burns

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a presentation on burns at trivanrum medical collage dept of surgery

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Presentation Transcript

Slide 1: 

BURNSDr Abdul Basith P.T

Causes : 

Causes Flame—damage from superheated, oxidized air    Scald—damage from contact with hot liquids    Contact—damage from contact with hot or cold solid materials    Chemicals—contact with noxious chemicals    Electricity—conduction of electrical current through tissues

Depth : 

Depth First degree —injury localized to the epidermis    Superficial second degree —injury to the epidermis and superficial dermis    Deep second degree —injury through the epidermis and deep into the dermis    Third degree —full-thickness injury through the epidermis and dermis into subcutaneous fat    Fourth degree —injury through the skin and subcutaneous fat into underlying muscle or bone

Slide 5: 

The skin provides a robust barrier to transfer of energy to deeper tissues; much of the injury is confined to this layer. the response of local tissues can lead to injury in the deeper layers The area of cutaneous injury has been divided into three zones: zone of coagulation, zone of stasis, zone of hyperemia

AIM : 

AIM To limit the injure to zone of coagulation To prevent injury to zone of stasis Management actually aims at preventing a second degree or first degree burn to becoming a higher one

First degree : 

First degree injuries confined to the epidermis. painful and erythematous blanch to the touch intact epidermal barrier. Eg: include sunburn or a minor scald from a kitchen accident. do not result in scarring treatment is aimed at comfort with the use of topical soothing salves, with or without aloe, and oral NSAIDS.

Second degree burns : 

Second degree burns superficial and deep All second-degree burns have some degree of dermal damage and the distinction is based on the depth of injury into this structure.

Superficial dermal burns : 

Superficial dermal burns erythematous and painful blanch to touch and often blister E.g.; include scald injuries from overheated bathtub water and flash flame burns from open carburetors spontaneously re-epithelialize from retained epidermal structures in the rete ridges, hair follicles, and sweat glands in 7 to 14 days. may result in some slight skin discoloration over the long term.

Deep dermal burns : 

Deep dermal burns reticular dermis appear more pale and mottled do not blanch to touch remain painful to pinprick These burns heal in 14 to 35 days by re- epithelialization from hair follicles and sweat gland keratinocytes, often with severe scarring as a result of the loss of dermis.

Third-degree burns : 

Third-degree burns full thickness through the epidermis and dermis characterized by a hard, leathery eschar that is painless and black, white, or cherry red. No epidermal or dermal appendages remain; thus, these wounds must heal by re- epithelialization from the wound edges. Deep dermal and full-thickness burns require excision with skin grafting to heal the wounds in timely fashion

Fourth-degree burns : 

Fourth-degree burns involve other organs beneath the skin, such as muscle, bone, and brain.

Burn size : 

Burn size Children have a relatively larger proportion of body surface area in their head and neck, which is compensated for by a relatively smaller surface area in the lower extremities. Infants have 21% of TBSA in the head and neck and 13% in each leg, which incrementally approaches the adult proportions with increasing age. The Berkow formula

SYSTEMIC CHANGES : 

SYSTEMIC CHANGES Inflammation and edema Altered hemodynamics Immunosuppression Hyper metabolism Decreased renal flow Increased gut mucosal permeability

Inflammation and Edema : 

Inflammation and Edema Massive release of inflammatory mediators produce vasoconstriction and vasodilation, increased capillary permeability, and edema locally and in distant organs The generalized edema occurs in response to changes in Starling forces in both burned and unburned skin As plasma oncotic pressure decreases and interstitial oncotic pressure increases as a result of the protein loss induced by increased capillary permeability, edema forms in the burned and non burned tissues. The edema is greater in the burned tissues because of lower interstitial pressure

Renal system : 

Renal system Diminished blood volume and cardiac output result in decreased renal blood flow and glomerular filtration rate Other stress-induced hormones and mediators such as angiotensin, aldosterone, and vasopressin further reduce renal blood flow immediately after the injury. result in oliguria, which if left untreated will cause acute tubular necrosis and renal failure. Early resuscitation decreases renal failure and improves the associated mortality rate

Gastro intestinal system : 

Gastro intestinal system highlighted by mucosal atrophy changes in digestive absorption increased intestinal permeability. Atrophy of the small bowel mucosa cytoskeleton of the mucosal brush border undergoes atrophic changes associated with vesiculation of microvilli and disruption of the terminal web actin filaments.

