Burn and wound management

MOHC 2012, Grand Rapids, MichiganMOHC 2012, Grand Rapids, Michigan

Burn and wound managementBurn and wound management

C Balakrishnan, MDC Balakrishnan, MDAssociate ProfessorAssociate Professor

Division of Plastic SurgeryDivision of Plastic SurgeryWayne State UniversityWayne State UniversityDetroit, Michigan, USADetroit, Michigan, USA


Burn care and Wound careBurn care and Wound care

No financial interestNo financial interest

Aim: Principles of Wound care principles, Aim: Principles of Wound care principles, Burn care and Reconstruction and Burn care and Reconstruction and rehabilitation following burn injuriesrehabilitation following burn injuries


Burn care and Wound careBurn care and Wound care

Burn care and wound care – what is in Burn care and wound care – what is in common?common?Skin is the largest organ in the bodySkin is the largest organ in the bodyLocal and systemic changes are best Local and systemic changes are best studied for burnsstudied for burnsAmerican Burn Association, Am Academy American Burn Association, Am Academy of Wound management, American College of Wound management, American College of certified Wound specialists (CWS, of certified Wound specialists (CWS, FCCWS)FCCWS)


Types of woundsTypes of wounds

Acute wounds:Acute wounds:

Acute thermal injuries (Burns, Frostbite)Acute thermal injuries (Burns, Frostbite)

Traumatic injuries Traumatic injuries

Chronic wounds:Chronic wounds:

Pressure soresPressure sores

Radiation injuriesRadiation injuries


BurnsBurns


Cold injuriesCold injuries

Frost biteFrost bite

Trench feetTrench feet


American Burn Association criteria for American Burn Association criteria for transfer to Burn unittransfer to Burn unit

Major burnsMajor burns

Burns associated with inhalation injuryBurns associated with inhalation injury

Burns of specific areas of the body – face, Burns of specific areas of the body – face, hand, feet, perineumhand, feet, perineum

Chemical injuriesChemical injuries

Electrical injuriesElectrical injuries


Etiology of BurnsEtiology of Burns

Causes : Causes :

Flame - damage from superheated, oxidized air Flame - damage from superheated, oxidized air

Scald - damage from contact with hot liquids Scald - damage from contact with hot liquids

Contact - damage from contact with hot or cold Contact - damage from contact with hot or cold solid materials solid materials

Chemicals - contact with noxious chemicals Chemicals - contact with noxious chemicals

Electricity - conduction of electrical current through Electricity - conduction of electrical current through tissues tissues


Etiology of BurnsEtiology of Burns

Incidence of work related burn injuries – Incidence of work related burn injuries – 26.4 per 10,000 workers (26.4 per 10,000 workers (Islam et al J T 2000Islam et al J T 2000))

Male – Construction and mechanicalMale – Construction and mechanical

Women – Service industryWomen – Service industry


Work force involvedWork force involved

WeldersWelders

CooksCooks

LaborersLaborers

Food serviceFood service

MechanicsMechanics

ElectricianElectrician

Fire fightersFire fighters


Area involvedArea involved

Hand, wrist – hot liquidHand, wrist – hot liquid

Eyes – chemicalEyes – chemical

Face flame, hot liquidFace flame, hot liquid

Contact burnsContact burns

Firefighters – face and posterior neckFirefighters – face and posterior neck


EtiologyEtiology

Age groups - Younger cooks and food Age groups - Younger cooks and food service personnelservice personnel

Depth – 1.3 per 10,000 deepDepth – 1.3 per 10,000 deep

Associated trauma – Inhalation injury, Associated trauma – Inhalation injury, Fractures, Crush injuriesFractures, Crush injuries


Psychological problems associated with Psychological problems associated with work related Burn injurieswork related Burn injuries

DepressionDepression

PTSDPTSD

Anxiety disordersAnxiety disorders

Workers with electrical injuries had higher Workers with electrical injuries had higher psychological sequlae (19%)psychological sequlae (19%)

JBCR 2011


Depth of injuryDepth of injury

First degree - Injury localized to the epidermis First degree - Injury localized to the epidermis

Superficial second degree - injury to the Superficial second degree - injury to the epidermis and superficial dermis epidermis and superficial dermis

Deep second degree - injury through the Deep second degree - injury through the epidermis and deep into the dermis epidermis and deep into the dermis

Third degree - full-thickness injury through the Third degree - full-thickness injury through the epidermis and dermis into subcutaneous fat epidermis and dermis into subcutaneous fat

