2. OVERVIEW
▶ Part I
▶ Historical perspective
▶ Statistics
▶ Classification of Burns
▶ Pathophysiology
▶ Evaluation
▶ Part II
▶ Management
▶ Pre-hospital Care
▶ Resuscitation & Nutritional support
▶ Burn wound care
▶ Complications
▶ Rehabilitation
2
3. Definition
Injuries that result from direct contact or exposure to any physical, thermal,
chemical, electrical, or radiation source are termed as Burns.
3
5. Historical Perspective
▶ First direct evidence of treatment for burns
- Cave paintings of Neanderthal man
▶ 1500 BC : Egyptian Smith Papyrus – Resin
& Honey
▶ Ambroise Pare ( AD 1510 – 1590) :
Technique of early excision of burn wounds
5
7. Historical Perspective
▶ 19th century : Dupuytren’s
classification based on depth
▶ 1842 : Curling : Gastric &
Duodenal Ulceration
Thom
asBlizardCurling
BaronGuillaum
eDupuytren
7
8. Historical Perspective
▶ 1947 : Texas city disaster
▶ Truman G. Blocker Jr:
Multidisciplinary team
approach of Burns.
▶ First Burn Institute for
children in Galveston
8
11. Problem Statement : Global
An estimated 265000 deaths every year are caused by burns.
One of leading causes of disability-adjusted life-years (DALYs) lost in low- and
middle-income countries.
In 2004, nearly 11 million people worldwide were burned severely enough to
require medical attention.
WHO Apr 14
11
12. Problem Statement: US
: 486,000
: 3,275
: 40,000
Burn Injuries Receiving Medical Treatment
Fire/Smoke Inhalation Deaths
Hospitalizations Related to Burn Injury
Survival Rate : 96.8%
American Burn Association, 2016
12
13. Problem Statement : India
70 lakh burn injury cases annually
Over 10,00,000 people are moderately or severely burnt every year
1.4 lakh people die of burn every year.
Around 70% of all burn injuries occur in most productive age group (15-35
years).
Around 4/5 are women & children.
As many as 80% of cases admitted are a result of accidents at home (kitchen-
related incidents)
13
16. Thermal Injuries
▶ Most common
▶ Types : Dry & wet
Contact
▶Direct contact with hot object (i.e. pan or iron)
▶Anything that sticks to skin (i.e. tar, grease or
foods)
16
17. Thermal Injuries
▶Flame
▶Direct contact with flame (dry heat)
▶structural fires / clothing catching on fire
▶Scalding
▶Direct contact with hot liquid / vapours (moist
heat)
▶Cooking, bathing or car radiator overheating
▶Single most common injury in the paediatric pt
17
18. Electrical Burns
▶ Usually follows accidental contact with exposed object conducting electricity
▶ Electrically powered devices
▶ Electrical wiring
▶ Power transmission lines
▶ Can also result from Lightning
▶ Damage depends on intensity of current
18
19. Electrical Burns
▶ Severity depends upon:
▶ what tissue current passes through (Low voltage/ High voltage)
▶ width or extent of the current pathway
▶ AC or DC
▶ duration of current contact
▶ Tissues with the lowest resistance eg. nerves, blood vessels & muscles
▶ Heat generation during passage of the current injures the tissues
▶ Skin has a relatively high resistance, hence is mostly spared
19
20. Electrical Burns
▶ Low-tension injuries(<1000 V)
▶ Low energy burns Minimal damage to subcutaneous tissue
▶ Entry & Exit points – fingers small deep burns
▶ AC Tetany within muscles, cardiac arrest due to interference with
normal cardiac pacing
20
21. Electrical Burns
▶ High-tension injuries(>1000V)
▶ Flash/ Flame / Current
▶ Earthed high tension lines Arc
over the patient Flash burn
▶ Heating of the surrounding air
Explosion Flame burn
▶ Direct contact patient acts as
conduction rod huge subcutaneous
damage
21
22. Electrical Burns
▶ Lightning
▶ HIGH VOLTAGE!!!
