SUBJECT SEMINARBURNS : SUBJECT SEMINARBURNS CHAIRPERSON : DR.M.A.BALAKRISHNA
PRESENTOR : DR.K.P.S.VINAYAKHRAM HISTORY…….. : HISTORY…….. Burns injuries were first described in the Ebers papyrus (1500 B.C.)
Dupuytren, the famous 19th century French surgeon who first described the contracture that bears his name wrote: ‘Burns had been the object of one of the most bizarre treatment methods’.
Fabricius Hildanus, a 15th century German physician,was the first to classify burns into three degrees Slide 3: After the First World War the best treatment for burns was surgical skin transplantation with subsequent scar reduction and pain control medications as needed.
In 1960 s treatment protocol for surgical burns therapy consisting of localized treatment and systemic medical management.
The localized treatment was typified by a drying of the burned skin which enabled a crust (deep, partial-thickness) or eschar (full-thickness) to develop over the burned tissue. This crusting was accompanied by surgical excision of necrotic skin tissues and of viable dermis (tangential excision of crust). Slide 4: In addition, whole subcutaneous tissue (fascial debridement of eschar) was also an all too frequent aspect of the treatment.
After this debridement was achieved, autografts or cultured epithelial autografts were placed on top of the lesion to close the wound from exogenous infectious agents.
In the 1970s the Chinese established an entirely new theory of burns physiology upon which they built a dramatically effective burns treatment which they called ‘Burns Regenerative Therapy’ (BRT). This innovation, which integrates moist-exposed burns treatment (MEBT) and moist-exposed burns ointment (MEBO), was a balm to the struggling burns therapy industry. Slide 5: The therapeutic essence of MEBT/MEBO is to maintain the burns wound in an optimum physiologically moist environment through the use of a specially designed ointment – MEBO.
MEBO serves as an analgesic , anti-shock,anti-bacterial,promotes epithelial repair and reduces scar formation. Anatomy & Physiology of the Skin : Anatomy & Physiology of the Skin Layers
Organs Functions of the Skin : Functions of the Skin Protection from infection
Controls loss and movement of fluids
Insulation from trauma
Flexible to accommodate free body movement BURNS : BURNS Burns is defined as a wound in which there is coagulative necrosis of the tissue. Types of Burn Injury : Types of Burn Injury Thermal burns: flame, flash, contact with hot objects.
Scald burns: hot fluids.
Chemical burns: necrotizing substances (acids, alkali).
Electrical burns: intense heat from an electrical current
Smoke & inhalation injury: inhaling hot air or noxious chemicals
Cold thermal injury: frostbite. Thermal Burns : Thermal Burns Heat changes the molecular structure of tissue
Causing Denaturion of proteins
Extent of burn damage depends on
Temperature of agent
Amount of heat
Duration of contact Slide 11: The effects of the burns are influenced by the:
1.Intensity of the energy
2.duration of exposure
3.type of tissue injured Pathophysiology of Burns : Pathophysiology of Burns Fluid Shift
Period of inflammatory response
Vessels adjacent to burn injury dilate → ↑ capillary hydrostatic pressure and ↑ capillary permeability
Continuous leak of plasma from intravascular space into interstitial space
Associated imbalances of fluids, electrolytes and acid-base occur
Lasts 24-36 hours Slide 13: Fluid remobilization
Capillary leak ceases and fluid shifts back into the circulation
Restores fluid balance and renal perfusion
Increased urine formation and diuresis
Continued electrolyte imbalances
Hemodilution SYSTEMIC CHANGES : SYSTEMIC CHANGES Cardiac
Decreased cardiac output
Respiratory insufficiency as a secondary process
Can progress to respiratory failure
Aggressive pulmonary toilet and oxygenation
Decreased or absent motility (may need NG tube)
Curling’s ulcer formation Slide 15: Metabolic
Increased oxygen and calorie requirements
Increase in core body temperature
Loss of protective barrier
Increased risk of infection
Suppression of humoral and cell-mediated immune responses Slide 16: stress