Fourth degree - injury through the skin and Fourth degree - injury through the skin and subcutaneous fat into underlying muscle or bone subcutaneous fat into underlying muscle or bone


Depth of burnDepth of burn


Depth of injuryDepth of injury

IncinerationIncineration Fourth degreeFourth degree


Physiology of depth of injuryPhysiology of depth of injury

Three zones: Three zones:

zone of coagulation zone of coagulation

zone of stasis zone of stasis

zone of hyperemiazone of hyperemia

This is similar for a pressure ulcerThis is similar for a pressure ulcer


Aim of managementAim of management

To limit the injure to zone of coagulationTo limit the injure to zone of coagulation

To prevent injury to zone of stasis To prevent injury to zone of stasis

Management actually aims at preventing a Management actually aims at preventing a second degree or first degree burn to second degree or first degree burn to becoming a deeperinjury becoming a deeperinjury


Burn sizeBurn size

Rule of nineRule of nine

ChartsCharts


Chemical burnsChemical burns

Hydrofluoric acidHydrofluoric acid

PhenolPhenol

PhosphorusPhosphorus

- Calcium gluconate- Calcium gluconate

- Ethylene glycol- Ethylene glycol

- Copper sulfate- Copper sulfate


Chemical burnsChemical burns

Phenol – chemical peelPhenol – chemical peel Cardiac toxicityCardiac toxicity

Monitor EKG Monitor EKG

Ethylene glycolEthylene glycol





Muscle injury without skin damageMuscle injury without skin damage

Myoglobinuria – treat to prevent renal Myoglobinuria – treat to prevent renal failurefailure

Cardiac arrhythmiaCardiac arrhythmia

Tetany, rupture of tendonsTetany, rupture of tendons

Neurological deficitNeurological deficit

Saliva good conductor of electricitySaliva good conductor of electricity


Electrical InjuriesElectrical Injuries

Impaired attention spanImpaired attention span

Memory problems (especially for short-term Memory problems (especially for short-term anterograde verbal informationanterograde verbal information

Persistent distress and frustrationPersistent distress and frustration

Mood disorders - often characterized by Mood disorders - often characterized by psychosocial difficulty and violent behavioral psychosocial difficulty and violent behavioral outbursts, accompanied by a background of outbursts, accompanied by a background of generalized depressiongeneralized depression



Survivors of severe electrical injury have Survivors of severe electrical injury have been noted to exhibit abnormal been noted to exhibit abnormal neuropsychologic findingsneuropsychologic findings several several years after trauma. years after trauma.

Late evaluation of patients with significant Late evaluation of patients with significant electrical injury has suggested a common electrical injury has suggested a common constellation of symptoms involving both constellation of symptoms involving both cognitive and affective disturbancescognitive and affective disturbances..


Systemic response to BurnsSystemic response to Burns

Inflammation and edema Inflammation and edema

Altered hemodynamics Altered hemodynamics

Immunosuppression Immunosuppression

Hyper metabolism Hyper metabolism

Decreased renal flow Decreased renal flow

Increased gut mucosal permeability Increased gut mucosal permeability


Principles of managementPrinciples of management

Burn ResuscitationBurn Resuscitation

Early managementEarly management

Wound careWound care

Surgical managementSurgical management

Management of complicationsManagement of complications

Management of Psychosocial issuesManagement of Psychosocial issues


Parkland formulaParkland formula

Parkland 4 ml/kg per % TBSA burn Total Parkland 4 ml/kg per % TBSA burn Total fluid =4 x body wt x BSA fluid =4 x body wt x BSA

½ of which is given in first 8 hours from the ½ of which is given in first 8 hours from the point of injury point of injury

Next half is given in the next 16 hours Next half is given in the next 16 hours


Wound managementWound management

EscharotomyEscharotomy

ExcisionExcision

Skin graftsSkin grafts

FlapsFlaps

OthersOthers


EscharotomyEscharotomy

IndicationsIndications - Improve circulation- Improve circulation


FasciotomyFasciotomy



Silver sulfadiazineSilver sulfadiazine

Mefenate acetateMefenate acetate

Silver dressingsSilver dressings



Biological dressingsBiological dressings Allograft (cadaver skin)Allograft (cadaver skin)

XenograftXenograft

Placental membranePlacental membrane

Bilayered Bilayered

Cultured epidermal cellsCultured epidermal cells


Wound healing PrinciplesWound healing Principles

Burn wounds are potentially contaminated Burn wounds are potentially contaminated and needs debridement.and needs debridement.

