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  1. 1. BURN
  2. 2. Definition• Damange to the skin caused by excessiveheat or caustic chemicals
  3. 3. CONTENT• Anatomy• Etiology• Pathophysiology• Burn severity• Body response to burn• Treatment
  4. 4. ANATOMY
  5. 5. ETIOLOGY• Flame• Scald• Electrical• Flash• Chemical• Contact• Radiation
  6. 6. PATHOPHYSIOLOGYZone of coagulationZone of stasisZone of hyperemia
  7. 7. PATHOPHYSIOLOGY• Zone of coagulation (central)– The most intimate contact with heatsource– Dead or dying cells: coagulation necrosisand absent blood flow– Depth of tissue destruction determinesthe degree of the burn– White or charred
  8. 8. PATHOPHYSIOLOGY• Zone of stasis (intermediate)– Usually is red and may blanch on pressure,appearing to have an intact circulation– After 24 hours: petechial hemorrhages may bepresent– 3rdday, becomes white because its superficialdermis is avascular and necrosis– Transformation of the zone of stasis coagulation– Progressive dermal ischemia– Edema
  9. 9. PATHOPHYSIOLOGY• Zone of hyperemia (outer)– A red zone that blanches on pressure,indicating that it has intact circulation– 4thday, deeper red color
  10. 10. Burn wound depthDepends on• Temperature of the agent• Duration of contact with the agent• Skin thickness– Globrous skin of the palms and soles ismore resistant to full-thickness injurythan is the thinner skin– Infant skin is also thinner than adultskin
  11. 11. Immersion time to produce fullthickness burnsTimeTemperature( ํํF)1 second158 ํํ (69ํํC)2 seconds 150 ํํ10 seconds140 ํํ (60ํํC)30 seconds 130 ํํ1 minute 127 ํํ10 minutes120 ํํ (48ํํC)
  12. 12. SEVERITY• Etiology• Time contact• Extent or %burn area• Depth• Age• Part of body burned• Concurrent injuries
  13. 13. Determination of burnEXTENT• TBSA: partial + full thickness dermalinjury (2rd+3ndburn)– Rule of 9– Patient’s hand = 1%– Lund and browder charts
  14. 14. Wallace’s ‘Rule of nines’Body Part %Head and neck 9Upper limb Right and Left 9+9Anterior trunk 18Posterior trunk 18Lower limb Right and Left 18+18Perineum 1Total 100%
  15. 15. Lund and Browder charts
  16. 16. Burn depth1st : superficial2nd : partialSuperficial partialthicknessDeep partialthickness3rd : full thickness4th : underlyingsubcutaneous tissue,tendon or bone
  17. 17. Superficial burns• Involve the epidermis only• Erythematous and painful• Heal within 3-5 days• Best treated with topical agents such asaloe lotion: accelerate re-epithelializationand soothe the patient• Oral analgesics• Sunburns
  18. 18. Superficial partial-thickness burns• Pink, moist, blister and painful to thetouch• Heal within 2 weeks• Generally do not result in scarring, butcould result in alteration of pigmentation• Treated with greasy gauze with antibioticointment• Water scald burns
  19. 19. Deep partial-thickness burns• Extend into the reticular portion of thedermis• Dry and mottled pink and white, variablesensation• Heal within 3-8 weeds, depending on thenumber of viable adnexal structures• Heal with contraction, scarring, andpossible contractures• Not be completely re-epithelialized in 3weeks, operative excision and grafting isrecommended
  20. 20. Full-thickness burns• Involve the epidermis and the entirety ofthe dermis• Brown-black (eschar), leathery, andinsensate• Fixed carboxyhemoglobin in the wound cherry-red color• Treated by excision and grafting, unlessthey are quite small
  21. 21. Classification of burn severityMINOR BURN 15%TBSA or less in adults (TBSA = total body surface area)10%TBSA or less in children and the elderly2% TBSA or less full-thickness burn in children or adults withoutcosmetic or functional risk to eyes, ears, face, hand, feet, or perineumMODERATEBURN15-25%TBSA in adults with less than 10% full-thickness burn10-20%TBSA partial-thickness burn in children under 10 and adults over40 years of age with less than 10% full-thickness burn10%TBSA or less full-thickness burn in children or adults withoutcosmetic or functional risk to eyes, ears, face, hand, feet, or perineumMAJORBURN25%TBSA or greater20%TBSA or greater in children under 10 and adults over 40 years of age10% TBSA or greater full-thickness burnAll burns involving eyes, ears, face, hand, feet, or perineum that likely toresult in cosmetic impairmentAll high voltage electrical burnsAll burn injury complicated by major trauma or inhalation injuryAll poor risk patients with burn injury
  22. 22. Body response to burn injury• Physiologic response and burn shock• Metabolic response• Neuroendocrine response• Immune response
