burn

1. BURN
1

2. Burn
Dr.Lamture Yash
Professor in surgery
Datta Meghe medical college Nagpur

3. Learning objectives
Type of burn injury
Classification of burns
Pathophysiology of burn
Treatment
Complications of burn

4. 10/22/2016 4
INTRODUCTION
Majorty of burns in children are SCALDS caused
by accidents with kettles,pans,hot drinks and
bath water
In young males burn caused by experimenting
With mathes and inflamable liquides
Electrical and chemical injuries occur in adults with
Associated conditions such as mental disease,
Epilepsy Alcohal and drug abuse

5. 10/22/2016 5
ETIOLOGY OF BURNS
DRY HEAT
FLAME
ELECTRICT CONTACT
CHEMICAL
FROSTBITE
IONIZING RADIATION

6. 10/22/2016 6
CLASSIFICATION OF BURNS
1.Depending on the percentage of burns
MILD
o Partial thickness burns <15% in adults and <10%
In children
or
o Full thickness <2%
o Can be treated on outpatient department

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Classification (cont…….
MODERATE
oSecond degree burn of 15-25% burns
oThird degree burn between 2-10% burns
oBurns which are not involving eyes,ears
Face,hand,feet and perineum

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CLASSIFICATION (CONT……)
SEVERE
oSecond degree burns more then 25% in adults
and More then 20% in children
oAll third degree burns more then 10%
oAll electrical burns and inhalation burns
oBurns with fracture
oBurns involving eyes,ears,feet,hands and
perineum

9. Classification(cont…..)
2.Depending on thickness of skin involved
 First degree
 Second degree
 Third degree
 Fourth degree
 Partial thickness burns
I. Superficial
II. Deep
 Full thickness
7

10. 1
0
CLASSIFICATION(CONT…..)
a.First degree
 Epidermiss looks red and painfull
 No blisters formation
 Heals rapidly In 5-7 days by epithelialization
Without scarring

11. Classification(cont…..)
b.2nd degreeburns
affected area is red,mottled,painfull
Blister formation
Heals in 14-21
days by epithelialization With scaring
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1

12. CLASSIFICATION(CONT……)
al
C.3rd degreeburns
Affected area is painless and insensetive with
Thrombosis of superfici
vessels
It requires grafting
D.4th degreeburns
It involves underlying
Tissues Muscles
bones 10

13. Degrees of burns.
Partial thickness and full thickness discuss in asessment of
burn
13

14. 1° burn
2° burn
14

15. 3° burn
15

16. Eschar:composed of
denatured protein
16

17. Full thickness (3°burn)
17

18. Zon of injury

19. Extent of surface area burned
 Rule of nines-An estimated
of the TBSA involved as a
result of a burn.
 The rule of nines measures
the percentage of the body
burned by dividing the body
into multiples of nine.
 The initial evaluation is
made upon arrival at the
hospital.
1
9

20. 10/22/2016 20
Pathophysiology of burn injury
Most common organ affected is the skin
Burn can also damage airways and lungs with life
Threatening consequenses
Respiratory system injuries occure if person trapped
In a burning vehicle,house,car and is forced to inhale
The hot and poisonous gases
Hot gases burn the lining of airway above the larynx
And lining start to swell later on block the airway
Steam causes damage to the lower airways,respiratory
Epithelium swells and detach from bronchial tree

21. 35
Thermal injury
Inflammation
Histamine release
Vasoconstriction
↑blood pressure
↑blood flow to injury
↑capillary permeability
Fluids leakage and
Loss from injury
Site (edema)
↓intravascular fluid
Hypovolemic shock
↑Protein
leakage
Hypoproteinemia
↓Plasma osmotic
pressure

22. Pathophysiology(cont……)
Metabolic poisoning
Carbon monoxide is a product of incomplete combustion
That is often produced by fires in a closed space is one of
Many poisonous gases
Co binds to hb with an affinity of 240> O2 so block
Transport Of O2
Level of carboxyhaemoglobin in blood can be measure
Conc >10% dangerous and need treatment with pure
Oxygen for more then 24hours
Hydrogen cynide causes metabolic acidosis by interefering
1W0/22i/t20h16 mitochondrial respiration 13

23. Pathophysiology(cont……)
Inhalational injury
caused by mainute particles within thick smoke because
Of their small size and are not filtered by the upper
Airwayand are carried down to
lung parenchyma
Stick to moist lining causes
intense reaction in alveoli
Causes chemical pneumonitis
followed by oedema within
Alveolar sac and dec gaseous
exchange
14