Clean wound with out coagulum heals Clean wound with out coagulum heals faster.faster.

Epithlialization occurs from the cells Epithlialization occurs from the cells remaining in the dermis.remaining in the dermis.


Wound therapyWound therapy

Management of burn wounds can be Management of burn wounds can be divided into three stages: assessment, divided into three stages: assessment, management, rehabilitation. management, rehabilitation.

Rehabilitation starts early in managementRehabilitation starts early in management

Positioning and splinting Positioning and splinting

Stretching of jointsStretching of joints



Primary excisionPrimary excision

Early excisionEarly excision

Excision with Skin graftingExcision with Skin grafting

Excision with allograftExcision with allograft

Excision with skin substitutesExcision with skin substitutes

Excision – Integra – Skin graftingExcision – Integra – Skin grafting

Excision with flap coverageExcision with flap coverage



Immediate excisionImmediate excision

Primary excisionPrimary excision

Early excisionEarly excision

Delayed excisionDelayed excision


Excision and grafting of the Burn woundExcision and grafting of the Burn wound

Early excision vs delayedEarly excision vs delayed


Outcome in BurnsOutcome in Burns

Early, aggressive resuscitation regimens Early, aggressive resuscitation regimens including early excision and wound including early excision and wound coverage have improved survival rates coverage have improved survival rates dramatically. dramatically.

By decrease in Sepsis and Multi organ By decrease in Sepsis and Multi organ failure failure


OutcomeOutcome

Hypertrophic scarHypertrophic scar

Burn contracturesBurn contractures

AmputationsAmputations


Prevention of contractures!!!!Prevention of contractures!!!!

Think neck and chest are a single unit Think neck and chest are a single unit when it comes to contracturewhen it comes to contracture

Hand splintsHand splints

Position elbows and axillaPosition elbows and axilla

Knee braceKnee brace

Prevent foot dropPrevent foot drop


Pressure garmentsPressure garments

Pressure garments appear to help in :Pressure garments appear to help in :reduce scar thickness/lumpiness reduce scar thickness/lumpiness

reduce scar redness reduce scar redness

reduce swelling reduce swelling

relieve itching relieve itching

protect newly healed skin/graft protect newly healed skin/graft

prevent contractures/ maintain contoursprevent contractures/ maintain contours


Silicone gel sheetsSilicone gel sheets

The exact mechanism of action of silicone The exact mechanism of action of silicone in the prevention and management of in the prevention and management of hypertrophic scars is unclear.hypertrophic scars is unclear.

Influences the collagen remodeling phase Influences the collagen remodeling phase of wound healing of wound healing

Soften, flatten and blanch the scar, making Soften, flatten and blanch the scar, making it comfortable and improves appearance it comfortable and improves appearance


Custom Compression Custom Compression GarmentsGarments

25 mm of Hg25 mm of Hg

Constant useConstant use

Clear masks for faceClear masks for face


Management of contracturesManagement of contractures

Serial castingSerial casting

Surgical releaseSurgical release

Post operative splintingPost operative splinting


Lip deformity secondary to neck contractureLip deformity secondary to neck contracture


Complications of Hand BurnsComplications of Hand Burns

Burn associated neuropathyBurn associated neuropathy

Reflex sympathetic dystrophyReflex sympathetic dystrophy

Pain syndromePain syndrome

Amputations and loss of partsAmputations and loss of parts


Hand burns - PrinciplesHand burns - Principles

Early excision and wound coverageEarly excision and wound coverage

Excision and skin graftingExcision and skin grafting

Flap coverage of exposed bones and Flap coverage of exposed bones and jointsjoints


Cross finger flapCross finger flap


Radial forearm flapRadial forearm flap


DISTANT FLAPS -Abdominal flapDISTANT FLAPS -Abdominal flap


Abdominal flapAbdominal flap


Amputation of digits / Fusion

DIPJs, PIPJs and possibly the middle phalanges. – Try to preserve length

Both for toes as well as fingers.

The thumb amputation deformity is treated either by pollicization or toe transfer.


Primary amputationPrimary amputation


Contact burnsContact burns


Complications of Hand BurnsComplications of Hand Burns

Loss of partsLoss of parts Adduction contractureAdduction contracture


Prevention of contracture by early Prevention of contracture by early excision and soft tissue coverageexcision and soft tissue coverageSoft tissue coverage of the knee joint following Soft tissue coverage of the knee joint following burns. Canadian Journal of Plastic Surgery 2006; burns. Canadian Journal of Plastic Surgery 2006; 14:163.14:163.


