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  • 1.Prof. AMSM SharfuzzamanProfessor of SurgeryTuesday, January 8, 2013 DR. RUBEL, SBMC 1

2. BURN Introduction : Burn trauma represents one of the most devastating conditions encounteredin surgery . A vast spectrum of injuries can arise from a burning accident,from thetrivial to some of the most dramatic injuries that humans survive. Themanagement of the major burn injury represents a significant challenge toevery member of the burns team burns doctors, surgeons, anaesthetists,ward and theatre nurses, physiotherapists, occupational therapists,dietitians, bacteriologists, physicians, psychiatrists, psychologists and themany ancillary staff whose cleaning and supply services are vital to thesuccessful running of a burns unit. The correct treatment of these injuries is vital to ensure a favourableoutcome & encompasses accurate assessment, careful resuscitation & precisesurgical management .Tuesday, January 8, 2013 DR. RUBEL, SBMC2 3. Epidemiology 1% of total population of a country in each year U.S - >1.2 million people per year. 50000 burns patients - Moderate to severe .- Require hospitalization . Among them >3900 people die of complications related to burns . Mechanism is age-related & situational: < 8 yrs. scalds all others flame burns work chemical/electrical/moltenTuesday, January 8, 2013 DR. RUBEL, SBMC 3 4. Definition Tissue injury from thermal application( heat and cold ) , absorption of physicalenergy ( electricity , friction and ionisingradiation ) and chemical ( corrosivesubstance ) contact .Tuesday, January 8, 2013 DR. RUBEL, SBMC 4 5. ClassificationA. According to causative agent: 1. Flame . 2. Scald . 3. Contact . 4. Chemicals . 5. Electricity . 6. Radiation.Tuesday, January 8, 2013 DR. RUBEL, SBMC 5 6. B. According to depths :1. 1st degree :2. 2nd degree : (i) Superficial (II) Deep3. 3rd degree .4. 4th degree . Tuesday, January 8, 2013 DR. RUBEL, SBMC 6 7. Pathophysiology of BurnBurns cause damage in a number of different ways, but byfar the most common organ affected is the skin A. Local changes :1. Zone ofcoagulation2. Zone of stasis .3. Zone ofhyperaemia Tuesday, January 8, 2013 DR. RUBEL, SBMC7 8. 3 Zones of T her malInjur y Hyperemia Stasis CoagulationTuesday, January 8, 2013 DR. RUBEL, SBMC 8 9. B. Systemic changes 1.Inflammation and oedema 2.Respiratory changes 3.Effects on the renal system 4.Effects on GIT 5.Effects on immune system 6. HypercatabolismTuesday, January 8, 2013 DR. RUBEL, SBMC 9 10. B. Systemic changesTuesday, January 8, 2013 DR. RUBEL, SBMC 10 11. 6. HypercatabolismTuesday, January 8, 2013 DR. RUBEL, SBMC 11 12. FACTORS DETERMINING THESEVERITY OF BURN As burn is the only truly quantifiable formof trauma, there are so many factorspredicting burn related mortality &morbidity.1) Age Reaction to burn Different healing process2) Source of burnTuesday, January 8, 2013 DR. RUBEL, SBMC 12 13. Candle fire Stove fireTuesday, January 8, 2013 DR. RUBEL, SBMC 13 14. Chemical fireTuesday, January 8, 2013DR. RUBEL, SBMC 14 15. DIATHERMY BURNTuesday, January 8, 2013 DR. RUBEL, SBMC 15 16. 2. Burn size: A General idea of the burn size can be made by using the rule of nines. Smaller burns can be calculated by using the pts palmer hand surface including the digits which is about 1% of T B S A. Calculation of burn size is necessary for diagnosis, treatment, prognosis & statistics.Tuesday, January 8, 2013DR. RUBEL, SBMC 16 17. 