24. Pathophysiology(cont……)
Inflamtion and circulatory changes
Burn skin release of neuropeptides activation of
Complement are intiated by stimulation of pain fibers and
Alteration of proteins by heat
Activation of hageman factor alter archidonic acid
Thrombin and kallikrein pathways
24

25. Pathophysiology(cont……)
At cellular level
Complement causes degranulation of mast cells
Attracts neutrophils which also degranulate and releases
Large amount of free radicals and proteases
Mast cells also releases TNF@ which act as chemotactic
Agent to inflamatory cells
These inflamatory factors alter permeability of bld vessels
Large protein molecules can also escape with ease
Damaged collagen and extravasated proteins oncotic
Pressure further increase flow of water from intravascular
Toextravascular space
25

26. Pathophysiology
Heat causes coagulation necrosis of skin and
subcutaneous tissue.
↓
Release of vasoactive peptides
↓
Altered capillary permeability
↓
Loss of fluid → Severe hypovolaemia
↓
Decreased cardiac → Decreased myocardial
output function
↓
Decreased renal blood → Oliguria
flow (Renal failure)
↓
Altered pulmonary resistance causing pulmonary
Oedema infection
Systemic Inflammatory Response Syndrome (SIRS)
↓
Multi Organ Dysfunction Syndrome (MODS).
26

27. ASSESSMENT OF BURNS
1.ASSESSING SIZE
Burn size should be assessed in a controlled environment
Toavoid hypothermia
In smaller burns just cut a piece a clean paper the size of
patient ,s whole hand (digit and palm)which present 1% TBSA
And match this to the area
Another accurate way of measuring the size of burns is to draw
The burn on a LUND AND BROWDER CHART
Age in
yrs
0 1 5 10 15 adult
A head 9 8 6 5 4 3
B thigh 2 3 4 4 4 4
01C6leg 2 2 3 3 3 3 18

28. 28
ASSESSMENT(CONT…..)
RULE OF 9 (wallace,s rule of 9
Each upper limb is 9% TBSA
Each lower limb is 18% TBSA
Torso 18% each side
Head and neck 9%
Perineum 1%
In children head and neck is 18% and
Lower limb is 13.5% each=13.5*2=27%

29. Superficial burn (1° burn)
29

30. Partial thickness (2°burn)
30

31. Blister may ↑size because continuous
exudation and collection of tissue fluid
31

32. Rule of 9
10/22/2016 32

33. 33
ASSESSMENT(CONT…..)
2.Assessing depth from the history
Burning of human skin is temperature and time dependent
It takes 6 hours for skin maintained at 44c* for irreversible changes
A surface teperature of 70c* for 1 second produce epidermal
destruction
example of exposure t o hot water at 65c*
45 second exposure produce full thickness burn
15 second exposure produce deep partial thickness burn
7 second exposure produce superficial partial thikness burn

34. 34
ASSESSMENT(CONT…..)
a) Superficial partial thickness burns
 No deeper then papillary dermis
 Blister formation
 Loss of epidermis
 Capillary return visible
When blanched
 Dermis is pink and moist
 Pin prick sensation normal
 Heal without scarring
In 2 weeks
 Treatment is non surgical

35. Superficial partial thickness burns
After 24 hours after burn After 2 weeks
35

36. Superficial partial thickness burn after 3 months
Pigment returning
36

37. 37
ASSESSMENT(CONT…..)
b)Deep partial thickness burn
Damage to deeper parts of dermis
Epidermis is usually lost
Fixed capillary staining
Colour does not blanch with pressure
Sensation is reduced
Pt is unable to distinguish sharp from blunt pressure
Takes 3 or more weeks to heal without surgery
Leads to hypertrophic scarring

38. 38
ASSESSMENT(CONT…..)
c)Full thicknessburns
Whole of the dermis destroyed
Hard and leathery feel
No capillary return
Often thrombosed vessels can be seen under
The skin
These are completely anesthetised
No pain and no bleeding

39. 39
Causes of death in burns
a. Hypovolaemia and shock
b. Renal failure
c. Pulmonary oedema and ARDS
d. Septicaemia
e. Multiorgan failure

