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Slide 1: 

BURNS DR.M.RAVICHANDRA,M.S ASST. PROFESSOR OF SURGERY RIMS, SRIKAKULAM

DEFINITION : 

DEFINITION A burn is an injury caused by an exogenous agent that produces a characteristic reaction to local tissues which may vary from mild erythema to full thickness destruction of the skin and deeper tissues.

Slide 3: 

ARRIVAL OF BURNS VICTIM AT EMERGENCY MEDICINE DEPARTMENT IS ONE OF THE MOST DRAMATIC EVENTS IN SURGICAL PRACTICE

WHY DRAMATIC???? : 

WHY DRAMATIC???? SUDDENNESS OF THE ACCIDENT VISIBILITY OF THE DAMAGE THE PAIN THE FEAR REACTIONS OF ONLOOKERS AN ATMOSPHERE OF TENSION

CAUSES : 

CAUSES THERMAL -DRY HEAT -MOIST HEAT -FLASH BURNS MOIST HEAT BURNS ARE CALLED SCALDS CONTACT BURNS FLAME BURNS

Slide 7: 

ELECTRIC -LOW VOLTAGE -HIGH VOLTAGE

CHEMICALS -ACIDS -ALKALI : 

CHEMICALS -ACIDS -ALKALI

RADIATIONS - IONIZING - NON-IONIZING : 

RADIATIONS - IONIZING - NON-IONIZING

COLD INJURY : 

COLD INJURY INDUSTRIAL ACCIDENTS LIQUID NITROGEN AND OTHER SIMILAR GASES FROST BITE PROLONGED EXPOSURE TO COLD

FAT BURNS : 

FAT BURNS DUE TO COOKING FAT OR OIL HIGH BOILING TEMPERATURE - 180 DEGREES CENTIGRADE COOLS SLOWLY ON BODY SURFACE CAUSES DEEP BURNS

FRICTION BURNS : 

FRICTION BURNS TISSUE DAMAGE IS DUE TO COMBINATION OF HEAT AND ABRASION SUPERFICIAL SKIN LOSS PROGRESSES TO FULL THICKNESS SKIN LOSS ASSOCIATED WITH DEGLOVING INJURY EARLY SURGICAL EXCISSION AND SKIN COVER

Slide 13: 

MECHANISMS OF INJURY

SCALDS : 

SCALDS DUE TO CONTACT WITH HOT LIQUIDS EXTENT OF DAMAGE DEPENDS ON TEMP. OF THE LIQUID, DURATION OF CONTACT, VOLUME OF LIQUID LEAST ABLE TO PROTECT THEMSELVES (THE VERY YOUNG, THE VERY OLD, THE VERY DRUNK) ARE MORE VULNERABLE SPILLS COOL RAPIDLY DECREASING DURATION OF DAMAGE, BUT WORST INJURIES MAY LEAVE PERMANENT SCARRING

FLAME BURNS : 

FLAME BURNS HOUSE FIRES,CLOTHING FIRES,SPILLS OF PETROL,BUTANE GAS FIRES ASSOCITED WITH INHALATIONAL INJURY AS THEY USULLY OCCUR IN CLOSED SPACES DEEP BURNS WILL RESULT BECAUSE OF CLOTHING

ELECTRICAL BURNS : 

ELECTRICAL BURNS PASSAGE OF ELECTRIC CURRENT THROUGH TISSUES CAUSES HEATING,CELL. DAMAGE HEAT PRODUCED DEPENDS ON RESISTANCE OF THE TISSUES, DURATION OF CONTACT, SQUARE OF CURRENT BONE IS POOR CONDUCTOR BLOOD VESSELS ,MUSCLES & NERVES ARE GOOD CONDUCTORS

ELECTRICAL BURNS(CONTD…) : 

ELECTRICAL BURNS(CONTD…) SO BONE BECOMES HOT AND CAUSE SEC. DAMAGE TO SURROUNDING TISSUES LOW VOLTAGE <1000V –CONTACT WOUNDS &CARDIAC ARREST, NO DEEP TISSUE DAMAGE HIGH VOLTAGE BURNS >1000V BY TWO MECHANISMS FLASH & CURRENT TRASMISSION FLASH CAUSES CUTANEOUS DAMAGE ONLY HIGH VOLT. TRANSMISSION – ENTRANCE & EXIT WOUNDS AND DEEP DAMAGE