Immune system : 

Immune system global depression in immune function, which is shown by prolonged allograft skin survival on burn wounds Burned patients are then at great risk for a number of infectious complications, including bacterial wound infection, pneumonia, and fungal and viral infections.

Initial treatment of burns : 

Initial treatment of burns Prehospital burned patients must be removed from the source of injury and the burning process stopped Inhalation injury is always suspected and 100% oxygen given by facemask. Rescuer safety Universal precautions Burning clothing All rings, watches, jewelry, and belts are removed because they retain heat and can produce a tourniquet-like effect. Room-temperature water can be poured on the wound within 15 minutes of injury to decrease the depth of the wound, but any subsequent measures to cool the wound are avoided to prevent hypothermia during resuscitation.

Initial Assessment : 

Initial Assessment primary and secondary survey. In the primary survey, immediately life-threatening conditions are quickly identified and treated. In the secondary survey, a more thorough head-to-toe evaluation of the patient is undertaken.

AIRWAY : 

AIRWAY Exposure to heated gases and smoke results in damage to the upper respiratory tract. Direct injury to the upper airway results in edema, which together with the generalized whole-body edema associated with a severe burn, may obstruct the airway. Airway injury must be suspected with facial burns, singed nasal hairs, carbonaceous sputum, and tachypnea Progressive hoarseness is a sign of impending airway obstruction, and endotracheal intubation needs to be instituted early before edema distorts the upper airway anatomy.

Breathing : 

Breathing The chest is exposed in order to assess breathing airway patency alone does not ensure adequate ventilation. Chest expansion and equal breath sounds with CO2 return from the endotracheal tube ensure adequate air exchange.

CIRCULATION : 

CIRCULATION Blood pressure may be difficult to measure in burned patients with edematous or charred extremities pulse rate as an indirect measure of circulation most burned patients remain tachycardic even with adequate resuscitation. Doppler signals in the distal extremities may be sufficient until better monitors can be established, such as arterial pressure measurements and urine output.

OTHER INJURIES : 

OTHER INJURIES In patients who have been in an explosion or deceleration accident, the possibility of spinal cord injury exists. Appropriate cervical spine stabilization must be accomplished by whatever means necessary, including the use of cervical collars to keep the head immobilized until the condition can be evaluated.

Wound Care &Transport : 

Wound Care &Transport The patient is wrapped in a blanket to minimize heat loss and for temperature control during transport. The first step in diminishing pain is to cover the wounds to prevent contact with exposed nerve endings Small doses of intravenous (IV) morphine may be given after complete assessment of the patient and once it is determined to be safe by an experienced practitioner mode of transport needs to be of appropriate size with emergency equipment available, with nurses, physicians, paramedics, or respiratory therapists who are familiar with trauma patients

Resuscitation : 

Resuscitation depends on establishment and maintenance of reliable IV access. delays must be minimized Venous access is best attained through short peripheral catheters in unburned skin veins in burned skin can be used and are preferable to no IV access. Superficial veins are often thrombosed in full-thickness injuries and are therefore not suitable for cannulation. Saphenous vein cut-down is useful in patients with difficult access and is used in preference to central vein cannulation because of lower complication rates

Parkland : 

Parkland 4 mL/kg per % TBSA burn Total fluid =4 x body wt x BSA ½ of which is given in first 8 hours from the point of injury Next half is given in the next 16 hours

Escharotomies : 

Escharotomies When deep second- and third-degree burn wounds encompass the circumference of an extremity, peripheral circulation to the limb can be compromised. impedes venous outflow and eventually affects arterial inflow to the distal beds. recognized by numbness and tingling in the limb and increased pain in the digits. require escharotomies, which consist of release of the burn eschar at the bedside by incising the lateral and medial aspects of the extremity with a scalpel or electrocautery unit.