40. Full thickness burn
Wraped in cling film
40

41. Deep partial thickness burn
tangential shaving to remove deaddermis
Dermis remove layer by layer untill bleeding
41

42. Hypertrophic scarring following a deep dermalburn.
After 3 or more weeks
42

43. 10/22/2016 43
Management of burns
Management of burns is consist of
prehospital care
&
hospital care

44. Management of burns
Prehospital care
Stop the burning process
Stop,drop and roll is a good method of extinguishing
Fire
Cool the burn wound
This provide analgesia and slow the delayed micro-
-vascular damage which occure after a burn injury
Cooling should be for minimum 10 mintues and up to
One hour to avoid hypothermia
Give oxygen
Give oxygen especialy if there is altered level concious_
10/22/20-1n6 ess level 32

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Management of burns
Elevate
Sitting a patient up with a burned airway may prove life
Saving
Elevation of burned limbs reduce swelling and discomfort
Check for other injuries
A standard ABC check followed by a secondary survey
Patients burned in explosions may have head and spine injuries
And other life threatening problems

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Management of burns
Indications for admission in burns
Susected airway or inhalational injury
Any burn require fluide resusciation
Any burn in extreme of ages
All electrical and chemical burns
Any burn which require surgery
Burn of any significance to hands,face,feet or perineum
Suspicious of non accidental injury

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Management of burns
Hospital care
Admit the patient
Airway control
Breathing and ventilation
Circulation
Disability
Exposure with environment control
Fluid resuscitation
Assess the %age,degree and type of burn
Keep the patient in clean environment
Sedation and proper analgesia

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Management of burns
A.AIRWAY CONTROL
Burned airway creates problems by swelling and can completely
Occlude the airway
Secure airway with an endotracheal tube until
swelling subsided which is Usually 48 hours
Delayed diagnosis of airway burn make difficult to intubate the
Patient in presence of lyrangeal oedema so cricothyroidectomy
Should be done
Early intubation of suspected airway burn is the treatment of
Choice in such patients

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Management of burns
B.BREATHING
A progressive increase in respiratory rate and effort ,anxiety
Rising pulse and confusion with decreasing o2 saturation
These symptoms take 24 hours to 5 days to appear
Treatment starts as soon as possible including
Physiotherapy
Nebulisers
Warm humidified oxygen

50. 10/22/2016 50
Management of burns
Fluide resuscitation
Iv volume must be maintained following a burn in order to
provide sufficient circulation to perfuse not only the organs but
also the peripheral tissues,especially damaged skin
Iv resuscitation is appropriate for any child with a burn greater
Then 10% and 15%for TBSA for adults
If oral resuscitation is to be commenced then water is given
Should not be salt free
It is appropriate to give oral rehydration with a solution such as
DIORALYTE*
Most common fluid used is ringer lactate

51. Management of burns
Fluid volume is relatively constant in proportion to the area
Of body burned therefore there are formulate that calculate
The approximate volume of fluid needed for the pt of a given
Body weight with a given %age of the body burned
Formulas to calculate the fluid replacement
1.parkland regime (commonly used)
4ML/%burn/kg body weight/24 hours
4*50*60=12000ml in 24 hours
Half this volume is given in the frist 8 hours
Second half is given in the subsequent 16 hours
Others
1. Evan,s formula
2. Muir and barclay
10/223/2.016Modified brook formula 39

52. 10/22/2016 52
Management (cont…)
Fluids used
Crystalloid resuscitation
Ringer lactate is the most commonly used crystalloid
These are as effective as colloids for maintaining intra-
-vascular volume
Less expensive
In children
Dextrose saline given for maintanaince
100ml/kg for 24 hours for frist 10kg
50ml/kg for 24 hours for next 10kg
20ml/kg for 24 hours for each kg above 20kg body weight

53. 10/22/2016 53
Management (cont…)
hypertonic saline
 it produces hyperosmolarity and hypernatremia
Reduces shift of intracellular water to extracellular space
Advantages
Include less tissue oedema and a resultant decrease in
Escharotomies and intubations

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Management (cont…)
Colloid resuscitation
Plasma proteins are responsible for the inward oncotic
Pressure that counteracts the outward capillary hydrostatic
Pressure.
Without proteins there will be oedema
Proteins should be given after frist 12 hours of burn before
This time proteins will leak out of cells
Given through muir and barclay formula
0.5*%agebsa burn*weight=one portion
Periods of 4/4/4, 6/6, 12 hours respectively
One portion to b given in each period

