burn care amit mitra md,ms,frcs,facs. burn statistics ranks 2 nd in cause death in childhood (1 st...

Burn care Burn care

Amit MitraAmit Mitra

MD,MS,FRCS,FACSMD,MS,FRCS,FACS

Burn statisticsBurn statistics

• Ranks 2nd in cause death in childhood (1st being trauma)

• 50% occur < age 20 yrs (peaks between age 2-4 and 17-25 yrs)

• 50% occurs at home and 2/3rd are preventable• 50% needs medical attention and 25% becomes

bedridden• 1% of US population is burned each year• 8000-12000 deaths/yr• Cost > 100 million/yr

Physiology of skinPhysiology of skin

• Consists of epidermis (.06-.8mm) and dermis (20-30 times thicker than epidermis)

• Protects from injury• Maintains water balance• Protects again solar exposure• Receives environmental stimulus• Excretory functions• Synthesizer of Vit D• Immunity• Maintains temperature• Slow thermal conductivity (heats and cools slowly)

Local changesLocal changes

• Increased vascular permeability

• Increased burn tissue osmolarity

• Fluid and protein shift – leads to edema

• Hypovolemia

• Hypoproteneimia

• Decreased tissue O2 tension

• Increased tissue pressure

Systemic changesSystemic changes

• Decreased cardiac output• Increased vascular resistance• Decreased cardiac contractility ( due to

circulating myocardial depressant factors)• Decreased CVP/PCWP• Hemoconcentration• Leucocytosis• Hypercoagulable state (platelets, PT, PTT)

Evolving zone of injuryEvolving zone of injury

From central to peripheral

zone of coagulation

zone of stasis

zone of hyperemia

Classification of burnClassification of burn(classification is based on depth)(classification is based on depth)

• 1st degree or Superficial– Painful and red. Does not need fluid correction

• 2nd degree or Partial thickness– Epidermis and part of the dermis– Hair follicles sweat glands are not destroyed and thus

heals with conservative management– Commonest type – Red, painful, blisters, intact hairs

• 3rd degree or deep/full thickness – Gray/white, leathery, non elastic, anesthetic

Initial evaluationInitial evaluation

• History of the injury– Mechanism of injury (flames, scald, electrical

or chemical contact)

• Exact time of the injury

• Duration of the exposure

• Any extrication/resuscitation problems

• Any associated in juries

• Depth of burn

Patient historyPatient history

• Past significant medical/surgical history

• Use of medications

• Drug abuse/suicidal history

• Allergies

• Socio economic status

Initial management Initial management

• Stop the burning process, remove clothes

• Cool the area

• Do not break blister

• Keep the patient warm

• Clean dry dressings

Acute care in the ERAcute care in the ER

• Never stray from ABC’s• History• Establish and maintain airway• Large bore IVs• Other injuries (failure to recognize other injuries is

possibly the biggest error)• Estimate the severity and size of the burn• Calculate the fluid management• Accurate measurement of I/O• Plan the local wound care• Evaluate the possibilities of inhalation injuries• Assess the need for escharotomy

Specific careSpecific care

• Calculate fluid requirement• NG suction (20% BSB)• Foley cath• Tetanus prophylaxis• Sedation (IV only)• ABG’s• CBC, Electrolytes, glucose, BUN, Creatinine• Chest Xray

How to calculate BSBHow to calculate BSB

• Rule of 9 (9 or its multiplier)– Head and neck - 9– Anterior trunk - 18– Post. Trunk - 18– Each arm - 9– Each leg - 18

• Measurement by patients palm size – 1%• Lund-Browder chart – relative adjustment

of BSB according to the pts age

Calculations of fluid managementCalculations of fluid management(most important in extensive burn)(most important in extensive burn)

Parkland formula (this is only for 1st.24 hrs)

4 cc of LR/ % of BSB/ Kg of pt.

Calculation starts at the time of injury, exact time of burn injury must be notedHalf of fluid amount to be given in 1st 8 hrs of the injury and next half over next 16 hrsD5 needs to be added in children

Other formulaeOther formulae

Evan’s formula1 ml of colloid/ % of BSB / Kg1 ml of LR/ %/ % of BSB / kg2000 ml of D5W Brooke’s formula0.5 ml of colloid/ % of BSB /Kg1.5 ml of LR/ % of BSB /kg2000 ml of D5W

( this is only for 1st 24 hours)

On the second 24 hrsOn the second 24 hrs

• In parkland formula 0.5 ml/ % /kg of colloid gets added. Other fluid and electrolytes as needed based on I/O and electrolyte levels

• In Evan and Brooke the calculations are different• Maintenance of Euvolumia based on urine

output is the most important criteria• On average 0.35 ml of colloid/ % /Kg +

maintenance of fluid is the common practice

Other considerations and fluid Other considerations and fluid management after 48 hrsmanagement after 48 hrs