Inhalation injury : 

Inhalation injury One major factor contributing to death in burn injury patients Smoke damage adds another inflammatory focus to the burn and impedes the normal gas exchange vital for critically injured patients. increases the amount of time spent on mechanical ventilation, which is a predictor of mortality damage is caused primarily by inhaled toxins. smoke and toxins are carried distally into the bronchi. Airway injury is principally chemical in nature. except in high-pressure steam inhalation, which has 4000 times the heat-carrying capacity of dry air Direct thermal damage to the lung is seldom seen Bz of dispersal of the heat in the pharynx.

Slide 41: 

The response to smoke inhalation is an immediate dramatic increase in blood flow in the bronchial arteries to the bronchi along with edema formation and increases in lung lymph flow. Neutrophils release proteases and oxygen free radicals, which can produce conjugated dienes by lipid peroxidation. High concentrations of conjugated dienes are present in lung lymph and pulmonary tissue after inhalation injury increased concentration of neutrophils is active in producing cytotoxic substances.. Hallmark is separation of ciliated epithelial cells from the basement membrane, followed by the formation of exudate within the airways.

Slide 42: 

Exudate coalesces to form fibrin casts Clinically, these fibrin casts can be difficult to clear with standard airway suction techniques Bronchoscopic removal could therefore be required. casts add to barotraumas to localized areas of lung by producing a so-called ball-valve effect thereby preventing the inhaled air from escaping. Increasing volume leads to localized increases in pressure that are associated with numerous complications pneumothorax and decreased lung compliance

Slide 44: 

The clinical course of patients with inhalation injury is divided into three stages. The first is acute pulmonary insufficiency. Patients with severe lung injury may begin to show signs of pulmonary failure from the time of injury, such as asphyxia, carbon monoxide poisoning, bronchospasm, and upper airway obstruction. Clinical signs of parenchymal damage with hypoxia are not common during this phase.

Slide 45: 

The second stage occurs 72 to 96 hours after injury associated with hypoxia and the development of diffuse lobar infiltrates. clinically similar to the adult respiratory distress syndrome (ARDS) that occurs in nonburned injured and critically ill patients.

Slide 46: 

clinical bronchopneumonia dominates These infections generally occur 3 to 10 days after inhalation injury and are associated with the expectoration of large mucous casts formed in the tracheobronchial tree Early pneumonia usually caused by penicillin-resistant Staphylococcus species, whereas after 5 to 7 days, the changing flora of the burn wound is reflected in the appearance of gram-negative species in the lung, especially Pseudomonas. Ball-valve effects and ventilator-associated barotrauma are also hallmarks of this period.

Management of inhalation injury : 

Management of inhalation injury directed at maintaining open airways and maximizing gas exchange while the lung heals. A coughing patient with a patent airway can clear secretions effectively, and effort is made to manage patients without mechanical ventilation if possible. If respiratory failure is imminent, intubation is instituted frequent chest physiotherapy and suctioning Frequent bronchoscopy may be needed to clear inspissated secretions Mechanical ventilation is used to provide gas exchange with as little barotrauma as possible.

Slide 48: 

Permissive hypercapnia and the current ARDS Network ventilation protocols can be used lower ventilatory rates and volumes to maintain arterial pH at greater than 7.25, minimizing positive airway pressure delivered by the ventilator ventilator volumes and rate are decreased in a graduated manner until the patient can be extubated. This process may take several weeks.

Indications of intubation : 

Indications of intubation

Inhalation treatments : 

Inhalation treatments effective in improving the clearance of tracheobronchial secretions and decreasing bronchospasm IV heparin has been shown to reduce tracheobronchial cast formation, minute ventilation, and peak inspiratory pressure after smoke inhalation. When heparin was administered directly to the lungs in a nebulized form, it had similar effects on casts without causing systemic coagulopathy. N-acetyl cysteine treatments are added to nebulized heparin in burned children with inhalation injury, re intubation rates and mortality rates are decreased. adequate humidification plus treatment of bronchospasm with ß-agonists is indicated Steroids have not been shown to be of benefit in inhalation injury and are not given unless the patient was steroid dependent before the injury or had bronchospasm resistant to standard therapy.

