New developments in burns management

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New developments in burns management

• Dr s naidoo
• Moderator Dr T luvengo

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INTRODUCTION

• Associated with high morbidity and mortality
• Acc to National Injury Mortality Surveillance
  System 2005 66 deaths due to burns (in tswhane)
• Burns leading cause of non traffic unintentional
  death
• Age groups 25-34 22
• 35-44 35
• 45-54 50
• 55-64 33
• 65 36
• Eyal et al showed between 1998 and 2005 there
  were 191 deaths due to burns at kalafong
  hospital.
• Aetiology
• open flame 30
• Paraffin stove associated 26
• Boiling water injury20

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Classification

• Cause
• Flame damage from superheated oxidized heat
• Scald damage from contact with hot liquid
• Contact damage from contact with hot or cold
  solid materials
• Chemical contact with noxious chemicals
• Electricity conduction of electrical current
  through tissue

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• Electrical
• Low voltage domestic electrocution deep burns
  at contact and exit sites
• High voltage gt1000v results in severe injury with
  tissue loss and renal failure due to
  rhabdomyolysis
• Chemical
• Acids cause coagulative necrosis
• Alkalis cause liquefactive necrosis with deeper
  wounds
• Irradiation exposure to high energy
  electromagnetic waves

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classification

• Depth
• First degree injury localised to epidermis.
  Painful, red, blanches to touch. Heals
  spontaneously. E.g. sunburn.
• Second degree superficial injury to the
  epidermis and superficial dermis. Red painful,
  blistering, blanches to touch. Usually heals from
  intact skin appendages with some skin
  discoloration.
• Second degree deep injury through the epidermis
  deep into dermis. Pale mottled, does not blanch
  to touch, painful to pin prick. Heals with
  scarring
• Third degree full thickness injury into
  subcutaneous fat. Hard leathery eschar, painless
  black, white or red. No visible skin appendages.
  Skin grafting necessary.
• Fourth degree injury to underlying muscle and
  bone

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Pathophysiology

• Local response Jackson's burn zones
• Zone of coagulation irreversible tissue loss due
  to coagulative necrosis
• Zone of stasis decreased tissue perfusion.
  Tissue is viable but can deteriorate to necrosis
  if not adequate resuscitation.
• Zone hyperaemia outermost zone with increased
  tissue perfusion. Tissue usually recovers in
  absence of severe infection or severe tissue hypo
  perfusion

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Pathophysiology

• Systemic Response.
• Associated massive release of inflammatory
  mediators leads to SIRS MODS and then death.
  Early adequate resuscitation and prevention of
  wound sepsis attenuates the SIRS response.
• Drugs to attenuate SIRS response can favorable
  improve outcomes. E.g. thalidomide , tromboxane
  inhibitors
• Increased vascular permeability and oedema
• Altered haemodynamics
• Decreased renal perfusion
• Decreased cardiac output
• Increased gut mucosal permeability
• Immunosuppression
• hyper metabolism

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management

• ABCS
• Primary survey
• Secondary survey
• Wound management
• Icu
• Rehabilitation

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ABCS

• ARWAY protect airway in suspected inhalation
  burns.
• Signs of inhalation injury
• History flame burns or injury in enclosed space
• Burns to face
• Nasal singing
• Hoarse voice
• Intubate if hypoxic , swollen oropharynx or
  signs of respiratory distress
• CONSIDER BRONCHOSCOPY, MUCOLYTICS, HIGH FREQUENCY
  OSCILLATING VENTILATION, BRONCHODILATORS
• BREATHING
• Escharectomy if circumferential burns restrict
  ventilation
• 100 o2 to treat carboxyhaemoglobinaemia
• Analgesia titrate ivi acc to pt discomfort
  monitor saturation and blood pressure

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circulation

• Cool burn wound over 20 mins with cool water
  (ice water damages viable tissue)
• Cover burn (cling wrap ,burn shield)
• Escharectomy for impaired circulation
  (circumferential burn has inelastic tissue which
  can swell with fluid resuscitation and
  precipitate compartment syndrome)
• Escharectomy only burnt tissue is divided, not
  underlying fascia differentiating from fasciotomy
• Fluid management
• Fluid losses must be replaced to prevent shock
  and MODS which are main causes of death in severe
  burns
• Burns gt 15 TBSA in adult and gt10 in child will
  require monitored resuscitation
• Good vascular access non burned tissue ,large
  bore catheter
• Fluid monitoring urine catheter , CVP line ,
  arterial line , pulse oximetry
• Maximum fluid loss occurs in 1st 24 hrs
• Several formulas have been developed,
• parklands, Brooke Evans etc. no formula has
  shown improved outcome over another.
• Globally the parklands formula is most commonly
  used.(4ml/kg/bsa burned. 50 over 1st 8hrs since
  time of injury and 50 over next 16hrs )

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circulation

• Pediatric fluid administration
• Most commonly used is parklands plus maintenance
  fluid as well
• Lund and bower chart most accurate to calculate
  fluid requirements in children
• Also varying formulas for children , but all
  similarly effective
• European survey of fluid management in burn pts
  showed
• use of crystalloids is dominant strategy
• Colloids not used often ( especially in first
  24hrs due to capillary leak)
• Colloid or crystalloid literature suggests equal
  efficacy
• Hypertonic saline not recommended
• More than 3 decades after Baxter formulated
  their concepts for fluid therapy we are still
  lacking the answers to what fluid, how much and
  how to guide fluid therapy
• Tradition based fluid concepts need to be
  revisited in the face of modern volume
  replacement strategies
• Monitoring (urine output ( 0.5 1ml/kg/hr ),
  cvp, cardiac index, mixed venous saturation) is
  more important than formulas!

