Transcript burn - helpfuldoctors

burn
•
•
•
•
•
Causes of burn;
1) thermal burn ; like flame and hot fluids
2)electrical burn ; high or low voltage
3) chemical burn ;acid or alkalie
4) radiation burn ; appear after an incubation
period
• The shorter the wavelength the longer the
incubation period e.g sunburn appear after
one to two days while X –ray burn appear
after few weeks
• Pathology
• 1) local lesion
• 2) constitutional response
• A) Local lesion;
• 1) zone of irreversible heat coagulation ;
• Its extend into skin and deep tissues depend
on duration of contact with heat
• If it is deep and wide , it will lead to
destruction of RBCs and heat hemolysis
• 2) zone of reversible enzymatic changes ;
• It is variable area surrounding the first zone in
which capillary permeability occurs by
enzymatic change
• It results in escape of water and electrolytes
and colloids into tissues
• It starts immediately after burn , reaches s its
maximum after 8 to 12 hours and decline till
the end of 24 hours
• B)Constitutional effects ;
1)Neurogenig shock
2)Oligemic shock
3)Liberation of ADH
4)Liberation of ACTH and adrenal corticoids
5) Acute tubular necrosis
Clinical assessment of burns
• 1) Assessment of depth
• 2) Assessment of extent
Assessment of depth
• Significance of depth
• It gives prognosis of local part and its
functions
• It gives the degree of RBCs loss and heat
haemolysis
• It affects prognosis of survival in extensive
burn
Classification according to depth
• 1) superficial burn ;
• There is heat coagulation of epidermis only
• Healing occur from survival deep layers within
2 weeks without scarring
• At first there is erythema followed in few
hours by the development of superficial
vesicles or bulla filled by serum
• 2)Deep burn ;
• There are heat coagulation of all layers of the
skin .the destroyed skin separate as slough
after about 3 weeks
• Healing will occur from periphery and there
will be much scarring leading to contracture
• The skin is usually cyanotic red or dead white
or greyish and is insensitive to touch
• After few days it become yellowish and
central parts become dry and shrivel forming
dark brown leathery slough .
• Deep to the slough and at its margin , a plane
of separation appear during the third week
• Later the slough separate leaving an area of
red granulation
• 3)Dermal burn ;
• There is destruction of epidermis and superficial
part of dermis
• Healing occur from the deeper layer dermis in 2
to 6 weeks with some residual scarring and
disability
• It appear cyanotic or white skin identical to deep
burn , then after 5 days thin slough separate and
a characteristic stippled appearance
Assessment of extent
•
•
•
•
•
•
•
Wallace Rule of nines ;
Head & neck 9%
Each upper limb 9%
Front of trunk 18%
Back of trunk 18%
Each lower limb 18%
Perineum 1%
Complications of burn
• 1) Neurogenic shock ; occur immediately after
burn
• 2) Oligamic shock
• 3) Infection ;the commonest organisms are
staphylococcus aureus and pseudomonas
pyocyaneus
• 4) Toxemia ;more common after deep burn
• 5)Suffocation
• 6)Contraction and disfigurement and keloid
formation
• 7) Corneal ulceration and panophthalmitis
• 8) Gangrene ; occur in circumferential burn
• 9) Acute renal failure
Treatment
• 1) First aid treatment
• 2) initial treatment during the first 48 hours
• 3) treatment after the first 2 days
First aid treatment
• Extinguish the flames
• In scalds rapidly cut off clothes
• Wash the part affected by under running cold
water
• Cover the burnt area with sterile gauze
• Morphia to relieve pain
• Transport to specialized center
Initial treatment during first 48 hours
•
•
•
•
•
•
A) General treatment
Sedation
Antibiotic
I/V fluid therapy
-Parkland’s formula
% of burn x weight of Pt x 4 ml of Ringer
lactate
• Half amount of fluid given in the first 8 hours
• Other half of amount of fluid given in the next
16 hours
• B) Local treatment
• It is done only after the shock is controlled
• 1) sterile toilet with normal saline or with
bland detergent like cetrimide-chlorhexidine
solution
• In extensive burn anaesthesia may be
necessary
• Dressing ; two methods
