Burns Surg

8/3/2019 Burns Surg

http://slidepdf.com/reader/full/burns-surg 1/7celimpin 2C 9/27/ 2011

BURNS

o Involves interdisciplinary skills of doctors, nurses, therapists,

and other health care specialists

o general surgeons will be at the forefront

o Partial-thickness burns >10% TBSA

o Burns involving the face, hands, feet, genitalia, perineum, or

major joints

o 3rd-degree burns in any age

o Electrical burns + lightning

o Chemical burns

o Inhalation injury… Etc…

tial evaluation

o Primary Survey

o Secondary Survey

tial evaluation

o airway management

o evaluation of other injuries

o estimation of burn size

o diagnosis of carbon monoxide and cyanide poisoning

direct thermal injury (upper airway) or smoke inhalation

rapid & severe airway edema

Early intubation

o Perioral burns and singed nasal hairs

o hoarse voice, wheezing, or stridor

o subjective dyspnea

o Burn patients should be first considered trauma patients

o Hypothermia

o wrap with clean blankets

o “Acute burn” injuries should never receive prophylactic

antibiotics

o tetanus booster

o Pain management

o treatment for possible anxiety

o Administer anxiolytic

Rule of 9’s

crude but quick and effective

ADULTS

o anterior trunk 18%

o posterior trunk 18%

o each lower extremity is 18%

o each upper extremity is 9%,

o head is 9%.

Rule of 9’s

o <3 years old

o head accounts for a larger relative surface area

be taken into account when estimating burn s

o “Lund and Browder chart”, more accurate acc

true burn size in children.

o Superficial or first-degree burns should not be

computing for TBSA

IV Resuscitation

Isotonic crystalloid formulas

1. Parkland formula

2. Modified Brooke formula

3. Haifa formula

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pertonic formulas

1. Monafo formula

2. Warden formula

lloid formulas

1. Evans formula

2. Brooke formula

3. Slater formula

4. Demling formula

rkland formula

o Lactated Ringer's

o 4 mL/kg per % TBSA burn

o 1/2 volume – 1st 8 hr

o 1/2 volume - next 16 hr

rbon Monoxide

o affinity of CO for hemoglobin = 200–250 x more than O2

o anoxia and death

o neurologic symptoms

o arterial carboxyhemoglobin level

o 100% oxygen is the gold

o “hyperbaric oxygen”

o cardiac arrest from CO poisoning have an extremely poor

prognosis regardless of the success of initial resuscitation

drogen cyanide

o persistent lactic acidosis

o S-T elevation on ECG

o Inhibits cytochrome oxidase = inhibits cellular oxygenation

eatment

1. Sodium thiosulfate

2. Hydroxocobalamin

3. and 100% oxygen

Burn Classification

o Thermal

(flame, contact, scald)

o Electrical burns

o Chemical burns

Flame Burns

o most common

o highest mortality

o related with structural fires

o inhalation injury

o and/or CO poisoning

Electrical Burns

o potential for cardiac arrhythmias

o compartment syndromes + concurrent rhabdo

common in high voltage injuries

Electrical Burns

o fasciotomies can be performed

o Long-term neurologic and visual symptoms

Chemical Burns

o less common, potentially severe burns

o remove toxic substance, irrigate area with wat

minutes minimum

o except in concrete powder or powdered forms

o offending agents can be systemically absorbed

o may cause specific metabolic derangements

o Formic acid, known to cause hemolysis and he

o hydrofluoric acid causes hypocalcemia

o Calcium-based therapies, mainstay + topical ca

gluconate applied to wounds

o Sub-q or IV infiltration of calcium gluconate

o Intra-arterial infusion of calcium gluconate

o electrocardiac abnormalities or refractory hyp

emergent excision of burned areas

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rn Depth

1. superficial (first degree)

superficial or deep by depth of involved epidermis

painful but do not blister

partial thickness (second degree)

dermal involvement

Epidermis + dermis

painful with weeping and blisters

Full thickness (third degree)