▶ Injury may result from
▶Direct Strike
▶Side Flash
▶ Severe injuries often result
22
26. Chemical Burns
▶ Usually associated with industrial exposure
▶ Accidental mishandling of household cleaners
▶ Degree of tissue damage determined by
- Chemical nature of the agent
- Concentration of the agent
- Duration of skin contact
26
27. Chemical Burns
▶ Acids
▶ Immediate coagulation necrosis creating an eschar; self-limiting
▶ Bases (Alkali)
▶ Liquefactive necrosis with continued penetration into deeper tissue resulting
in extensive injury
Eg. Lime, potassium hydroxide, cement
27
29. Radiation Exposure
▶ Waves or particles of energy that are emitted from radioactive sources
▶ Alpha radiation
Large, travel a short distance, minimal penetrating ability
Can harm internal organs if inhaled, ingested or absorbed
▶ Beta radiation
Small, more energy, more penetrating ability
Usually enter through damaged skin, ingestion or inhalation
29
30. Radiation Exposure
▶ Gamma radiation & X-rays
Most dangerous penetrating radiation
May produce localized skin burns & extensive internal damage
30
31. Classification
Based on Depth
▶ I Degree - Epidermis
▶ II Degree - Epidermis+ Dermis
▶ III Degree - Epidermis+ Dermis +
Subcutaneous tissue
▶ IV Degree - Above + Muscles/bone
31
32. Classification
Degree 1st Degree
of Burn
2nd Degree
Partial Thickness
2nd Degree
Deep Burns
3rd Degree
Involvement Epidermis Epidermis + Dermis E+ D E+D+Subcut tissue E+D+S+muscles,
tendons & bone
Appearance
Severe Edema
Symptoms &
Signs
Pain ++ Pain ++++ Painful -less severe Painless,insensitive, No Edema
Healing 3-5 days ,
spontaneous
No Scarring
2 weeks, min
scarring, minimal
discolouration
2-6 weeks
Hypertrophic
scarring / formation
of contractures
No spontaneous
healing
No spontaneous
healing
4th D
e
3g
2r
e
e
35. Pathophysiology : Local Effects
▶ Zone of coagulation
▶ Necrotic area with cellular disruption
▶ Irreversible tissue damage
▶ Zone of stasis
▶Moderate insult with decreased tissue
perfusion
▶ Can survive or go on to coagulative
necrosis depending on wound
environment
36
JACKSON’s burn zones
36. Pathophysiology : Local Effects
▶ Zone of hyperemia
▶Viable tissue, not at risk for
further necrosis
37
38. Pathophysiology : Local Effects
▶ Edema in non-burned tissue
▶ Loss of capillary endothelial integrity
▶ Reduced transmembrane potentials of skeletal muscle at the site of
injury as well as away from the site of damage [-90mv -70 to -80mv]
▶ Increase in intracellular Na & water leading to edema
39
50. Pathophysiology : Systemic Effects
▶ Immune system
▶ Global depression in immune function
▶ Diminished production of macrophages
▶ Increased neutrophil count (dysfunctional) followed by decrease after 48-
72 hrs
▶ Impaired cytotoxic T cell activity
▶ Increase risk of infections
▶ Depressed Th function
51
51. Pathophysiology : Systemic Effects
▶ Hypermetabolic response
▶Phase I [ebb]
▶First 48 hrs
▶Decrease in
▶cardiac output
▶urine output
▶O2 consumption
▶BMR
▶Impaired glucose tolerance with hyperglycemia
52
52. Pathophysiology : Systemic Effects
▶ Hypermetabolic response
▶ Metabolic variables gradually increase within first five days post injury to reach a plateau
▶ Phase II [flow]
▶ Increase in metabolic rate
▶ Urine cortisol
▶ Serum catecholamines
▶ Basal energy expenditure
▶ Serum cytokines
▶ Hyperdynamic state – increase in cardiac output
▶ Insulin resistance
▶ Persists for upto 3 years
53
55. Pathophysiology : Systemic Effects
▶ Carbon Monoxide
▶ Most frequent cause of death in smoke induced inhalational injury
▶ Pathology : 0.1% of CO 50% Carboxy Hb
▶ Hb affinity of CO 200-250 times that of O2
▶ Mechanism: Competitive inhibition of Cyt P450
Free radical formation
(Xanthine dehydrogenase Xanthine Oxidase)
56
57. Pathophysiology
▶ Hydrogen cyanide
▶ Fires involving N2 containing
compounds
▶ Mechanism :
▶Inhibition of cellular oxygenation
with resultant tissue anoxia
▶Reversible inhibition of Cyt oxidase
(Fe 3+) by CN
58
58. Pathophysiology : Oropharynx
Heat
Denaturation of proteins
Complement Activation
Histamine release
Formation of Xanthine Oxidase
Converts Uric acid to urea
Release of O2 free radicals
Edema formation
Release of Eicosanoids
Attract PMNs to the site
(Amplify effects)
Massive Edema
59
59. Pathophysiology : Tracheo-bronchial areas
Chemical Injury to airway
Seperation of ciliated epi-cells from
BM
Increased Circulation to lung &
bronchial circulation
Edema formation
Diffuse transudate in early changes
Bronchoconstriction Fibrin casts
Obstruction of smaller airways
Culture media for infections
Pneumonia , Sepsis & Death
60
66. Palm Method
▶ Size of Patient’s palm 1% of TBSA
▶ Irregular wounds with scattered distribution.
