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Lecture By.DR Bassim Moh'd Jesraha

Lecture By.DR Bassim Moh'd Jesraha
Plastic surgeon King Saud Medical City

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    Burn Burn Presentation Transcript

    • Management of Burn Wounds Dr/ Bassim Mohamad Gesraha Plastic Surgeon King Saud Medical City
    • Outline • • • • What do superficial and deep burns look like? What patients can be treated as inpatients? Who will need skin grafting? What is new in burn care?
    • Goals of Management • • • • • • Patient safety Patient comfort Spontaneous healing without scars Minimal cost to patient Maintain patient independence Early return to function
    • Initial Burn Evaluation • • • • Burn size and depth Mechanism Time of injury Circumstances of accident • Potential for inhalation • Associated trauma • Very young or elderly • Other medical conditions • Tetanus status • Substance abuse • Living situation • Work history
    • Burn Depth • Old terminology – First degree - never blisters – Third degree - never heals – Second degree - everything else • Modern terminology – Superficial - heals without hypertrophic scars – Deep - prolonged healing, with marked scars
    • Skin Layers and Depth of Burn Injury Epidermis Upper Dermis Lower Dermis Subcutaneous Tissue 1° - Superficial Superficial Partial Thickness Deep Partial Thickness 3° - Full Thickness
    • First Degree Burn Sunburn
    • Sunburn Treatment • UV radiation • Oral ibuprofen for 24 hours rapidly reduces pain, redness and peeling • Topical lotion is soothing • > 30% TBSA sunburns do not respond to NSAIDS, may require hospitalization
    • Superficial Second Degree Burn Scald
    • Scald Burn First Aid • Immediately remove clothing • Cool the burn, but don’t use ice • Typically burns are superficial in exposed areas, deeper where hot liquid pools • Immersion burns are of greatest concern
    • Deep Second Degree Burns
    • Third Degree Burns Flame Chemical Electrical
    • Full Thickness Burns • Burns are waxy white or hard and leathery with no pain sensation • Escharotomy is needed if third degree burns are completely circumferential • Small third degree burns - refer for elective skin grafting
    • Skin Grafting Decisions Superficial (first degree) Partial thickness (second degree) Superficial Heal in < 3 weeks Deep Full thickness (third degree) Early grafting
    • Estimating Burn Size • Rule of the palm - the patient’s palm with fingers equals one percent TBSA
    • Estimating Burn Size • Rule of 9’s – Head = 1 entire arm = 9% – Ant. trunk or back = 18% – Entire leg = 18%
    • Lund and Browder Most Accurate A 1 1/2 2 A 1 13 2 1 1/2 1 1/2 2 1 1/2 B 1 1/2 1 1/2 1 1/2 B B 1 1/2 C C C C 1 3/4 2 21/2 21/2 1 B 13 Areas change with growth 1 1 3/4 Age Half of Half of in years head one thigh (A) (B) Half of one leg (C) Infant 1 5 10 15 Adult 2 1/2 2 1/2 2 3/4 3 3 1/4 3 1/2 9 1/2 8 1/2 6 1/2 5 1/2 4 1/2 3 1/2 2 3/4 3 1/4 4 4 1/4 4 1/2 4 3/4
    • Burn Admission - Physical Criteria • • • • • • • Burns which require fluid resuscitation Chemical burns like hydrofluoric acid High voltage conduction injuries Burns with associated trauma Intoxication or clinical depression Uncontrolled pain Inhalation injury
    • Inhalation Injury • Occurs with closed space or clothing fires, not flash injuries outdoors • Hoarseness, stridor, carbonaceous sputum, elevated CO, acute chest infiltrates, or hypoxia suggest the diagnosis • Burned nasal hair or facial hair is an insignificant finding
    • Outpatient Selection Criteria • Mechanism of injury – Scalds – Flash burns – Small contact burns • Consider outpatient referral – Low voltage electrical injuries – Some chemical burns
    • Electrical Burns • Low voltage (<1,000 V) – Minimal visible damage – High incidence of PTSD and incapacitating atypical pain of delayed onset • High voltage (>1,000 V) – Deep injury from muscle heating – Often require fasciotomies
    • Chemical Burns • Acids crosslink dermis – Tannic acid makes leather from rawhide • Alkalis cause liquefaction necrosis • Wash at scene while removing all clothing • Document agent, concentration, area affected, initial temperature of liquid and duration of contact
    • Chemical Burns • Wash massively with water • Check skin pH for acid/alkali injuries • Topical calcium gel for HydroFloric burns – No pain medication - marker for inactivation – Persistent pain after 2 hours of topical calcium - refer for intra-arterial calcium – Large area or high concentration of HF - calcium gluconate drip is life-saving
    • Time to Burn Mortality  First hour   First Day   Hypovolemic shock, neck swelling and occlusion of airway First week   Incineration, anoxia, carbon monoxide poisoning Renal failure, inhalation injury Delayed  Sepsis, extreme malnutrition, rare complications
    • Initial Cares • • • • Adequate pain control Clean technique Shave hair Selective deflation or debridement for blisters
    • Indications for Early Escharotomy • Circumferential third degree burns of digit or extremity • Loss of pulse or capillary refill distal to deep burn • Third degree burns of the chest which limit chest wall motion and ability to ventilate the patient
    • How Do We Calculate the Fluid Volume? • Obtain the weight of the patient • Calculate the burn size as % total burn surface area (%TBSA) • For resuscitation only calculate the second and third degree burns • Generally resuscitation is not needed for burns less than 15-20%TBSA