hard, painless, and nonblanching

Epidermis + dermis + sub-q

Fourth-degree burns

which affect underlying soft tissue

fascia, muscles, tendons,nerves, bones

Usually seen in electrical burns

3 Zones

1. The zone of coagulation

most severely burned portion

in the center of the wound

affected tissue is coagulated and sometimes fr

will need excision and grafting

2. Zone of stasis

Peripheral to zone of coagulation

vasoconstriction and resultant ischemia

Appropriate resuscitation and wound care ma

conversion to a deeper wound

infection or suboptimal perfusion may result i

in burn depth

3. Zone of hyperemia

last area of a burn

will heal with minimal or no scarring

3 Zones

o Burn wounds evolve over 48–72 hours after in

o Techniques to predict burn depth

1. Full-thickness biopsy

2. Laser Doppler

3. Noncontact ultrasound

Prognosis

I. Baux score

o (mortality = age + percent TBSA)

o was used for many years to predict mortality i

o Advancements in burn care have lowered ove

that the Baux score may no longer be accurate

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Age, burn size, inhalation injury

o most robust markers for burn mortality

o Age, even as a single variable, strongly predicts mortality in

burns

o In-hospital mortality in elderly burn patients is a function of

age regardless of other comorbidities

Comorbidities

o such as pre-injury HIV, metastatic cancer, and kidney or liver

disease –

o In nonelderly patients

o influence mortality and length of stay

Age, percent TBSA, inhalation injury, coexistent trauma, and

eumonia

o the variables with the highest predictive value for mortality

suscitation

o A myriad of formulas exist for calculating fluid needs

o No one formula benefits all patients

rkland / Baxter

o most commonly used formula

o 3 to 4 mL/kg per % TBSA burned (3-4 x TBSA)

o ½ given = first 8 hours

o remaining ½ over the next 16 hours

burn (and/or inhalation injury)

inflammatory response

leads to capillary leak

plasma leaks into extravascular space

*crystalloid admin. maintains the intravascular vol.

o patient receives large fluid bolus, that fluid has likely leaked

into the interstitium

o Thus, patient will still require ongoing burn resuscitation,

according to the estimates

o Continuation of fluid volumes should depend on

1. time since injury

2. urine output

3. and MAP

o as the leak closes, the patient will require less

maintain these two resuscitation endpoints

o formula for burn resuscitation are merely guid

o fluid must be titrated based on appropriate madequate resuscitation

o widely used & most common are (a) BP and (b

o target MAP is 60 mmHg to ensure optimal end

perfusion

o Urine output should be 30 mL/h in adults and

per hour in pedia

o Complication of overhydration

1. abdo comp. syndrome

2. Extrem. comp. syndrome

3. intraocular comp. syndrome

4. pleural effusions

o FLUID RESUSCITATION EXCEEDS ACTUAL NEED

increased opioid analgesic = peripheral va

hypotension

inhalation injury (5.76 mL/kg per percent

3.98 mL/kg per percent burned for patieninhalation injury

Prolonged mechanical ventilation may als

in increased fluid needs

o Colloids

Used in 2nd

24 hours

capillary leak closed, colloid may decreas

vol, and potentially may decrease asso. c

as intra-abdominal hypertension

albumin has never been shown to improv

o Hypertonic solutions decrease initial resuscita

as expected

o it appears to be a transient benefit and has the

causing hyperchloremic acidosis

o Other adjuncts used during initial burn resusci

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1. High-dose ascorbic acid (vitamin C)

2. Plasmapheresis

o Transfusion

associated with increased infections and a higher

mortality rate in burn patients

Given only when physiologically needed

recombinant human erythropoietin did noteffectively prevent anemia

ntilatory Mgmt

o Due to inhalational or smoke injury

drastically increase mortality in burn patients

burns, inhalation injury, and pneumonia increases

mortality by up to 60% over burns alone

adult respiratory distress syndrome (ARDS)

ARDS + burn + inhalation injury = mortality of up

to 66%

60% TBSA or > + inhalation injury + ARDS = 100%

mortality

oke Inhalation

o Causes injury in two ways

1. by direct heat injury to the upper airways

2. by inhalation of combustion products into the lower

airways

o by direct heat injury to the upper airways

airway swelling leads to maximal edema in first 24 to 48

hours

course of endotracheal intubation

o by inhalation of combustion products into the lower airways

combustion products found in smoke

direct mucosal injury

lead to ARDS

o Inhalational injury

Clinical diagnosis

Bronchoscopy, CT Scans

o Treatment (Inhalational injury)

1. consists primarily of supportive care

2. Aggressive pulmonary toilet

3. routine use of nebulized bronchodila

4. Steroids traditionally has been avoid

promising data in late ARDS

ARDS

o New ventilator strategies

o multisystem organ failure

o low tidal volume or "lung-protective ventilatio

o High-frequency percussive ventilation (HFPV)