67
67. OVERVIEW
▶ Part I
▶ Historical perspective
▶ Statistics
▶ Classification of Burns
▶ Pathophysiology
▶ Evaluation
▶ Part II
▶ Pre-hospital Care
▶ Resuscitation & Nutritional support
▶ Burn wound care
▶ Complications
▶ Rehabilitation
68
69. PHASES OF TPT
▶ Phase 1: Treatment at the scene and tpt to initial care facility
▶ Phase 2: Assessment and stabilization at initial care facility and tpt to
burn ICU.
70. PRE HOSPITAL MANAGEMENT
▶ Rescuer to avoid injuring himself
▶ Remove patient from source of injury
▶ Stop burn process
▶ Burning clothing; jewelry, watches, belts to be removed
▶ Pour ample water on burnt area (not ice/ ice packs – skin injury &
hypothermia)
71. PRE HOSPITAL MANAGEMENT
▶ Chemical burns:
▶ Remove saturated clothing
▶ Brush skin if agent is powder
▶ Irrigation with copious amount water to be started and continued in
hospital
▶ Electrical burns:
▶ Turn off the current
▶ Use non-conductor item to separate from source
72. PRE HOSPITAL MANAGEMENT
PRIMARYASSESSMENT
▶ A – B – C – Cervical spine immobilization
▶ Respiratory tract:
▶ Edema of upper airway sets in very fast
▶ Upper airway obstruction
▶ 100% humidified O2 if no obvious resp distress
73. PRE HOSPITAL MANAGEMENT
PRIMARYASSESSMENT
▶ ET intubation + assisted ventilation with 100% O2 if:
▶ Overt signs and symptoms of airway obstruction (Progressive hoarseness)
▶ Suspected inhalational injury (smoke/ carbon monoxide intoxication)
▶ Unconscious patient/ rapidly deteriorating patient
▶ Acute respiratory distress
▶ Burns of face & neck
▶ Extensive Burns (> 40% TBSA)
74. PRE HOSPITAL MANAGEMENT
PRIMARYASSESSMENT
▶ Pulse rate better monitor than BP
▶ Spinal immobilization:
▶ Explosion/ deceleration injury
▶ Cervical collar (Philadelphia collar)
75. PRE HOSPITAL MANAGEMENT
Ice/ice cold water causes numbness, intense vasoconstriction, hypothermia
causing further damage.
Do not break blisters.
Do not apply lotions, powders, grease, ghee, gentian violet, calamine lotion,
toothpastes, butter and other sticky agents over the burn wound.
Prevent contamination: Wrap burn part in clean dry sheet /cloth.
Assess for life threatening injuries.
