Prof. AMSM SharfuzzamanProfessor of SurgeryTuesday, January 8, 2013   DR. RUBEL, SBMC   1
BURN• Introduction : Burn trauma represents one of the most devastating conditions encountered  in surgery . A vast spec...
Epidemiology•   1% of total population of a country in each year•   U.S - >1.2 million people per year.     • 50000 burns ...
Definition• Tissue injury from thermal application  ( heat and cold ) , absorption of physical  energy ( electricity , fri...
ClassificationA. According to causative agent:   1. Flame .   2. Scald .   3. Contact .   4. Chemicals .   5. Electricity ...
B. According to depths :  1. 1st degree :  2. 2nd degree :         (i) Superficial         (II) Deep  3. 3rd degree .  4. ...
Pathophysiology of BurnBurns cause damage in a number of different ways, but byfar the most common organ affected is the s...
3 Zones of T her malInjur y                                             Hyperemia                                         ...
B. Systemic changes    1.Inflammation and oedema    2.Respiratory changes    3.Effects on the renal system    4.Effect...
B. Systemic changesTuesday, January 8, 2013   DR. RUBEL, SBMC   10
6. HypercatabolismTuesday, January 8, 2013   DR. RUBEL, SBMC   11
FACTORS DETERMINING THE    SEVERITY OF BURN•     As burn is the only truly quantifiable form      of trauma, there are so ...
Candle fire   Stove fireTuesday, January 8, 2013   DR. RUBEL, SBMC                 13
Chemical fireTuesday, January 8, 2013    DR. RUBEL, SBMC   14
DIATHERMY BURNTuesday, January 8, 2013   DR. RUBEL, SBMC   15
2.       Burn size:     •     A General idea of the burn size can be made by           using the rule of nines.     •     ...
3. Burn depth:•    Burn depth is dependent upon the temperature of the burn     source, the thickness of the skin, the dur...
Burn severity map according todepthTuesday, January 8, 2013   DR. RUBEL, SBMC   18
Depth of Burn• First- degree or epidermal:   • Involves only epidermis, erythematous, non blistering quite     painful• Se...
Depth of Burn                                       Appearance of     Sensitivity to     Healing timeDepth of Burn    Tiss...
Superficial partialthickness burn  Tuesday, January 8, 2013   DR. RUBEL, SBMC                 21                          ...
Full thickness burn    Tuesday, January 8, 2013   DR. RUBEL, SBMC   22
4. Site of Burn        Inhalation injury should be        suspected in a flame burn.        Burn to the face could affect ...
6. Co-morbid factors:  •    Associated trauma  •    Impaired sensation due to diabetes or       intoxication  •    Pre-exi...
Management of BurnThe priorities in management of burnA.   Air way control .B.   Breathing and ventilation .C.   Circulati...
Pre-hospital car eThe principles of pre-hospital care are:• Ensure rescuer safety.• Stop the burning process.• Check for o...
Pre-hospital care-contd.• Give oxygen. Anyone involved in a fire in an  enclosed space should receive oxygen,  especially ...
Initial assessment :Primary surveyImmediate life threateningconditions are quickly identifiedand treated                  ...
• Indications for intubation:  (I) Erythema / swelling of the oropharynx on direct visualization .   (II) Change in voice ...
 In an explosion or deceleration  accident --      appropriate cervical  spine stabilization until the condition  can be ...
C. Initial Wound care• Cover the wound with clean dry dressing or  sheet Pain reduced by cover the wound to  prevent conta...
D. Transport :   What ever the mode of transport it should   be to appropriate place having emergency   equipment availabl...
Criteria for hospitalization :  •  Age : < 5yrs or > 60 yrs.  •  Site : face , hands , feet , perineum or fracture.  •  In...
Assessment of burn wound : (I) Assessment of burn size by      - Wallace’s rule of nines      - Patients whole hand ( palm...
Tuesday, January 8, 2013   DR. RUBEL, SBMC   35
Lund andBrowderchart . Tuesday, January 8, 2013   DR. RUBEL, SBMC   36
Resuscitative fluid management :Principle : Maintenance of intra vascular volume in  order to provide sufficient circulati...
Resuscitation by oral fluid : Indication :   < 10 % TBSA in child.   < 15% TBSA in adult . Fluid :   Salt containing oral ...
Resuscitation by I V fluid    Indication :    >10% TBSA in child .    >15% TBSA in adult .    Fluids:                     ...
Formula :1. Parkland Formula : 1st 24 hrs Total fluid = 4 ml X body weight in kg X % of burn = ml Fluid : Ringer’s lactate...
