3. Etiology of Burns
Causes :
Flame - damage from superheated, oxidized air
Scald - damage from contact with hot liquids
Contact - damage from contact with hot or cold
solid materials
Chemicals - contact with noxious chemicals
Electricity - conduction of electrical current through
tissues
5. Area involved
Hand, wrist – hot liquid
Eyes – chemical
Face flame, hot liquid
Contact burns
Firefighters – face and posterior neck
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Depth of injury
First degree - Injury localized to the epidermis
Superficial second degree - injury to the
epidermis and superficial dermis
Deep second degree - injury through the
epidermis and deep into the dermis
Third degree - full-thickness injury through the
epidermis and dermis into subcutaneous fat
Fourth degree - injury through the skin and
subcutaneous fat into underlying muscle or bone
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Aim of management
To limit the injure to zone of coagulation
To prevent injury to zone of stasis
Management actually aims at preventing a
second degree or first degree burn to
becoming a deeperinjury
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Electrical injuries
Muscle injury without skin damage
Myoglobinuria – treat to prevent renal
failure
Cardiac arrhythmia
Tetany, rupture of tendons
Neurological deficit
Saliva good conductor of electricity
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Electrical Injuries
Impaired attention span
Memory problems (especially for short-term
anterograde verbal information
Persistent distress and frustration
Mood disorders - often characterized by
psychosocial difficulty and violent behavioral
outbursts, accompanied by a background of
generalized depression
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Electrical injuries
Survivors of severe electrical injury have
been noted to exhibit abnormal
neuropsychologic findings several
years after trauma.
Late evaluation of patients with significant
electrical injury has suggested a common
constellation of symptoms involving both
cognitive and affective disturbances.
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Systemic response to Burns
Inflammation and edema
Altered hemodynamics
Immunosuppression
Hyper metabolism
Decreased renal flow
Increased gut mucosal permeability
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Principles of management
Burn Resuscitation
Early management
Wound care
Surgical management
Management of complications
Management of Psychosocial issues
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Parkland formula
Parkland 4 ml/kg per % TBSA burn Total
fluid =4 x body wt x BSA
½ of which is given in first 8 hours from the
point of injury
Next half is given in the next 16 hours
25. Wound healing Principles
Burn wounds are potentially contaminated
and needs debridement.
Clean wound with out coagulum heals
faster.
Epithlialization occurs from the cells
remaining in the dermis.
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Wound therapy
Management of burn wounds can be
divided into three stages: assessment,
management, rehabilitation.
Rehabilitation starts early in management
Positioning and splinting
Stretching of joints
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Surgical management
Primary excision
Early excision
Excision with Skin grafting
Excision with allograft
Excision with skin substitutes
Excision – Integra – Skin grafting
Excision with flap coverage
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Surgical management
Immediate excision
Primary excision
Early excision
Delayed excision
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Outcome in Burns
Early, aggressive resuscitation regimens
including early excision and wound
coverage have improved survival rates
dramatically.
By decrease in Sepsis and Multi organ
failure
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Prevention of contractures!!!!
Think neck and chest are a single unit
when it comes to contracture
Hand splints
Position elbows and axilla
Knee brace
Prevent foot drop
33. Pressure garments
Pressure garments appear to help in :
reduce scar thickness/lumpiness
reduce scar redness
reduce swelling
relieve itching
protect newly healed skin/graft
prevent contractures/ maintain contours
34. Silicone gel sheets
The exact mechanism of action of silicone
in the prevention and management of
hypertrophic scars is unclear.
Influences the collagen remodeling phase
of wound healing
Soften, flatten and blanch the scar, making
it comfortable and improves appearance
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Custom Compression Garments
25 mm of Hg
Constant use
Clear masks for face
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Management of contractures
Serial casting
Surgical release
Post operative splinting
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Amputation of digits / Fusion
DIPJs, PIPJs and possibly the middle
phalanges. – Try to preserve length
Both for toes as well as fingers.
The thumb amputation deformity is treated either
by pollicization or toe transfer.
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Complications of Hand Burns
Loss of parts Adduction contracture
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Prevention of contracture by early
excision and soft tissue coverage
Soft tissue coverage of the knee joint following
burns. Canadian Journal of Plastic Surgery 2006;
14:163.
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Psychological problems associated
with work related Burn injuries
Depression
PTSD
Anxiety disorders
Workers with electrical injuries had higher
psychological problems (19%)
JBCR 2011
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Occupational Burn injuries
Preventable?
Appropriate education
Work place training
PPE (Personal Protective equipment)
Safe work place procedures
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Worker training
Worker illness and Injury prevention
programs
Reporting all injuries
First aids
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Back to work programs
Can the worker return to previous
occupation
Is there any work place adjustments
required
Retraining
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Impaired wound healing - Extrinsic
Nutritional deficiency
Diabetes mellitus
Chronic renal sufficiency
Steroids – reversed by Vit A
Chemo
Liver disease
Old age
Heredity
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Hyperbaric oxygen
2.5 atmospheres for 2 hours
Tissue oxygen measured transcutanously.
Oxygen tension of 30 mmHg required for
normal cell division and wound healing.
Optimal oxygen requirement for nonhealing
wound is unknown.
Reinisch suggested that the beneficial effect
of hyperbaric oxygen is due to the
vasoconstructive property of oxygen, which
acts to close arteriovenous shunts and thus
improves capillary circulation
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Categories of wound dressing
Absorbents – to control drainage
Impregnated dressings - Adaptic
Transparent dressing- Opsite
Foams
Hydrogels – DuoDerm Gel
Xerogels – Alginates, Sorbsan
Hydrocolloids – Cutinova, DuoDerm
Active dressing – hydrogel with antimicrobial
VAC system – subatmospheric wound healing
Biotherapy - maggots
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Fetal wound healing
Contain few granulocytes
Increased turn over of matrix
Early gestation fetal skin heals by
regeneration or growth rather than scaring.
Extra cellular matrix rich in hyaluronic acid
Low hyaluronidase activity and increased
fibronectin production
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Fetal wound healing
Highly organized collagen architecture
TGF – induces acute inflammation and
subsequent fibrosis in fetal wound
Collagen type III increased
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Gene therapy
Two methods:
- Genetically engineered keratinocyte or
fibroblast to over express growth factor
genes
- Transfer of DNA directly by gene gun or
direct subcutaneous injection of DNA
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Transplantation
Research to reality
Partial vs total face
Extremity