ElbowElbow


ElbowElbow


ElbowElbow


Axillary contractureAxillary contracture


Knee joint burnsKnee joint burns


Knee joint burnsKnee joint burns


Psychological problems associated Psychological problems associated with work related Burn injurieswith work related Burn injuries

DepressionDepression

PTSDPTSD

Anxiety disordersAnxiety disorders

Workers with electrical injuries had higher Workers with electrical injuries had higher psychological problems (19%)psychological problems (19%)

JBCR 2011


Occupational Burn injuriesOccupational Burn injuries

Preventable?Preventable?

Appropriate educationAppropriate education

Work place trainingWork place training

PPE (Personal Protective equipment)PPE (Personal Protective equipment)

Safe work place proceduresSafe work place procedures


Worker trainingWorker training

Worker illness and Injury prevention Worker illness and Injury prevention programsprograms

Reporting all injuriesReporting all injuries

First aidsFirst aids


Back to work programsBack to work programs

Can the worker return to previous Can the worker return to previous occupationoccupation

Is there any work place adjustments Is there any work place adjustments requiredrequired

RetrainingRetraining


Classification of Chronic woundsClassification of Chronic wounds

Pressure ulcersPressure ulcers

Vascular insufficiencyVascular insufficiency

MetabolicMetabolic

InfectionsInfections

Inflammatory disordersInflammatory disorders

HematologicHematologic

MalignantMalignant

MiscellaneousMiscellaneous



Decubitous ulcersDecubitous ulcers

Neuropathic ulcersNeuropathic ulcers

Contributing factors include Contributing factors include Pressure, Pressure, Immobility, Shear, Moisture, NutritionImmobility, Shear, Moisture, Nutrition


Etiology - nomenclatureEtiology - nomenclature

Pressure sore, decubitus ulcer, bedsorePressure sore, decubitus ulcer, bedsore

Unrelieved pressureUnrelieved pressure, altered sensory , altered sensory perception, incontinence, exposure to perception, incontinence, exposure to moisture, altered activity and mobility, moisture, altered activity and mobility, friction, and shear force.friction, and shear force.


Staging and risk factorsStaging and risk factors

Pressure Ulcer Staging (depth & tissue type)Pressure Ulcer Staging (depth & tissue type)– Stage IStage I Persistent redness (culturally Persistent redness (culturally

sensitive)sensitive)– Stage IIStage II Partial thickness skin lossPartial thickness skin loss– Stage IIIStage III Full thickness skin lossFull thickness skin loss

(subcutaneous)(subcutaneous)– Stage IVStage IV Full thickness skin loss (fascia)Full thickness skin loss (fascia)

Norton scale: Norton scale: Physical condition, mental condition, Physical condition, mental condition, activity, mobility, incontinence (score ≥ 12 is at risk)activity, mobility, incontinence (score ≥ 12 is at risk)

Norton scale: Norton scale: Activity, mobility, sensory perception, Activity, mobility, sensory perception, moisture, nutrition, friction, and shear moisture, nutrition, friction, and shear




