Transcript Burn Injury - UHCW Medical Education

BURN INJURY
Joseph Hardwicke
SpR Burns & Plastic Surgery
West Midlands Deanery
Junior Academic Half Day May 1st 2012
TIMELINE OF BURN CARE
THEN
GREAT WAR
WWII
FALKLANDS
NUTRITIONAL
SUPPORT
ANTI-SEPSIS
FLUID
RESUSCITION
"BURN
TOXINS"
BURN
EXCISION
SKIN
GRAFTS
MESHED
GRAFTS
MULTI-DISCIPLINARY
APPROACH
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TIMELINE OF BURN CARE
REHABILITATION
NOW
ORGAN
SUPPORT
SKIN
SUBSTITUTES
?
SKIN CELL
CULTURE
SCAR
MANAGEMENT
PSYCHOLOGICAL
SUPPORT
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FIRE DISASTER
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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
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CAUSES OF BURNS AND THE
DEMOGRAPHICS OF UK BURN
INJURY
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CAUSES OF BURNS
• THERMAL
– Hot or cold
• HOT

COLD
– Liquid
- scald
- Freezing
– Solid
- contact
- Non-freezing - trench foot
– Gas
- flame
• Direct cellular destruction


- frostbite / nip
Freeze-thaw
Embolic/thrombotic
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CAUSES OF BURNS
• ELECTRICAL
– Low voltage < 1,000V
– High voltage > 1,000V
– Superhigh voltage > 10,000V
• Conduction through tissues
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CAUSES OF BURNS
• Deep tissue destruction
– Myoglobinuria
– Compartment syndrome
– Cardiac dysrhythmias
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CAUSES OF BURNS
• CHEMICAL
– Acid
– Alkali
• ACID

ALKALI
– Coagulative necrosis
- Liquifactive necrosis
– Painful
- Non-painful tissue destruction
• IRRIGATION
– Copious water to correct pH
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CAUSES OF BURNS
• RADIATION
– UVB
– Ionising radiation
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UK BURN DEMOGRAPHICS
250,000 burns/year
175,000 A&E attendances
13,000 hospital admissions
1,000 resuscitation burns
300 deaths/year
50% < 16 yrs
Majority > 60 yrs
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CAUSES OF BURNS
1. THERMAL
2. ELECTRICAL
3. CHEMICAL
4. RADIATION
•
Extremes of age
•
Non-accidental injury
•
Psychiatric co-morbidity
•
Industrial / workplace
KEY POINT
BURNS FIRST AID
1. Stop the burning process
2. Cool the burn
• Cool running water
• 10-30 minutes
3. Cover the burn
4. A&E if area of SKIN LOSS
bigger than palm of hand
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THE ANATOMY OF THE SKIN,
DEPTH OF BURN AND THE
JACKSON BURN WOUND MODEL
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ANATOMY OF THE BURN
• Functions of the skin
SENSORY
BARRIER
THERMOREGULATION
METABOLIC
PSYCHOSOCIAL
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DEPTH OF BURN
1. SUPERFICIAL ERYTHEMA
•
No skin loss
•
Not included in burn %TBSA
2. PARTIAL THICKNESS
•
Superficial
•
Deep
3. FULL THICKNESS
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BURN ZONE OF STASIS
• Adequate fluid
resuscitation may
preserve zone of stasis
unburnt skin
zone of
coagulation
• Infection may cause
burn extension
• Early burn excision
reduces necrotic load
zone of
hyperaemia
• Prognosis determined
by the size of the burn
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INITIAL BURNS MANAGEMENT
KEY POINT
A:
B:
C:
D:
E:
F:
AIRWAY + C-SPINE CONTROL
OXYGEN
BREATHING + VENTILATION
CIRCULATION
IV ACCESS, STOP BLEEDING
DISABILITY
GCS
EXPOSURE
TEMPERATURE CONTROL
%TBSA
FLUID CALCULATION
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ESTIMATION OF BURN % TOTAL
BODY SURFACE AREA (%TBSA)
AND FLUID RESUSCITATION
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ESTIMATION OF %TBSA BURN
• Average adult TBSA 1.7m2
• Distribution changes with age
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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
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FLUID RESUSCITATION
• Hartman's solution / Ringer's lactate
KEY POINT
2 - 4 mls/kg/%TBSA
From time of burn
Half given in first 8h
Half given in next 16h
Higher value for:
1. Inhalation injury
2. Electrical burns
3. Paediatric burns
• Then titration of fluids depending upon urine output etc.
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INHALATION INJURY
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INHALATION INJURY
• Mortality increased by 40%
• Early airway management
KEY POINT
POINTERS TO INHALATION INJURY
1.
2.
3.
4.
5.
6.
Enclosed space
Delayed extraction
Facial burns
Singed facial hair
Carbonaceous sputum
Hoarse voice / stridor
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SITE OF INJURY
• Supraglottic
– Thermal injury from inhaled gases
– Airway spasm
• Infraglottic
– Chemical burns from products of combustion
• Bronchoalveolar lavage
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TOXINS
• Products of combustion
• CARBON MONOXIDE
– Preferential binding to Hb (200x)
– Arterial blood gas
• <10% normal
Oxygen-dissociation curve
shifts to the left
>60% fatal
• HYDROGEN CYANIDE
– Synthetic rubber, polyurethane
– Inhibits cytochrome C oxidase
– Antidote and oxygenate
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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
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WOUND HEALING
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BASICS OF WOUND HEALING
• Sequential
process
• Driven by
cellular and
matrix
components
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BURN WOUNDS
• Superficial partial thickness
wounds heal by reepithelialisation
• Keratinocyte reserve in
"epidermal derivatives"
– Hair follicles
– Sweat glands
• Should heal by 2 weeks
– Minimal scarring
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YUV420 codec decompressor
are needed to see this picture.
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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
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SCARS
• End stage of normal wound healing
NORMAL
PATHOLOGICAL
contracture
hypertrophic
keloid
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IMPAIRED WOUND HEALING
• PATIENT FACTORS
– Medications
– Nutrition
– Mobility
– Systemic disease
– Continence
– Smoking
• LOCAL FACTORS
– Infection
– Skin loss
– Pressure necrosis
– Wound tension
– Tissue maceration
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WOUND DRESSINGS
• …don't need to be confusing
• Adequate cleaning or surgical debridement
• Aim for:
– Controlled wound environment
– Moist wound healing
– Infection control
– Analgesia
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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
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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
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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
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SPLIT THICKNESS SKIN GRAFT
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QUESTIONS?
[email protected]
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FURTHER READING
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