Burn injury by zhangyun

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									Burn injury
 Division of Plastic Surgery
 Division of Plastic Surgery
  Department of Surgery
   Department of Surgery
   University of Ibadan..
   University of Ibadan
       Burn injury: aetiology
04/08/03                                               2




           Moist heat (scald)
           Dry heat
           Chemical
           Electricity
           Friction
           Others (abroad):
              ultraviolet radiation
              cold     Burn injury; Plastic Surgery,
                          University of Ibadan
04/08/03                                                  3




                                           Site of burn is
                                           shifting from the
           Burn injury; Plastic Surgery,
              University of Ibadan         Home to the Streets
04/08/03                                   4




           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                           5




Careless lantern
refill is a very
common source
 of burning




                   Burn injury; Plastic Surgery,
                      University of Ibadan
04/08/03                                                                     6


               Burn injury: age and sex
             incidence (Ibadan, 1992-1996).
  25

  20                                                       38% of patients were
                                    0 - 10
                                    !11-20
                                                           under 15 years
  15
                                    21-30                  Overall:
                                    31-40
  10                                41-50                     males = 53%
                                    51-60
    5                               61-70                   females = 47%

    0
           male   female

                           Burn injury; Plastic Surgery,
                              University of Ibadan
Study                 Number     Male:         Mean                 Mortality   LA50
04/08/03                                                                                7
                                 female        TBSA
                      studied                                                   value
                                 ratio
Mungadi,               108        1.6:1                               6.5%
(Sokoto) 2002
                      children
Mzezewa,               451       46:54                                22%
(Harare)
                                                   13%
                                                 (median)
El-Badawy,             305                       87% had              4.3%
(Cairo) 1998                                   minor burns
                      children
Kalayi, (Zaria)         84                                           27.4%
   1996
                      children
Olabanji, (Ile-Ife)    474       1.75:1                              21.8%
   2003
                                                   25.4
Adigun,                164         2:1                                36%       68%
(Ibadan) 2004
                                                      36
Sowemimo,                                                                       63%
  (Lagos)
                                    Burn injury; Plastic Surgery,
Iregbulem              644             University of Ibadan           9.87
(Enugu), 1993
04/08/03                                                                           8




Study           Number    Male:         Mean                 Mortality   LA50
                          female        TBSA
                studied                                                  value
                          ratio
Tokyo (Japan)   6401  63:37                                   15.4%
  1983-2003
                25%                     18.8                             53
                above
                 60yr
                                        %
Birmingham                                                               54 for
1989-1998                                                                30yr
                                                                         old
                                                                         59 for
                                                                         15 year
Singapore                                                                old
                2019       2.2:1          11.5%                4.6%
1997-2003
                             Burn injury; Plastic Surgery,
                                University of Ibadan
04/08/03                                                          9



     Mediators of the burn response:

                                        Cathecholamines
           Cytokines                    Aldosterone
           Oxygen radicals              Growth hormone
                                        Antidiuretic hormone
           Arachidonic                  5HT
           acid metabolites             Histamine
                                        Thyroxin
           Endotoxins                   Adrenocortical steroids
                                        Glucagon
                                        Insulin
                       Burn injury; Plastic Surgery,
                          University of Ibadan
04/08/03                                              10




           Inflammatory mediators:
                    Repressed production in
                    healthy individuals
                    Production continues, no
                    negative feedback
                    Activate release of others
                    and pottentiate their action
                    Acute exaggerated response
                    can cause cardiovascular
                      Burn injury; Plastic Surgery,
                    collapse
                         University of Ibadan
04/08/03                                                                  11




           Cytokines
           Interleukin-1                         Increase in vascular
                                                 permeability
           Interleukin-2
                                                 Catabolism of muscle
           Interleukin-6                         Production of anaemia
           Interferon gamma                      Initiate wound healing
                                                 Produce fever



                           Burn injury; Plastic Surgery,
                              University of Ibadan
04/08/03                                                            12




               Oxygen radicals:
           Super oxides                      Alter vascular
           Hydrogen peroxide                 permeability
                                             Cause RBC
                                             haemolysis
                                             Disrupt interstitial
                                             matrix


