junior academic half day may 1 st 2012 burn injury joseph hardwicke spr burns & plastic surgery...

Junior Academic Half Day May 1st 2012

BURN INJURY

Joseph Hardwicke

SpR Burns & Plastic Surgery

West Midlands Deanery


TIMELINE OF BURN CARE

THEN GREAT WAR WWII FALKLANDS

FLUIDRESUSCITION

FLUIDRESUSCITION

ANTI-SEPSISANTI-SEPSIS

SKINGRAFTS

SKINGRAFTS

MESHEDGRAFTS

MESHEDGRAFTS

BURNEXCISION

BURNEXCISION

"BURNTOXINS"

"BURNTOXINS"

MULTI-DISCIPLINARYAPPROACH

MULTI-DISCIPLINARYAPPROACH

NUTRITIONALSUPPORT

NUTRITIONALSUPPORT


TIMELINE OF BURN CARE

NOW

SKINSUBSTITUTES

SKINSUBSTITUTES

SKIN CELLCULTURE

SKIN CELLCULTURE

PSYCHOLOGICALSUPPORT

PSYCHOLOGICALSUPPORT

ORGANSUPPORT

ORGANSUPPORT

REHABILITATIONREHABILITATION ?

SCARMANAGEMENT

SCARMANAGEMENT


FIRE DISASTER


AIMS

1. Causes of burns and the demographics of UK burn injury

2. The anatomy of the skin, depth of burn and the Jackson burn wound model

3. Estimation of burn % total body surface area (%TBSA) and fluid resuscitation

4. Inhalation injury


CAUSES OF BURNS AND THE DEMOGRAPHICS OF UK BURN

INJURY


CAUSES OF BURNS

• THERMAL– Hot or cold

• HOT COLD– Liquid - scald - Freezing - frostbite / nip

– Solid - contact - Non-freezing - trench foot

– Gas - flame

• Direct cellular destruction Freeze-thaw

Embolic/thrombotic


CAUSES OF BURNS

• ELECTRICAL– Low voltage < 1,000V

– High voltage > 1,000V

– Superhigh voltage > 10,000V

• Conduction through tissues


CAUSES OF BURNS

• Deep tissue destruction– Myoglobinuria

– Compartment syndrome

– Cardiac dysrhythmias


CAUSES OF BURNS

• CHEMICAL– Acid

– Alkali

• ACID ALKALI– Coagulative necrosis - Liquifactive necrosis

– Painful - Non-painful tissue destruction

• IRRIGATION– Copious water to correct pH


CAUSES OF BURNS

• RADIATION– UVB

– Ionising radiation


UK BURN DEMOGRAPHICS

250,000 burns/year

175,000 A&E attendances

13,000 hospital admissions

1,000 resuscitation burns 50% < 16 yrs

300 deaths/year Majority > 60 yrs


CAUSES OF BURNS

1. THERMAL

2. ELECTRICAL

3. CHEMICAL

4. RADIATION

• Extremes of age

• Non-accidental injury

• Psychiatric co-morbidity

• Industrial / workplace

BURNS FIRST AID

1. Stop the burning process2. Cool the burn

• Cool running water• 10-30 minutes

3. Cover the burn4. A&E if area of SKIN LOSS bigger than palm of hand

KEY POINT


THE ANATOMY OF THE SKIN, DEPTH OF BURN AND THE

JACKSON BURN WOUND MODEL


ANATOMY OF THE BURN

• Functions of the skin

BARRIER

THERMO-REGULATION

SENSORY

METABOLIC

PSYCHO-SOCIAL


DEPTH OF BURN

1. SUPERFICIAL ERYTHEMA• No skin loss

• Not included in burn %TBSA

2. PARTIAL THICKNESS• Superficial

• Deep

3. FULL THICKNESS


BURN ZONE OF STASIS

• Adequate fluid resuscitation may preserve zone of stasis

• Infection may cause burn extension

• Early burn excision reduces necrotic load

• Prognosis determined by the size of the burn

unburnt skin

zone of coagulation

zone ofhyperaemia


INITIAL BURNS MANAGEMENT

A : AIRWAY + C-SPINE CONTROLOXYGEN

B : BREATHING + VENTILATION

C : CIRCULATIONIV ACCESS, STOP BLEEDING

D : DISABILITYGCS

E : EXPOSURETEMPERATURE CONTROL%TBSA

F : FLUID CALCULATION

KEY POINT


ESTIMATION OF BURN % TOTAL BODY SURFACE AREA (%TBSA)

AND FLUID RESUSCITATION


ESTIMATION OF %TBSA BURN

• Average adult TBSA 1.7m2

• Distribution changes with age


BODY WEIGHT

• Important to calculate fluid requirements

• Measure or estimate

MEASURE ESTIMATE

Under 10 yrs

(age + 4) x 2 = kg

Over 10 yrs

age x 3 = kg


FLUID RESUSCITATION

• Hartman's solution / Ringer's lactate

• Then titration of fluids depending upon urine output etc.