2. Muir and Barclay formulaSix rations in 1st 36 hours -4/4/4, 6/6 and 12 hours respectivelyEach ration= % burn X body wei...
Monitoring• Clinical.• Biochemical & Hematological.• Invasive. Tuesday, January 8, 2013   DR. RUBEL, SBMC   42
Clinical :• Pulse - <120/Min.• BP-• Urinary output*      0.5 ml – 1.5 ml /kg/hr. in adult.      10-20 ml / hr. in child.• ...
Management Contd.Biochemical1. Hb%2. Urinary osmolality3. Serum electrolytes4. Serum creatinine & Blood ureaInvasive1. CVP...
MANAGEMENT OF BURN WOUNDTuesday, January 8, 2013   DR. RUBEL, SBMC   45
Wound management• Depends on –     1. Types of burn.     2. Site of burn .     3. Percentage of burn .     4. Depth of bur...
Flame burn (Carelessness)Tuesday, January 8, 2013   DR. RUBEL, SBMC   47
ScaldTuesday, January 8, 2013   DR. RUBEL, SBMC   48
HomicidalTuesday, January 8, 2013   DR. RUBEL, SBMC   49
Electric Burny by - Prof. Dr. A. January 8, 2013         Tuesday,                    J. M. Salek       DR. RUBEL, SBMC   50
                                   Electric BurnTuesday, January 8, 2013   DR. RUBEL, SBMC     51
lectric Burn   Tuesday, January 8, 2013   DR. RUBEL, SBMC   52
Electric Burn    Tuesday, January 8, 2013   DR. RUBEL, SBMC   53
Electric BurnCourtesy by - Prof. Dr. A. J. M. Salek      Tuesday, January 8, 2013           DR. RUBEL, SBMC   54
Diathermy Burn   Tuesday, January 8, 2013   DR. RUBEL, SBMC   55
ShareeTuesday, January 8, 2013   DR. RUBEL, SBMC   56
Floor level cookingTuesday, January 8, 2013   DR. RUBEL, SBMC   57
EpilepsyTuesday, January 8, 2013   DR. RUBEL, SBMC   58
Perineum                                              warmingTuesday, January 8, 2013   DR. RUBEL, SBMC           59
WarmingTuesday, January 8, 2013   DR. RUBEL, SBMC   60
Gas misuse Tuesday, January 8, 2013   DR. RUBEL, SBMC   61
Burning ashTuesday, January 8, 2013   DR. RUBEL, SBMC             62
Children Playing with FireTuesday, January 8, 2013   DR. RUBEL, SBMC             63
Electric Burn  Tuesday, January 8, 2013   DR. RUBEL, SBMC   64
Wound ManagementInfection is a common problem& Major cause of late death    Skin – ‘keeps the outsides out and the insides...
Wound ManagementWound Dressing             • Various dressings             • Review at 48 hours             • Then dress a...
Wound ManagementWound Dressing – Special Areas         •        Face - expose with antiseptic         •        Hands – In ...
Dressing description1.   Antimicrobials.    Silver sulfadiazine.    Mafenide acetate.    Bacitracin.    Neomycin.    ...
2 . Antimicrobial soaks. 0.5% silver nitrate. 5% mefenide acetate. 0.025% sodium hypochlorite. 0.25% acetic acid .Tues...
3. Synthetic covering. Opsite . Biobrane. Transcyte. Integra.Tuesday, January 8, 2013   DR. RUBEL, SBMC   70
4. Biological coverings. Xenograft (pig skin). Allograft (homograft, cadaver skin ).Tuesday, January 8, 2013   DR. RUBEL...
Principles of dressingsfor burns :• Full thickness and deep dermal burns need  antibacterial dressings to delay colonisati...
Exposure versus Closed Management1. Exposure therapy :       • Advantages –            a. Less bacterial growth.          ...
2. Closed method :     Advantages –           - less pain .           - less heat loss .           - less cross-contaminat...
Surgical treatment of deep burn : • Deep dermal burns need tangential shaving and split-skin   grafting . • All but the sm...
Tangential Excision(TE)                                   • Done “early” (w/in 7 d)                                   • Va...
Technique                               Escharotomy                               ANATOMIC POSITION!!                     ...
After…Tuesday, January 8, 2013   DR. RUBEL, SBMC   78
Electrical burn wound :  • Debribed to underlying healthy    tissue.  • Second debribement usually    indicated 24 - 48 hr...