76. PRE HOSPITAL MANAGEMENT
NO I/M or S/C inj (Capillary leakage results in unpredictable absorption)
I/V morphine to allay anxiety
Pain relief and reassurance
Withhold oral intake
77. PRE HOSPITAL MANAGEMENT
▶ Co-morbid conditions/ pre-existing illness
▶ Initiate rapid transfer to hospital
▶ Secure and protect the airway
▶ Cervical spine immobilization; if necessary
78. PRE HOSPITAL MANAGEMENT
SECONDARY ASSESSMENT
▶ Performed only if no immediate life threatening injury/ hazard present
▶ Thorough head to toe evaluation
▶ Medical history, medication, allergies, mechanism of injury
▶ Start IV line (not reqd in hospital <60 min away)
79. PRE HOSPITAL MANAGEMENT
SECONDARY ASSESSMENT
▶ RL infusion:
▶ ≥ 14 yrs
▶ 6-14 yrs
▶ ≤ 5yrs
– 500mL/hr
– 250mL/hr
– 125mL/hr
▶ Apply clean dressing/ sheet to protect area and minimize heat loss
▶ IV Tramadol to relieve pain
▶ No topical antimicrobial
80. HOSPITAL MANAGEMENT
INITIAL CARE FACILITY
▶ C – A – B
▶ Establish adequate airway
▶ ET intubation – impending airway edema (post initiation of IV therapy)
▶ Maintain cervical spine immobilization
81. INITIAL CARE FACILITY
▶ History
▶ Mechanism of injury
▶ Time of injury
▶ Surroundings (closed space/ chemicals)
▶ Physical examination
▶ Head to toe assessment
▶ Careful neurological examination (cerebral anoxia)
▶ Corneal fluorescent examination in facial burns
▶ Labs: CBC, electrolytes, BUN
▶ Pulmonary assessment: ABG, CXR, carboxyhemoglobin
82. INITIAL CARE FACILITY
▶ Pulse in extremities: manual/ doppler
▶ Loss of distal circulation
▶Pallor/coolness/absent pulse/loss capillary refill/decreased oxygen
saturation
▶ Pain on passive extension
▶ Deep pain at rest
▶ Absent pulse: emergency escharotomy to release constrictive, unyielding
eschar
83. ESCHAROTOMY
▶ Deep 2nd & 3rd degree circumferential burns
▶ Chest: To allow respiratory movement
▶ Limb: To restore circulation in limb with excess swelling under rigid eschar
▶ Bedside, IV sedation, cautery
▶ Midaxial incision into eschar, Across joints
▶ Caution at elbow, wrist, fibular head, medial ankle, neck
▶ Not in SC tissue Exposes SC fat
84.
85. ESCHAROTOMY
▶ Elevate limbs above level of heart
▶ Monitor pulses for 48 hrs
▶ Chemical escharotomy if pulses +nt but feeble.
▶ Useful in hand burns.
▶ Enzyme – collagenase
▶ Complications : bleeding, infection
▶ Antimicrobial prophylaxis must to prevent sepsis
86. INDICATIONS FOR ADMISSION
▶ >15% burns in adults
▶ 10% burns in children
▶ Airway and inhalation injury.
▶ Significant burn involving face, hands, feet and perineum.
▶ Extremes of age.
▶ Suspected non-accidental burns.
▶ Burns that require early surgery (deep partial thickness / full thickness)
▶ Patients deficient of nursing care by attendants at home
▶ Severe electric and acid burns that is likely to have serious sequelae
87. RECEPTION
• Resuscitation –ensure ABC
• Large gauge I.V catheter
• Central line Insertion
• Venesection
• Foleys catheter and NG tube placement
• Quick assessment of extent
• Tetanus prophylaxis (the only IM administered inj)
• Weigh the patient
88. Respiratory Care
Assess airway, respiration & breath sounds
Removal of pulmonary secretions
O2 Humidification
Chest physiotherapy, deep breathing & coughing
Frequent position changes and suction
Pharmacologic Considerations:
Bronchodilators and mucolytics
Circumferential chest burns can impair ventilation
Escharotomy may be required
89. Cardiovascular Care
▶ Increase capillary permeability
▶ “Capillary Leakage Syndrome”
▶ Fluid shift intravascular to interstitial space blistering and massive
edema
▶ Excessive insensible loss via burn wound 3-5 lit/d !!