2 - 4 mls/kg/%TBSA

From time of burn

Half given in first 8h

Half given in next 16h

KEY POINTHigher value for:

1. Inhalation injury2. Electrical burns3. Paediatric burns


INHALATION INJURY


INHALATION INJURY

• Mortality increased by 40%

• Early airway management

POINTERS TO INHALATION INJURY

1. Enclosed space2. Delayed extraction3. Facial burns4. Singed facial hair5. Carbonaceous sputum6. Hoarse voice / stridor

KEY POINT


SITE OF INJURY

• Supraglottic– Thermal injury from inhaled gases

– Airway spasm

• Infraglottic– Chemical burns from products of combustion

• Bronchoalveolar lavage


TOXINS

• Products of combustion

• CARBON MONOXIDE– Preferential binding to Hb (200x)

– Arterial blood gas• <10% normal >60% fatal

• HYDROGEN CYANIDE– Synthetic rubber, polyurethane

– Inhibits cytochrome C oxidase

– Antidote and oxygenate

Oxygen-dissociation curveshifts to the left


OVERVIEW

1. Causes of burns and the demographics of UK burn injury

2. The anatomy of the skin, depth of burn and the Jackson burn wound model

3. Estimation of burn % total body surface area (%TBSA) and fluid resuscitation

4. Inhalation injury


WOUND HEALING


BASICS OF WOUND HEALING

• Sequential process

• Driven by cellular and matrix components


BURN WOUNDS

• Superficial partial thickness wounds heal by re-epithelialisation

• Keratinocyte reserve in "epidermal derivatives"

– Hair follicles

– Sweat glands

• Should heal by 2 weeks– Minimal scarring


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DEEPER BURNS

• Loss of keratinocyte reserve– Loss of epidermal derivatives

• Hair follicles

• Oil / sweat glands

• May heal by contraction from wound edge

– Myofibroblasts

• New matrix formed– Fibroblasts

• SCAR FORMATION


SCARS

• End stage of normal wound healing

NORMAL PATHOLOGICAL

contracture hypertrophic keloid


IMPAIRED WOUND HEALING• PATIENT FACTORS

– Medications

– Nutrition

– Mobility

– Systemic disease

– Continence

– Smoking

• LOCAL FACTORS

– Infection

– Skin loss

– Pressure necrosis

– Wound tension

– Tissue maceration


WOUND DRESSINGS

• …don't need to be confusing

• Adequate cleaning or surgical debridement

• Aim for:– Controlled wound environment

– Moist wound healing

– Infection control

– Analgesia


THREE COMPONENTS

• When putting a dressing on, consider who will be taking it off (and when)….

• All (nearly!) are made of 3 things:

– A NON-ADHERENT LAYER ± antimicrobials

– AN ABSORBANT LAYER depending on exudate

– AN ADHESIVE LAYER depending on anatomy

• Tailor-made for each patient


BURN DRESSINGS

• After initial assessment and stabilisation

• If the burn is suitable for treatment in primary care– Clean wound, deroof large blisters

– Definitive dressing

– Review at 48h

• If transfer is needed to burns centre– Temporary wound cover

– Minimal interference

– Reduce need for analgesia


SKIN GRAFTS

• The ideal wound dressing?

• Supplies cellular and matrix components and is incorporated into the wound

– Speeds up wound healing

– Reduces pathological scarring in large burn wounds

• BUT…– Limited resource

– Donor site


SPLIT THICKNESS SKIN GRAFT


QUESTIONS?

[email protected]

junior academic half day may 1 st 2012 burn injury joseph hardwicke spr burns & plastic surgery...

Documents

junior academic half

depth of burn

estimation of burn

burn functions

thickness slide

yrs slide

timeline of burn care

inhalation injury slide