Burn SurgeryBasic Science LectureGeneral SurgeryKanene Ubesie, M.D.Virginia Commonwealth University (VCU)Burn Surgery Fellow

ObjectivesBurn pathophysiology, classification, and anatomy

Non-operative and operative plans for burn wounds

Initial burn evaluation and management

Burn TBSA and resuscitation

Thermal Burn

Inhalation injury

Electrical Burn

Chemical Burn

Frostbite

History of Burn Surgery1940s: Early excision of burn to reduce mortality

1940s: Lund and Browder chart, Rule of 9s (G.A. Knaysi), Parkland formula (Charles Baxter and G. Tom Shires)

1947: First civilian US burn center at MCV by Dr. Everett I. Evans (Evans-Haynes Burn Center)

1960s: Zora Janzekovic developed the concept of tangential excision with an uncalibrated knife

Burn Epidemiology

Common populationsVery young

Elderly

Impaired

Low socioeconomic groups

Substance Abuse

Trauma

Nonaccidental

Self-induced

Thermal Burns: Classification

Dual layer skinEpidermis

Keratinocytes

Barrier (infection, toxins, UV, dehydration, thermal)

DermisConnective tissue, Mechanoreceptors, Glands, Lymphatics and Blood vessels

Durability/Elasticity

Papillary and Reticular

Classification of BurnsSuperficial epidermal (1st)

Partial thickness (2nd)Superficial

Deep

Full thickness (3rd)

Muscle/Bone (4th/5th)

Thermal Burns: Classification

Burn PathophysiologyZones of injury

Zone of CoagulationFull thickness burn

Necrotic

Irreversible

Must debride and graft

Zone of StasisPartial thickness burn

Vasoconstriction/Ischemia

Reversible

Protect from - edema, infection, or poor perfusion

Zone of HyperemiaSuperficial epidermal injury

Quickly heals without scarring

Not included in TBSA

Thermal Burns: Initial Management

ABCs!!!!! Secondary Survey

Stabilize and transfer to nearest burn center

Burn Center

Goal: early surgical excision and/or closure of burn wounds

Systematic Approach

Multidisciplinary team

Psychosocial support

Education

Rehabilitation

Reconstruction

Criteria to refer to a burn center:

Thermal Burns: Initial Management

Thermal Burns: Initial Management

Indication for hospitalizationInhalation injury

Large and/or infected wound

Wound care and education

Physical therapy

Pain management

Discharge planning

Prognostic Factors>60 years of age

Full thickness burn >40% TBSA

Inhalation injury

Question: Name the zones of injury

Total Body Surface Area

Rule of 9sMore surface area for pediatric head

1% for the palm (tips to wrist)

SAGE

Lund & Browder

Burn Resuscitation: Parkland Formula

Partial thickness and deeper

Adult >20% TBSA

Pediatric >10% TBSA

4 x kg x %TBSAGive half in the first 8 hours

Lactated Ringers in the first 8 hours

Maintenance fluid in pediatrics <20 Kg D5 ½ NS

No colloid until after at least 8 hours

Titrate by UOPAdult – 0.5cc/kg/hr

Pediatric – 1cc/kg/hr

Over-resuscitationCompartment syndrome, pulmonary edema, swelling, ARDS

Non-operative Management of BurnsSuperficial epidermal to dermal wounds

Daily dressing changeGently wash away fibrinous exudate and biofilm

Debride large blisters

Ointment

Protective non-adherent dressing

MOBILITYDecrease: edema, infection, pain, contractures

Non-operative Management of Burns:

AntimicrobialsSilver SulfadiazineBroad spectrum, Pseudomonas and fungal

Not very effective for Klebsiella, new resistance with Pseudomonas

Soothing however does not penetrate eschar

Can retard wound healing

Reversible granulocyte reduction

Mafenide Acetate (Sulfamylon)Cream and solution

Broadest spectrum, all strains of Pseudomonas

Painful – penetrates escharEars

Metabolic acidosis – ventilator complications

Silver NitrateStaph aureus, E. Coli, Pseudomonas

Activate with water (not NaCl)