    • Parkland Resuscitation Example: 4 ml x Wt (Kg) x %TBSA 100 Kg man, 40% TBSA 4 X 100 X 40 = 16,000 mL total 1,000 mL / hr in 1st 8 hrs 500 mL / hr in next 16 hrs
    • How Much is Enough Fluid? • Goal is to give best tissue perfusion • Urine flow of 0.5-1 ml/Kg/Hr • Adequate blood pressure –MAP >60 mmHg • Decreasing tachycardia
    • How Long is Resuscitation Given? • Goal is to reduce IV fluid rate to maintenance rate • Minimize fluid overload • Maintain good vital signs and urine flow • Begin nutritional intake
    • Excessive Resuscitation Complications • Facial swelling • Respiratory distress/pulmonary edema • Increased ventilator days • Extremity compartment syndrome • Abdominal compartment syndrome
    • Blister Management Options • Leave intact - will limit motion, become messy when leaking • Completely debride - increased pain, must not allow to desiccate • Deflate blisters - minimal pain, excellent ROM, limited quantity of topical agent needed, remove at 2 weeks
    • Acute Pain Control • Intravenous morphine sulfate – Repeat doses until pain breaks – May require large amount • Cool burns for a limited time • Dress wounds early to alleviate pain
    • Tetanus/Antibiotics • • • • Immunization in last 5 years adequate Re-immunize after 1 year if dirty wound Add Hypertet if never immunized Prophylactic antibiotics are ineffective
    • Principles of Wound Management • Keep exposed dermis moist – Reduces pain – Prevents desiccation – Topical antimicrobials reduce infection • Increase protein intake to speed healing • Continue range of motion exercises
    • Dressings • Functional • Inexpensive
    • Local Wound Care • Wash daily, remove loose dead skin, and apply occlusive dressings to unhealed areas • For face burns, shave beard daily, apply bacitracin to keep wounds moist • Moderate fevers are expected • Observe for redness beyond burned areas • Apply hand lotion to pink healed skin
    • Traditional Topical Agents • None - appropriate for first degree burns • Silver sulfadiazine Covered dressing • Bacitractin Open
    • Silver Sulfadiazine • • • • Most soothing agent Not very cheap Turns yellow on contact with serum Melts, so occlusive dressings are required • Change once daily
    • Bacitracin • Adheres even without occlusive dressings - easy to use on face burns • Cheap, readily available • Prolonged use often causes a papular rash
    • What’s New for Burns • • • • • Acticoat Aquacel Ag Mepelex Silver MEBO etc., etc.
    • Acticoat • Rather expensive • Two silver impregnated non-stick sheets with center absorbent pad (like Telfa) • Water releases elemental sliver • Usually changed every three days • Can dry out a wound unless moistened t.i.d. or covered with an Unna dressing
    • Aquacel-AG • • • • • Silver impregnated alginate pad Rather expensive Can be left for > 7 days Cannot be applied over dead tissue Contracts as it absorbs fluid, must overlap wound 2 cm • Inflexible, do not use across joints
    • Mepelex Silver • • • • • • • Silver impregnated open cell foam pad Rather expensive Can be left for > 7 days Cannot be applied over dead tissue Does not contract as it absorbs fluid Flexible, easy to use across joints Easily removed
    • Temporary Skin Indications • Biobrane or other synthetic materials – Coverage of clean superficial wounds – Superficial second degree burns – Donor sites
    • Temporary Skin Indications • Fresh or frozen cadaver skin – Temporary wound closure in unstable or ill burn patients or those with only small donor sites – Coverage of face burn bed before autografting – Protection for widely meshed autograft
    • Permanent Skin Materials • Autotransplanted skin grafts - the gold standard – No rejection, superb viability – Sheet grafts are ideal - avoid mesh pattern • Cultured epidermal autografts • Synthetic dermis replacement - Integra • Processed cadaver dermis - MatriDerm
    • Permanent Skin Materials • Primary epidermal closure: • Cultured epidermal autografts alone • Dermal replacement or regeneration, followed by epidermal grafting: • Dermal template matrix – Integra, MatriDerm • Processed cadaver dermis -
    • The Perfect Autograft • • • • • Thick enough to be durable Thin enough to heal without donor site scars Donor near wound for good color match Large enough to avoid seams or meshing Small enough so donor minimally increases burn size
    • Autograft Challenges • Graft too thin - not durable • Graft too thick - poor donor healing and site donor scars • Distant donor - poor color match • Meshed grafts - permanent mesh pattern • Donor too large - increases total wound size • Massive burns - donor skin inadequate to permit patient survival
    • Future Options • Cultured split thickness autografts • A living bilayer skin of cultured fibroblasts and patient’s epidermis, a cultured composite skin
    • Future Options • Fetal epidermal stem cells • Researchers have used cells extracted from amniotic fluid to make epithelial stem cells
    • Future Options • Adult stem cells • Advanced Cell Technology Inc. has engineered stem cells from adult human skin
    • Future Options • Cultured composite skin • A living bilayer skin of cultured fibroblasts and cultured autogenous epidermis
    • Future Options • Fetal epidermal stem cells • cultured fetal cells grown in collagen sponges were applied to full thickness wounds of newborns, which healed without scars
    • Future Options • Cultured fetal tissue constructs • cultured human mesenchymal stem cells are grown in collagen sponges and applied to full thickness wounds • The fetal cells engraft and close the wounds with heterologous skin
    • Questions?
    • Thanks