Upload
gregory-horton
View
215
Download
0
Tags:
Embed Size (px)
Citation preview
Junior Academic Half Day May 1st 2012
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
FLUIDRESUSCITION
FLUIDRESUSCITION
ANTI-SEPSISANTI-SEPSIS
SKINGRAFTS
SKINGRAFTS
MESHEDGRAFTS
MESHEDGRAFTS
BURNEXCISION
BURNEXCISION
"BURNTOXINS"
"BURNTOXINS"
MULTI-DISCIPLINARYAPPROACH
MULTI-DISCIPLINARYAPPROACH
NUTRITIONALSUPPORT
NUTRITIONALSUPPORT
Junior Academic Half Day May 1st 2012
TIMELINE OF BURN CARE
NOW
SKINSUBSTITUTES
SKINSUBSTITUTES
SKIN CELLCULTURE
SKIN CELLCULTURE
PSYCHOLOGICALSUPPORT
PSYCHOLOGICALSUPPORT
ORGANSUPPORT
ORGANSUPPORT
REHABILITATIONREHABILITATION ?
SCARMANAGEMENT
SCARMANAGEMENT
Junior Academic Half Day May 1st 2012
FIRE DISASTER
Junior Academic Half Day May 1st 2012
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
CAUSES OF BURNS AND THE DEMOGRAPHICS OF UK BURN
INJURY
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
CAUSES OF BURNS
• ELECTRICAL– Low voltage < 1,000V
– High voltage > 1,000V
– Superhigh voltage > 10,000V
• Conduction through tissues
Junior Academic Half Day May 1st 2012
CAUSES OF BURNS
• Deep tissue destruction– Myoglobinuria
– Compartment syndrome
– Cardiac dysrhythmias
Junior Academic Half Day May 1st 2012
CAUSES OF BURNS
• CHEMICAL– Acid
– Alkali
• ACID ALKALI– Coagulative necrosis - Liquifactive necrosis
– Painful - Non-painful tissue destruction
• IRRIGATION– Copious water to correct pH
Junior Academic Half Day May 1st 2012
CAUSES OF BURNS
• RADIATION– UVB
– Ionising radiation
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
THE ANATOMY OF THE SKIN, DEPTH OF BURN AND THE
JACKSON BURN WOUND MODEL
Junior Academic Half Day May 1st 2012
ANATOMY OF THE BURN
• Functions of the skin
BARRIER
THERMO-REGULATION
SENSORY
METABOLIC
PSYCHO-SOCIAL
Junior Academic Half Day May 1st 2012
DEPTH OF BURN
1. SUPERFICIAL ERYTHEMA• No skin loss
• Not included in burn %TBSA
2. PARTIAL THICKNESS• Superficial
• Deep
3. FULL THICKNESS
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
ESTIMATION OF BURN % TOTAL BODY SURFACE AREA (%TBSA)
AND FLUID RESUSCITATION
Junior Academic Half Day May 1st 2012
ESTIMATION OF %TBSA BURN
• Average adult TBSA 1.7m2
• Distribution changes with age
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
INHALATION INJURY
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
SITE OF INJURY
• Supraglottic– Thermal injury from inhaled gases
– Airway spasm
• Infraglottic– Chemical burns from products of combustion
• Bronchoalveolar lavage
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
WOUND HEALING
Junior Academic Half Day May 1st 2012
BASICS OF WOUND HEALING
• Sequential process
• Driven by cellular and matrix components
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
QuickTime™ and aYUV420 codec decompressor
are needed to see this picture.
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
SCARS
• End stage of normal wound healing
NORMAL PATHOLOGICAL
contracture hypertrophic keloid
Junior Academic Half Day May 1st 2012
IMPAIRED WOUND HEALING• PATIENT FACTORS
– Medications
– Nutrition
– Mobility
– Systemic disease
– Continence
– Smoking
• LOCAL FACTORS
– Infection
– Skin loss
– Pressure necrosis
– Wound tension
– Tissue maceration
Junior Academic Half Day May 1st 2012
WOUND DRESSINGS
• …don't need to be confusing
• Adequate cleaning or surgical debridement
• Aim for:– Controlled wound environment
– Moist wound healing
– Infection control
– Analgesia
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
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
Junior Academic Half Day May 1st 2012
SPLIT THICKNESS SKIN GRAFT
Junior Academic Half Day May 1st 2012
FURTHER READING