retention of Na,Cl, and water with excretion of Potassium
Alteration in capillary permeablity allowing egress of electrolytes and proteins from the vascular compartment ACUTE PHASE : ACUTE PHASE Clinical shock
External loss of plasma
Loss of circulating red cells
Burn edema SUB ACUTE PHASE : SUB ACUTE PHASE Diuresis
Accelerated metabolic rate
Disordered Fat metabolismn
Abnormal vitamin metabolism
Impaired Hepatic Function Slide 19: Bone and joint changes
Electrolyte and chemical imbalance
Loss of of function of skin as an organ Body’s Response to Burns : Body’s Response to Burns Emergent Phase (Stage 1)
Tachycardia, Tachypnea, Mild Hypertension, Mild Anxiety
Fluid Shift Phase (Stage 2)
Length 18-24 hours
Begins after Emergent Phase
Reaches peak in 6-8 hours
Damaged cells initiate inflammatory response
Increased blood flow to cells
Shift of fluid from intravascular to extravascular space
MASSIVE EDEMA Slide 21: Hypermetabolic Phase (Stage 3)
Last for days to weeks
Large increase in the body’s need for nutrients as it repairs itself
Resolution Phase (Stage 4)
General rehabilitation and progression to normal function Jackson’s Theory of Thermal Wounds : Jackson’s Theory of Thermal Wounds Jackson’s Theory of Thermal Wounds
Zone of Coagulation
Area in a burn nearest the heat source that suffers the most damage as evidenced by clotted blood and thrombosed blood vessels
Zone of Stasis
Area surrounding zone of coagulation characterized by decreased blood flow.
Zone of Hyperemia
Peripheral area around burn that has an increased blood flow Classification of Burn Injury : Classification of Burn Injury Severity is determined by:
depth of burn
extend of burn calculated in percent of total body surface (TBSA)
location of burn
patient risk factors Depth of Burns : Depth of Burns Medicolegal Classification
Clinical classification CLASSIFICATION OF BURNS : CLASSIFICATION OF BURNS Slide 27: DUPUYTREN S CLASSIFICATION
WILSON CLASSIFICATON Superficial Burn : 1st Degree Burn : Superficial Burn : 1st Degree Burn Reddened skin
Pain at burn site
Involves only epidermis Partial-Thickness Burn: 2nd Degree Burn : Partial-Thickness Burn: 2nd Degree Burn Intense pain
White to red skin
Involves epidermis & dermis Full-Thickness Burn:3rd Degree Burn : Full-Thickness Burn:3rd Degree Burn Dry, leathery skin (white, dark brown, or charred)
Loss of sensation (little pain)
All dermal layers/tissue may be involved ASSESSMENT OF BURNS : ASSESSMENT OF BURNS Rule of Nine
Best used for large surface areas
Expedient tool to measure extent of burn
Rule of Palms
Best used for burns < 10% BSA Lund-Browder Chart : Lund-Browder Chart Location of Burns : Location of Burns Vital organs of burn:
Other areas Patient risk factors… : Patient risk factors… Associated trauma
Age (young or old)
Abuse Classification of Burns Severity : Classification of Burns Severity Slide 39: Clinical evaluation,– Accuracy of 50% only
– Vital dyes, flourescein fluorometry, US, thermography, light reflectance, laser doppler, MRI.
Methods detect cell death, blood flow, edema Systemic Complications : Systemic Complications Hypothermia
Disruption of skin and its ability to thermoregulate
Shift in proteins, fluids, and electrolytes to the burned tissue
General electrolyte imbalance
Hard, leathery product of a deep full thickness burn
Dead and denatured skin Assessment of Thermal BurnsGeneral Signs & Symptoms : Assessment of Thermal BurnsGeneral Signs & Symptoms Pain
Changes in skin condition at affected site
Sloughing of skin
Dysphasia Burnt hair
Other soft tissue injury
Chest pain Assessment of Thermal Burns : Assessment of Thermal Burns Any partial or full thickness burn involving hands, feet, joints,
face, or genitalia >30% BSA Partial Thickness Inhalation Injury >10% BSA Full Thickness Critical >2% BSA Full Thickness >50% BSA Superficial <2% BSA Full Thickness <15% BSA Partial Thickness <50% BSA Superficial >15% BSA Partial Thickness Moderate Minor Burn Severity MANAGEMENT OF BURNS : MANAGEMENT OF BURNS Pre-hospital Care : Pre-hospital Care Remove from area! Stop the burn!