ELECTRICAL BURNS (CONTD) : 

ELECTRICAL BURNS (CONTD) LIGHTNING CAUSES VERY HIGH VOLTAGE VERY SHORT DURATION DISCHARGE DIRECT STRIKE HIGH MORTALITY SIDE STRIKE –SUP. BURNS TO SKIN DEEP EXIT BURN TO FEET,INTERNAL DAMAGE NOT COMMON , RESP. & CARD. ARREST CAN OCCUR

COLD INJURY : 

COLD INJURY INDUSTRIAL ACCIDENTS –LIQUID NITROGEN AC. CELL. DAMAGE, PARTIAL OR FULL THICK NESS BURN SEVERE COOLING– FREEZING OF TISSUES--& ICE FORMATION—CELLULAR DISRUPTION LESS DAMAGE TO CONNECTIVE TISSUE MATRIX FROST BITE – DUE TO PROLONGED EXPOSURE TO COLD TISSUE DAMAGE IS DUE TO COMBINATION OF COLD ISHAEMIA (VASO CONSTRICTION)& FREEZING

CHEMICAL BURNS : 

CHEMICAL BURNS DAMAGE DEPENDS ON STRENGTH , QUANTITY & DURATION OF CONTACT CAUSE COAGULATIVE NECROSIS OF PROTIENS TANNIC,FORMIC &PICRIC ACIDS PRODUCE LIVER & KIDNEY DAMAGE

CLASSIFICATION : 

CLASSIFICATION FOR MORE DETAILS ICD 10’ T20-T32

SUPERFICIAL /FIRST DEGREE BURN : 

SUPERFICIAL /FIRST DEGREE BURN DEPTH Epidermis involvement CLINICAL FINDINGS Erythema Mild pain Lack of blisters Outer layer of the skin is damaged only

PARTIAL THICKNESS/SECOND DEGREE BURN : 

PARTIAL THICKNESS/SECOND DEGREE BURN DEPTH Superficial (papillary) dermis Deep (reticular) dermis CLINI CLINICAL FINDINGS Severe Pain Blisters Clear fluid Outer layer of the skin and the layer underneath it

FULL THICKNESS / THIRD DEGREE BURN : 

FULL THICKNESS / THIRD DEGREE BURN DEPTH Dermis and underlying tissue and possibly fascia, bone or musle Destroys the deepest layer of the skin and tissues beneath it CLINICAL FINDINGS No sensation Hard Leather like eschar Purple fluid

PATHOPHYSIOLOGY OF THERMAL BURN INJURY : 

PATHOPHYSIOLOGY OF THERMAL BURN INJURY JACKSON’S THERMAL WOUND THEORY ZONE OF COAGULATION AREA NEAREAST TO BURN CELL MEMBRANES RUPTURE,BLOOD CLOTTS,VESSELS GET THROMBOSED ZONE OF STASIS AREA SURROUNDING ZONE OF COAGULATION INFLAMATION+, DECREASED BLOOD FLOW ZONE OF HYPERAEMIA PERIPHERAL AREA OF BURNS LIMITED INFECTION &MORE BLOOD FLOW

EFFECTS OF BURN INJURY : 

EFFECTS OF BURN INJURY LOCAL EFFECTS TISSUE DAMAGE CELL NECROSIS & COLLAGEN DENATURATION BLOOD CLOTS THROMBOSED CAPILLARIES INCREASED CAPILLARY PERMEABILITY TISSUES BECOME OEDEMATOUS SEROUS EXUDATE

EFFECTS (CONTD)… : 

EFFECTS (CONTD)… INFLAMMATION IMMEDITE INFL. RESPONSE –ERYTHEMA IN LEAST DAMAGED AREAS –IMMEDIATE VASODILATATION PROLONGED INFL. RESPONSE MACROPHAGES-CYTOKINES(TGF-P) PHAGOCYTOSE NECROSED CELLS NEUTROPHILS &LYMPHOCYTES –PROTECTION AGAINST INFECTION DAMAGED TISSUE SEPERATES BY AN ACTIVE CELLULAR PROCESS CALLED DESLOUGHING BY ABOUT 3 WKS