▶ Finally hypovolemia untreated BURNS’ SHOCK
90. Severity of Burn Injuries
▶ Treatment of burns as per severity of injury
▶ Severity is determined by:
▶ Depth of burns
▶ TBSA involved
▶ Site - face, hands, feet, face or perineum
▶ Age
▶ Associated injuries
N Engl J Med 1996;335:1581 J Trauma 1994;36;59
94. Parkland Formula
Fluid of Choice
Lactated Ringer’s (RL)
NS can produce hyperchloremic acidosis
4 ml x % of burn x weight (Kg) in 24 hours
First ½ of total volume given in the first 8 hours
Remaining ½ of total volume given over following 16 hours
NEXT 24 HRS
Total volume ½ of first day
Colloids ( 0.5 ml / kg / % )
5 % glucose to make up the rest
95. Parkland Formula
Maximum applicable TBSA – 50%
Fully dilated capillaries
Maximum capillary permeability
No further mounting of inflammatory response
96. Adult Fluid Resuscitation
Evan’s formula:
Requirement for first 24 hrs
Colloids : 1ml/kg/% burn
Saline
D5
: 1ml/kg/% burn
: 2000ml
Requirement for second 24 hrs
½ of first 24 hrs
97. Adult Fluid Resuscitation
Brooke formula
Requirement for first 24 hrs
Colloids : 0.5ml / kg /% burn
RL
D5
: 1.5ml / kg / %burn
: 2000ml in adults
Requirement for second 24 hrs
½ of first 24hrs
98. Pediatric age group
Carvajal Formula
5000cc x m2 x % BSA initial + 2000cc x m2 maint /d
Change to 5%D+RL with albumin after 6 hrs
Urine output 1-2 cc/ kg/h
99.
100. Assessment of Adequacy of
Fluid Resuscitation
▶ Monitor
▶ Urinary Output
▶Adult: > 1 ml/ kg/ hr
▶ Daily Weight
▶ Vital Signs
▶Heart rate and blood pressure
▶CVP
▶Level of Consciousness
▶ Laboratory values
102. Nutritional Support
▶ Burn wounds consume large amounts of energy:
▶ Requires massive amounts of nutrition to promote wound healing
▶ Monitoring Nutritional Status
▶ Weekly albumin levels
▶ Daily weight
▶ EMR (Estimated metabolic requirement) (Curreri formula)
=25kcal x body weight (kg) + 40 kcal x % BSA
103. Routes of Nutritional Support
▶ High-protein & high-calorie diet
▶ Often requiring various supplements
▶ Routes:
▶ORAL (BEST)
▶Enteral
▶ Gut is the preferred alternative route
▶ G-tube or J-tube (Head injury/ surgery/ unconscious)
▶Parenteral
▶ TPN and PPN
▶ Associated with an increased risk of infections
104. Nutritional Support
Formulas to Predict Caloric Needs in Severely Burned Children
Age group Maintenance needs Burn wound needs
Infants (0-12 mo) 2100 KCal/ %TBSA/ 24hr 1000 KCal/ %TBSA/ 24hr
Children (1-12 yr) 1800 KCal/ %TBSA/ 24hr 1300 KCal/ %TBSA/24 hr
Adolescents (12-18 yr) 1500 KCal/ %TBSA/ 24hr 1500 KCal/ %TBSA/ 24hr
106. Burn Wounds
Risk for Infection
▶ Skin first line of defense
▶ Necrotic tissue bacterial growth
▶ Management
▶Burn wounds are frequently monitored for bacterial colonization
▶Wound swab cultures and invasive biopsies
107. Role of burn wound cultures
▶ Early cultures positive/ high counts early contamination of the burn wound
▶ Routine cultures aid in empiric antimicrobial coverage if the patient subsequently
becomes ill
▶ Increasing colony counts change topical antimicrobial agents.
▶ Colonization by virulent or resistant organisms predictor of impending invasive burn
wound infection.
▶ Wound colony counts >106 high risk of infectious & graft failure.
108. Burn Wound Care
Hydrotherapy
▶Shower, bed baths or clear water spray
▶Maintain appropriate water and room temperature
▶Limit duration to 20-30 minutes
▶Don’t burst blisters, aspirate them!!!
▶Trim hair around wound; except eyebrows
▶Dry with towel; pat dry, don’t rub!