If thermal burn is large--FOCUS on the ABC’s
A=airway-check for patency, soot around nares, or signed nasal hair
B=breathing- check for adequacy of ventilation
C=circulation-check for presence and regularity of pulses Slide 45: Burn too large--don’t immerse in water due to extensive heat loss
Never pack in ice
Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth Effects of burn injury : Effects of burn injury Local
- Tissue damage
- Circulation problem
- Fluid loss
- Multi-organ failure Slide 47: Airway
Exposure 3 Phases of Burn Management : 3 Phases of Burn Management Emergent/Resuscitative
First 48 hours
Approximately 48 hours after injury to complete wound closure
Begins with wound closure and ends when client returns to highest possible level of functioning Emergent Phase (Resuscitative Phase) : Emergent Phase (Resuscitative Phase) Lasts from onset to 5 or more days but usually lasts 24-48 hours
begins with fluid loss and edema formation and continues until fluid motorization and diuresis begins
Greatest initial threat is hypovolemic shock to a major burn patient! Slide 50: Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn)
6-12 hours later: Bronchoscopy to assess lower respiratory tact
chest physiotherapy, suction SEDATION : SEDATION Burns is a very painful condition.
Sedation not only helps in relieving pain but can also be useful in shock.
Intravenous route is preferred in an absolute minimum dose which ensures rapid and predictable concentration.
It should be given for 4-5 days but the dosage can be markedly reduced in 48hrs.
Usually morphine is preferred in adults and barbiturates in childrens. Smoke Inhalation Injury : Smoke Inhalation Injury Responsible for most deaths
Evolution may require several days
Exposure of airways and lungs to toxic
Tracheobronchitis, epithelial fibrin
Airway obstruction, PMN activation
with release of oxygen radicals, proteases
Pulmonary edema within 2-3 days Slide 54: Physical findings may be suggestive (carbonaceous sputum, singed vibrissae, facial edema, stridor)
Bronchoscopy allows direct visualization
When combined with xenon scan 93% accuracy TREATMENT : TREATMENT High frequency percussive jet ventilation reduces airway pressures and improves survival.
Racemic Epinephrine. Slide 57: Complications during emergent phase of burn injury are 3 major organ systems...
Renal systems Fluid Resuscitation : Fluid Resuscitation Hypovolemia was major cause of death
Massive transudation of fluids from
vessels due to increased permeability
Edema intensifies over 8-48 hours
Goal: preservation of organ perfusion
and urine output
Rapid resuscitation in children (1/2 over
4 hours) may be preferred ABA Recommendations : ABA Recommendations Guidelines
Burns > 20% TBSA require fluid resuscitation(C)
Common formulas 2-4 ml/kg/%TBSA/24 hrs (C)
Titrate to UO of 0.5-1.0 ml/kg (1-1.5 in kids) (C)
Add maintenance fluids in kids Fluid Resuscutaion : Fluid Resuscutaion Many different formulas
Crystalloids preferred over colloids during first 12-24 hours Assessment of adequacy of fluid replacement : Assessment of adequacy of fluid replacement Urine output is most commonly used parameter
Urine osmolarity is the most accurate parameter
UOP = U/O > 0.5-1.0 ml/kg/hr
CVP 5-10 cm/H2O. Fluid Resuscitation Complications : Fluid Resuscitation Complications Overresuscitation complications:
Poor tissue perfusion
Electrolyte abnormalities Fluid Creep : Fluid Creep First described by Pruitt.
Excessive fluid resuscitation in the belief that more is better.