Fascial Excision (FE)                                      • Done “early”                                        (w/in 7 d...
Chemical burn wound                          Incident with chemical agent                     Irrigate copiously water (se...
Radiation burn wound : • Local burns causing ulcerations   need excision and vascularised   flap cover – usually with free...
Complications of Burn : Infection     Bacteraemia .     Septecemia Renal failure Pulmonary complication     Inhalation inj...
Complications of hyper metabolism and nutrition :  • A catecholamine mediated hyper metabolism is    manifested by tachyca...
Electrolyte imbalance :      - Hypokalaemia .      - Hyponatraemia .      - Seizure – a complication unique to            ...
Gastrointestinal                complication :      Curling’s ulcer.      Hematemesis and melaena .      DiarrhoeaCardiova...
Hematological & Immunological :    Anaemia    Immunosuppression increases the risk of septic     complications .Multi-orga...
Local complications:Eschar formationScar formation :    Hypertrophic scar    Keloid .    Contracture :               a. Sk...
Non specific complications :    UTI ( from catheterization ).     Deep vein thrombosis.     Pulmonary embolism .Tuesday, J...
Late management :• Wound management : Skin graft :  - full thickness burns : require skin grafts. Transposition flaps ....
Management of scar & contracture:•        Scar contracture –                          Broad contracture require release an...
Tissue expansion This technique allows gradual stretching of marginal skin by implanting expander balloons  under the adj...
Hypertrophic scar         Pressure garments ‍         Revision of hypertrophic scars is         appropriate where the scar...
Pressure garmentsTuesday, January 8, 2013   DR. RUBEL, SBMC   94
Keloid scar        Some keloids will improve with        the application of pressure .        Intralesional injection of s...
Late management :         • Wound management :                   Skin graft .                   Trans position flaps .  ...
Outcome of Burn :Major determinants       1. Percentage of surface area          involved       2. Depth of burn       3. ...
Thanks!                                   Have a nice                                   day.Tuesday, January 8, 2013   DR....
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Burn rubel

  1. 1. Prof. AMSM SharfuzzamanProfessor of SurgeryTuesday, January 8, 2013 DR. RUBEL, SBMC 1
  2. 2. BURN• Introduction : Burn trauma represents one of the most devastating conditions encountered in surgery . A vast spectrum of injuries can arise from a burning accident,from the trivial to some of the most dramatic injuries that humans survive. The management of the major burn injury represents a significant challenge to every member of the burns team – burns doctors, surgeons, anaesthetists, ward and theatre nurses, physiotherapists, occupational therapists, dietitians, bacteriologists, physicians, psychiatrists, psychologists and the many ancillary staff whose cleaning and supply services are vital to the successful running of a burns unit. The correct treatment of these injuries is vital to ensure a favourable outcome & encompasses accurate assessment, careful resuscitation & precise surgical management . Tuesday, January 8, 2013 DR. RUBEL, SBMC 2
  3. 3. Epidemiology• 1% of total population of a country in each year• U.S - >1.2 million people per year. • 50000 burns patients – - Moderate to severe . - Require hospitalization . • Among them >3900 people die of complications related to burns .• Mechanism is age-related & situational: • < 8 yrs. → scalds • all others → flame burns • work → chemical/electrical/moltenTuesday, January 8, 2013 DR. RUBEL, SBMC 3
  4. 4. Definition• Tissue injury from thermal application ( heat and cold ) , absorption of physical energy ( electricity , friction and ionising radiation ) and chemical ( corrosive substance ) contact .Tuesday, January 8, 2013 DR. RUBEL, SBMC 4
  5. 5. ClassificationA. According to causative agent: 1. Flame . 2. Scald . 3. Contact . 4. Chemicals . 5. Electricity . 6. Radiation.Tuesday, January 8, 2013 DR. RUBEL, SBMC 5