Vascular insufficiencyVascular insufficiency

Acute vascularAcute vascular

Chronic venousChronic venous

ArtherosclerosisArtherosclerosis

LymphedemaLymphedema


Fx pelvis – SP embolozationFx pelvis – SP embolozation


LymphedemaLymphedema


MetabolicMetabolic

Diabetes mellitusDiabetes mellitus

GoutGout


DiabetesDiabetes


Infected woundsInfected wounds

BacterialBacterial

FungalFungal

ParasiticParasitic


Bacterial infectionsBacterial infections

Necrotizing fascitis


Bacterial infectionBacterial infection


Inflammatory disordersInflammatory disorders

Pyoderma gangrenosaPyoderma gangrenosa

VasculitisVasculitis

Necrobiosis lipodica diabeticorumNecrobiosis lipodica diabeticorum


Hematologic disordersHematologic disorders

Sickle cell diseaseSickle cell disease

Polycythemia veraPolycythemia vera

Hypercoagulable statesHypercoagulable states


Malignant ulcersMalignant ulcers

Marjolin’s ulcersMarjolin’s ulcers

Primary cutaneous neoplasmPrimary cutaneous neoplasm

Metastic Cutaneous neoplasmMetastic Cutaneous neoplasm

Kaposi’s sarcomaKaposi’s sarcoma


Radiation associated woundsRadiation associated wounds

Poor granulationPoor granulation

Rule out CancerRule out Cancer

? Hyperbaric? Hyperbaric


Radiation associated woundsRadiation associated wounds

Can develop AngiosarcomaCan develop Angiosarcoma

Diagnosis by biopsyDiagnosis by biopsy


Toxic drug ulcersToxic drug ulcers

Extravasation injuryExtravasation injury

Paint gun injuriesPaint gun injuries


Etiology of Chronic woundsEtiology of Chronic wounds

Nutritional deficiencyNutritional deficiency

Tissue hypoxiaTissue hypoxia

InfectionInfection

MetabolicMetabolic

Malignant changeMalignant change

Immune compromiseImmune compromise

Mechanical factorsMechanical factors


Impaired wound healing – Intrinsic Impaired wound healing – Intrinsic factorsfactors

IschemiaIschemia

InfectionInfection

Foreign bodyForeign body

SmokingSmoking

Venous insufficiencyVenous insufficiency

Radiation fibrosisRadiation fibrosis

Repeated traumaRepeated trauma

MalignancyMalignancy


Impaired wound healing - ExtrinsicImpaired wound healing - Extrinsic

Nutritional deficiencyNutritional deficiency

Diabetes mellitusDiabetes mellitus

Chronic renal sufficiencyChronic renal sufficiency

Steroids – reversed by Vit ASteroids – reversed by Vit A

ChemoChemo

Liver diseaseLiver disease

Old ageOld age

HeredityHeredity


Hyperbaric oxygenHyperbaric oxygen

2.5 atmospheres for 2 hours2.5 atmospheres for 2 hours

Tissue oxygen measured transcutanously. Tissue oxygen measured transcutanously. Oxygen tension of 30 mmHg required for Oxygen tension of 30 mmHg required for normal cell division and wound healing. normal cell division and wound healing. Optimal oxygen requirement for nonhealing Optimal oxygen requirement for nonhealing wound is unknown.wound is unknown.

Reinisch suggested that the beneficial effect Reinisch suggested that the beneficial effect of hyperbaric oxygen is due to the of hyperbaric oxygen is due to the vasoconstructive property of oxygen, which vasoconstructive property of oxygen, which acts to close arteriovenous shunts and thus acts to close arteriovenous shunts and thus improves capillary circulationimproves capillary circulation


Categories of wound dressingCategories of wound dressing

Absorbents – Absorbents – to control drainageto control drainage

Impregnated dressings - Impregnated dressings - AdapticAdaptic

Transparent dressing- Transparent dressing- OpsiteOpsite

FoamsFoamsHydrogels – Hydrogels – DuoDerm GelDuoDerm Gel

Xerogels – Xerogels – Alginates, SorbsanAlginates, Sorbsan

Hydrocolloids – Hydrocolloids – Cutinova, DuoDermCutinova, DuoDerm

Active dressing –Active dressing – hydrogel with antimicrobial hydrogel with antimicrobial

VAC system – VAC system – subatmospheric wound healingsubatmospheric wound healing

Biotherapy - Biotherapy - maggotsmaggots


Fetal wound healing Fetal wound healing

Contain few granulocytesContain few granulocytes

Increased turn over of matrixIncreased turn over of matrix

Early gestation fetal skin heals by Early gestation fetal skin heals by regeneration or growth rather than scaring.regeneration or growth rather than scaring.

Extra cellular matrix rich in hyaluronic acidExtra cellular matrix rich in hyaluronic acid

Low hyaluronidase activity and increased Low hyaluronidase activity and increased fibronectin productionfibronectin production


Fetal wound healing Fetal wound healing

Highly organized collagen architectureHighly organized collagen architecture

TGF – induces acute inflammation and TGF – induces acute inflammation and subsequent fibrosis in fetal woundsubsequent fibrosis in fetal wound

Collagen type III increasedCollagen type III increased


Gene therapyGene therapy

Two methods:Two methods:

- Genetically engineered keratinocyte or - Genetically engineered keratinocyte or fibroblast to over express growth factor fibroblast to over express growth factor genesgenes

- Transfer of DNA directly by gene gun or - Transfer of DNA directly by gene gun or direct subcutaneous injection of DNAdirect subcutaneous injection of DNA


TransplantationTransplantation

Research to realityResearch to reality

Partial vs total facePartial vs total face

ExtremityExtremity


Thank youThank you

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