Consequences may be life threatening.
Modified Brooke formula, (2 ml/kg/%burn) with lower initial volume preferred. Slide 65: Overestimation of burn size common
Hesitancy to reduce fluid rates with adequate UO
Opioid creep leading to vasodilatation
Higher likelihood with more severe burns (>80% TBSA) Abdominal compartmentsyndrome : Abdominal compartmentsyndrome Risk increased by high infusion rates – > 0.25 L/kg
Risk lowered by use of colloids after 12-24 hr Slide 67: Addition of colloids, especially after 12-24hrs decreases volume requirements
Oral resuscitation in alert, moderate sized burns
Hypertonic saline only by experienced, with close monitoring of Na+
Plasma exchange as salvage procedure Nutritional Therapy : Nutritional Therapy Burn patients need more calories & failure to provide will lead to delayed wound healing and malnutrition. Slide 70: SUTHERLAND FORMULA
PROTEIN NEEDS WOUND MANAGEMENT : WOUND MANAGEMENT Escharotomy / Fasciotomy
Escharectomy + homograft
Dressing / hydrotherapy
Application of autograft
PB contractures management Positioning of burn patient : Positioning of burn patient Aim : To prevent contracture
Head and neck- Extended (no pillow)
Eyelids - apply eye ointment 3 times daily
Lips – apply moisturizing agent (Vaseline)
Lip commissure – apply maintainer
Hand – elevation and apply splint in functional position
Axilla (abducted ) , knee (extended)
Foot- dorsiflexed with foot support Circumferential burn : Circumferential burn Limb is burned all the way around.
Soft tissues under the skin always swell with burns
(due to capillary leak of fluids in first day or so).
There is a loss of skin expansion due to the loss of turgor/elasticity in burned tissue
Pressure inside limb gradually increases.
Eventually, pressure inside limb exceeds arterial pressure occluding blood supply.
This requires escharotomy to relieve the pressure. Escharotomy : Escharotomy Eschar is a dry scab or slough formed on the skin as a result of a burn or by the action of corrosive or caustic substance
Escharotomy = cut burned skin to relieve underlying pressure
Cut along inside and outside of limb from good skin to good skin
Knife can be used, or cautery. Escharotomy : Escharotomy Indications
Circulation to distal limb is in danger due to swelling.
Progressive loss of sensation / motion in hand / foot.
Progressive loss of pulses in the distal extremity by palpation or doppler.
In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest Escharotomy : Escharotomy Incise along medial and/or lateral surfaces.
Avoid bony prominences.
Avoid tendons, nerves, major vessels. Fasciotomy : Fasciotomy Fascia = thick white covering of muscles.
Fasciotomy = fascia is incised (and often overlying skin)
Skin and fascia split open due to underlying swelling.
Blood flow to distal limb is improved.
Muscle can be inspected for viability. Debridement : Debridement Types of debridement: 1. Auto debridement.
2. Tangential excision (at the end of 1st week)
3. Staged primary debridement (1-3 days post burn). This early debridement of dead tissue interrupts and attenuates the systemic inflammatory response and normalize immune function.
4. For deep circumferential burn, urgent escharotomy is done BLISTERS : BLISTERS Intact blister barrier to microbial invasion
Intact blister creates moist environment hence more rapid reepithelialization
More rapid angiogenesis
Rupture of blisters under contaminated conditions may increase infection rates BLISTERS : BLISTERS In the pre-hospital setting, there is no hurry to remove blisters.
Leaving the blister intact initially is less painful and requires fewer dressing changes.
The blister will either break on its own, or the fluid will be resorbed. Before and after debridement : Before and after debridement Dressings : Dressings Standard
Multiple gauze layers over topical agent or antibiotic
Homograft (allograft) from cadaver
Heterograft (xenograft) from animal (pig)
Two-layer product which creates an artificial dermis
Solid silicone and plastic membrane
Can see through to monitor wound status DRESSING : DRESSING Exposure method
Closed method TEMPORARY COVERAGE MATERIALS : TEMPORARY COVERAGE MATERIALS These are two categories:
1. Biologic.2. Bio-engineered.
Advantages of biological cover:
1. They maintain clean wound environment until skin grafting achieved or the wound get epithelized if it is partial in thickness.