55. 10/22/2016 55
Management (cont…)
Monitoring of resuscitation
The key to monitoring of resuscitation is urinary output
Output should be between 0.5ml and 1.0ml/kg/hour
If urine output is below this infusion rate should increase
By 50%
If still output is inadequate then a bolus of 10ml/kg given
2ml/kg/hr urinary output signals decrease in the rate of
Perfusion
Haematocrit measurement is a usefull tool in confirming
Suspected under or overhydration

56. 10/22/2016 44
As an absorbent
Management (cont…)
Treating the burn wound
Dressings
Paraffine guaze
Hydrocolloids (duoderm)
Biological dressings
synthetic (biobrane)
natural (amniotic membrane)
Full-thickness and deep dermal burns need antibacterial
dressings to delay colonisation prior to surgery
Open method
Silver sulfadiazine application without dressings commonly
Used in burns of face,head and neck.
Closed method
Dressing done to soothen and to protect the wound
Toreduce the pain

57. Management (cont…)
Treating the burn wound (cont……
Tangential excision
Can be done within 48 hours with skin grafting in patients with less
Then 25% burn
Usually done in deep
dermal burns
Dead dermis is removed
layer by layer Untill fresh
bleeding occurs
Later skin grafting done
10/22/2016 45

58. Treating the burn wound
(cont……
Treating the burn wound (cont……
escharotomy
Circumferential full-thickness burns to the limbs require emergency
Surgery
The tourniquet effect of this injury
is easily treated by incising the whole length of full-thickness
burns.
This should be done in the mid-axial line, avoiding major
Nerves
The burn needs to be cleaned and the size and depth need to be
Full thickness burns and deep partial-thickness burns that will
requireoperative treatment will need to be dressed with an
antibacterialdressing to delay the onset of colonisation of the
wo10
u/22
n/2
d016 46

59. A full-thickness burn to the upper limb with a mid-axial
escharotomy.
The soot and debris have been washed off.
10/22/2016 59

60. 10/22/2016 60
Topical agent advantages problems
Silver sulfadiazine 1 -Antiseptic (G +ve -Neutropenia,
% and G –ve pseudoeschar
-Soothening, good -- Causes wound
penetration maceration
- Hydration and
softening of eschar
occurs
Sulfamylon – 5% - Antipseudomonal, Very irritant,painful
(Mafenide acetate) anticlostridial Causes acidosis
- Penetrates very
well in to tissues
Silver nitrate – 0.5% - Antiseptic Stains burn area
Povidone iodine Irritant
(5%) - Used on Painfull
granulation tissue - Not used in partial
after eschar burns
separation
Silver sulphadiazine - Boosts cell
and cerium nitrate mediated immunity
and forms sterile
eschar

61. 10/22/2016 61
Additional aspects of treating burn
patient
Analgesia
Oral form of paracetamol and nsaids in superficial burns
Iv opiates for large burns
Im should not be given in over 10% of TBSA as absorption is
Unpredictable
Short acting analgesia given before dressing
Energy balance
Feeding should start within 6 hrs of injury to reduce gut mucosal damag
Burns patients need extra feeding
A nasogastric tube should be used in all patients with burns over 15%
of TBSA and 10% in case of children
 Burn injuries are catabolic in the acute episode.
Removing the burn and achieving healing stops the catabolic drive

62. Additional aspects of treating burn
patient
control of infection
Patients with major burns are immunocompromised,
pathogenic and opportunistic bacteria and fungi enter via the burn
wound,cathetars and iv lines
They have compromised local defences in the lungs and gut due to
oedema
Sterile precautions must be rigorous
 Swabs should be taken regularly
 A rise in white blood cell count, thrombocytosis and
increased catabolism are warnings of infection
Nursing care
Physiotherapy
Psy10c/2h2/2o016logical support 50

63. 10/22/2016 63
SURGERY FOR THE ACUTE BURN
Any deep partial-thickness and full-thickness burns except
those that are less than about 4 cm2, need surgery
A topical solution of 1:500 000 adrenaline also helps to reduce
bleeding,
deep dermal burns, the top layer of dead dermis is shaved
off until punctate bleeding is observed and the dermis can be
seen to be free of any small thrombosed vessels
Full-thickness burns require full-thickness excision of the
Skin
Postoperative management of these patients obviously
requires careful evaluation of fluid balance and levels of haemoglobin.