• After 48 hrs maintenance of electrolytes and fluid balance is the goal

• Patients with cardiac failure or pulmonary edema is managed by less fluid and hypertonic saline may be indicated

• Patients who need more fluid than the BSB calculations are– Massive burns, electrical burns, pre burn hypovolumia

as seen in intoxicated patients, patients with other associated injuries, inhalation injuries, 4th degree burn when bones are involved

monitormonitor

• Urine output ( most important)

• CBC, Electrolytes

• ABG

• Cardiac parameter if CVP, Swan Gantz catheter is in place

Adequacy of resuscitationAdequacy of resuscitation

1. Urine output 30 – 50 cc/hr I adult and 1 cc/kg an hr. in

children

2. Sensorium : clear and lucid

3. Pulse : 100 -120 / min

4. BP : Normal to slightly high

5. Lack of nausea and ileus

Special considerations in childrenSpecial considerations in children

• Decreased glucose stores

• Decreased buffering capacity

• hypothermia

Problems to look forProblems to look for

• Acidosis – Inadequate resuscitation

• Hyperkalemia– Acidosis, electrical injury

• Hypernatremia– Inadequate resuscitation

• Hyponatremia– Over fluid resuscitation

• Hypoglycemia– Seen in children due to limited glycogen reserve and poor glucose

mobilization• Dehydration

– Usually seen in patients on air fluidized bed due to evaporative loss

Topical wound careTopical wound care

• Reduction of burn wound infection and mortality by 50 -60%

• Loose necrotic skin should be debrided• Blisters can be aspirated, do not need to be

debrided immediately• Likely organisms for BW infections are

– 1st. Wk : strep– 2nd wk : pseudomonas– 3rd wk : fungi ( most common cause of death after 24 hrs)

Common source of infectionCommon source of infection

• Burn wound

• Canulated arteries or veins

• pulmonary

Topical agentsTopical agents

• Silver nitrate 0.5% solution

• Silver sulfadiazine (Silvadene)

• Betadine

• Nitrofurazone (Furacene)

• Mafendine acetate 10% ( sulfamylon)

Biologic dressingsBiologic dressings

• Xenograft ( pig skin )

• Allograft ( human cadaver)

• Bio synthetics

• Synthetics (biobrane, integra)

• Cultured epithelial auto graft

Operative wound managementOperative wound management

• Early debridement

• Skin grafting

• Escharotomy

• Release of compartment syndrome

NutritionNutrition

• All burn patients are in hypermetabolic state and needs to be supported– Hosp. diet– Oral supplement– Tube feed– Peripheral intravenous supplements– TPN

Goal is 1-2 gm protein/kg/day in adult and 2-3 gm /kg /day in children.

Carb : 5 mg/kg/minute

Complications besides burn wound Complications besides burn wound sepsis and pulmonary complication sepsis and pulmonary complication• Ileus• Curling's ulcer• Pancreatitis• Acalculus cholecystitis• Ischemic enterocolitis• SMA syndrome• Otitis media in children• Osteomyelitis, chondritis specially in ear• Burn scar, contracture, keloid as a long term sequelle• Burn scar carcinoma (marjolins ulcer)

Be mindful ofBe mindful of

• Inhalation injury ( mostly due to CO)– Doubles mortality rate– Occurs in 50% of cases in closed space injury

• Difficult to diagnose initially• Closed space fire• Carboxy hgb 10%• Carbonaceous sputum• Confused, lethargic, head ache, nausea, vomiting,

decreased manual dexterity

Also rememberAlso remember

• Electrical burn• Chemical burns specially HFA (water ignites,

calcium gluconate and zephiran neutralises)• Frost bite• Radiation burns• Alkali burn• Acid burn• Phosphorus( ignites on air contact and copper

sulfate can identify the retained particles)• tar

PrognosisPrognosis

• Age• BSB• Inhalation injury• Other associated medical issues and

injuries

SPLINTS, THERAPY,COMPRESSION, REHABILITATION

Who are plastic surgeonsWho are plastic surgeons

• Presently almost anyone• To be board certified in plastic surgery one needs to

have training in either General Surgery (most of plastic surgeons) or ENT and two to three years in Plastic surgery residency in an ACGME approved program

• Plastic surgery training is regarded as residency not a fellowship

• As plastic surgery covers almost all areas of the body a broad based residency in general is helpful

• Plastic surgery is regarded, at the present time, as the “last bastion” of general surgery

Plastic surgery now Plastic surgery now encompasses over 12 encompasses over 12

subspecialtiessubspecialties

Skin CancersSkin Cancers

Abdominal wall Abdominal wall ReconstructionReconstruction

Breast ReconstructionBreast Reconstruction

Back ReconstructionBack Reconstruction

Lower ExtremityLower Extremity

Microvascular SurgeryMicrovascular Surgery

ReplantReplant