▶Clean unburned skin and hair
109. Burn Wound Care
Antimicrobial Agent
▶ Silvadene (silver sulfadiazine)
▶ Broad spectrum; the most common agent used
▶ Painless & easy to use
▶ Doesn’t penetrate eschar
▶ Leaves black tattoos from silver ion
▶ Sulfamylon (mafenide acetate)
▶ Penetrates eschar
▶ Painful for approximately 20 minutes after application
▶ Metabolic acidosis
110. Burn Wound Care
Antimicrobial agent
▶ Bacitracin/ Neomycin/ Polymyxin B
- not broad spectrum, painless, easy to apply
▶ Nystatin(Mycostatin)
- antifungal
▶ Mupirocin(Bactroban)
- anti staphylococcal
111. Burn Wound Care
Betadine
Drying effect makes debridement of the eschar easier
Acticoat (antimicrobial occlusive dressing)
A silver impregnated gauze that can be left in place for 5 days
Moist with sterile water only; remoisten every 3-4 hours
112. Soak silver dressings and gauze
in WATER (not saline).
Apply the
silver dressing.
Wrap with moist gauze.
Secure with mesh, gauze or tape.
114. Closed Dressing
▶ Advantages
• Less wound desiccation
• Decreased heat loss
• Decreased cross
contamination
• Debriding effect
• More comfortable
• Disadvantages
• Time consuming
• Expensive
• Increase chances of
infection if not changed
frequently
115. Burn Wound Care
Cover with a Sterile Dressing
▶ Most wounds covered with several layers of sterile gauze dressings.
▶ Special Considerations:
▶ Joint area lightly wrapped to allow mobility
▶ Facial wounds may be left open to air
▶ Circumferential burns: wrap distal to proximal
▶ All fingers and toes should be wrapped separately
▶ Splints over dressings
116. Burn Wound Care
Debridement of the wound
▶ May be completed at the bedside or as a surgical procedure.
▶ Types of Debridement:
▶Natural
▶ Body & bacterial enzymes dissolve eschar; takes a long time
▶Mechanical
▶ Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
▶Surgical
117. Why excise the burn?
Burn wound is a focus for sepsis
Burn stimulates inflammatory mediators
Deep burns cannot heal without grafts
Possible effect on future scar quality
118
Non full-thickness burns may heal
spontaneously
Superficial burns heal with acceptable
scars
Excised burn wound must be closed
Major burn surgery is hazardous
but
121. Early excision of burns
▶Tangential excision to
viable tissue on day 2-3
▶Janzekovic (1970)
Jackson & Stone (1972)
▶ Current concept – within hours
▶ Hardly any bleed
▶ Upto 60% burns
122
123. TANGENTIAL BURN EXCISION
& EARLY SPLIT SKIN GRAFTING
124
▶ Early wound closure; shorter hospital stay
▶ No increase in morbidity
▶ Significant ↓ in mortality
▶ Reduced bacterial colonization
▶ Tissue preservation
▶ Maintenance of function
▶ Less scaring
124. Early burn surgery
Superior outcomes where suitably equipped
▶ mortality
▶ length of hospital stay
▶ morbidity during acute burn
▶ scar quality
125
125. Desirable surgical management
Excision of all non-shallow burns as soon as practicable in as few stages as
possible
Closure of excised wounds with autograft, allograft or artificial material
Definitive wound closure
126
126. Surgical Management
Skin Grafting
▶ Closure of burn wound
▶ Spontaneous wound healing would take months for even a small full-thickness
burn
▶ Eschar is removed as soon as possible to prevent infection
▶ Wound needs to be covered to prevent infection, loss of heat, fluid and
electrolytes
▶ Therefore, skin grafting is done for most full-thickness burns.
▶ Can be permanent or temporary
127. Burn Wound Closure
Permanent Skin Grafts
▶ Two types:
▶Autografts and Cultured Epithelial Autografts (CEA)
▶ Autograft
▶ Harvested from pt
▶ Non-antigenic
▶ Less expensive
▶ Decreased risk of infection
▶ Can utilize meshing to cover large area
▶ Disadvantage : lack of sites and painful
128. Burn Wound Closure
▶ Cultured Epithelial Autografts (CEA)
▶A small piece of pt’s skin is harvested and grown in a culture medium (PDGF
impregnated)
▶Takes 3 weeks to grow enough for the first graft
▶Very fragile; immobile for 10 days post grafting
▶Useful for limited donor sites
▶Disadvantage : very expensive; poor long term cosmetic results and skin
remains fragile for years
130. Burn Wound Closure
Temporary Skin Grafts
▶ Why temporary ??