64. 10/22/2016 64
Delayed reconstruction and scar
management
is common for large Full thickness burns
Eyelids must be treated before exposure keratitis arises
Transposition flaps and Z-plasties with or without tissue
expansion are useful
Full-thickness grafts and free flaps may be needed for large
or difficult areas
Hypertrophy is treated with pressure garments to be worn
for 6-18 months
Smaller areas of hypertrophy, silicone patches will speed
scar maturation,as will intralesional injection of steroid.
 Pharmacological treatment of itch is important

65. 10/22/2016 65
Effects of burn
 Shock due to hypovolaemia
 Renal failure(toxins from burn&myoglobin)
Pulmonary oedema,resp infections,ARDS,resp failure
Infection by staph aureus,pseudomonas,klebsella leads to
Septicemia
 Fungal and viral infections of dangerous type can occure
GIT: Hypovolaemia, ischaemia of mucosa, erosive
gastritis—Curling’s ulcer (seen in burns > 35%).
 Fluid and electrolyte imbalance.
immunosuppression predisposes to severe opportunistic infection.
Eschar formation and its problems like defective
circulation, ischaemia when it is circumferential.
Electrical injuries often cause fractures, major
internal organ injury, convulsions.

66. 10/22/2016
.
66
Effects of burn(cont…..)
Inhalation burn causes pulmonary oedema,
respiratory arrest, ARDS.
Chemical injury causes severe GIT disturbances like
erosions, perforation, stricture oesophagus (alkali),
pyloric stenosis (acid), mediastinal injury.
Other problems
DVT, pulmonary embolism
bed-sores,
severe malnutrition with catabolic status,
 Toxic shock syndrome:
It is a life-threatening exotoxin mediated disease caused by
Staphylococcusaureus. It is common in children, presents with
rashes, myalgia, diarrhoea, vomiting, and multiorgan
failure with high mortality

67. 10/22/2016 67
Effects of burn(cont…..)
Development of contracture is a late problem. It
leads to ectropion, microstomia, disability of
different joints, defective hand functions, growth
retardation causing shortening
COMPLICATIONS OF BURNS CONTRACTURE
Ectropion of eyelid causing keratitis and corneal
ulcer.
Disfigurement in face.
Narrowing of mouth microstomia.
Contracture in the neck causing restricted neck movements.
Disability and nonfunctioning of joints due to contracture
Hypertrophic scar and keloid formation.

68. COMPLICATIONS OF BURNS CONTRACTURE
Marjolin’s ulcer
It is a very well-differentiated squamous cell carcinoma
occurring in a scar ulcer due to repeated breakdown (unstable
scar of long duration).
• It is locally malignant.
•As there are no lymphatics in the scar, so there
is no spread to lymph nodes.
• As there are no nerves in the scar it is painless.
• It has raised and everted edge with induration.
• Biopsy confirms the diagnosis.
Treatment
Radiotherapy is not given for Marjolin’s ulcer.
Treatment is either wide excision or amputation. It is curable.
Once it spreads out of the scar tissue it behaves like
any other squamous cell carcinoma and so can spread to
10/22/20r1e6gional lymph nodes 56

69. Marjolin’s ulcer developed over burns contracture
69

70. Contracture at different parts of body
chest and neck
70

71. Contracture at different parts of body
Severe contracture at knee joint
causing deformity Contracture at face
71

72. Complication of contracture
Hypertrophic scar Keloid formation
72

73. 10/22/2016 73
Treatment of burn contracture
• Release of contracture surgically and use of skin graft
or “Z” plasty or different flaps.
• Proper physiotherapy and rehabilitation is essential.
• Pressure garments to prevent hypertrophic scars.
• Management of itching in the scar using aloe vera,
antihistamines and moisturizing creams.