novel ventilator therapies : 

novel ventilator therapies devised to minimize barotrauma, including high-frequency percussive ventilation. This method combines standard tidal volumes and respirations (ventilator rates of 6-20/min) with smaller high-frequency respirations (200-500/min) permits adequate ventilation and oxygenation in patients who have failed conventional ventilation. it recruits alveoli at lower airway pressure. This ventilator method may also have a percussive effect that loosens inspissated secretions and improves pulmonary toilet..

Recent studies : 

Recent studies Liquid ventilation using per fluorocarbons inhaled nitric oxide as a selective pulmonary vasodilator per fluorocarbons, however, have had disappointing results, which has led to decreased enthusiasm for this treatment

WOUND CARE : 

WOUND CARE After the airway is assessed and resuscitation is under way, attention must be turned to the burn wound. Treatment depends on the characteristics and size of the wound. All treatments are aimed at rapid and painless healing. Current therapy directed specifically toward burn wounds can be divided into three stages: assessment, management rehabilitation.

Slide 55: 

Each wound is dressed with an appropriate covering that serves several functions. it protects the damaged epithelium, minimizes bacterial and fungal colonization, and provides splinting action to maintain the desired position of function Second, the dressing is occlusive to reduce evaporative heat loss and minimize cold stress. Third, the dressing needs to provide comfort over the painful wound.

choice of dressing : 

choice of dressing First-degree require no dressing and are treated with topical salves to decrease pain and keep the skin moist. Second-degree wounds can be treated with daily dressing changes and topical antibiotics, cotton gauze, and elastic wraps. Alternatively, the wounds can be treated with a temporary biologic or synthetic covering to close the wound. Deep second-degree and third-degree wounds require excision and grafting for sizable burns, initial dressing is aimed at holding bacterial proliferation in check and providing occlusion until surgery is performed

Antimicrobial Salves : 

Antimicrobial Salves Silver sulfadiazine (Silvadene) Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; may leave black tattoos from silver ion; mild inhibition of epithelialization Mafenide acetate (Sulfamylon)Broad-spectrum antimicrobial; penetrates eschar; may cause pain in sensate skin; wide application may cause metabolic acidosis; mild inhibition of epithelialization Bacitracin Ease of application; painless; antimicrobial spectrum not as wide as above agents NeomycinEase of application; painless; antimicrobial spectrum not as wide Polymyxin B Ease of application; painless; antimicrobial spectrum not as wide Nystatin (Mycostatin)Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate Mupirocin (Bactroban) More effective staphylococcal coverage; does not inhibit epithelialization; expensive

Synthetic Coverings : 

Synthetic Coverings OpSite Provides a moisture barrier inexpensive decreased wound pain use complicated by accumulation of transudate and exudate requiring removal no antimicrobial properties

OpSite : 

OpSite

Biobrane : 

Biobrane Provides a wound barrier associated with decreased pain use complicated by accumulation of exudate risking invasive wound infection no antimicrobial properties

Biobrane : 

Biobrane

Transcyte : 

Transcyte Provides a wound barrier decreased pain accelerated wound healing use complicated by accumulation of exudate no antimicrobial properties

Integra : 

Integra Provides complete wound closure leaves a dermal equivalent sporadic take rates no antimicrobial properties

4. Integra™ Bilayer Matrix Wound Dressing (Integra LifeSciences : 

4. Integra™ Bilayer Matrix Wound Dressing (Integra LifeSciences The Integra dressing is a porous matrix of cross-linked bovine tendon collagen, glycosaminoglycan and a layer of silicone, according to the manufacturer, Integra LifeSciences. made for one-time use, is indicated for a variety of wounds, including partial- and full-thickness wounds; pressure, venous, surgical, diabetic and chronic vascular ulcers; and surgical and trauma wounds. Integra cites a study of 158 ulcers in which 92 percent of 107 patients achieved complete healing either with Integra alone or with small subsidiary flaps.2

Biologic Coverings : 

Biologic Coverings Xenograft (pig skin) Completely closes the wound provides some immunologic benefits; must be removed or allowed to slough Allograft (homograft, cadaver skin) Provides all the normal functions of skin can leave a dermal equivalent; epithelium must be removed or allowed to slough

Excision and Grafting : 

Excision and Grafting Early excision plus grafting is currently done by most burn surgeons Attempts are made to excise tangentially to optimize cosmetic outcome Rarely, excision to the level of fascia is required to remove all nonviable tissue, or it may become necessary at subsequent operations for infectious complications.