• A) closed method ;
• Put layer of flamazine (silver sulphadiazine )
then put tulle-gras then put hydrophilic cotton
wall then put crepe bandage
• B) open method ;
• The burn area is exposed and covered by thin
layer of antibiotic treatment
• Open method is suitable for face , head ,neck,
• Buttock in children , single surface of trunk
Treatment after 48 hours
•
•
•
•
•
High protein diet
High calories diet
If HB is low , we can give blood transfusion
Continue antibiotic
Dressing are not touched unless there are
fever or soaked
• Superficial burn will heal completely with 2 to
3 weeks
• In deep burn . After 2 to 3 weeks ,we excise
the slough and the raw area is prepared to be
covered with split or full thickness skin graft
Skin cover
A) permanent skin cover;
1) Free grafts
• 2) Pedicle Flaps
• 3)Free flaps
• B) Temporary skin cover ;
• 1) cadaver allograft
• 2)Biobrane
• 3)TransCyte
Free Grafts
•
•
•
•
1) Thin skin graft (Thiersch)
2) Intermediate spit skin graft
3) thick skin graft ( Wolf)
4)Postage stamp
Thin skin graft
• It consists of superficial part of epidermis , this
graft always takes because exudate is
sufficient to maintain its nutrition until
circulation invade it
• Disadvantages
• 1) pigmentation
• 2) contraction
• 3)it does not bear pressure well
Intermediate split thickness skin graft
• It consists of epidermis and part of dermis
• The success of taking the graft is less than
Thiersch graft
• Less pigmentation ,less contracture ,less
scaring
• It is the most commonly used method in
grafting
• It is taken by Humby skin graft knife or
electrical dermatome
Thick graft (Wolf)
•
•
•
•
It consists of whole skin devoid of fat
It need optimum condition to be taken
Asepsis must be perfect
It is only used to cover small area which are
surgically clean
• It does not become pigmented ,it does not
followed by contracture
Postage stamp graft
• A thin or split thickness skin graft is taken from
donor site , then it divided into small squares
and used to cover large granulation surface
area
Pedicle flap
• The flap consists of skin and subcutaneous
tissue
• It is mainly used for correction of contracture
or in closure of defect or the formation of
new cheek or nose
• It has an advantage over skin graft of
maintain circulation through the pedicle,
ensuring adequate nutrition until new
circulation is developed
• Types ;
• 1)one pedicle flap ;
•
sliding flap
•
swinging flap
•
distant flap
• 2) Double pedicle flap ; used in repair wound of
hand by using this flap from abdomen
• 3) Tubed pedicle flap ; used for distant
transplantation ex ; acromiopectoral flap for
formation of cheek
Free flap
• A piece of skin and subcutaneous tissue with
its related artery and vein are transplanted
from one area to another area , using
microvascular technique
Treatment of special types of burn
• 1) Burn of hand and foot ;
• They can be placed in in plastic bags containing
antiseptic solution , this will exclude bacteria and
allow free movement and maintain function
• 2) pulmonary burn ; there are liability of oedema
of glottis and bronchial spasm
• Pt need humidified oxygen ,bronchodilator drugs
• If not enough nasotracheal intubation or
tracheostomy
• 3)circumferential burn ;
• In the limbs lead to ischemia and gangrene
• In the neck and thorax may embarrass
respiration
• Pt need escharotomy
• If Pt develop compartment syndrome in
limbs Pt need fasciotomy
• 4) Electrical burn ;
• It is localized and deep
• It had entry and exit points It can lead to
arrythmia of heart
Wounds
• Types of wounds ;
• 1) incised wound ;result from knife or sharp
objects
• 2) lacerated wound; result from blunt objects
the edges and surface will contain devitalised
tissues
• 3) crushed wound ; include all war wounds
and RTA and industrial accident
• 4) wound with skin loss
• Complications of wounds ;
• 1)associated injuries ; artery ,nerve ,tendon ,
bone , viscera
• 2)infections ; pyogenic ,tetanus, gas gangrene
Treatment
•
•
•
•
1) incised wounds ;
Primary suture if seen in the first 6 hours
Nerve and tendons repaired are also suture
Blood vessel are repaired if big or ligated if
small
• 2)lacerated wounds ;
