Dr Victor Zielinski
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Clinical
Aboriginal Health
SurgeryBurns Management
Treatment Objectives Burns Units Definitions First Aid, ABCs Management - General Management - Wound New Things
Treatment objectives are:
- 1. Prevention and treatment of shock
- 2. Control of bacterial proliferation
- 3. Conversion of an open wound to a closed one
- maintain and preserve body function, appearance
- healing within a minimum period
- mental and emotional stability of the patient
Frequency: In the USA 2 million are annually burned, 5% require hospital treatment, 10,000 die. In Australia we have no reliable figures but we estimate that about 100,000 burns occur annually. In Sydney we treat about 150 to 250 major burn patients in hospital. Most burns involve the upper limbs and or the head and neck region.
Why have Burns Units ?
- cost efficiency
- concentration of expertise
- usage pattern is very variable
What is a Burn ?
Heat can cause partial or complete destruction of the skin and underlying issues. There may be great local and general effects. A large burn is a major illness and can be life threatening.DEFINITIONS
Burn injuries can be classified on the basis of the extent or the depth of the injury. The extent is expressed as a percentage of the total body surface area. Depth is classified as partial or full thickness. This is a better way than the older method of degrees.
PARTIAL thickness
- damage to epidermis but the dermis intact, therefore skin can regenerate. There is also so called DEEP partial, which has lost much of the dermis but there are epithelial pockets. With infection or inappropriate care it can become full thickness.FULL thickness
- both epidermis and dermis are destroyed and will not regenerate the skin.RULE OF 9's
- is a quick way of estimating, tbe surface area that is affected by a burn.In children the head is more than 9% and a good way of estimating burns is to say the child's palm is 1% of it's surface area.
- Face & Scalp 9%
- Back 18%
- Perineum 1%
- Arm each 9%
- Front 18%
- Upper arm each 9%
- Lower leg each 9%
FIRST AID
Remove the person from further dangerNeutralise chemicals, water in copious amounts is good
acid - 3% sodium bicarbonate alkali - 1% acetic acid (vinegar) phosphorous - keep wet at all times, then copper sulphate and sodium bicarbonate hydrofluric acid - apply calcium gluconate gel
Wound - cover with a clean wet towel
Fluids - major burn nil by mouth, get an IV going
Evaluation of the ABC's
AIRWAY - BREATHING - CIRCULATIONGuidelines for management
Admit:
- any burn over 10% in area,
- IV fluids for burns over 15%
- burns in special areas face, neck, hands, feet, perineum
- electrical burns any burn with history of smoke inhalation
- chemical burns
- full thickness burns where grafting is indicated
On admission:
- Get a history, include time and place of burn, causing agent, details of the accident (can provide clue to the depth of burn)
- Age of patient, weight, general health (heart,lung,kidney)
- Ask for possibility of inhalational injury
- Look for cofactors that can affect course eg. drug addiction, immune or CVS system
- Fluids prior to admission, urine output since injury
- Medication given, Tetanus status
The burn wound should never take precedence over potential life threatening complications
Examination:
- estimate area of burn, how much is full thickness
- look for signs of respiratory burns
- examine eyes
- look for circumferential burns on chest, limbs
- complete full physical examination
Treatment:
IV fluidsAirway in unconscious patients
How much and what type of fluid, work out the requirement from the following formula
Volume = weight x percent burn x 4ml
V = 70 x 30 x 4
Type of fluid is Hartmann's solution
Adjust volume for each patient according to urine output ( 30-35ml per hour minimum), hematocrit (40-45)
Must provide the daily maintenance requirement of 2-3 litres on top of the calculated amount Insert urinary catheter
Pathology tests: full blood count, urea, electrolytes, proteins
Analgesia, preferably IV
Routine medication: Tetanus toxoid, Cimetidine
Care of the Burn wound
Structure of skin - Stratum corneum is the surface layer composed
of non living, dry, keratinised cells. Under this is the epidermis.
Cell division is limited to the basal layer. Under this is the
dermis, the thickness of which varies with age and part of the body.
It is composed of collagen fibres and fibroblasts. The blood vessels
and nerves run through this layer. Hair follicles and sweat glands
originate in the dermis. Under the dermis is fat of varying
thickness. The corneal layer prevents drying out and to some extent
protects from bacterial invasion.