Hyponatremia, Hypochloremia, Methemoglobenemia

Does not penetrate Eschar

Stains black

Sodium Hypochlorite (Dakins)

Toxic to tissue if not diluted

0.025% - Pseudomonas, MRSA, Enterococci

MupirocinMRSA

Operative Management of Burns

Full* thickness and deeper

Early excisionBetter survival rates

Shorter LOS

Lower costs

After 24 hours of initial management and within 7 days

Stage every 2-3 days, 20% at a time

Tangential vs FascialBlood Loss

Aesthetics

Length of stay

Allograft vs Autograft

Cultured Epidermal Autograft

Operative Management of Thermal Burns

EscharotomiesCircumferential burns

Fluid resuscitation

Skin only

Perform in anatomical position

No benefit for digital escharotomies

Can perform at the bedside with cautery

Question: What it the TBSA?

Question: Calculate Burn Resuscitation

(20kg)#12% TBSA

Burn: Inhalation InjurySignificant increase in morbidity and mortality when combined with cutaneous burn

History and examClosed space

Toxic fumes

Facial burn

Singed nasal/facial/scalp hair

Soot

Flexible laryngoscopy

When to intubateCarbonaceous sputum below the vocal cords

Respiratory distress or failure

Altered mental status

Hoarseness, wheezing, stridor

Large burns undergoing resuscitation (>40% TBSA)

Burn: Inhalation InjuryCarbon Monoxide (CO) poisoning

Petroleum

200x higher affinity than oxygen to bind Hgb (carboxyhemoglobin)

Most common symptoms: Nausea, dizziness, fatigue, headache

Increasing altered mental status with increasing levels

100% FiO2

Hyperbaric

Burn: Inhalation Injury#

Cyanide poisoningNatural/Synthetic compounds

Structural fires

Disrupts cellular oxidation Lactic Acidosis

CyanoKit (hydrocobalamin, Vit B12)

Hypertension

Burn: ElectricalCategories

Low voltage, <1000V

High voltage, >1000V

Super-high voltage, Lightening

Tissue injuryLow voltage: localized, oral cavity

High voltage: deep tissue and organ injury

Lightening: Cardiopulmonary arrest, ruptured TMs

Thermal injury

Tetanic contractionsSpinal fractures

Concomitant injuries (Fall)

Burn: ElectricalWork up

Complete trauma evaluation

Neurologic exam

Ophthalmology exam

MonitoringTelemetry

Foley insertion

Neurovascular exams

TreatmentCompartment Syndrome

Fasciotomies

RhabdomyolysisUOP >100cc/hr

Alkanalize Urine

Rarely need mannitol

Question: Best, painless, colorless

antimicrobial with the least side effect profile?

#

Burn: ChemicalDo not soak affected area

Avoid neutralizing agents

LiquidAlkali vs Acid

Irrigate with water x30 minutes

PowderBrush away

Avoid water

Hydrofluoric acidSevere hypocalcemia

Irrigation and topical calcium gluconate are soothing

Gold Standard treatment:Intra-arterial calcium gluconate over 4 hours

TarRemove with lipophilic solvent (Medi-Sol)

Treat thermal injury

Frostbite

EtiologyDirect freezing or chronic exposure to extremely cold environment

Pathologic process is provoked by repeat exposure

Higher risk in patients with alcohol abuse, impairment, or psychiatric issues

TreatmentRemoval from cold environment

ABCs

Elevation of affected limb and protect from further trauma

Up to date Tetanus

Correct hypothermia

CONTINUOUS rewarming at room temperature

Warm bath, 37-39C, 30 minutes

Warm IVFs

Narcotics

Delay operative intervention until rewarming complete

Do not rub/massage

Do not unroof blisters

DONE!