  6. 6. B. According to depths : 1. 1st degree : 2. 2nd degree : (i) Superficial (II) Deep 3. 3rd degree . 4. 4th degree . Tuesday, January 8, 2013 DR. RUBEL, SBMC 6
  7. 7. Pathophysiology of BurnBurns cause damage in a number of different ways, but byfar the most common organ affected is the skin• A. Local changes : 1. Zone of coagulation 2. Zone of stasis . 3. Zone of hyperaemia Tuesday, January 8, 2013 DR. RUBEL, SBMC 7
  8. 8. 3 Zones of T her malInjur y Hyperemia Stasis CoagulationTuesday, January 8, 2013 DR. RUBEL, SBMC 8
  9. 9. B. Systemic changes  1.Inflammation and oedema  2.Respiratory changes  3.Effects on the renal system  4.Effects on GIT  5.Effects on immune system  6. HypercatabolismTuesday, January 8, 2013 DR. RUBEL, SBMC 9
  10. 10. B. Systemic changesTuesday, January 8, 2013 DR. RUBEL, SBMC 10
  11. 11. 6. HypercatabolismTuesday, January 8, 2013 DR. RUBEL, SBMC 11
  12. 12. FACTORS DETERMINING THE SEVERITY OF BURN• As burn is the only truly quantifiable form of trauma, there are so many factors predicting burn related mortality & morbidity.1) Age  Reaction to burn  Different healing process2) Source of burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 12
  13. 13. Candle fire Stove fireTuesday, January 8, 2013 DR. RUBEL, SBMC 13
  14. 14. Chemical fireTuesday, January 8, 2013 DR. RUBEL, SBMC 14
  15. 15. DIATHERMY BURNTuesday, January 8, 2013 DR. RUBEL, SBMC 15
  16. 16. 2. Burn size: • A General idea of the burn size can be made by using the rule of nines. • Smaller burns can be calculated by using the pts palmer hand surface including the digits which is about 1% of T B S A. • Calculation of burn size is necessary for diagnosis, treatment, prognosis & statistics.Tuesday, January 8, 2013 DR. RUBEL, SBMC 16
  17. 17. 3. Burn depth:• Burn depth is dependent upon the temperature of the burn source, the thickness of the skin, the duration of contact, the heat dissipation capability of skin (blood flow). Thickness further depends upon age, sex & the area of the body.• Depth may be non uniform through out the burn extent and depth may progress ē time. Tuesday, January 8, 2013 DR. RUBEL, SBMC 17
  18. 18. Burn severity map according todepthTuesday, January 8, 2013 DR. RUBEL, SBMC 18
  19. 19. Depth of Burn• First- degree or epidermal: • Involves only epidermis, erythematous, non blistering quite painful• Second-degree or superficial partial: • Includes papillary layers of dermis.• Second-degree or deep partial: • Extend into the reticular layers of the dermis• Third degree or full thickness: • Involve all the layers of dermis• Fourth degree: • Involves skin, subcutaneous tissue & deeper structures Tuesday, January 8, 2013 DR. RUBEL, SBMC 19
  20. 20. Depth of Burn Appearance of Sensitivity to Healing timeDepth of Burn Tissues destroyed burns pain Prognosis - Epidermis & - Red -Painful and - 7 - 14 days Superficial upper layer of - Blisters hypersensitive - Pigment Partial dermis change thickness - Hair follicles, - Blanching possible or sweat and Superficial sebaceous dermal glands intact. - Epidermal and - white with red Generally - 21- 35 days deeper dermis - No blisters insensitive to - SevereDeep partial - Most nerve - No blanching pain scarring thickness endings, hair - Eschar forms - Risk of or follicles and contracturesDeep dermal sweat glands - May need destroyed. grafting All skin layers White charred, No pain - No skinFull-thickness January 8, 2013 Tuesday, destroyed DR. RUBEL, SBMC dry, inelastic 20 regeneration
  21. 21. Superficial partialthickness burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 21 Deep dermal burn
  22. 22. Full thickness burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 22
  23. 23. 4. Site of Burn Inhalation injury should be suspected in a flame burn. Burn to the face could affect airway management or the eyes. Burn to the hand and feet could impede movement of fingers and toes.Tuesday, January 8, 2013 DR. RUBEL, SBMC 23