Determination of burn depth can be difficult. Superficial burns tend to blister and skin retains its colour (blanches on pressure) is very sensitive to pin prick. As the burn gets deeper, the pink surface changes to a dry white reticulated surface. Pin prick is less sensitive. Sometimes it takes several days before it is obvious that a burn is superficial. Experience is helpful.
Therapy
Silver sulphurdiazine is the main agent used. The rationale is that by controlling local infection we will prevent systemic infection. Antibiotics given systematically have limited use as they cannot get to the injured site. Topical SSD and bulky dressings which are changed daily are the main methods of local wound care. Daily baths help in the process debridement. SSD slows down eschar separation.Dressings
There have been many vogues and new products are coming on the market all the time. Pig skin, potato peels, synthetic membranes have all been used. Simple dressings with vaseline gauze are cost effective and work well.Positioning of the limbs and the hands especially is very important. Early involment of the physiotherapist, splinting is important
Grafting
Hands should be grafted early to prevent contractures and tearing of extensor tendons. Eyelids and ears need early intervention to prevent permament loss. Areas of motion such as elbows, knees must receive early attention. Large flat areas should be covered early. General emphasis is on early interference for functional and economic reasons.Donor site - can be anywhere depending on the availability, generally the thigh is used as it is easier to harvest. The abdomen and back are difficult. Using a dermatome makes the process more efficient. When short of skin a mesher can be used to increase the area of coverage. To speed things up in the theatre we now use staples to fix the skin.
Rehabilitation
An important aspect of care that we cannot cover adequately here.
Treatment problems
I . Elderly may have other disease2. Circumferential burns, need for escharotomy
3 Stress ulcer, with the usage of Cimetidine (histamine H2 receptor antagonist) Is less frequent. It blocks gastric acid secretion by parietal cells. It also inhibits gastric acid secretion stimulaled by insulin, food, vagal reflex. Dosage 300mg 6 hrly
4 Hypothermia, mainly due to insensible water loss
5 Catabolism and hypermetabolism
Special types of injury
Electrical - AC current is more dangerous than DC. Amps more imponant then volts. Danger is due to effects of the current on the heart and direct heating effect.New things
1. Aescalop and Zimmer Dermatome This is a general purpose instrument that has attachments for a drill, saw and a hand piece for taking skin. Due to this we have been able to harvest skin from areas such as the abdomen or chest which otherwise would be almost impossible.2. Staples
Suturing skin is slow and tedious as well as introduces lots of foreign material. Since staples have been available and they have been great time savers. Shorter anaesthetic is an important consideration. There are even Vicryl staples but they are not very good as they fall out too easily and are too dear.
3. Skin-mesher
This is a drum which has sharp blades built into it, the carrier made of plastic is used for inserting the skin. There is a pattern engraved onto the plastic. This determines the distance between the cuts, we can have 1.5 : 1 or 2 : 1 or 3: 1 expansion. The ability to cover much larger areas with limited skin is important. The cosmetic result is not quite as good as with sheets of skin but in life saving situation this less important.
4. Tissue Expansion
The resulting scars can be quite disfiguring, especially on the scalp, large areas of baldness can be removed by making use of this technique. A silastic bag is inserted away from the scar and it is then gradually expanded over 6 to 8 weeks. This results in actual epithelial proliferation. When the desired amount of skin is obtained, the scar is cut out and the bag removed.
5.. Fibrin Glue
It is a very useful adjunct as bleeding is still a major problem in these cases. Injection of various substances has only a limited effect. By using fibrin we cam actually glue the skin graft onto the raw wound and get better take as well as cut down on bleeding. We hope to get it made in large amounts and store it. We obviously have to he careful of introducing any viruses
6. Pressure garments
Are not really new but their use is now almost universal. By applying continuous pressure we seem to get better quality scars and less need of subsequent scar excisions. They are costly but worthwhile in the long term.
7. Skin substitutes
These have been around for sometime, the earliest were pigskin, in India potato skin has been used. The latest skin culture, that is growing sheets of epithelium and applying it to the burn woumd. It has lots of problems in that it is very thin and does not have supporting dermis. The result is a lot of shrinkage and no durability. It is also a slow process. There is research into producing an artificial dermis and methods of storage so that it can be ready for a sudden big burn.
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