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Burns

Kriska Shalin L. Joaquin. Burns. Objectives. At the end of this session the group is expected: To be able to identify the salient features in the history and physical examination of a burn patient To discuss the approach to management of burn patients

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Burns

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  1. Kriska Shalin L. Joaquin Burns

  2. Objectives At the end of this session the group is expected: • To be able to identify the salient features in the history and physical examination of a burn patient • To discuss the approach to management of burn patients • To know the anatomy of the skin - review • To discuss the pathophysiology of burns • To discuss prevention and psychosocial dimension

  3. Patient data • WN • 34/M • Micronesian • 17-November-1977 • Single • Electrician • Weno City, Micronesia • Can speak English, limited

  4. Chief Complaint • Electric burn

  5. History of Present Illness • Patient was working on an electric post with his hands • lasted minutes ? • Sustaining burns on Left forearm and Left thigh • Immediately brought to the hospital in Micronesia 1 month prior (33 days)

  6. History of Present Illness • Findings: • 3x4 cm deep tissue burns on dorsum of left arm and forearm, erythematous, hyperemic, tender • (+) limitation of movement • 3x4 cm deep tissue burns dorsum of left thigh, erythematous, hyperemic, tender • (+) limitation of movement

  7. History of Present Illness 17thhospital day • Fasciotomy and debridement was done • Arranged for transfer to this institution for skin grafting • (+) some degree of necrosis on Lateral aspect of Left thigh, referral to this institution Transfer to this institution 32ndhospital day

  8. Past Medical History • No known co-morbidities • No previous hospitalizations • No previous surgeries • No known allergies to food or drugs

  9. Family History • (-) HTN • (-) DM • (-) Allergies

  10. Personal/Social • Electrician • Denies smoking • Occasional alcohol drinker • Denies illicit drug use

  11. Review of Systems • No fever • No weight changes • No cough/colds • No vomiting/diarrhea/constipation • No heat/cold intolerance

  12. Physical Examination • Conscious and coherent, could not understand English very well • HR 84 • RR 16 • T 37.0 • Weight 81 kg • Height 178 cm • VAS 0/10

  13. Skin • (+) graphic tattoos on left shoulder • (+) ulceration on left arm and forearm, with length of about 1 foot, dry, well circumscribed but irregular borders • (+) deep ulceration of the lateral aspect of the left thigh, 1x1 feet, non-foul smelling, no discharge, minimal bleeding

  14. Head and Neck • Normocephalic head • Anictericsclerae, pink palpebral conjunctivae • Ears symmetric, (-) discharge • Nasal septum midline, (-) nasal discharge • (-) tonsillopharyngeal congestion • Neck lymph nodes not palpable, thyroid not enlarged

  15. Chest and Lungs • Symmetric chest expansion • (-) retractions, no use of accessory muscles • Clear breath sounds • (-) wheezes, rales

  16. Heart • Adynamicprecordium • Normal rate • Regular rhythm • Good S1 and S2 • No murmurs, no skip beats

  17. Abdomen • Flat abdomen • Normoactive bowel sounds • Soft, non-tender • No organomegaly

  18. Genitourinary and DRE • Not examined

  19. Salient Features SUBJECTIVE • 34/M • electrician • Electric burn • On his 42nd hospital day • OBJECTIVE • 14% TSBA electric burns, full thickness • Fasciotomy and wound debridement done • Stable VS • Left arm • Lateral left thigh

  20. Primary impression • Electrical burns, 14% TBSA Full thickness type, Right arm, forearm, and thigh secondary to Electrical Injury with Partial disability

  21. Course in the Wards:

  22. Course in the Wards:

  23. Course in the wards

  24. Patient is currently on his 42ndhospital day, (10thhospital day in this institution) for skin grafting tomorrow

  25. DISCUSSION

  26. SKIN • Largest and most complex organ • FUNCTION – protective barrier • - Regional variation • LAYERS • Epidermis • Basement membrane • Dermis

  27. BURNS • 90% of burns are preventable • Nearly one half are smoking related or due to substance abuse • Advances in medicine have decreased mortality, hospital stay • Quality of burn care measured by survival and long-term function and appearance

  28. surgeon's goal: well-healed, durable skin with normal function and near-normal appearance • In children <8 : SCALD BURNS • Older children and adults: FLAME-RELATED • Work-related: Chemicals, hot liquids, electricity, molten/hot metals

  29. TYPES • SCALD BURNS • FLAME BURNS • FLASH BURNS • CONTACT BURN

  30. Hospital admission & Burn Referral • Any patient who has a symptomatic inhalation injury • Rule of thumb: • If burns cover more than 5-10% TSBA • Otherwise healthy patients, with a place to go and someone to stay with them could be observed 1-2 hours then discharged

  31. Burn Center Referral Criteria   1.    Partial-thickness and full-thickness burns totaling greater than 10% TBSA in patients under 10 or over 50 years of age.   2.    Partial-thickness and full-thickness burns totaling greater than 20% TBSA in other age groups.   3.    Partial-thickness and full-thickness burns involving the face, hands, feet, genitalia, perineum, or major joints.   4.    Full-thickness burns greater than 5% TBSA in any age group.   5.    Electrical burns, including lightning injury.