74. 74
Prevention of development of
contracture
•Joint exercise in full range during recovery period of
burns
• Pressure garments for a long period
• Topical silicon sheeting
• Saline expanders for scars

75. 75
NON THERMALINJURIES
Electrical burns
Chemical burn
Cold injuries
Ionising radiation

76. 76
Non thermal(cont……)
Electrical burns 1000v
Low tension injuries
Low tension injuries do not have enough energy to cause
Significant destruction
Entry and exit points normally in the fingers suffers small
Deep burns may damage underlying nerves and vessels
Accreates a tetany within muscles so patient unable to
Release the device untill the power was turned off
May interfere with normal cardiac pacing and can cause
Cardiac arrest

77. Electrical burns(cont…..)
high tension injuries
3 sources of damage
1) The flash
2) The flame
3) The current
When a high tension line is earthed it can arc over the pt
And causes a flash burn
Extremely rapid heating of the air causes an explosion
That propel the victim backward
It is always a major burn
There is a wound of entry and wound of exit
Major internal organ injuries occures
Convulsions can develope 65

78. Electrical burns(cont…..)
Management
Depending on injury it is managed accordingly
Patient should always be admitted and should be assessed by
i. ECG
ii. u/s abdomen
iii. Chest x-ray
iv. Ct scan head sometimes
v. Cardiac enzyme analysis
Acidosis is common so bicarbonate infusion needed
Fractures and dislocations common so managed accordingly
Release of myoglobin can cause renal tubular damage and renal
Failure so manitol is used to prevent myoglobin induced renal
failure (compartment syndrome)
66

79. Wound of entry in an electric burn.
Electric burn
79

80. Electrical burns(cont…..)
An exit wound of a high-tension
injury,
Amputation and cover with the
lateral portion of the second toe.
80

81. 81
Chemical burns
There are 70000 different chemicals in regular use within industry
Occasionally these cause burns
There are two aspects to a chemical injury
1. Physical destruction to the skin
2. Systemic absorption
The initial management of any chemical injury is copious lavage
With water but some need to be remove physically eg.phosphorus
A component of millitary devices
The more common injuries are caused by either
1. Alkalis
2. acids

82. 10/22/2016 82
Chemical burns(cont…)
Alkalis
alkalis are more destructive and especially when come in contact
With eyes
Commonly used alkalis are sodium hydroxide,lime,bleach
They cause fat sponification,fluide loss,release of alkali proteinase
Alkali burns occur in oral cavity and oesophagus
which leads to multiple oesophageal strictures.
After copious lavage, the next step in themanagement of any
chemical injury is to identify the chemical
and its concentration and to elucidate whether there is any
underlying threat to the patient’s life if absorbed systemically

83. Acidaemia should be corrected by IV sodium bicarbonate.
83
Chemical burns(cont…)
Acids
Acid burn occurs in skin, soft tissues and GIT. In GIT,
Burns affecting the fingers and caused by dilute acid are relatively
common.
The initial management is with calcium gluconate gel topically
severe burns or burns to large areas of the hand can be
subsequently treated with Bier’s blocks containing calcium
gluconate 10 per cent gel
it is common in stomach either due to nitric acid or sulphuric acid
which may lead to severe gastritis or pyloric stenosis.
Other acids are formic acid, hydrofluoric acid.
They cause metabolic acidosis, renal failure, ARDS, haemolysis.

84. Cold injuries
Cold injuries are principally divided into two types
1. Acute cold injuries from industries
2. Frost bite
inflammatory reaction is not as marked.
The tissue is more resistant to cold injury than to heat injury
The assessment of depth of injury is more difficult,
Frostbite
injuries affect the peripheries in cold climates
cold injury produces delayed microvascular damage similar to
that of cardiac reperfusion injury.
The initial treatment is with rapid rewarming in a bath at 42°C.
The level of damage is difficult to assess
10/
s2
u2/2
r0
g16
eryusually does not play a role in its management 72

85. 10/22/2016 85
Ionising radiation
These injuries can be divided into
1. Localised
2. Whole body exposure
The management of localised radiation damage is usually
Conservative until the true extent of the tissue injury is apparent.
If damage have caused an ulcer, then excision and coverage with
vascularised tissue is required.
A patient who has suffered whole-body irradiation and is suffering
From acute desquamation of the skin has received a lethal dose of
Radiation which can cause a particularly slow and unpleasant death
Dose may be lethal and may not be lethal
Giving iodine tablets, the management of these injuries is supportive

86. References.
1. Bailey & Love’s Short Practise of surgery 25th edition.
2. ACS Surgery: Principles & Practice, 2007 Edition
3. Heffner, Hess.Clinics in Chest Medicine 22 , 2001.
4. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.2005.
5. SRB’s Manual of Surgery Paperback – 1 January 2016
6. SCHWARTZ'S PRINCIPLES OF SURGERY 2-volume set 11th
edition
21 October 202086

87. THANKS
10/22/2016 87