Burns

BurnsKriska Shalin L. Joaquin

Objectives

At the end of this session the group is expected:

To be able to identify the salient features in the history and physical examination of a burn patient

To discuss the approach to management of burn patients

To know the anatomy of the skin - review To discuss the pathophysiology of burns To discuss prevention and psychosocial

dimension

Patient data

WN 34/M Micronesian 17-November-1977 Single Electrician Weno City, Micronesia Can speak English, limited

Chief Complaint

Electric burn

History of Present Illness1 month prior (33 days)

Patient was working on an electric post with his hands

lasted minutes ? Sustaining burns on

Left forearm and Left thigh

Immediately brought to the hospital in Micronesia

History of Present Illness

Findings: 3x4 cm deep tissue burns on

dorsum of left arm and forearm, erythematous, hyperemic, tender

(+) limitation of movement 3x4 cm deep tissue burns

dorsum of left thigh, erythematous, hyperemic, tender

(+) limitation of movement

History of Present Illness17th hospital day Fasciotomy and

debridement was done Arranged for transfer to

this institution for skin grafting

(+) some degree of necrosis on Lateral aspect of Left thigh, referral to this institution32nd hospital day Transfer to this institution

Past Medical History

No known co-morbidities No previous hospitalizations No previous surgeries No known allergies to food or drugs

Family History

(-) HTN (-) DM (-) Allergies

Personal/Social

Electrician Denies smoking Occasional alcohol drinker Denies illicit drug use

Review of Systems

No fever No weight changes No cough/colds No vomiting/diarrhea/constipation No heat/cold intolerance

Physical Examination

Conscious and coherent, could not understand English very well

HR 84 RR 16 T 37.0 Weight 81 kg Height 178 cm VAS 0/10

Skin (+) graphic tattoos on left shoulder

(+) ulceration on left arm and forearm, with length of about 1 foot, dry, well circumscribed but irregular borders

(+) deep ulceration of the lateral aspect of the left thigh, 1x1 feet, non-foul smelling, no discharge, minimal bleeding

Head and Neck

Normocephalic head Anicteric sclerae, pink palpebral

conjunctivae Ears symmetric, (-) discharge Nasal septum midline, (-) nasal

discharge (-) tonsillopharyngeal congestion

Neck lymph nodes not palpable, thyroid not enlarged

Chest and Lungs

Symmetric chest expansion (-) retractions, no use of accessory

muscles Clear breath sounds (-) wheezes, rales

Heart

Adynamic precordium Normal rate Regular rhythm Good S1 and S2 No murmurs, no skip beats

Abdomen

Flat abdomen Normoactive bowel sounds Soft, non-tender No organomegaly

Genitourinary and DRE

Not examined

Salient Features

SUBJECTIVE 34/M electrician Electric burn On his 42nd

hospital day

OBJECTIVE• 14% TSBA

electric burns, full thickness

• Fasciotomy and wound debridement done

• Stable VS• Left arm• Lateral left thigh

Primary impression

Electrical burns, 14% TBSA Full thickness type, Right arm, forearm, and thigh secondary to Electrical Injury with Partial disability

Course in the Wards: SUBJECTIVE

OBJECTIVE ASSESSMENT

PLAN

1 No subjective complaints

Stable VS(+) deep ulcer on left arm and left thigh

Electric burns, 14% TBSA , full thicknessS/P Fasciotomy S/P Wound debridement

CBCWound GSCSBUNCreaNaK

2 No subjective complaints

(+) pus from wound on left thigh

Organism: Enterococcus gallinarum

PT normalAPTT normal

Electric burns, 14% TBSA , full thicknessS/P Fasciotomy S/P Wound debridement

For wound debridementBUN 0.82Crea 13.45Na 137K 3.7CBC 140/0.42/8.6/0.61/0.22/210

Course in the Wards: SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLAN

3 No subjective complaints

Stable VS

Wound GSCS: (+) Candida tropicalis

Electric burns, 14% TBSA , full thickness

4 No subjective complaints

Stable VS

Wound GSCS: (+0 Stenotophomonas maltophila

Electric burns, 14% TBSA , full thicknessS/P Wound debridement

Wound debridement done

5 No subjective complaints

Stable VS Electric burns, 14% TBSA , full thickness

Course in the wardsSUBJECTIVE

OBJECTIVE ASSESSMENT

PLAN

6 No subjective complaints

Stable VS Electric burns, 14% TBSA , full thickness

For repeat wound debridement

7 No subjective complaints

Stable VS Electric burns, 14% TBSA , full thickness

For repeat wound debridement

8 No subjective complaints

Stable VS Electric burns, 14% TBSA , full thickness

Repeat wound debridement doneFor skin grafting on Day 11

Patient is currently on his 42nd hospital day,( 10th hospital day in this institution)for skin grafting tomorrow

