Burn

Management of Burn Wounds

Dr/ Bassim Mohamad GesrahaPlastic Surgeon

King Saud Medical City

Outline

• What do superficial and deep burns look like?

• What patients can be treated as inpatients?

• Who will need skin grafting?

• What is new in burn care?

Goals of Management

• Patient safety • Patient comfort• Spontaneous healing without scars• Minimal cost to patient• Maintain patient independence • Early return to function

Initial Burn Evaluation

• Burn size and depth

• Mechanism

• Time of injury

• Circumstances of accident

• Potential for inhalation

• Associated trauma

• Very young or elderly

• Other medical conditions

• Tetanus status

• Substance abuse

• Living situation

• Work history

Burn Depth

• Old terminology – First degree - never blisters

– Third degree - never heals

– Second degree - everything else

• Modern terminology– Superficial - heals without hypertrophic scars

– Deep - prolonged healing, with marked scars

Skin Layers andDepth of Burn Injury

1° - Superficial

SuperficialPartial

Thickness

DeepPartial

Thickness

3° - Full Thickness

Epidermis

Upper Dermis

Lower Dermis

SubcutaneousTissue

First Degree BurnSunburn

Sunburn Treatment

• UV radiation

• Oral ibuprofen for 24 hours rapidly reduces pain, redness and peeling

• Topical lotion is soothing

• > 30% TBSA sunburns do not respond to NSAIDS, may require hospitalization

Superficial Second Degree BurnScald

Scald Burn First Aid

• Immediately remove clothing

• Cool the burn, but don’t use ice

• Typically burns are superficial in exposed areas, deeper where hot liquid pools

• Immersion burns are of greatest concern

Deep Second Degree Burns

Third Degree Burns

Electrical

ChemicalFlame

Full Thickness Burns

• Burns are waxy white or hard and leathery with no pain sensation

• Escharotomy is needed if third degree burns are completely circumferential

• Small third degree burns - refer for elective skin grafting

Skin Grafting Decisions

Superficial (first degree)

Partial thickness (second degree)

Superficial

DeepFull thickness (third degree)

Earlygrafting

Heal in< 3 weeks

Estimating Burn Size

• Rule of the palm - the patient’s palm with fingers equals one percent TBSA

Estimating Burn Size

• Rule of 9’s -

– Head = 1 entire arm = 9%

– Ant. trunk or back = 18%

– Entire leg = 18%

Lund and Browder Most Accurate

Areas change with growthAge

in yearsHalf of

head (A)

Half of one thigh (B)

Half of one leg (C)

Infant 9 1/2 2 3/4 2 1/21 8 1/2 3 1/4 2 1/25 6 1/2 4 2 3/410 5 1/2 4 1/4 315 4 1/2 4 1/2 3 1/4Adult 3 1/2 4 3/4 3 1/2

A A

B BBB

CCC C

13131 1/2

1 1/2

1 3/4

1 1/2

1 3/4

1 1/2

1 1/2 1 1/2

1 1/2 1 1/2

21/2 21/2

2 222

11

1

Burn Admission - Physical Criteria

• Burns which require fluid resuscitation

• Chemical burns like hydrofluoric acid

• High voltage conduction injuries

• Burns with associated trauma

• Intoxication or clinical depression

• Uncontrolled pain

• Inhalation injury

Inhalation Injury

• Occurs with closed space or clothing fires, not flash injuries outdoors

• Hoarseness, stridor, carbonaceous sputum, elevated CO, acute chest infiltrates, or hypoxia suggest the diagnosis

• Burned nasal hair or facial hair is an insignificant finding

Outpatient Selection Criteria

• Mechanism of injury– Scalds– Flash burns– Small contact burns

• Consider outpatient referral– Low voltage electrical injuries– Some chemical burns

Electrical Burns

• Low voltage (<1,000 V) – Minimal visible damage– High incidence of PTSD and incapacitating

atypical pain of delayed onset

• High voltage (>1,000 V)– Deep injury from muscle heating– Often require fasciotomies

Chemical Burns

• Acids crosslink dermis– Tannic acid makes leather from rawhide

• Alkalis cause liquefaction necrosis• Wash at scene while removing all clothing• Document agent, concentration, area

affected, initial temperature of liquid and duration of contact

Chemical Burns

• Wash massively with water

• Check skin pH for acid/alkali injuries

• Topical calcium gel for HydroFloric burns– No pain medication - marker for inactivation

– Persistent pain after 2 hours of topical calcium - refer for intra-arterial calcium

– Large area or high concentration of HF - calcium gluconate drip is life-saving

Time to Burn Mortality

First hour Incineration, anoxia, carbon monoxide poisoning

First Day Hypovolemic shock, neck swelling and occlusion of

airway

First week Renal failure, inhalation injury

Delayed Sepsis, extreme malnutrition, rare complications

Initial Cares

• Adequate pain control

• Clean technique

• Shave hair

• Selective deflation or debridement for blisters

Indications for Early Escharotomy

• Circumferential third degree burns of digit or extremity

• Loss of pulse or capillary refill distal to deep burn

• Third degree burns of the chest which limit chest wall motion and ability to ventilate the patient

How Do We Calculate the Fluid Volume?