▶ Available donor sites are used first, but in large burns not
enough donor sites.
▶While waiting for donor site to heal it can be reused as a temporary
covering.
132. Burn Wound Closure
Biosynthetic Temporary Skin Grafts
▶ Homograft
▶ Allograft
▶ Live or cadaver human donors
▶ Fairly expensive/ all the function of skin
▶ Best infection control of all biologic coverings
▶ Disadvantage :
▶ Disease transmission (HBV & HIV)
▶ Antigenic: body rejects in 2 weeks
▶ Not always available
▶ Storage problems
133. Biosynthetic Temporary Skin Grafts
▶ Heterograft
▶ Xenograft
▶ Graft between 2 different species
▶ Porcine most common
▶ Fresh, frozen or freeze-dried (longer shelf life)
▶ Amenable to meshing & antimicrobial impregnation
▶ Antigenic: body rejects in 3-4 days
▶ Fairly inexpensive
▶ Disadvantage : Higher risk of infection
134. Biosynthetic Temporary Skin Grafts
▶ Artificial Skins
▶Transcyte:
▶A collagen based dressing impregnated with newborn fibroblasts.
▶Integra:
▶A collagen based product that helps to form a “neodermis”
▶no anti-microbial property
▶ Synthetic
▶Any non-biologic dressing that will help prevent fluid & heat loss
▶Biobrane, Xeroform, OpSite or Beta Glucan collagen matrix
135. Biobrane
▶ Artificial dressing has elastic
property
▶ Bilayer fabric
▶ Inner layer - knitted nylon threads
coated with porcine collagen
▶ Outer layer - rubberized silicone
▶ Pervious to gases but not to liquids
and bacteria
▶ Epithelialization takes place under
the dressing in
partial thickness wound in 1-2 wks
136. Donor Site: Wound Considerations
▶ The donor site is often the most painful aspect for the post-operative pt
▶ brand new wound !!
▶ Variety of products are used for donor sites
▶Most are left in place for 24 hours and then left open to air
▶ Donor sites usually heal in 3 wks
138. Burn Wound Infection
▶ Focal/ multi focal/ generalized
▶ More the area of infection ↑chances of septicemia
▶ Common org- Strep, Staph & Pseudomonas
139. Monitoring Wound Infection
▶ Definite diagnosis wound biopsy
▶ More than 100,000 organisms is highly suggestive of burn wound infection
▶ Concomitant positive blood culture is a reliable indicator
▶ Children & burns > 30% TBSA are more likely to develop burn sepsis
140. Clinical Signs of Burn Wound Infection
▶ 2nd degree burn full-thickness necrosis
▶ Focal dark-brown or black discoloration
▶ Wound degeneration “neo-eschar” formation
▶ Unexpectedly rapid eschar separation
▶ Hemorrhagic discoloration of sub-eschar fat
▶ Erythematous or violaceous edematous wound margin
▶ Septic lesions in unburned tissue
▶ Crusted serrations of wound margin
143. Sepsis in burn pt concern for infection.
Age-dependent definition with adjustments for children.