DISCUSSION

SKIN•Largest and most complex organ•FUNCTION – protective barrier- Regional variation•LAYERS• Epidermis• Basement membrane• Dermis

BURNS

90% of burns are preventable Nearly one half are smoking related

or due to substance abuse Advances in medicine have

decreased mortality, hospital stay Quality of burn care measured by

survival and long-term function and appearance

surgeon's goal: well-healed, durable skin with normal function and near-normal appearance

In children <8 : SCALD BURNS Older children and adults: FLAME-

RELATED Work-related: Chemicals, hot liquids,

electricity, molten/hot metals

TYPES

SCALD BURNS FLAME BURNS FLASH BURNS CONTACT BURN

Hospital admission & Burn Referral Any patient who has a symptomatic

inhalation injury Rule of thumb:

If burns cover more than 5-10% TSBA Otherwise healthy patients, with a place

to go and someone to stay with them could be observed 1-2 hours then discharged

Burn Center Referral Criteria

  1.    Partial-thickness and full-thickness burns totaling greater than 10% TBSA in patients under 10 or over 50 years of age.

  2.    Partial-thickness and full-thickness burns totaling greater than 20% TBSA in other age groups.

  3.    Partial-thickness and full-thickness burns involving the face, hands, feet, genitalia, perineum, or major joints.

  4.    Full-thickness burns greater than 5% TBSA in any age group.

  5.    Electrical burns, including lightning injury.

  6.    Chemical burns  7.    Inhalation injury.  8.    Burn injury in patients with preexisting medical

disorders that could complicate management, prolong the recovery period, or affect mortality.

  9.    Any burn with concomitant trauma  10.    Burn injury in children admitted to a hospital

without qualified personnel or equipment for pediatric care.

  11.    Burn injury in patients requiring special social, emotional, and/or long-term rehabilitative support

Emergency Care

ABC: airway, breathing, circulation Suspect inhalational injury to anyone with

flame burn Inspect mouth and pharynx Hoarseness and wheezes Copious mucus production and

carbonaceous sputum Carboxyhemoglobin levels Decreased P:F ration – early indicator

(<300, <250 intubate

Fluid Resuscitation in the ER (>20%TBSA) IV LR 1000 mL/h in adults IV LR 20mL/kg in children Foley catheter▪ 30ml/h in adults, 1.0ml/kg/h in children

Patients <50% TBSA, begin with 2 large-bore peripheral IV lines avoiding the lower extremities

>50% (including extremes of age, inhalation injuries) – additional central venous access

>65% refer immediately to a burn center, requires ICU

Tetanus Prophylaxis for those without previous immunization

within 5 years, unknown status – hyperimmune serum

Gastric decompression – NGT Pain control – IV Psychosocial care Care of Burn Wound – after all

assessments

ESCHAROTOMY Thoracic escharotomy-seldom required Extremities – to prevent neuromuscular and

vascular compromise

Assess skin color, sensation, CRT, peripheral pulses q1 hour

WOF: cyanosis, deep tissue pain, progressive paresthesia, progressive decrease or absence of pulses, sensation of cold

BURN SEVERITY

Size and depth of the burn, and the body part involved

TSBA – single most important factor in prognosis

Burn size

Rule of nines Upper extremity – 9%

each Lower extremity – 18%

each Anterior trunk – 18% Posterior trunk – 18% Head and neck – 9% Perineum – 1%

Burn depth

Primary determinant of patient’s long-term appearance and functional outcome

Burns that heal within 3 weeks usually do so without hypertrophic scarring or functional impairment

Early excision and grafting Dependent on:

temperature, skin thickness, duration of contact, heat-dissipating capability of skin

SHALLOW BURNS

First degree – Epidermal burns Do not blister Erythematous Painful Desquamates on

4th day

Second degree –Superficial partial-thickness Upper layers of dermis Blisters with fluid

accumulation Pink and wet Hypersensitive Blanch with pressure Heals in 3 weeks if

infection is prevented

DEEP BURNS Second degree- Deep

Partial thickness Reticular layers Blister Mottled pink and white Discomfort rather than

pain Slow to absent CRT Become dry and white Heals in 3-9 weeks

DEEP BURNS Third degree – Full

thickness All layers Contracture Epithelialization of wound

margin Skin grafting White, cherry red, black With or without blisters Leathery, firm, depressed Insensate Do not blanch with pressure eschar