  23. 23. Physiologic response and burnshock• Systemic inflammatory responsesyndrome (SIRS)– Arteriolar vasodilatation– Increase venular membranepermeability  intravascular fluidleakage  tissue edema
  24. 24. Metabolic response• Hypermetabolism– Increase gluconeogenesis– Increase proteolysis– Increase energy expenditure
  25. 25. Neuroendocrine response• Hematologic changes– Hemolysis VS Hemoconcentration inearly phase– Leukocytosis– Mild hypercoagulable state
  26. 26. Immune response• Dysfunction of immune system– Cell-mediated immunity– Humoral immunity– Increase infection, sepsis, death
  27. 27. Treatment• Initial evaluation and management• Fluid resuscitation• Wound care• Nutrition• Complication
  28. 28. Initial evaluation andmanagement• Primary survey– ATLS: ABCs• Airway– Early recognition of impending airwaycompromise– Prompt intubations• Fluid resuscitation– Warmed fluid
  29. 29. Initial evaluation andmanagement• Secondary survey– Mechanism of injury– Inhalation injury– Assessment of burn wound• Cooling of burned tissue– No benefit if delayed >30 minutes– Do not use ice water• Major burn– NG tube– Foley’s catheter
  30. 30. Initial evaluation andmanagement• Analgesic drugs• Tetanus immunization
  31. 31. Fluid resuscitation• Early and adequate• Extent of burn and size, and fluidreplacement should proceed at the samerate as the loss• Constant rate, boluses are avoided• Both peripheral and central lines can beplaced through burned tissue whenrequired
  32. 32. Fluid resuscitation• Children: Galveston formula• First 24 hours– Fluid = 5,000 ml/m2 burned + 2,000/m2 TBSA– Age > 1 yr.: LRS 950 ml + alb 12.5 gm/L (25% albumin 50ml)– Age < 1 yr.: 5% D/N/2 930 ml + alb 12.5 gm/L + NaHCO320 ml• Subsequent day– Fluid = 3,750 ml/m2 burned + 1,500/m2 TBSA + NG loss+ diarrhea/24 hr.– Age > 1 yr.: Na+ 50 mEq/L K+ phosphate 30-40 mEq/L– Age < 1 yr.: Na+ 35-40 mEq/L + K+ phosphate 30-40mEq/L• ½ in first 8 hr. and ½ in 16 hr.
  33. 33. Wound management• Prevent infection• Prevent tissue ischemia• Adequate nutritional
  34. 34. Wound management• Conventional or Conservative treatment– Open dressing– Close dressing• Early excision and grafting
  35. 35. Wound management• Dressings with a moist, antibacterialcovering to minimize microbial growth,fluid loss, and painful stimuli and tomaximize skin regeneration
  36. 36. Topical antimicrobial dressing• Silver sulfadiazine (Silvadene)• Mafenide acetate• Dakin solution (0.25% sodiumhypochlorite)• Silver nitrate
  37. 37. Biological dressing• Xenograft• Human amnion membrane (amnioticmembrane)• Allograft
  38. 38. Synthetic dressing• Hydrocolloid: Duoderm• Hydro active: Cutinova• Calcium alginate: Kaltostat, Sorbsan,Urgosorb• Polyurethane foam: Allevyn, Lyofoam• Silver based dressing: Acticoat, UrgotulSSD, Tegaderm Ag, Aquacel Ag
  39. 39. Early excision and grafting• Surgical procedures– In adults, blood loss reaches 100 ml forevery 1% TBSA– Limit each operative session todebridement of 10-20% TBSA– Tangential debridement involvescutting the skin tissue at the depth ofthe dermal and subcutaneous capillarynetwork• 1 cm2 of burn causes 1 ml of blood loss
  40. 40. Early excision and grafting• Autologous split-thickness skin grafts– Gold standard for burn wounds ifenough donor sites are available
  41. 41. Nutrition• Increase basal metabolic rate 50-100% of thenormal resting rate– Increase glucose production, insulinresistance, lipolysis, and muscle proteincatabolism. Without adequate nutritionalsupport– Delayed wound healing, decreased immunefunction, and generalized weight loss.• Increase intake of both total calories and protein(1.5-3 of protein/kg/day)
  42. 42. Nutrition• Measuring weight loss and gain during treatmentis not useful because of the large fluid shifts• Carbohydrate 65-80%• Protein 15-20%• Lipid 5-15%
  43. 43. Modification of the Harris-Benedict EquationMenBMR = [66.47 + (13.75 x W) + (5.0 x H) - (6.76 x A) ] x (Activityfactor) x (injury factor)WomenBMR = [665.1 + (9.56 x W) + (1.85 x H) - (4.68 x A) ] x (Activityfactor) x (injury factor)BMR = basal metabolic rate W = weight in kg, M = height in cm, A =age in yearsActivity factorConfined to bed = 1.2Out of bed = 1.3Injury factorMinor operation = 1.2Skeletal trauma = 1.35Major sepsis = 1.6Severe thermal burn = 1.5
  44. 44. NutritionCaloric Requirement in burned adult= (25 x BW) + (40 x %burn) Kcal/dayModified Curreri ‘junior formula’1-12 yrs. = (60 x BW) + (30-35 x %burn) Kcal/day< 1 yrs. = (80 x BW) + (30 x %burn) KCal/day
  45. 45. Nutrition• Protein requirement– Burn < 30% TBSA– Total caloric need x 0.143– Burn > 30% TBSA– Total caloric need x 0.167
  46. 46. Nutrition• Enteral feeding through nasogastric ornasoduodenal tubes are the preferred method