  24. 24. 6. Co-morbid factors: • Associated trauma • Impaired sensation due to diabetes or intoxication • Pre-existing cardiovascular, respiratory, renal disease. • Seizure disorders • Pre existing hypovoluaemia or shock • Immunization history • Known allergy • Social circumstances • Suicide or homicide attempts • Child abuse • Lack of care Tuesday, January 8, 2013 DR. RUBEL, SBMC 24
  25. 25. Management of BurnThe priorities in management of burnA. Air way control .B. Breathing and ventilation .C. Circulation .D. Disability - neurological status .E. Exposure with environmental control.F. Fluid resuscitation .Tuesday, January 8, 2013 DR. RUBEL, SBMC 25
  26. 26. Pre-hospital car eThe principles of pre-hospital care are:• Ensure rescuer safety.• Stop the burning process.• Check for other injuries. A standard ABC (airway, breathing, circulation) check followed by a rapid secondary survey will ensure that no other significant injuries are missed.• Cool the burn wound. This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury. Cooling should occur for a minimum of 10 min and is effective up to 1 hour after the burn injury. It is a particularly important first aid step in partial-thickness burns, especially scalds. In temperate climates, cooling should be at about 15°C, and hypothermia must be avoided. Tuesday, January 8, 2013 DR. RUBEL, SBMC 26
  27. 27. Pre-hospital care-contd.• Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen, especially if there is an altered consciousness level.• Elevate. Sitting a patient up with a burned airway may prove life-saving in the event of a delay in transfer to hospital care. Elevation of burned limbs will reduce swelling and discomfort. Tuesday, January 8, 2013 DR. RUBEL, SBMC 27
  28. 28. Initial assessment :Primary surveyImmediate life threateningconditions are quickly identifiedand treated Secondary survey Thorough head to toe evaluation. Tuesday, January 8, 2013 DR. RUBEL, SBMC 28
  29. 29. • Indications for intubation: (I) Erythema / swelling of the oropharynx on direct visualization . (II) Change in voice with hoarseness / harsh cough (III) Stridor. (IV) Dyspnoea.Tuesday, January 8, 2013 DR. RUBEL, SBMC 29
  30. 30.  In an explosion or deceleration accident -- appropriate cervical spine stabilization until the condition can be evaluated .Tuesday, January 8, 2013 DR. RUBEL, SBMC 30
  31. 31. C. Initial Wound care• Cover the wound with clean dry dressing or sheet Pain reduced by cover the wound to prevent contact to exposed nerve ending.• I.V. narcotics .• The parts should be immobilized to a safe functional position and the injured extremity elevated if possible . Tuesday, January 8, 2013 DR. RUBEL, SBMC 31
  32. 32. D. Transport : What ever the mode of transport it should be to appropriate place having emergency equipment available and trained personnel with necessary facilities .Tuesday, January 8, 2013 DR. RUBEL, SBMC 32
  33. 33. Criteria for hospitalization : • Age : < 5yrs or > 60 yrs. • Site : face , hands , feet , perineum or fracture. • Inhalation injury . • Mechanism of injury.  Chemical injury >5% TBSA.  Exposure to ionizing radiation .  High pressure steam injury  High tension electrical injury .  Suspicion of non accidental injury .  Hydrofluoric acid injury > 1% TBSA . • Size : < 16yrs - > 5% TBSA 16 yrs or > 16 yrs - > 10% TBSA • Require fluid resuscitation. Require surgery . • Psychiatric patient . • Coexisting condition. Tuesday, January 8, 2013 DR. RUBEL, SBMC 33
  34. 34. Assessment of burn wound : (I) Assessment of burn size by - Wallace’s rule of nines - Patients whole hand ( palm and digit ) - Lund and Browder chart . (II) Assessment of burn depth - From history – temperature , time of exposure and burning material . - Superficial burns have capillary filling . - Deep partial thickness burns don’t blanch but have some sensation . - Full thickness burns feel leathery and have no sensation. Tuesday, January 8, 2013 DR. RUBEL, SBMC 34
  35. 35. Tuesday, January 8, 2013 DR. RUBEL, SBMC 35
  36. 36. Lund andBrowderchart . Tuesday, January 8, 2013 DR. RUBEL, SBMC 36
  37. 37. Resuscitative fluid management :Principle : Maintenance of intra vascular volume in order to provide sufficient circulation to perfuse not only the essential visceral organs such as the brain , kidneys and the gut but also the peripheral tissues. Tuesday, January 8, 2013 DR. RUBEL, SBMC 37