                       Burn injury; Plastic Surgery,
                          University of Ibadan
04/08/03                                                   13




           Arachidonic acid metabolites:
            Cyclooxygenase pathway:
               prostaglandins-
               vasodilators, pain,
               erythema
            Lipoxygenase pathway:
               leukotrienes-C4, D4
               vasoconstrictors
                           Burn injury; Plastic Surgery,
                              University of Ibadan
04/08/03                                                    14




           Skin:
            Coagulative necrosis
            Disruption of
            basement membrane
            Blistering
            Vascular changes
            3 zones (Janzekovic):
                coagulation
                stasis
                hyperaemia
                            Burn injury; Plastic Surgery,
                               University of Ibadan
04/08/03                                                           15




           Cardiovascular:
            Vascular and RBC                    Cardiac muscle
            damage
            Increased vascular
                                                damage from
            porosity                            mediators, fluid
            Cathecholamines                     overload,
            cause peripheral                    drugs, sepsis
            and splanchnic
            vasoconstriction

                          Burn injury; Plastic Surgery,
                             University of Ibadan
04/08/03                                   16




Renal:
                Splanchnic
                vasoconstriction
                Reduced GFR
                Reduced parenchymatous
                flow
                Myoglobin, haemoglobin
                precipitates in tubules

           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                                17




           Gastrointestinal tract:
            Curling’s ulceration
            Gastric dilatation
            Ileus
            Gut barrier disruption and bacterial
            translocation

                        Burn injury; Plastic Surgery,
                           University of Ibadan
04/08/03                                                 18

       Respiratory system
    upper              lower
    Upper airway              Restricted chest
    oedema from heat          expansion
    component of
    smoke                     Interstitial damage and
    Upper airway              pulmonary oedema
    oedema from               Carbon monoxide and
    chemicals (noxious        cyanide poisoning
    gasses)
                         Burn injury; Plastic Surgery,
                            University of Ibadan
04/08/03                                                     19



           MANAGEMENT OF ACUTE
           BURN INJURY:
            First aid and ABC of resuscitation
            Fluid administration
            History and examination
            Initial investigation
            Anaelgesic, antitetanus, antibiotics
            Antiulcer drugs, anticoagulants.
            Management of inhalation
            Wound debridement and dressing
            Wound excision and skin graft
            Physiotherapy BurnUniversity of Ibadan
                                  injury; Plastic Surgery,
04/08/03                                                  20




           Fluid administration:
            Parkland formula:
               In the 1st 24 hours, 4ml/kg/% of
               Hartman's solution
            Colloids: Watson’s modification of Muir
            and Barclay’s formula
            Hypertonic saline
            Evans’ formula
            Brooke’s formula
                          Burn injury; Plastic Surgery,
                             University of Ibadan
04/08/03                                                   21




           Monitor patient by:
            clinical response
            ensure urine output of at least 30ml/hr in
            adult.
            PCV
            Pulse oximetry



                           Burn injury; Plastic Surgery,
                              University of Ibadan
04/08/03                                                22




           History
            Time of occurrence
            Part of body involved
            Associated injuries
            Accident site
            Premorbid status
            Treatment received so far
                        Burn injury; Plastic Surgery,
                           University of Ibadan
04/08/03                                          23




           General examination


                  Burn injury; Plastic Surgery,
                     University of Ibadan
04/08/03                                   24




                       Wallace’s
                       rule of 9


           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                                     25




           Clinical examination:
    Wallaces rule of 9 in
    patients aged >12 yrs.
    Berkow’s
    modification of Lund
    and Browder chart in
    children below 12
    years.
    Depth of burn
                             Burn injury; Plastic Surgery,
                                University of Ibadan
04/08/03                                   26




           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                         27
           Full thickness burn




                 Burn injury; Plastic Surgery,
                    University of Ibadan
04/08/03                                             28




           Wound dressings

            Debridement
            Meshed gauze
            Cotton gauze
            Cotton wool
            Bandage
                     Burn injury; Plastic Surgery,
                        University of Ibadan
04/08/03                                                 29