MINIMIZING COMPLICATIONS : 

MINIMIZING COMPLICATIONS Early, aggressive resuscitation regimens have improved survival rates dramatically. Sepsis Multi organ failure

Etiology and Pathophysiology : 

Etiology and Pathophysiology progression from systemic inflammatory response syndrome to multiorgan failure is not well explained, most are found in patients with inflammation from infectious sources. infectious sources most likely emanate from invasive wound infection or from lung infections (pneumonia). endotoxins are liberated from gram-negative bacterial walls, and exotoxins are released from gram-positive and gram-negative bacteria. causes the initiation of a cascade of inflammatory mediators result, if unchecked, in organ damage and progression to organ failure.

Insulin : 

Insulin Stress-induced hyperglycemia is ubiquitously found in the intensive care unit The nearly 50% reduction in mortality in a mixed adult ICU population is a motivator to test the efficacy of tight glycemic control in other populations. Follow-up studies in burn patients have supported tight glycemic control. tight glycemic control is recommended and further studies are ongoing to understand the full impact of such care on burn patients

Prevention : 

Prevention early excision and an aggressive surgical approach to the treatment of deep wounds. Oxidative damage from reperfusion after low-flow states makes early, aggressive fluid resuscitation imperative. Topical and systemic antimicrobial therapy has significantly diminished the incidence of invasive burn wound sepsis.. Pneumonia, which contributes significantly to death in burned patients, is vigilantly anticipated and aggressively treated.. Another potential source, however, is the gastrointestinal tract, which is a natural reservoir for bacteria. Early enteral feeding reduces septic morbidity and prevents failure of the gut barrier.

Renal Failure : 

Renal Failure 2 to 14 days after resuscitation Renal failure is hallmarked by decreasing urine output; fluid overload; electrolyte abnormalities, Azotemia Elevated creatinine level.. Urine output greater than 1 mL/kg/hr is an adequate measure of renal perfusion If the problems listed earlier overwhelm the conservative measures, some form of dialysis may be necessary. Peritoneal dialysis is effective Occasionally, hemodialysis is required

Pulmonary Failure : 

Pulmonary Failure The first sign of impending pulmonary failure is a decline in oxygenation. This is best monitored by continuous oximetry, and a decrease in saturation to less than 92% is indicative of failure require intubation Many burned patients require mechanical ventilation to protect the airway in the initial phases of their injury. The goal is extubation as soon as possible to allow patients to clear their own airways they can perform their own pulmonary toilet better than through an endotracheal tube or tracheostomy.

Hepatic Failure : 

Hepatic Failure challenging problem without many solutions. protein concentrations of the coagulation cascade decrease to critical levels and the patient becomes coagulopathic. Toxins are not cleared from the bloodstream concentrations of bilirubin increase. treatment is directed at replacement of factors II, VII, IX, and X until the liver recovers. Albumin replacement may also be required. Obstructive causes of hyperbilirubinemia, such as acalculous cholecystitis, need to be considered as well. Initial treatment is gallbladder drainage performed percutaneously.

Hematologic Failure : 

Hematologic Failure Burned patients may become coagulopathic through two mechanisms:    1.    Depletion and impaired synthesis of coagulation factors   2.    Thrombocytopenia

Disseminated intravascular coagulation : 

Disseminated intravascular coagulation associated with sepsis can result in depletion of coagulation factors. common with coincident head injury. With breakdown of the blood-brain barrier, brain lipids are exposed to plasma, which activates the coagulation cascade. Treatment of disseminated intravascular coagulation includes infusion of fresh frozen plasma and cryoprecipitate monitoring the concentration of fibrinogen and repleting levels with cryoprecipitate are the most specific indicators.