  32.   6.    Chemical burns   7.    Inhalation injury.   8.    Burn injury in patients with preexisting medical disorders that could complicate management, prolong the recovery period, or affect mortality.   9.    Any burn with concomitant trauma   10.    Burn injury in children admitted to a hospital without qualified personnel or equipment for pediatric care.   11.    Burn injury in patients requiring special social, emotional, and/or long-term rehabilitative support

  33. Emergency Care • ABC: airway, breathing, circulation • Suspect inhalational injury to anyone with flame burn • Inspect mouth and pharynx • Hoarseness and wheezes • Copious mucus production and carbonaceous sputum • Carboxyhemoglobin levels • Decreased P:F ration – early indicator (<300, <250 intubate

  34. Fluid Resuscitation in the ER (>20%TBSA) • IV LR 1000 mL/h in adults • IV LR 20mL/kg in children • Foley catheter • 30ml/h in adults, 1.0ml/kg/h in children • Patients <50% TBSA, begin with 2 large-bore peripheral IV lines avoiding the lower extremities • >50% (including extremes of age, inhalation injuries) – additional central venous access • >65% refer immediately to a burn center, requires ICU

  35. Tetanus Prophylaxis • for those without previous immunization within 5 years, unknown status – hyperimmune serum • Gastric decompression – NGT • Pain control – IV • Psychosocial care • Care of Burn Wound – after all assessments

  36. ESCHAROTOMY • Thoracic escharotomy-seldom required • Extremities – to prevent neuromuscular and vascular compromise • Assess skin color, sensation, CRT, peripheral pulses q1 hour • WOF: cyanosis, deep tissue pain, progressive paresthesia, progressive decrease or absence of pulses, sensation of cold

  37. BURN SEVERITY • Size and depth of the burn, and the body part involved • TSBA – single most important factor in prognosis

  38. Burn size • Rule of nines • Upper extremity – 9% each • Lower extremity – 18% each • Anterior trunk – 18% • Posterior trunk – 18% • Head and neck – 9% • Perineum – 1%

  39. Burn depth • Primary determinant of patient’s long-term appearance and functional outcome • Burns that heal within 3 weeks usually do so without hypertrophic scarring or functional impairment • Early excision and grafting • Dependent on: • temperature, skin thickness, duration of contact, heat-dissipating capability of skin

  40. SHALLOW BURNS • First degree – Epidermal burns • Do not blister • Erythematous • Painful • Desquamates on 4th day • Second degree –Superficial partial-thickness • Upper layers of dermis • Blisters with fluid accumulation • Pink and wet • Hypersensitive • Blanch with pressure • Heals in 3 weeks if infection is prevented

  41. DEEP BURNS • Second degree- Deep Partial thickness • Reticular layers • Blister • Mottled pink and white • Discomfort rather than pain • Slow to absent CRT • Become dry and white • Heals in 3-9 weeks

  42. DEEP BURNS • Third degree – Full thickness • All layers • Contracture • Epithelialization of wound margin • Skin grafting • White, cherry red, black • With or without blisters • Leathery, firm, depressed • Insensate • Do not blanch with pressure • eschar

  43. DEEP BURNS • Fourth degree • Involves subcutaneous fat and deeper structures • Charred appearance • Electrical burns, contact burns, immersion burns, unconscious people at time of burning

  44. Clinical observation is still most commonly used, however: • Ability to detect dead cells or denatured collagen • Biopsy, utrasound, vital dyes • Assessment of changes in blood flow • Fluometry, laser Doppler, thermography • Analysis of color of wounds • Light reflectance methods • Evaluation of physical changes • Nuclear MRI

  45. Electrical Injury and Burns • Severity depends on the amperage of the current • Pathway of the current through victims body • Duration of contact • Electric burn • Electrical injury from the current • An arc or flash flame • Flame injury from ignition of clothing or surroundings

  46. Care at the scene • Rescuer should avoid touching the victim until current is shut off • StandardABCs • BLS/ACLS if necessary • Rule out fractures

  47. Don’t be fooled by the size • Other systems • Cardiac • Nervous • Eyes - cataracts

  48. Wound management • Immediate surgery for • Massive deep tissue necrosis will lead to acidosis/myoglobinuria • Injured deep tissues undergo significant swelling – risk of compartment syndrome • Escharotomies and fasciotomies at compartment pressure >30mmHg

  49. Physiologic response • SIRS • BURN SHOCK • Tissue trauma and hypovolemic shock • Loss of microvascular integrity and thermal injury at cellular level • Histamine • Serotonin • Eicosanoids (PGE2 and prostacyclin PGI2) • Bradykinins

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