burns surg
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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
8/3/2019 Burns Surg
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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
8/3/2019 Burns Surg
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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
8/3/2019 Burns Surg
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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
8/3/2019 Burns Surg
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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
8/3/2019 Burns Surg
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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
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