3. Burn depth:Burn depth is dependent upon the temperature of the burn source, the thickness of the skin, the duration of contact, the heat dissipation capability of skin (blood flow). Thickness further depends upon age, sex & the area of the body.Depth may be non uniform through out the burn extent and depth may progress time.Tuesday, January 8, 2013 DR. RUBEL, SBMC17 18. Burn severity map according todepthTuesday, January 8, 2013 DR. RUBEL, SBMC 18 19. Depth of Burn First- degree or epidermal: Involves only epidermis, erythematous, non blistering quite painful Second-degree or superficial partial: Includes papillary layers of dermis. Second-degree or deep partial: Extend into the reticular layers of the dermis Third degree or full thickness: Involve all the layers of dermis Fourth degree: Involves skin, subcutaneous tissue & deeper structuresTuesday, January 8, 2013 DR. RUBEL, SBMC19 20. Depth of Burn Appearance of Sensitivity to Healing timeDepth of BurnTissues destroyedburnspainPrognosis - Epidermis & - Red -Painful and - 7 - 14 days Superficialupper layer of - Blisters hypersensitive- PigmentPartial dermis change thickness - Hair follicles, - Blanching possible or sweat and Superficialsebaceousdermalglands intact. - Epidermal and - white with red Generally - 21- 35 daysdeeper dermis- No blistersinsensitive to- SevereDeep partial - Most nerve- No blanching painscarringthickness endings, hair- Eschar forms - Risk of or follicles and contracturesDeep dermal sweat glands- May needdestroyed.grafting All skin layers White charred, No pain - No skinFull-thickness January 8, 2013Tuesday, destroyed DR. RUBEL, SBMC dry, inelastic20 regeneration 21. Superficial partialthickness burnTuesday, January 8, 2013 DR. RUBEL, SBMC 21 Deep dermal burn 22. Full thickness burnTuesday, January 8, 2013 DR. RUBEL, SBMC 22 23. 4. Site of BurnInhalation injury should besuspected in a flame burn.Burn to the face could affect airwaymanagement or the eyes.Burn to the hand and feet couldimpede movement of fingers andtoes.Tuesday, January 8, 2013 DR. RUBEL, SBMC 23 24. 6. Co-morbid factors:Associated traumaImpaired sensation due to diabetes or intoxicationPre-existing cardiovascular, respiratory, renal disease.Seizure disordersPre existing hypovoluaemia or shockImmunization historyKnown allergySocial circumstancesSuicide or homicide attemptsChild abuseLack of care Tuesday, January 8, 2013 DR. RUBEL, SBMC 24 25. Management of BurnThe priorities in management of burnA. Air way control .B. Breathing and ventilation .C. Circulation .D. Disability - neurological status .E. Exposure with environmental control.F. Fluid resuscitation .Tuesday, January 8, 2013 DR. RUBEL, SBMC 25 26. Pre-hospital car eThe principles of pre-hospital care are: Ensure rescuer safety. Stop the burning process. Check for other injuries. A standard ABC (airway,breathing, circulation) check followed by a rapidsecondary survey will ensure that no other significantinjuries are missed. Cool the burn wound. This provides analgesia andslows the delayed microvascular damage that canoccur after a burn injury. Cooling should occur for aminimum of 10 min and is effective up to 1 hour afterthe burn injury. It is a particularly important first aidstep in partial-thickness burns, especially scalds. Intemperate climates, cooling should be at about15C, and hypothermia must be avoided. Tuesday, January 8, 2013 DR. RUBEL, SBMC 26 27. Pre-hospital care-contd. Give oxygen. Anyone involved in a fire in anenclosed space should receive oxygen,especially if there is an altered consciousnesslevel. Elevate. Sitting a patient up with a burnedairway may prove life-saving in the event of adelay in transfer to hospital care. Elevation ofburned limbs will reduce swelling anddiscomfort. Tuesday, January 8, 2013 DR. RUBEL, SBMC 27 28. Initial assessment :Primary surveyImmediate life threateningconditions are quickly identifiedand treatedSecondary surveyThorough head to toe evaluation. Tuesday, January 8, 