EFFECTS (CONTD) : 

EFFECTS (CONTD) INFECTION COLONISED BY BACTERIA BY 24-48HRS MAY REMAIN AS LOCAL WOUND /REGIONAL INF. / MAY CAUSE SEPTICAEMIA /METASTATIC INFECTION SEPTICEMIA CAUSE FOR MORTALITY BETA HAEMOLYTIC STREPTOCOCCI , AND PSEUDOMONAS PRODUCE PROTEASE ENZYMES THAT PREVENT SKIN GRAFT ADHESION

REGIONAL PROBLEMSESCHAR : 

REGIONAL PROBLEMSESCHAR SKIN DENATURATION-HARD AND LEATHERY SKIN CONSTRICTS OVER WOUND INCREASES PRESSURE UNDERNEATH RESTRICTS BLOOD FLOW RESPIRATORY COMPRAMISE SEC. TO CIRCUMFERENTIAL ESCHAR OVER THORAX

REGIONAL CONTD : 

REGIONAL CONTD COMPARTMENTAL SYNDROME IN EXTREMITIES – SWELLING & GROSS EDEMA LEADS TO VENOUS OBSTRUCTION THIS ALONG WITH ESCHAR INCREASES THE CHANCES OF COMPARTMENTAL SYNDROME ISCHAEMIC FIBROSIS &CONTRACTURES CLAW POSTURE OF HAND (MP JOINT EXT. ,PIP JOINT FLEXION)

PATHOPHYSIOLOGY : 

PATHOPHYSIOLOGY BURNS SKIN LOSS AIRWAY & LUNG INJURIES INFLAMMATORY & CIRCULATORY CHANGES KIDNEYS STOMACH INTESTINE OTHER CHANGES

Slide 42: 

SKIN LOSS LOSS OF PROTECTIVE BARRIER ENTRY OF MICROORGANISMS LOSS OF FLUID LOSS OF HEAT IMMUNOSUPPRESSION SEPTICEMIA SUSCEPTIBILITY TO INFECTIONS HYPOTHERMIA HYPOVOLEMIA

Slide 43: 

INJURIES TO THE AIRWAY & LUNGS FIRE, BLAST etc INHALATIONAL INJURY CARBON MONOXIDE POISONING MECHANICAL BLOCK 0N RIB MOVEMENT

INFLAMMATORY CHANGES : 

INFLAMMATORY CHANGES BURNS PAIN & ALTERATION OF PROTEINS BY HEAT RELEASE OF NEUROPEPTIDES AND ACTIVATION OF COMPLEMENT DEGRANULATION OF MAST CELLS NEUTROPHILS ATTRACTION & GRANULATION RELEASE OF FREE RADICALS & PROTEASES FURTHER DAMAGE TO TISSUES

Slide 45: 

CIRCULATORY CHANGES LOSS OF SKIN VESSELS PERMEABILITY DIRECT FLUID LOSS THIRD SPACE FLUID COLLECTION NON-BURN TISSUE OEDEMA CIRCULATORY SHOCK

Slide 46: 

OTHER CHANGES LUNGS STOMACH INTESTINE KIDNEYS

Slide 47: 

MANAGEMENT

IMMEDIATE CARE : 

IMMEDIATE CARE STOP THE BURNING PROCESS ABC COOL THE BURN WOUND WASH THE WOUND COVER WITH BLANKET CHECK FOR OTHER INJURIES PRE-HOSPITAL CARE

HOSPITAL CARE : 

HOSPITAL CARE A Airway B Breathing and ventilation C Circulation D Disability_ neurological status E Exposure AND environmental control F Fluid resuscitation

AIRWAY : 

AIRWAY Early intubation Emergency cricothyroidotomy Thracheostomy

BREATHING AND VENTILATION : 

BREATHING AND VENTILATION MECHANICAL BLOCK TO BREATHING - Eschar - Escharotomy INHALATIONAL INJURY - Soot in nose and oropharynx - Warm humified 100% oxygen CO POISONING - Carboxy haemoglobin level > 10% - ABGs - Oxygen

Slide 52: 

CIRCULATION MAINTAIN AN I/V LINE - Two wide bore cannula peripherally - One in the centre ESCHAROTOMY CIRCUMFERENTIAL BURNS OF - EXTREMITIES