Thrombocytopenia : 

Thrombocytopenia frequent in severe burns as a result of depletion of platelets during excision of the burn wound. Platelet counts lower than 50,000 are common and do not require treatment. Only when the bleeding is diffuse and is noted to occur from IV sites should administration of exogenous platelets be considered.

Central Nervous System Failure : 

Central Nervous System Failure Obtundation is one of the hallmarks of sepsis A new onset of mental status changes not attributed to sedative medications in a severely burned patient incites a search for a septic source. Treatment is supportive

NUTRITION : 

NUTRITION

Slide 89: 

hyper metabolism occurs dramatically after a severe burn. Increases in oxygen consumption, metabolic rate, urinary nitrogen excretion, lipolysis, and weight loss are directly proportional to the size of the burn. as the metabolic rate is so high, energy requirements are immense. requirements are met by mobilization of carbohydrate, fat, and protein stores. Results loss of active muscle tissue and malnutrition ensue. This malnutrition is associated with functional impairment of many organs, delayed and abnormal wound healing, decreased immunocompetence altered active transport functions of the cellular membrane.

nutritional support : 

nutritional support Malnutrition in patients with burns can be subverted to some extent by the delivery of adequate exogenous nutritional support. The goals of nutritional support are to maintain and improve organ function and prevent protein-calorie malnutrition.

Calorie requirement : 

Calorie requirement One formula multiplies the basal energy expenditure determined by the Harris-Benedict formula by 2 in burns greater than 40% TBSA, assuming a 100% increase in total energy expenditure 1.55 may be enough Curreri formula = 25 kcal/kg/day plus 40 kcal per percent TBSA burned per day

composition : 

composition optimal dietary composition contains 1 to 2 g/kg/day of protein, which provides a calorie-to-nitrogen ratio of around 100:1 provides for the synthetic needs of the patient, thus to some extent sparing the proteolysis occurring in active muscle tissue. Nonprotein calories can be given either as carbohydrate or as fat. Carbohydrates have the advantage of stimulating endogenous insulin production, which may have beneficial effects on muscle and burn wounds as an anabolic hormone.

Slide 93: 

The diet may be delivered in two forms: either enterally through enteric tubes or parenterally through IV catheters Total parenteral nutrition associated with increased complications and mortality Total parenteral nutrition is reserved only for patients who cannot tolerate enteral feeding. Enteral feeding has, however, been associated with some complications that can be disastrous, including mechanical complications, enteral feeding intolerance, and diarrhea.

OUTCOMES : 

OUTCOMES Many of the burn treatments are directed at improving functional, psychological, and work outcomes, severely burned adult patients adjust relatively well, clinically significant psychological disturbances develop in some patients, somatization and phobic anxiety. Children with severe burns were found to have similar somatization problems, as well as sleep disturbances,. major burns can lead to significant disturbances in psychiatric health and outcomes,

Electrical injuries : 

Electrical injuries

Slide 97: 

high- and low-voltage injuries. Low-voltage injury is similar to thermal burns without transmission to deeper tissues House hold voltage causes only local damage. The worst of these injuries are those involving the edge of the mouth (oral commissure), which are sustained when children gnaw on household electrical cords.

high-voltage injury : 

high-voltage injury consists of varying degrees of cutaneous burn at the entry and exit sites, combined with hidden destruction of deep tissue. also have cutaneous burns associated with ignition of clothing from the discharge of electrical current. Initial evaluation consists of cardiopulmonary resuscitation if ventricular fibrillation is induced. if the initial electrocardiographic findings are abnormal or there is a history of cardiac arrest associated with the injury, continued cardiac monitoring is necessary along with pharmacologic treatment of any arrhythmias.

other injuries : 

other injuries being thrown by the electrical jolt falling from heights after disengaging from the electrical current. violent tetanic muscular contractions that result from alternating current sources may cause a variety of fractures and dislocations. These patients are assessed as any other patient with blunt traumatic injuries.