2013 DR. RUBEL, SBMC28 29. Indications for intubation:(I) Erythema / swelling of the oropharynx on direct visualization . (II) Change in voice with hoarseness / harsh cough (III) Stridor. (IV) Dyspnoea.Tuesday, January 8, 2013 DR. RUBEL, SBMC 29 30. In an explosion or decelerationaccident --appropriate cervicalspine stabilization until the conditioncan be evaluated .Tuesday, January 8, 2013 DR. RUBEL, SBMC 30 31. C. Initial Wound care Cover the wound with clean dry dressing orsheet Pain reduced by cover the wound toprevent contact to exposed nerve ending. I.V. narcotics . The parts should be immobilized to a safefunctional position and the injured extremityelevated if possible . Tuesday, January 8, 2013 DR. RUBEL, SBMC 31 32. D. Transport : What ever the mode of transport it should be to appropriate place having emergency equipment available and trained personnel with necessary facilities .Tuesday, January 8, 2013 DR. RUBEL, SBMC 32 33. Criteria for hospitalization :Age : < 5yrs or > 60 yrs.Site : face , hands , feet , perineum or fracture.Inhalation injury .Mechanism of injury. Chemical injury >5% TBSA. Exposure to ionizing radiation . High pressure steam injury High tension electrical injury . Suspicion of non accidental injury . Hydrofluoric acid injury > 1% TBSA . Size : < 16yrs - > 5% TBSA16 yrs or > 16 yrs - > 10% TBSA Require fluid resuscitation. Require surgery . Psychiatric patient . Coexisting condition.Tuesday, January 8, 2013DR. RUBEL, SBMC 33 34. Assessment of burn wound : (I) Assessment of burn size by- Wallaces rule of nines- Patients whole hand ( palm and digit )- Lund and Browder chart . (II) Assessment of burn depth- From history temperature , time of exposure andburning material .- Superficial burns have capillary filling . - Deep partial thickness burns dont blanch but havesome sensation .- Full thickness burns feel leathery and have nosensation. Tuesday, January 8, 2013 DR. RUBEL, SBMC34 35. Tuesday, January 8, 2013 DR. RUBEL, SBMC 35 36. Lund andBrowderchart . Tuesday, January 8, 2013 DR. RUBEL, SBMC 36 37. Resuscitative fluid management :Principle : Maintenance of intra vascular volume inorder to provide sufficient circulation toperfuse not only the essential visceral organssuch as the brain , kidneys and the gut butalso the peripheral tissues. Tuesday, January 8, 2013 DR. RUBEL, SBMC 37 38. Resuscitation by oral fluid : Indication : < 10 % TBSA in child. < 15% TBSA in adult . Fluid : Salt containing oral fluid e.g. ORS , fruit juice . Tuesday, January 8, 2013 DR. RUBEL, SBMC 38 39. Resuscitation by I V fluidIndication :>10% TBSA in child .>15% TBSA in adult .Fluids:a.Crystalloids I) Ringers lactate, Hartmanns solution. II)0.9% NaCl solution III) Hypertonic saline solution . IV) 5% DNS.b. ColloidsI) PlasmaII) Plasma substitutesTuesday, January 8, 2013 DR. RUBEL, SBMC39 40. Formula :1. Parkland Formula : 1st 24 hrs Total fluid = 4 ml X body weight in kg X % of burn = ml Fluid : Ringers lactate . Schedule : 1st 8 hours = of total fluid . 2nd 8 hrs = th of total fluid. 3rd 8 hrs = 1/4th of total fluid. Next 24 hrsI) .5 ml X body weight in Kg X % of burn.fluid usually colloid or plasma.II) 5% DA to get urine out put. {.5 1.5 ml / Kg /hrs .} 5% DNS instead of 5% DATuesday, January 8, 2013 DR. RUBEL, SBMC40 41. 2. Muir and Barclay formulaSix rations in 1st 36 hours -4/4/4, 6/6 and 12 hours respectivelyEach ration= % burn X body weight in Kg/2 = ml.Fluid : Plasma3. Galveston ( Pediatric ) 5000 ml/ m2 TBSA burned+1500 ml / m2 TBSA. Fluid- 5% dextrose , Ringers lactate .Tuesday, January 8, 2013 DR. RUBEL, SBMC41 42. Monitoring Clinical. Biochemical & Hematological. Invasive. Tuesday, January 8, 2013 DR. RUBEL, SBMC 42 43. Clinical : Pulse -