  38. 38. Resuscitation by oral fluid : Indication : < 10 % TBSA in child. < 15% TBSA in adult . Fluid : Salt containing oral fluid e.g. ORS , fruit juice . Tuesday, January 8, 2013 DR. RUBEL, SBMC 38
  39. 39. Resuscitation by I V fluid Indication : >10% TBSA in child . >15% TBSA in adult . Fluids: a. Crystalloids I) Ringers lactate, Hartmann’s solution. II)0.9% NaCl solution III) Hypertonic saline solution . IV) 5% DNS. b. Colloids I) Plasma II) Plasma substitutes Tuesday, January 8, 2013 DR. RUBEL, SBMC 39
  40. 40. Formula :1. Parkland Formula : 1st 24 hrs Total fluid = 4 ml X body weight in kg X % of burn = ml Fluid : Ringer’s lactate . Schedule : 1st 8 hours = ½ of total fluid . 2nd 8 hrs = ¼ th of total fluid. 3rd 8 hrs = 1/4th of total fluid. Next 24 hrs I) .5 ml X body weight in Kg X % of burn. fluid – usually colloid or plasma. II) 5% DA to get urine out put. {.5 – 1.5 ml / Kg /hrs .} 5% DNS instead of 5% DATuesday, January 8, 2013 DR. RUBEL, SBMC 40
  41. 41. 2. Muir and Barclay formulaSix rations in 1st 36 hours -4/4/4, 6/6 and 12 hours respectivelyEach ration= % burn X body weight in Kg/2 = ml.Fluid : Plasma3. Galveston ( Pediatric ) 5000 ml/ m2 TBSA burned+1500 ml / m2 TBSA. Fluid- 5% dextrose , Ringer’s lactate . Tuesday, January 8, 2013 DR. RUBEL, SBMC 41
  42. 42. Monitoring• Clinical.• Biochemical & Hematological.• Invasive. Tuesday, January 8, 2013 DR. RUBEL, SBMC 42
  43. 43. Clinical :• Pulse - <120/Min.• BP-• Urinary output* 0.5 ml – 1.5 ml /kg/hr. in adult. 10-20 ml / hr. in child.• Core & Shell temp.• Thirst.* If the urine output is below this, the infusion rate should be increased by 50%. If the urine output is inadequate and the patient is showing signs of hypoperfusion (restlessness with tachycardia, cool peripheries and a high haematocrit), then a bolus of 10 ml/kg body weight should be given. It is important that patients are not over-resuscitated, and urine output in excess of 2 ml/kg body weight per hour should signal a decrease in the rate of infusion.Tuesday, January 8, 2013 DR. RUBEL, SBMC 43
  44. 44. Management Contd.Biochemical1. Hb%2. Urinary osmolality3. Serum electrolytes4. Serum creatinine & Blood ureaInvasive1. CVP2. Invasive arterial pressureTuesday, January 8, 2013 DR. RUBEL, SBMC 44
  45. 45. MANAGEMENT OF BURN WOUNDTuesday, January 8, 2013 DR. RUBEL, SBMC 45
  46. 46. Wound management• Depends on – 1. Types of burn. 2. Site of burn . 3. Percentage of burn . 4. Depth of burn . 5. Age of the patient . 6. General condition of the patient.Tuesday, January 8, 2013 DR. RUBEL, SBMC 46
  47. 47. Flame burn (Carelessness)Tuesday, January 8, 2013 DR. RUBEL, SBMC 47
  48. 48. ScaldTuesday, January 8, 2013 DR. RUBEL, SBMC 48
  49. 49. HomicidalTuesday, January 8, 2013 DR. RUBEL, SBMC 49
  50. 50. Electric Burny by - Prof. Dr. A. January 8, 2013 Tuesday, J. M. Salek DR. RUBEL, SBMC 50
  51. 51.  Electric BurnTuesday, January 8, 2013 DR. RUBEL, SBMC 51
  52. 52. lectric Burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 52
  53. 53. Electric Burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 53
  54. 54. Electric BurnCourtesy by - Prof. Dr. A. J. M. Salek Tuesday, January 8, 2013 DR. RUBEL, SBMC 54
  55. 55. Diathermy Burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 55
  56. 56. ShareeTuesday, January 8, 2013 DR. RUBEL, SBMC 56
  57. 57. Floor level cookingTuesday, January 8, 2013 DR. RUBEL, SBMC 57
  58. 58. EpilepsyTuesday, January 8, 2013 DR. RUBEL, SBMC 58
  59. 59. Perineum  warmingTuesday, January 8, 2013 DR. RUBEL, SBMC 59
  60. 60. WarmingTuesday, January 8, 2013 DR. RUBEL, SBMC 60
  61. 61. Gas misuse Tuesday, January 8, 2013 DR. RUBEL, SBMC 61
  62. 62. Burning ashTuesday, January 8, 2013 DR. RUBEL, SBMC 62
  63. 63. Children Playing with FireTuesday, January 8, 2013 DR. RUBEL, SBMC 63
  64. 64. Electric Burn Tuesday, January 8, 2013 DR. RUBEL, SBMC 64
  65. 65. Wound ManagementInfection is a common problem& Major cause of late death Skin – ‘keeps the outsides out and the insides in’. Universal precautions. Barrier nursing. Tetanus prophylaxis. Do not routinely give strong antibiotics Tuesday, January 8, 2013 DR. RUBEL, SBMC 65
