d steroids are of no benefit and are potentially harmful.

Nasotracheal suctioning to clear the upper airway. If frequent suctioning is required a soft rubber nasopharyngeal trumpet may be placed to minimize trauma.

Prehospital and emergency room care Scene of the injury

Resuscitation

remove the patient from heat extinguish burning cloth remove from electrical contact ice or cold water soaks to decrease pain ( p (burns less than 25% of TBSA), ), and reduce tissue heat content (if applied within 10 minutes after injury).

Cardiopulmonary function - CPR., i.v. line is necessary at patients with cardiac irregularity, massive blood loss (coexisting trauma), and if the transport takes longer 30 min . Inhalation injury: Carbon monoxide poisoning (closed space injury) - administration of 100% p g ( p j y) oxygen. An endotracheal tube (airway protection) is needed to patients with severe inhalation injury. Patient with burns more than 30%, those of the extreme of age and those with the significant preexisting disease should by cared for in burn centers.

i.v. fluid replenishment through venous cannulation a catheter in the bladder (to patients with greater than 20% burn) nasogastric tube to decompress the dilated stomach patients are wrapped in clean sheets or blankets resuscitative fluids should be warmed burn-injured extremities should by elevated above the level of the heart.

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Resuscitation
The first 24h: crystalloid solutions. The amount is based on the patient response to resuscitation. Administered solutions should maintain a normal: BP HR UO (1ml/kg/h or 30-50ml/kg). maintenance of mean arterial pressure at 60mmHg (requires IAL) measurement of blood lactate levels (requires IAL) Goodwin formula: 3ml/kg per percent of the body surface area is burned. Parkland formula: 4ml of LR/ kg / % of burn surface. The Th second 24h: colloid-containing solutions d 24h ll id i i l i Evaporative loss (25+% of burned area) multiplied by total body surface area in square meters (100%). This formula is used for fluid replacement at the following days.

Initial wound care Burned area

small blisters are left intact larger blisters and full-thickness burns: debridement and topical agent. g p g

Chemical injury

irrigation (normal saline or tap water) for as long as 6h.

Prophylaxis against wound infection

Systemic antimicrobial prophylaxis is not used (only if infection has occur).

Commonly used topical agents: C l d i l

silver sulfadiazine (prophylaxis against infection but not for therapy) aqueous solution of silver mefenide acetate.

Surgical wound care

Excision and closure of wounds (is best done when the patient has been stabilized and within 3 to 4 days after injury) using: a) tangential excision until viable tissue (preferred); b) excision of the wound to the level of fascia (for deep full-thickness and infected). The cosmetic results are poor and lymphatic drainage is impaired . Cuttong a split skin graft. The graft is taken from normal thigh skin

Consider the skin donor sites at patients with deep partial and full-thickness burns y( y q g g) more than 40% body (they require skin grafting).
a) b)

Autograft (for ultimate closure). sufficient donor sites - split-thickness autograft or full-thickness graft. donor sites are limited - autograft can be expanded (mashing device).

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Full-thickness burn wounds covered by mesh grafts. Mashing increases the area of the skin grafts and allows blood and exudate to escape thus minimizing hematoma

Temporary coverage with biological or manufactured dressing

Temporary skin substitutes

allograft skin from cadavers (free of jaundice, cutaneus malignancy and viral disease). synthetic membranes (Biobrand, Silastic). autologus keratinocytes skin substitutes: Integra artificial skin, Alloderm (that is a human dermis with nonantigenic matrix provides a scaffold for a new dermis on which a thin epidermal graft may be placed. g Pigskin, Biograne, TransCyte, etc.

Allograft can be used no longer than 7 days

Circumferential burns
A full-thickness burn injury possesses a risk of compression and compromise of blood flow: elevate extremity to reduce edema evaluated hourly for signs of vascular compromise (pallor, pain, parastesia, paralysis, pulse) Doppler examination

An escharotomy is an incision done through the eschar. If escharotomy does not restore blood flow a fasciotomy is required. Preferred sites for escharotomy incisions (dashed lines). The solid portions of the lines demonstrate the importance of extending the incision across joints in areas of full-thickness burns.

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General aspects in burn injury

SIRS is responsible for a clinical syndrome which is difficult to distinguish from infection: temperature of 39 to 39,5C, alteration of consciousness (disoriented), intestinal ileus, hyperglycemia, changes in fluid balance. SIRS results from action of mediators of inflammation and activation of cells (polymorphonuclear leukocytes and granulocytes), elevated level of IL-1, IL-6 and TNF leading to susceptibility to i f i d TNF l di ibili infection, di distant organ d damage, and d further tissue injury.

Infection complications Open wound infection with cellulitis

The infection may occur in an ungrafted excised burn.

Clinical picture

Pathophysiologic changes at the body

Hypopoteinemia (due to colloid-free fluids and loss of plasma: replaced by colloid fluids (albumin 5%) GIT: Paralytic ileus (precludes oral resuscitation) more than 25% of TBSA (recovery at third to fifth postburn day). Increase of Ht level due to loss of fluids and increase in vascular permeability it is caused by heat, humoral factors liberated from damaged tissue, and cytokines produced by activated leukocytes, (histamine from mast cells, arachidonic acid metabolites like the tromboxane A2 and leukotriens, substance P, activated proteases, products of complement activation, lysosomal enzymes, oxygen radicals).

localized pain tenderness swelling or heat at the affected site systemic signs of infection: presence of fever (leukocytosis or septicemia) signs of lymphangitis, lymphadenitis, or both.