           Treatment by exposure
            Areas that are difficult to dress: face,
            genitalia and perineum
            Minimally discharging wound
            To allow for frequent monitoring: finger
            tips
            To allow for joint movement (polythene bag
            on the hand)

                         Burn injury; Plastic Surgery,
                            University of Ibadan
04/08/03                                   30




           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                             31



           Treatment of partial thickness
                       burn

           Change dressing 5 days
            after or as necessary
           Wound heals in 14 days

                     Burn injury; Plastic Surgery,
                        University of Ibadan
04/08/03                                                 32




           Treatment of full thickness burn wound

            Early wound excision
            Partial thickness skin graft



                         Burn injury; Plastic Surgery,
                            University of Ibadan
04/08/03                                                               33




            Burn wound excision




                                       Burn injury; Plastic Surgery,
                                          University of Ibadan
Harvesting a partial thickness skin graft from the thigh
04/08/03                                                 34



           Management of burn wound /
             donor site discrepancy

           Temporary skin graft: allograft, porcine skin
           Staged skin grafting
           Meshed skin grafting
           Cultured keratinocytes (skin culture)
           Skin substitutes: integra, biobrane


                         Burn injury; Plastic Surgery,
                            University of Ibadan
04/08/03
           Meshed graft obtained by passing a partial thickness   35

                     skin graft through the mesher




                               Burn injury; Plastic Surgery,
                                  University of Ibadan
04/08/03                                            36



           Wide meshed skin graft




                    Burn injury; Plastic Surgery,
                       University of Ibadan
04/08/03                                                37

           A SHEET OF CULTURED KERATINOCYTES
             READY FOR CLINICAL APPLICATION




                        Burn injury; Plastic Surgery,
                           University of Ibadan
04/08/03
           Management of inhalation injury:                     38




            Clinical suspicion, escharotomy
            Bronchoscopy and intubation
            Blood oximetry
            Oxygen and oxygen tent
            Antidotes
            Positive pressure ventilation (arterial o2<10kpa)




                            Burn injury; Plastic Surgery,
                               University of Ibadan
04/08/03                                                         39

           Clinical indications for intubation

           absolute:                           relative:

            Burn of the palate,                   Hoarseness
            tongue and pharynx                    Facial burn
            Oedema of the                         Sooty sputum
            posterior pharynx and
            upper glottis
            Burn of vocal cords
                            Burn injury; Plastic Surgery,
                               University of Ibadan
04/08/03                                                       40




           Management in the subacute phase
            Blood transfussion
            Early wound cover: tangential / fascial excision
            Delayed wound cover (on granulation tissue after
            escharectomy)
            Treatment of fever
            Treatment of psychiatric manifestations
            Physiotherapy
            Nutrition
                            Burn injury; Plastic Surgery,
                               University of Ibadan
04/08/03                                                                 41




           Metabolism and Nutrition:
            Early burn wound                    Oral
            cover                               Nasogastric: elemental
            Carbohydrate:                       feeds
            Protein                             Parenteral
            Vitamins
            Electrolytes



                          Burn injury; Plastic Surgery,
                             University of Ibadan
Early physiotherapy

         Chest
         Hand
   Early ambulation
      Other joints
 Prevent pressure sores
04/08/03                                                                    43




           Infection in Burns
            Prevention:                             Wound infection
            1. first aid period –                      Bacterial
                patient’s bed                          Fungal
            2. isolation                               Viral
            3. sterile procedures
            4. early definitive                      Chest infection
                wound cover
            5. antibiotics                          UTI, thrombophlebitis
            6. selective gut                        Deep vein thrombosis
                decontamination

                              Burn injury; Plastic Surgery,
                                 University of Ibadan
04/08/03                                                     44



           Chronic complications of burns

            Skin
                dyspigmentation
                abnormal scars: hypertrophy, keloid
                contractures
                chronic ulcers
                Marjolin’s ulcer
            Anaemia
            Chronic pulmonary insufficiency
            Psychiatric disturbances
            Tetanus          Burn injury; Plastic Surgery,
                                University of Ibadan
04/08/03                                   45




           Burn injury; Plastic Surgery,
              University of Ibadan
04/08/03                                   46




           Burn injury; Plastic Surgery,
              University of Ibadan

								
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