DEEP BURNS Fourth degree

Involves subcutaneous fat and deeper structures

Charred appearance Electrical burns,

contact burns, immersion burns, unconscious people at time of burning

Clinical observation is still most commonly used, however:

Ability to detect dead cells or denatured collagen Biopsy, utrasound, vital dyes

Assessment of changes in blood flow Fluometry, laser Doppler, thermography

Analysis of color of wounds Light reflectance methods

Evaluation of physical changes Nuclear MRI

Electrical Injury and Burns Severity depends on the

amperage of the current Pathway of the current

through victims body Duration of contact Electric burn

Electrical injury from the current

An arc or flash flame Flame injury from ignition of

clothing or surroundings

Care at the scene

Rescuer should avoid touching the victim until current is shut off

StandardABCs BLS/ACLS if necessary Rule out fractures

Don’t be fooled by the size Other systems

Cardiac Nervous Eyes - cataracts

Wound management

Immediate surgery for1. Massive deep tissue necrosis will

lead to acidosis/myoglobinuria2. Injured deep tissues undergo

significant swelling – risk of compartment syndrome

Escharotomies and fasciotomies at compartment pressure >30mmHg

Physiologic response

SIRS BURN SHOCK

Tissue trauma and hypovolemic shock Loss of microvascular integrity and

thermal injury at cellular level Histamine Serotonin Eicosanoids (PGE2 and prostacyclin

PGI2) Bradykinins

Metabolic response to Burn Injury Hypermetabolism

Hyperglycemia Lypolysis▪ Fatty acids are re-esterized into TG▪ Propanol – promising as means to manipulate

peripheral lupolysis prevents hepatic steatosis Proteolysis increased

Neuroendocrine response Cathecolamines GH attenuated Altered thyroid hormone serum concentrations

Pathophysiology of a burn shock Hypovolemic and cellular in etiology dec CO, inc ECF, dec Plasma volume, Oliguria Increase in microvascular permeability Maximal edema occurs 8-12 hours after in small

burns, 12-24 hours in major thermal injuries

>30% TBSA: systemic decrease in cell transmembrane potential

Goal – ensure end-organ perfusion, principally aimed at 24-48 h after injury

Fluid resuscitation

Crystalloid resuscitation

Lactated Ringers Na 130 mEq/L

Urinary output of 0.5ml/kg – adequate end organ perfusion 3 ml/kg x %TSBA

for the first 24 hours

PARKLAND 4 mL LR/kg x

%TSBA ½ in the First 8 hours ½ in the next 16 hour

Modified Brooke Army Hospital 2 ml LR/kg x %

TSBA over 24 hours

Colloid

Three approaches1. Protein solutions are not given in

the 1st 24 hours 2. Proteins (albumin) given beginning

of resuscitation WITH crystalloid3. Proteins should not be given

between 8-12 hours postburn because of massive fluid shifts

Maintenance fluid

1500 mL/m2 + evaporative water loss [(25 +%TBSA) x m2 x 24]

Monitor output Adults 1000-1500 ml/25h Peia 3-4ml/kg/hour over 24h

Special considerations

PEDIA <20 kg require addition of glucose-

based fluids 6ml/kg/%TBSA 2-fold increase to ensure end-organ

perfusion INHALATION INJURY

Fluid resuscitation - 1.5 times

Wound care

Small (<20%) full thickness burns and burns of indeterminate depth: Excision and Grafting

Early E&G dramatically decreases the number of painful debridements required

Patients with 20-40% TBSA will havefewer infectious wound complications with early E&G

Tangential excision

To excise layers of eschar at a tangential angle to the surface until viable tissue is reaced

Fascial excision Typically reserved for

deep full-thickness burns or with large, life-threatening full thickness burns

Electrocautery ADV

Reliable bed of known viability

Tourniquets can be used for extremities

Operative loss is less than with tangential excision

Less experience is required

DISADV Longer operative times Possibility of cosmetic

deformity Higher incidence of distl

edema Greater danger of

damage to superficial neuromuscular structures

Cutaneous denervation Over joints – ungraftable

bed

Nutritional support

TOPICAL ANTIMICROBIAL AGENTS

Public Health concern

Preventable up to 90% Smoke detectors City ordinances for buildings Protective equipment

Psychosocial

Long-term treatment Chronic implications Cosmetic Post traumatic disorder Financial aspect