• a) early case (seen with in 6 hours )
• wound excision and primary suture
• b) neglected case ;
• if seen after 6 hours , the wound is excised and if after
4 to 6 days the wound is clean , then delayed primary
closure is done
• 3) Crushed wounds ;
• Treated by wound excision only
• After 4 to 6 days if wound is clean then delayed
primary suture
• If the wound become infected ,then we treat the
wound from infection till it become clean then
secondary suture
• 4)wounds with primary skin loss;
• a ) if incised ; primary skin grafting
• b) if lacerated ; wound excision and primary
skin grafting
• c) if crushed ; wound excision and delayed
primary or secondary grafting
Skin and subcutaneous lesions
• Sebaceous cyst ;
• It is a retention cyst due to obstruction of the
opening of a sebaceous gland by debris or fibrosis or
inflammation
• Occur anywhere in the body but commonest to occur
in face , scalp , scrotum
• Never occur in palm or sole
• Usually solitary but may multiple in scrotum and scalp
• It grows very slowly
• It has punctum
• Complications of sebaceous cyst ;
• 1)secondary infection
• 2)pressure necrosis of overlying skin of scalp
causes fungation ( Cock ΄s peculiar tumor )
• 3)baldness
• 4)sebaceous horn
• 5)sebaceous carcinoma
• Treatment is surgical excision
Lipoma
•
•
•
•
It is benign tumor arising from adult fat cell
May be single or multiple (Dircum΄s disease)
It is encapsulated
It has 2 capsules , a false capsule from the body and
true capsule which is part of tumor
• It is tumor of adult life , rarely seen in children
• Sites ; subcutaneous is the commonest site of tumor
,subaponeurotic ,submucous ,subperiosteal, subserous
,intermuscular ,extradural , retroperitoneal which is a
common to be liposarcoma
• Complications ;infection ,ulceration ,
calcification , compression of surrounding
structures
• Treatment is enucleation between true and
false capsules
Dermoid cyst
• It is formed due to persistence & and growth
of epithelial cells under the skin
• Types ;
• 1)Sequestration dermoid
• 2)Implantation demoid
• 3)Tubulodermoid
• 4)Teratomatous dermoid
• Treatment is excision
Squamous cell carcinoma
• Occurs in the skin or any area covered by
squamous epithelium like mouth , tongue
,oesophagues , etc
• In the skin it is commonest at junction of
mucocutaneous junction
• In the face the commonest site is the junction
of the outer and middle thirds of lower lip
• More common in male than female
• More common in fair skin& blond people
•
•
•
•
•
•
Naked eye appearance ;
Nodule
Ulcer with everted margina
Cauliflower mass
Diffuse infiltrating type
Fissure
• Sq. cell .ca spread mainly by lymphatic or by
direct spread
• Treatment by
• 1) irradiation
• 2) surgical excision
Basal cell carcinoma ( rodent ulcer)
• It arise from basal cells of skin or hair follicle cells
• Growth is very slow
• Naked eye appearance ;
• nodular
• ulcer
• cystic
• pigmented
• fire -field
• More common in male
• The edge of the ulcer is rolled in edge
• Regional lymph node are never affected by
secondaries but when they are enlarged , this
is either infection ( firm ,tender nodes) or
epitheliomatous changes occurred ( hard
nodes)
• Treatment ;
• 1) irradiation
• 2 ) surgical excision
Melanoma
•
•
•
•
It is pigmented tumor arise from melanocytes
It may benign or malignant
1)Benign (Mole or Nevus )
it is painless localized pigmented area that
may be flat or raised , may be present since
birth or appear later , may be hairy or hairless
, occurs in skin & nail bed & uveal tract &
genitilia
• 2)Malignant melanoma
• May occur spontaneously or on top of benign
mole , in the later case malignancy is
suspected by rapid growth & pain & increase
vascularity & increase pigmentation or
depigmentation
• Spontaneous malignant melanoma is common
in palm ,sole , nail bed , uveal tract of eye ,
axilla , genital area
• Highly malignant tumor that spread by lymphatic
or by blood to liver or brain
• C/P
• rapidly growing black swelling which is painful
,ulcerated , itchy , bleeding is common
• Treatment ;
• excision with wide safety margin of skin and
uderlying fascia
• amputation if arise from nail bed