Burn wound tx

Topical therapies

Silver sulfadiazine

o most widely used

o wide range of antimicrobial activity

o inexpensive and easily applied

o Soothing

o causing neutropenia

o destroy skin grafts & contraindicated on b

proximity to newly grafted areas

Mafenide acetate

o effective topical antimicrobial

o effective even in the presence of eschar

o excellent antimicrobial for fresh skin graft

o limited by pain with application to partia

burns

o absorbed systemically

Silver nitrate

o broad-spectrum antimicrobial activity

o topical application can lead to electrolyte

with resulting hyponatremia

o rare complication is methemoglobinemia

o causes black stains

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bacitracin, neomycin, and polymyxin B

o nearly healed, small or large

o superficial partial-thickness facial burns

o Meshed skin grafts

Mupirocin

o methicillin-resistant Staphylococcus aureus

o only be used in culture-positive burn wound

Silver-impregnated dressings such as Acticoat and Aquacel

Ag

o used for both donor sites and skin grafts

o as well as for burns that are clearly partial-thickness on

admission

o help reduce the number of dressing changes

o not be used in wounds of heterogeneous depth

Biologic membranes such as Biobrane

o provide a prolonged barrier under which wounds may

heal

o occlusive nature, used only on fresh superficial partial-

thickness burns that are clearly not contaminated

trition

o impt in patients with large burns

o immune responsiveness

o Early enteral feeding, gastric ileus can often be avoided

o metoclopramide inc GI motility

o Immune modulating supplements such as glutamine

trition

o Harris-Benedict equation

o Curreri formula

o Indirect calorimetry

rn Care Compx

o Ventilator-associated pneumonia

o Massive resuscitation of burn patients

o Deep vein thrombosis (DVT)

o Heparin-induced thrombocytopenia (HIT)

o Catheter-related bloodstream infections (CVP)

Surgery

Full-thickness burns with a rigid eschar (Extrem

o tourniquet effect as the edema progresse

o compromised venous outflow

o eventually arterial inflow

o paresthesias, pain, decreased capillary re

progression to loss of distal pulses

Abdominal compartment syndrome

o decreased urine output, increased ventila

pressures, and hypotension

Thoracic compartment syndrome

o hypoventilation, increased airway pressu

hypotension

Escharotomy

o rarely needed within the first 8 hours

o not be performed unless indicated

o (Extremity) incisions on lateral and media

extend to thenar & hypothenar

o Digital escharotomies, not recommended

o Inadequate perfusion despite escharotom

fasciotomy

o Thoracic escharotomies placed along the

axillary lines with bilateral subcostal and

extension

o anterior axillary incisions down the latera

typically will allow adequate release of ab

eschar

Early excision and grafting

o improve mortality

o early excision decreased reconstruction s

o ideally start within the first several days

o Excision is performed with repeated tang

until only nonburned tissue remains

o leave healthy dermis

o Excision to fat or fascia in deeper burns

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o Pneumatic tourniquets

o fibrinogen and thrombin spray sealant

o deep burns and concern for excessive blood loss, fascial

excision may be used

o cosmetically inferior appearance due to the loss of

subcutaneous tissue

ound Coverage

Full-thickness grafts

o impractical for most burn wounds

Split-thickness sheet autografts

o Dermatome

o durable wound coverings

o have a decent cosmetic appearance

o larger burns = meshing of autografted skin

o face, neck, and hands grafted with nonmeshed sheet

grafts to ensure optimal appearance

Temporary Wound Coverage

1. Human cadaveric allograft

2. Integra

3. AlloDerm

4. Epidermal skin substitutes

nor Sites

Thigh

o convenient anatomic donor sites

o easily harvested

o hidden from an aesthetic standpoint.

thicker skin of the back

o in older patients, who have thinner skin elsewhere andmay have difficulty healing donor sites

The buttocks

o excellent donor site in infants and toddlers

o Silvadene can be applied to the donor site with a diaper

as coverage.

The scalp

o also an excellent donor site

o skin is thick and many hair follicles so it h

o completely hidden once hair

Rehabilitation

o Equally important

o physical and occupational therapy is mandato

loss of physical function.

o On mech vent, passive range of motion done a

day

o Psychological rehabilitation

PREVENTION

o Very much important

Documents

Burns Surg