  66. 66. Wound ManagementWound Dressing • Various dressings • Review at 48 hours • Then dress accordinglyTuesday, January 8, 2013 DR. RUBEL, SBMC 66
  67. 67. Wound ManagementWound Dressing – Special Areas • Face - expose with antiseptic • Hands – In bags • Perineum – Expose with creamTuesday, January 8, 2013 DR. RUBEL, SBMC 67
  68. 68. Dressing description1. Antimicrobials. Silver sulfadiazine. Mafenide acetate. Bacitracin. Neomycin. Polymyxin B. Silver nitrate solution. Mupirocin.Tuesday, January 8, 2013 DR. RUBEL, SBMC 68
  69. 69. 2 . Antimicrobial soaks. 0.5% silver nitrate. 5% mefenide acetate. 0.025% sodium hypochlorite. 0.25% acetic acid .Tuesday, January 8, 2013 DR. RUBEL, SBMC 69
  70. 70. 3. Synthetic covering. Opsite . Biobrane. Transcyte. Integra.Tuesday, January 8, 2013 DR. RUBEL, SBMC 70
  71. 71. 4. Biological coverings. Xenograft (pig skin). Allograft (homograft, cadaver skin ).Tuesday, January 8, 2013 DR. RUBEL, SBMC 71
  72. 72. Principles of dressingsfor burns :• Full thickness and deep dermal burns need antibacterial dressings to delay colonisation prior to surgery.• Superficial burn will heal and need simple dressing.• An optimal healing environment can make a difference to outcome in borderline depth burn.Tuesday, January 8, 2013 DR. RUBEL, SBMC 72
  73. 73. Exposure versus Closed Management1. Exposure therapy : • Advantages – a. Less bacterial growth. b. Remains visible. c. Readily accessible. • Disadvantages- a. Increased pain. b. Heat loss. c. Cross contamination. Tuesday, January 8, 2013 DR. RUBEL, SBMC 73
  74. 74. 2. Closed method : Advantages – - less pain . - less heat loss . - less cross-contamination . Disadvantages – - increases bacterial growth .The closed method is generally preferred .Tuesday, January 8, 2013 DR. RUBEL, SBMC 74
  75. 75. Surgical treatment of deep burn : • Deep dermal burns need tangential shaving and split-skin grafting . • All but the smallest full-thickness burns need surgery • All burnt tissue needs to be excised . • Stable cover , permanent or temporary , should be applied at once to reduce burn load . • Escharotomy – the tourniquet effect of full thickness burn injury is easily treated by incising the whole length of burn This should be done in the mid- axial line , avoiding major nerves. Tuesday, January 8, 2013 DR. RUBEL, SBMC 75
  76. 76. Tangential Excision(TE) • Done “early” (w/in 7 d) • Various adjustable knives • Sequentially remove only non-viable tissue • Standard burn operation • BLOODY!!! • Tourniquets on extremities • Speed is essentialTuesday, January 8, 2013 DR. RUBEL, SBMC 76
  77. 77. Technique Escharotomy ANATOMIC POSITION!! • Med & lat lines of extremities, over lumbricals on dorsal hands, ant or mid axillary lines on chest, & lateral neck lines • Thru eschar only -- RELEASE • Use cautery (knife OK) • Not a sterile procedure • Digits are controversialTuesday, January 8, 2013 DR. RUBEL, SBMC 77
  78. 78. After…Tuesday, January 8, 2013 DR. RUBEL, SBMC 78
  79. 79. Electrical burn wound : • Debribed to underlying healthy tissue. • Second debribement usually indicated 24 - 48 hrs after injury. • Microvascular flaps now used routinely to replace large tissue losses.Tuesday, January 8, 2013 DR. RUBEL, SBMC 79
  80. 80. Fascial Excision (FE) • Done “early” (w/in 7 days) • Used for deep FT w/ dead subcut. tissue • Excise to fascia • “Inferior” cosmesis (?) • Blood loss < TETuesday, January 8, 2013 DR. RUBEL, SBMC 80
  81. 81. Chemical burn wound Incident with chemical agent Irrigate copiously water (several liters ) Acid burns Alkali burn Check surface PH Check surface PHIf <7 ,continue irrigating untill range ( 7- If >7.5, continue irrigating untill PH7.5). Take care to direct the irrigant reaches the physiologic ranges (7-7.5) .away from non-injures skin. Once theC PH should be checked again afterwound PH reaches a physiologic h range , debridement , as alkaki agents canthe injury process has finished. e penitrate through the surface . Thereafter , c treat the wound with standard techniques k Tuesday, January 8, 2013 DR. RUBEL, SBMC 81