Treatment requires e e equ es

change in local wound care, more frequent dressing c ge oc ou d c e, o e eque d ess g changes and administration of systemic AB.

Pneumonia
Inhalatory injury is a cause of respiratory complications. Development of respiratory distress syndrome is possible. Diagnosis: chest X ray, Gram stain of sputum. initiation of empirical AB therapy, specific antimicrobials after culture. p py, p pulmonary failure: respiratory support with volume-cycled ventilators

Gastrointestinal complications
Occurrence of acute ulceration of stomach and duodenum (Curling's ulcer) is possible. When a paralytic ileus is present an antacide is instillated through a nasogastric tube. After return of GI motility antacides are administered orally. Nasogastric tube should be removed as soon as GI motility has restored. restored

Suppurative thrombophlebitis
It is due to colonization of venous catheters (especially central) with bacteria. Prophylaxis: i.v. catheter should be changed once-a-week. The nl lini l presentation may b p i t nt f Th only clinical p nt ti n be persistent fever and b t nd bacteremia. i Diagnosis is confirmed by aspiration of purulent material from the affected vein. Treatment consists of excision of the involved vein to the point that the vessel is normal where bleeding is encountered.

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Tetanus prophylaxis Evaluate patient's immunization status.

Prognosis
Risk scoring system in which one point is given for each of burn size greater than 40% of TBSA age greater then 60 years presence of i h l f inhalatory i j injury

Burned patients who have undergone previous active immunization within 5 years of the time of injury require no further prophylaxis. Patients who have received their most recent booster injection more than 5 years before injure should be administered a booster dose of toxoid. Patients who have not undergone prior immunization or without hi ih history of i f immunization should b given 250 500 i i h ld be i 250-500

Mortality rate

0,3% with no risk factors 3% with one risk factor 33 % with two risk factors 90% three factors

units of human antitetanus globulin at one site and initial immunizing dose of toxoid administered at another site.

The system does not consider preexisting pathology, stratification of age and extend of injury.

Later consequences
Burn scar contracture and hypertrophic scarring. Especially dangerous at the joint area.

The treatment of hypertrophic scars with pressure garment. A typical example of active hypertrophic scaring following a full-thickness scald. Pressure garments were worn continuously for 14 months and the scar matured with reduced contracture formation.

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Z-plasty is used to relief scar contracture

Methods of releasing burn scar contractures. The fish-tail incision and graft method of releasing broad contractures.

Frostbite
Pathology:

Classification (depth of frostbite) and clinical presentation.

First degree: hyperemia ant edema; Second degree: hyperemia ant edema with vesicle formation (partialthickness injury), cutaneous sensation is intact. injury) intact

freezing of tissue, damage by tissue ice crystallization, tissue crystallization cellular dehydration, and microvascular occlusion. poor clothing during winter months acute alcoholism psychiatric illness

Epidemiology:

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Third degree: necrosis of entire skin thickness, formed vesicles mach smaller than those with second degree frostbite. Fourth degree: full-thickness necrosis of the skin and extends into underlying muscle and bone.

After thawing

Mild injury : capillary flow restores. Area is red and warm with throbbing pain (arterial pulsation), sensation and motor function return. Large vesicles appear within few hours, are filled with straw-colored fluid. Most of these changes resolve in 1 to 2 weeks with little or no tissue loss. Severe frostbite: c p e e e os b e: capillary flow is never restored (arteriovenous s u y o s e e es o ed ( e o e ous shunting), g), the injured area is cold and deep red. A patient is still able to move the distal parts. Extensive edema may persists for months. Eventually the nonviable skin and deep structures demarcate and mummify. Most cases of frostbite are between the two extremes described. Determination of tissue viability is impossible during the first several weeks following injury and often can be made only after gangrenous tissue has demarcated and sloughed.

Local care Treatment

remove constricting clothes wrap in warm blankets give hot fluids rewarming (40 C0 20 to 30 minutes).

Prevention of infection vesicles are left intact (not leaking or infected) bed rest wounds are exposed to the air foot cradle lamb's wool is inserted between affected digits cleansed daily with an AB solution in a whirlpool bath use of pressure dressing is contraindicated.

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Surgery must be delayed until clear demarcation. (may require several weeks)

The Alaskan algorithm for treatment of frostbite.

Wet gangrene requires immediate surgical removal of the source of sepsis. Tetanus prophylaxis is based on the patient's prior immunization status. Antibiotics are indicated when infection is evident. In the rare situations in which a large volume of tissue has been frozen massive fluid loss may require i.v. fluid resuscitation. Chronic postfrostbite sequelae: hyperhidrosis, paresthesias, cool extremities, cold sensitivity and edema Surgical division of segment sympathetic trunk sensitivity, edema. provides long-term relief.

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