Slide 53: 

Oral analgesia Intravenous opiates TETANUS PROPHYLAXIS PREVENTION OF STRESS ULCER

ASSESSMENT OF THE BURN WOUND : 

ASSESSMENT OF THE BURN WOUND ASSESSING THE SIZE AND SITE Lund and browder chart Rule of nine Palm size ASSESSING DEPTH Superficial burns Partial thickness burns Full thickness burn

LUND AND BROWDER CHART : 

LUND AND BROWDER CHART

Slide 56: 

AREA OF PALM = 1% BODY SURFACE AREA

Slide 57: 

RULE OF NINES

CRITERIA FOR ADMISSION : 

CRITERIA FOR ADMISSION 15% Partial or full thickness burn in adults and 10% in Extremes of ages Suspected airway or inhalational injury Significant burns of hands, face, feet or perineum Chemical burns High tension Electric burns Major associated life threatening injuries circumferential limb /chest burns Children & elderly FULL THICKNESS>5%

Slide 60: 

RESUSCITATION FLUID CRYSTALLOIDS COLLOIDS Vs

OBJECTIVES OF FLUID RESUSCITATION : 

OBJECTIVES OF FLUID RESUSCITATION H.R<110/Mt NORMAL SENSORIUM(AWAKE,ALERT , ORIENTED URINE OUT PUT ADULTS 30-50cc/Hr CHILDREN 0.5-1cc/Kg/Hr

ESTIMATION OF FLUID REQUIRED : 

ESTIMATION OF FLUID REQUIRED PARKLAND FORMULA [ Total %age of TBSA X Weight(kg) X 4 = volume (ml) ] _ half of the volume is given in the first 8 hours _ the second half is given in the subsequent 16 hours FOR CRYSTALLOID RESUSCITATION ( Ringer’s lactate or hartmann’s solution ) URINE OUTPUT - ADULTS > 1ml /kg/hr - CHILDREN > 0.5ml/kg/hr

DRESSING THE WOUND : 

DRESSING THE WOUND TOPICAL ANTIBIOTICS - silver sulfadiazine cream - mafenide cream NON-ADHERENT - paraffin gauze LOOSE BULKY DRESSING 1st layer` paraffin gauze 2nd layer` cotton 3rd layer` crepe bandage ELEVATION OF LIMBS

Slide 64: 

BLOOD COMPLETE PICTURE CROSS MATCH X-RAYS URINE ANALYSIS ABGs ECG RFTs ELECTROLYTES INVESTIGATIONS

Slide 65: 

GENERAL MEASURES

ENERGY BALANCE AND NUTRITION : 

ENERGY BALANCE AND NUTRITION - Burn patient need extra feeding - NG tube should be passed in all patient with burns over 15% of TBSA PROTEIN NEEDS - Greatest nitrogen loss b/w days 5 and 10 - 20% of kcal should be provided by proteins

MONITORING AND CONTROL OF INFECTION : 

MONITORING AND CONTROL OF INFECTION I/V LINES & CATHETERS CHEST INFECTIONS - PNEUMONIA TISSUE BIOPSY FOR CULTURE & SENSITIVITY SYSTEMIC ANTIBIOTICS

Slide 68: 

SUPERFICIAL BURNS Healing occur within 03 weeks DEEP BURNS Excision and grafting is needed

RECONSTRUCTIVE SURGERY : 

RECONSTRUCTIVE SURGERY SIMPLE CLOSURE GRAFTS FLAPS SKIN SUBSTITUTES TISSUE EXPANSION

GRAFTS : 

GRAFTS Split thickness graft Full thickness graft

Slide 71: 

FLAPS Random flaps Axial flaps - Pedicle / islanded flaps Free flaps

COMPLICATIONS : 

COMPLICATIONS LOCAL SYSTEMIC HYPERTROPHY SCAR HYPO / HYPER PIGMENTATION KELOID CONTRACTURES SEPSIS RENAL FAILURE RESPIRATORY FAILURE MULTIORGANS FAILURE DEATH

Slide 73: 

BURNS WOUND MANAGEMENT REQUIRES LOT OF PATIENCE

Slide 74: 

THANK YOU

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