management : 

management treatment of the wound. The most significant injury is within the deep tissue, and subsequent edema formation can cause vascular compromise in any area distal to the injury. evaluation of the circulation to distal vascular beds because immediate escharotomy and fasciotomy may be required. early amputation may be necessary

Chemical burns : 

Chemical burns

Alkali : 

Alkali lime, potassium hydroxide, bleach, and sodium hydroxide Three factors are involved in the mechanism of alkali burns:    1.    Saponification of fat causes loss of the insulation of heat formed in the chemical reaction with tissue    2.    Massive extraction of water from cells causes damage because of the hygroscopic nature of alkali    3.    Alkalis dissolve and unite with the proteins of tissues to form alkaline proteinates, which are soluble and contain hydroxide ions (these ions induce further chemical reactions that penetrate deeper into the tissue)

Treatment : 

Treatment immediate removal of the causative agent with lavage of large volumes of fluid, usually water. Attempts to neutralize alkali agents with weak acids are not recommended because the heat released by neutralization reactions induces further injury. Particularly strong bases are treated by lavage and consideration of the addition of wound debridement in the operating room. Tangential removal of affected areas is performed until the tissues removed are at normal pH.

Acid : 

Acid treated initially like any other chemical injury: removal of all chemicals by disrobing the affected area and copious irrigation. Acids induce protein breakdown by hydrolysis, which results in a hard eschar that does not penetrate as deeply as alkalis do. also induce thermal injury by generation of heat after contact with skin, thus causing additional soft tissue damage. Some acids have added effects,

Formic acid : 

Formic acid relatively rare and usually involve an organic acid used for industrial descaling and as a hay preservative. Electrolyte abnormalities with metabolic acidosis, renal failure, intravascular hemolysis, and pulmonary complications ARDS Acidemia is corrected with IV sodium bicarbonate. Hemodialysis may be required when extensive absorption of formic acid has occurred. Mannitol diuresis formic acid wound typically has a greenish appearance and is deeper than it initially appears to be best treated by surgical excision

Hydrofluoric acid : 

Hydrofluoric acid toxic substance used widely in both industrial and domestic settings strongest inorganic acid known dehydration and corrosion of tissue by free hydrogen ions. the fluoride ion complexes with bivalent cations such as calcium and magnesium to form insoluble salts. Systemic absorption of the fluoride ion can then induce intravascular calcium chelation and hypocalcemia, life-threatening arrhythmias.

management : 

management initial copious irrigation with clean water, the burned area is treated immediately with copious 2.5% calcium gluconate gel. These wounds are generally extremely painful because of the calcium chelation and associated potassium release. intradermal injection of 10% calcium gluconate / intra-arterial injection of calcium gluconate into the affected extremity, or both may be required to alleviate symptoms. If the burn is not treated in such a fashion, decalcification of the bone underlying the injury and extension of the soft tissue injury may occur.

Slide 109: 

cardiac monitoring, with particular attention paid to prolongation of the QT interval. A total of 20 mL of a 10% calcium gluconate solution is added to the first liter of resuscitation fluid Any ECG changes require a rapid response consisting of IV administration of calcium chloride to maintain heart function. Several grams of calcium may be required in the end until the chemical response has run its course. Serum magnesium and potassium are also closely monitored and replaced.

Hydrocarbons : 

Hydrocarbons promote cell membrane dissolution and skin necrosis. erythema and blistering, burns are typically superficial and heal spontaneously. If absorbed systemically, toxicity can produce respiratory depression and eventual hepatic injury Ignition of hydrocarbons on the skin induces a deep full-thickness injury

future : 

future less stressful treatment options friendly to both the skin and the mind, inventing as well as researching innovative wound covering materials to cope with the shortage of donor skin, enhancing the anti-inflammatory properties of the parasympathetic nervous system through appropriate use of analgesics and sedatives, etc. We also expect cultured skin to become available soon f some hundreds of burn survivors and their families, is hoping to help burn survivors to feel normal

THANK YOU : 

THANK YOU

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