2. They reduce heat and fluid loss.
3. They reduce pain.
4. Allow early mobilization by protecting the nerve endings. BIOLOGIC COVERINGS : BIOLOGIC COVERINGS Opsite
Integra BIO-ENGINEERED : BIO-ENGINEERED Xenograft ( Pig Skin)
Allograft ( Homograft,cadaver skin) Occlusive dressings : Occlusive dressings May speed healing.
Enhanced epithelialization and angiogenesis.
Pain reduction (reduced dressing changes).
Fluid collections common and should be drained.
Occlusive therapy does not increase infection rates.
Duoderm and Biobrane result in faster healing
and less pain than silver sulfadiazine. Hydrocolloid dressing (Duoderm) : Hydrocolloid dressing (Duoderm) Artificial Skin : Artificial Skin Yannas and Bruke
“Pioneers of Artificial Skin”
Complex of collagen and condroiton sulphuric acid with silicon membrane How it Works : How it Works Artificial skin is secured over wound during surgery
The skin remains in place for several weeks and allows new tissue to grow in to bottom matrix layer
Top layer provides protection from infection and dehydration Benefits : Benefits Protect skin from infection
Keep in moisture to prevent dehydration
Encourage healing through construction of new tissue by infiltration of epidermal cells and fibroblasts
Allow for less severe scarring
More readily available Topical Antibiotics : Topical Antibiotics MEBO Dressing : MEBO Dressing TETANUS PROPHYLAXIS : TETANUS PROPHYLAXIS 0.5 ml Tetanus toxoid given through intramuscular route.
In case of absence of active immunisation within 10yrs 250 units of tetanus immunoglobbulin should be administered. GASTRIC DECOMPRESSION : GASTRIC DECOMPRESSION Reflex Paralytic ileus in the first 24hrs.
Intestinal motility is gradually lost in the first 12hrs of burn injury.
Nasogasric tube insertion helps not only to decompress the stomach and proximal intestine but also to instill h2 blockers like cimetidine (400mg 4th hourly ) to prevent stress induced hemorrhagic gastritis. Burn Excision & Grafting : Burn Excision & Grafting Early excision & grafting improves burn patient mortality & functional outcome
Initial excision should occur soon after resuscitation
Full-thickness skin grafts (FTSG)
Split-thickness skin grafts (STSG)
Dermal substitutes: Integra Excision and Grafting : Excision and Grafting POST-OPERATIVE CARE : POST-OPERATIVE CARE Because of the lack of glandular tissue, graft has tendency to dry. Therefore must be moitsturized with thick moisturizing cream at least 3 times daily. Local & Minor Burns : Local & Minor Burns Local cooling
Partial thickness: <15% of BSA
Full thickness: <2% BSA
Cool or Cold water immersion
Consider analgesics Moderate to Severe Burns : Moderate to Severe Burns Dry sterile dressings
Partial thickness: >15% BSA
Full thickness: >5% BSA
Consider aggressive fluid therapy
Moderate to severe burns
Burns over IV sites
Place IV in partial thickness burn site. Moderate to Severe Burns : Moderate to Severe Burns Caution for fluid overload
Frequent auscultation of breath sounds
Consider analgesic for pain
Prevent infection COMPLICATIONS OF BURNS : COMPLICATIONS OF BURNS Curlings ulcer
Acute Acaculous Cholecystitis
Superior Mesentric Artery syndrome
Non-Occlusive Ischaemic Enterocolitis
Myocardial infarction Rehabilitative Phase : Rehabilitative Phase Emphasis:
Psychological adjustment of client
Prevention of scars and contractures
Resumption of pre-burn activity
Social GOAL OF PHYSIOTHERAPY : GOAL OF PHYSIOTHERAPY 1. Prevent, minimize or correct deformity.