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Primary /secondary survey

• Assess extent of burn
• Erythema should not be considered
• Lund and Browder chart most accurate method ,it
  compensates for variation in body shape with age.
  Useful in children
• Wallace rule of nines good quick assessment, not
  accurate in kids
• Palmar surface area of palm and fingers 0.8
  TBSA
• Burn card method
• Using gauze on the wound

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Rule of nines
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Assessing burn depth

• Gold standard is clinical assessment by the
  doctor who is going to treat pt. 60-70 accuracy
• Biopsy and histology disadvantages are
  invasive, early biopsies inaccurate due to wound
  progression, experienced pathologist required
• Laser Doppler techniques
• Assesses perfusion-90-97 accurate. disadvantages
  are ambient light problems, high cost, wound
  infection and topical substances affect readings.
• Video microscopy_ 90-97 accurate. disadvantages
  are skin contact so risk for infection. Pt
  compliance necessary so problematic in kids and
  restless pts

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Wound management

• The major change in burn wound management over
  the past 40 years has been the more rapid removal
  of devitalized tissue and earlier wound closure.
• After the initial resuscitation , the major cause
  for mortality and morbidity is wound infection
• Without topical antimicrobial agents the wound
  becomes colonized with gram pos organisms within
  48hrs.most common gram pos beta hemolytic
  streptococcus and staphylococcus.
• Gram negative organisms appear after 3-21days.
  Pseudomonas , proteus and acinetobacter baumani
  are the most common organisms
• Eschar will become infected unless its removed
  by re - epithealization process or surgical
  excision
• Systemic antibiotics only if systemic infection.
• Showering better than bathing- less wound cross
  contamination
• Dressing wound must be done under sterile
  conditions
• Blister removal controversial-recommendation is
  to aspirate blister and leave skin intact
• Wound swab useful to dx bacteria but cant
  differentiate between colonisation and wound
  infection, tissue culture is superior
  (quantifies bacteria)
• PCT, CRP, WCC, NEUTROPHILS ,TEMP useful markers
  to monitor sepsis
• Delayed burn surgery associated with increased
  infection

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Wound management

• Superficial and small burns heal within 2 weeks
• Large deep dermal burns heal within 2-3 weeks
• Any burn not healed after 3weeks needs grafting
• Open dressings inexpensive but increased heat
  and fluid loss , though decrease incidence of
  pseudomonas
• Closed dressings reduce heat and moisture loss,
  less painful, but higher incidence of pseudomonas
• Wound surface drying impedes ability of
  epithelial cells to migrate across the wound
• Moist wound healing
• Increased activity of growth factors
• Increased activity of surface proteolytic enzymes
• Improved oxygen and nutrient delivery

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Wound management

• Early excision and grafting associated with
  better outcomes
• Grafting should be done within 1st week
• Humby knife or dermatome with mesher
• Versa jet new technology good outcomes. useful
  in paediatrics and difficult access areas. Hydro
  surgery using pressurised saline
• Donor sites used 3x with 10day intervals
• Graft maximum 20 at a time
• Pt must be able to tolerate stress of theatre
• Large variety of topical wound treatments
• Future- icu surgery

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Topical agents

• Silver sulfadiazine- effective 24hrs ,water
  soluble, low toxicity, most commonly used.
• Pov-iodine short half life ,inactivated by wound
  exudates ,did not improve healing times
• Mupirocin broad spectrum antimicrobial but not
  effective against pseudomonas
• Chlorhexidineeffective against pseudomonas but
  difficult to apply
• Mafenide broad spectrum and good penetration.
  Causes electrolyte imbalance and painful
  application
• Acriflavin good antiseptic. Can be cytotoxic,
  irritate skin , stain skin
• Acticoat anti bacterial anti fungal , 5 day
  application. Treatment choice with good outcomes
• Melladerm local honey based products ,
  antibacterial , promotes moist wound healing
  ,very promising results

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Skin substitutes

• allograft cadaver skin for temporary cover.
  Tissue lasts 3 weeks before rejection. Expensive
  needs special preservation , disease transfer
• Xenografts (pig skin) temporary coverage, less
  expensive than allograft, more readily available,
  sloughs easily
• Human amnion for temporary wound closure,
  superficial wounds and excised wounds, poor
  screening for viruses so not recommended.
• Synthetic coverings
• Opsite provides moisture barrier, accumulation
  of exudates.
• Biobrane 2layer membrane with outer silicone
  membrane to prevent bacterial invasion.accumalatio
  n of exudates but otherwise good product.
  inexpensive long shelve life
• Transcyte similar to biobrane, can stimulate
  wound healing
• Integra provides complete wound closure, leaves
  a dermal equivalent, sporadic take rates

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Icu considerations

• No place for prophylactic antibiotics
• Stress ulcer prevention
• Tight glucose control
• Recombinant factor 7 decreases bleeding
• Early enteral nutrition superior to parenteral
  feeding . Curreri formula ( 25kcal x weight) (40
  kcal x TBSA burned)
• Immunonutrition glutamine , arginine , omega
  fatty acids
• B blockers to attenuate hyper metabolism
• Icu monitoring
• Dvt prophylaxis-clexane
• Anabolic steroids-controversial. Oxandrolone
  attenuates post burn catabolism
• Address myoglobinaemia

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references

• Sabistons textbook of surgery 18th ed
• Burns journal 2006-2008
• Burnsurgery.com