The trigger includes at least three of the following:
I. Temperature >39° or <36.5°C
II. Progressive tachycardia
Adults >110 bpm
Children >2 SD above age-specific norms (85% age-adjusted max
heart rate)
Burn Sepsis
144. ▶ III. Progressive tachypnea
▶ Adults >25 /min not ventilated
Minute ventilation >12 L/min ventilated
▶Children >2 SD above age-specific norms
(85% age- adjusted max respiratory rate)
▶ IV. Thrombocytopenia (only 3 days after initial resuscitation)
▶ Adults <100 000/mcl
▶ Children <2 SD below age-specific norms
Burn Sepsis
145. ▶ V. Hyperglycemia (in the absence of pre-existing diabetes mellitus)
▶ Untreated plasma glucose >200 mg/dL or equivalent mM/L
▶ Insulin resistance – examples include
▶ >7 units of insulin/h intravenous drip (adults)
▶ Resistance to insulin (>25% increase in insulin requirements over 24 hours)
▶ VI. Inability to continue enteral feedings >24 hours
▶ Abdominal distension
▶ Enteral feeding intolerance (residual >150 mL/h in children or 2× feeding rate in adults)
▶ Uncontrollable diarrhoea (>2500 mL/d for adults or >400 mL/d in children)
Burn Sepsis
150. ▶ Begins day one and may last several years
▶ Nursing care
▶ Meticulous asepsis continues to be important
▶ Major areas of focus:
▶ Support for adequate wound healing
▶ Prevention of hypertrophic scarring & contractures
▶ Psychosocial Support
▶ Patient and family
▶ Promotion of maximal functional independence
Rehabilitation
151. Hypertrophic Scar Formation
▶ Excessive scar formation, which rises above the skin
▶ Management: Pressure Garments
▶ Elasticized garments that are custom fitted
▶ Maintains constant pressure on the wound
▶ Result: smoother skin & minimized scar appearance
▶ Pt Considerations:
▶ Must be worn 2-3 hours a day
▶ Up to 1-2 years
▶ Jobst garments, foam sponge, foam tape, silicon gel sheet
152. Contracture Formation
▶ Shrinkage and shortening of burned tissue
▶ Results in disfigurement
▶ Especially if burn injury involves joints
▶ Management is application of opposing force:
▶ Splints, proper positioning, mobilisation
▶Must begin at day one
▶Multidisciplinary approach is essential
153. Psychosocial Considerations
Alterations in Body Image
▶ Loss of Self-Esteem
▶ Returning to community, work or school
▶ Sexuality
▶ Supports Services
▶ Psychologist, social work & vocational counselors
▶ Local or national burn injury support orgs
▶ Psy Considerations
▶ Encourage pt & family to express feelings
▶ Assist in developing positive coping strategies
155. RAs (grafts)
▶Liposomal gene transfer Branski L, Pereira CT, Herndon DN, Jeschke MG. Gene therapy in
wound healing: Present Status and Future Directions. Gene Therapy, 2006 Aug 24
▶ cationic cholesterol-containing liposomal constructs
(best so far)
▶ Naked DNA application,
▶ Viral transfection,
▶ High-pressure injection
▶ Liposomal delivery
156. RAs (grafts)
▶ ARTIFICIAL SKIN SUBSTRATES
▶ Dermal matrices with epidermal components Boyce ST, Kagan RJ, Yakuboff KP, Meyer
NA, Rieman MT, Greenhalgh DG, Warden GD. Cultured skin substitutes reduce donor skin
harvesting for closure of excised, full-thickness burns. Ann surg, 2002 Feb; 235(2):269-279
▶ Amniotic wound coverage devices . Branski LK, Herndon DN, Masters OE, Celis M,
Norbury WB, Jeschke MG. Amnion in the treatment of pediatric partial-thickness facial
burns. Burns, 2007 Oct 4.
▶ Dermal component matrices Schulz JT 3rd, Tompkins RG, Burke JF.Artificial skin. Ann
Rev Med, 2000; 51:231-244
157. CONCLUSION
▶ Early, aggressive, controlled fluids
▶ Monitor urine output as a guide to resuscitation
▶ Prevent extension of injury
▶ Maintain high suspicion for inhalation injury & low thresh hold for intubation
▶ Always rule out co-incident trauma
▶ Frequent reassessment of extremities
▶ Seek out & treat CO poisoning
▶ Liberal use of analgesia
▶ Prevent hypothermia
▶ Provide for increased metabolic demands
158. BURNS !!!
Rule of Nines & Resuscitation with fluid
Nutrition
B Breathing
U Urinary output
R
N
S Shock & Silvadene
159. References
▶ Total Burn Care; David N Herndon 4th Ed
▶ Bailey And Love's Short Practice of Surgery 26th Ed 2013
▶ Schwartz’s Principles of Surgery, 10th Ed
▶ Sabiston Textbook of Surgery 19th ed 2012
160