2. Protect weak muscles from over stretching.
3. Maintain range of motion.
4. Provide positional function.
5. Protect any exposed joints or tendons.
6. Provide immobilization across joints after grafting.
7. Minimize scarring with pressure garment.
8. Develop functional skills Indications for Admission : Indications for Admission Adults > 15% 2°
Children > 10% 2°
3° burns > 2%
Face, hands, feet, perineum
Serious underlying diseases
Social considerations Long Term Complications : Long Term Complications Hypertrophic scarring, keloids, contractures
Social and employment dysfunction
Most burn patients need follow up with specialist to consider rehabilitation Hypertrophic Scarring and Hyperpigmentation : Hypertrophic Scarring and Hyperpigmentation Flame : Flame Remove the person from the source of the heat.
b. If clothes are burning, make the person lie down to keep smoke away from their face.
c. Use water, blanket or roll the person on the ground to smother the flames.
d. Once the burning has stopped, remove the clothing.
e. Manage the persons airway, as anyone with a flame burn should be considered to have an inhalation injury SCALDS : SCALDS Scalding-typically result from hot water, grease, oil or tar. Immersion scalds tend to be worse than spills, because the contact with the hot solution is longer. They tend to be deep and severe and should be evaluated by a physician. Cooking oil or tar (especially from the “mother pot”) tends to be full- thickness requiring prolonged medical care. TREATMENT : TREATMENT Remove the person from the heat source.
Remove any wet clothing which is retaining heat.
With tar burns, after cooling, the tar should be removed by repeated applications of petroleum ointment and dressing every 2 hours. Chemical Burns : Chemical Burns Acids
• Protein injury by hydrolysis.
• Thermal injury is made with skin contact.
• Saponification of fat
• Hygroscopic effect- dehydrates cells
• Dissolves proteins by creation of alkaline
proteinates (hydroxide ions) Electrical Burns : Electrical Burns Greatest heat occurs at the points of resistance
Entrance and Exit wounds
Dry skin = Greater resistance
Wet Skin = Less resistance
Longer the contact, the greater the potential of injury
Increased damage inside body
Smaller the point of contact, the more concentrated the energy, the greater the injury. Slide 121: Electrical Current Flow
Tissue of Less Resistance
Tissue of Greater Resistance
Bone Results in……….. : Results in……….. Serious vascular and nervous injury
Immobilization of muscles
Late complications: cataracts, progressive demyelinating neurologic loss Slide 123: Assess patient
Entrance & Exit wounds
Remove clothing, jewelry, and leather items
Treat any visible injuries
Bradycardia, Tachycardia, VF or Asystole
Treat cardiac & respiratory arrest
Aggressive airway, ventilation, and circulatory management.
Consider Fluid bolus for serious burns
Consider Sodium Bicarbonate: 1 mEq/kg
Consider Mannitol: 10 g REFERENCES : REFERENCES BAILEY AND LOVE S SHORT PRACTICE OF SURGERY 25TH EDITION
SABISTONS TEXTBOOK OF SURGERY 18TH EDITION
SCHWARTZ S PRINCIPLES OF SURGERY 9TH EDITION
A CONCISE TEXTBOOK OF SURGERY BY S.DAS 5TH EDITION
CLINICAL AND PATHOLOGICAL ASPECTS OF FORENSIC MEDICINE ; JASON PAYNE JAMES,ANTHONY BUSUTTIL,WILLIAM S SMOCK.
AMERICAN BURN ASSOCIAION ; BURN CARE SERVICES IN NORTH AMERICA COMMITTEE ON ORGANISATION AND DELIVERY OF BURN CARE ; 1985
7.BAXTER C.R. 1974 FLUID VOLUME AND ELECTROLYTE CHANGES IN THE EARLY POST BURN PERIOD , CLINICAL PLASTIC SURGERY ,1693
ESSENTIALS OF FORENSIC MEDICINE AND TOXICOLOGY ; DR.K.S.NARAYANA REDDY Thank You…… : Thank You……