• Obtain the weight of the patient

• Calculate the burn size as % total burn surface area (%TBSA)

• For resuscitation only calculate the second and third degree burns

• Generally resuscitation is not needed for burns less than 15-20%TBSA

Parkland Resuscitation

4 ml x Wt (Kg) x %TBSA

100 Kg man, 40% TBSA

4 X 100 X 40 = 16,000 mL total

1,000 mL / hr in 1st 8 hrs

500 mL / hr in next 16 hrs

Example:

•Goal is to give best tissue perfusion

•Urine flow of 0.5-1 ml/Kg/Hr

•Adequate blood pressure–MAP >60 mmHg

•Decreasing tachycardia

How Much is Enough Fluid?

•Goal is to reduce IV fluid rate to maintenance rate

•Minimize fluid overload

•Maintain good vital signs and urine flow

•Begin nutritional intake

How Long is Resuscitation Given?

Excessive Resuscitation Complications

• Facial swelling

• Respiratory distress/pulmonary edema

• Increased ventilator days

• Extremity compartment syndrome

• Abdominal compartment syndrome

Blister Management Options

• Leave intact - will limit motion, become messy when leaking

• Completely debride - increased pain, must not allow to desiccate

• Deflate blisters - minimal pain, excellent ROM, limited quantity of topical agent needed, remove at 2 weeks

Acute Pain Control

• Intravenous morphine sulfate

–Repeat doses until pain breaks

–May require large amount

• Cool burns for a limited time

• Dress wounds early to alleviate pain

Tetanus/Antibiotics

• Immunization in last 5 years adequate

• Re-immunize after 1 year if dirty wound

• Add Hypertet if never immunized

• Prophylactic antibiotics are ineffective

Principles of Wound Management

• Keep exposed dermis moist– Reduces pain– Prevents desiccation– Topical antimicrobials reduce infection

• Increase protein intake to speed healing• Continue range of motion exercises

Dressings

• Functional

• Inexpensive

Local Wound Care

• Wash daily, remove loose dead skin, and apply occlusive dressings to unhealed areas

• For face burns, shave beard daily, apply bacitracin to keep wounds moist

• Moderate fevers are expected

• Observe for redness beyond burned areas

• Apply hand lotion to pink healed skin

Traditional Topical Agents

• None - appropriate for first degree burns

• Silver sulfadiazine

Covered dressing

• BacitractinOpen

Silver Sulfadiazine

• Most soothing agent• Not very cheap• Turns yellow on contact with serum• Melts, so occlusive dressings are

required• Change once daily

Bacitracin

• Adheres even without occlusive dressings - easy to use on face burns

• Cheap, readily available

• Prolonged use often causes a papular rash

What’s New for Burns

• Acticoat

• Aquacel Ag

• Mepelex Silver

• MEBO

• etc., etc.

Acticoat

• Rather expensive

• Two silver impregnated non-stick sheets with center absorbent pad (like Telfa)

• Water releases elemental sliver

• Usually changed every three days

• Can dry out a wound unless moistened t.i.d. or covered with an Unna dressing

Aquacel-AG

• Silver impregnated alginate pad

• Rather expensive

• Can be left for > 7 days

• Cannot be applied over dead tissue

• Contracts as it absorbs fluid, must overlap wound 2 cm

• Inflexible, do not use across joints

Mepelex Silver

• Silver impregnated open cell foam pad

• Rather expensive

• Can be left for > 7 days

• Cannot be applied over dead tissue

• Does not contract as it absorbs fluid

• Flexible, easy to use across joints

• Easily removed

Temporary Skin Indications

• Biobrane or other synthetic materials– Coverage of clean superficial wounds

– Superficial second degree burns

– Donor sites

Temporary Skin Indications

• Fresh or frozen cadaver skin– Temporary wound closure in unstable or ill

burn patients or those with only small donor sites

– Coverage of face burn bed before autografting

– Protection for widely meshed autograft

Permanent Skin Materials

• Autotransplanted skin grafts - the gold standard– No rejection, superb viability

– Sheet grafts are ideal - avoid mesh pattern

• Cultured epidermal autografts

• Synthetic dermis replacement - Integra

• Processed cadaver dermis - MatriDerm

Permanent Skin Materials

• Primary epidermal closure:

• Cultured epidermal autografts alone

• Dermal replacement or regeneration, followed by epidermal grafting:

• Dermal template matrix – Integra, MatriDerm

• Processed cadaver dermis -

The Perfect Autograft

• Thick enough to be durable

• Thin enough to heal without donor site scars

• Donor near wound for good color match

• Large enough to avoid seams or meshing

• Small enough so donor minimally increases burn size

Autograft Challenges

• Graft too thin - not durable

• Graft too thick - poor donor healing and site donor scars

• Distant donor - poor color match

• Meshed grafts - permanent mesh pattern

• Donor too large - increases total wound size

• Massive burns - donor skin inadequate to permit patient survival

Future Options

• Cultured split thickness autografts

• A living bilayer skin of cultured fibroblasts and patient’s epidermis, a cultured composite skin

Future Options

• Fetal epidermal stem cells• Researchers have used cells extracted

from amniotic fluid to make epithelial stem cells

Future Options

• Adult stem cells

• Advanced Cell Technology Inc. has engineered stem cells from adult human skin

Future Options

• Cultured composite skin

• A living bilayer skin of cultured fibroblasts and cultured autogenous epidermis

Future Options

• Fetal epidermal stem cells• cultured fetal cells grown in collagen

sponges were applied to full thickness wounds of newborns, which healed without scars

Future Options

• Cultured fetal tissue constructs

• cultured human mesenchymal stem cells are grown in collagen sponges and applied to full thickness wounds

• The fetal cells engraft and close the wounds with heterologous skin

Questions?

Thanks