  82. 82. Radiation burn wound : • Local burns causing ulcerations need excision and vascularised flap cover – usually with free flaps . • Systemic overdose needs supportive treatment . Tuesday, January 8, 2013 DR. RUBEL, SBMC 82
  83. 83. Complications of Burn : Infection Bacteraemia . Septecemia Renal failure Pulmonary complication Inhalation injury. Aspiration in unconscious pts. Bacterial pneumonia. Pulmonary edema. Pulmonary embolism Atelectasis Brochiectasis Post traumatic pulmonary insufficiency. Tuesday, January 8, 2013 DR. RUBEL, SBMC 83
  84. 84. Complications of hyper metabolism and nutrition : • A catecholamine mediated hyper metabolism is manifested by tachycardia and hyper dynamic cardiac activity with resultant increase in the myocardial oxygen requirements . • A syndrome of hyperglycemia , glycosuria, acute dehydration , shock , coma and renal failure may be seen . • Combined with hyperglycemia resulting from the necessary high calorie replacement of a major burn a syndrome of pseudo-diabetis can occur . Tuesday, January 8, 2013 DR. RUBEL, SBMC 84
  85. 85. Electrolyte imbalance : - Hypokalaemia . - Hyponatraemia . - Seizure – a complication unique to children which may result from electrolyte imbalance .Tuesday, January 8, 2013 DR. RUBEL, SBMC 85
  86. 86. Gastrointestinal complication : Curling’s ulcer. Hematemesis and melaena . DiarrhoeaCardiovascular : ArrhythmiaTuesday, January 8, 2013 DR. RUBEL, SBMC 86
  87. 87. Hematological & Immunological : Anaemia Immunosuppression increases the risk of septic complications .Multi-organ failure: There may be progressive failure of renal , hepatic or heart failure . Tuesday, January 8, 2013 DR. RUBEL, SBMC 87
  88. 88. Local complications:Eschar formationScar formation : Hypertrophic scar Keloid . Contracture : a. Skin contracture b. Muscle contracture ( fibrosis ) c. Joint contracture . d. Tendon adherence to bones. Marjolin’s ulcer . Tuesday, January 8, 2013 DR. RUBEL, SBMC 88
  89. 89. Non specific complications : UTI ( from catheterization ). Deep vein thrombosis. Pulmonary embolism .Tuesday, January 8, 2013 DR. RUBEL, SBMC 89
  90. 90. Late management :• Wound management : Skin graft : - full thickness burns : require skin grafts. Transposition flaps . Free flaps . Tuesday, January 8, 2013 DR. RUBEL, SBMC 90
  91. 91. Management of scar & contracture:• Scar contracture – Broad contracture require release and insertion of skin grafts; such operations are particularly valuable in restoring the range of motion of a joint Where there is a localized linear contracture a better technique may be Y- V plasty. Z-plasty is useful in the situation in which there is a single band and a transposition flap is useful in wider bands of scarring. Tuesday, January 8, 2013 DR. RUBEL, SBMC 91
  92. 92. Tissue expansion This technique allows gradual stretching of marginal skin by implanting expander balloons under the adjacent normal skin . These are serially injected with saline through a part , there by enlarging the expander & stretching the over lying skinTuesday, January 8, 2013 DR. RUBEL, SBMC 92
  93. 93. Hypertrophic scar Pressure garments ‍ Revision of hypertrophic scars is appropriate where the scar cross skin tension lines or where a specific wound healing complication occurred. Tuesday, January 8, 2013 DR. RUBEL, SBMC 93
  94. 94. Pressure garmentsTuesday, January 8, 2013 DR. RUBEL, SBMC 94
  95. 95. Keloid scar Some keloids will improve with the application of pressure . Intralesional injection of steroids . Best cure by combination surgery and postoperative interstitial radiotherapy.Tuesday, January 8, 2013 DR. RUBEL, SBMC 95
  96. 96. Late management : • Wound management :  Skin graft .  Trans position flaps .  Free flaps .Tuesday, January 8, 2013 DR. RUBEL, SBMC 96
  97. 97. Outcome of Burn :Major determinants 1. Percentage of surface area involved 2. Depth of burn 3. Presence of an inhalational injury.Percentage of burn+ age of patient =100 indicates the bad prognosis.Tuesday, January 8, 2013 DR. RUBEL, SBMC 97
  98. 98. Thanks! Have a nice day.Tuesday, January 8, 2013 DR. RUBEL, SBMC 98
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