Burn and Bite/Sting

Seok Joo Han, M.D.

Department of Surgery,

Yonsei University College of Medicine,

Seoul, Korea

General Aspect of Burn

� 1,200,000 burn/year in USA���� 50,000 (4%) urn/year required hospitalization����5,000 (0.4%)burn died per year-->10% mortaility

� Populations:

– Toddler: hot water (scalding burn)

– Young adults: flame burn

– Elderly

– Low social economic group

� Morbidity and mortality rates associated with burns are decreased.

� 50% decline in burn-related deaths and hospital admission in the United States over 20 years

Burn Unit

� Experienced burn surgeons

� Dedicated nursing personnel

� Physical and occupational therapists

� Social workers

� Dietitians

� Pharmacist

� Respiratory therapist

� Psychiatrists and clinical psychologists

� Prosthetists

Criteria for refer to burn center

1. Partial thickness burn greater than 10% TBSA

2. Burn involving the face, hands, feet, genitalia, perineum, or major joints

3. Any full-thickness burn

4. Electrical burns, including lightning injury

5. Chemical burns

6. Inhalation injury

7. Burns in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect outcome.

8. Any patient with burns and concomitant trauma

Pathophysiology of Burn (I)

� Thermal injury���� coagulation necrosis of the epidermis

and underlying tissue

� The depth of burn: the temperature and the duration of

exposure

� Classification of Burn according to the causes

– Flame

– Scald

– Contact

– Chemical

– Electrical

Coagulation necrosis

from the transfer of the

heat energy

+ Direct injury of cell

membrane

Pathophysiology of Burn (II)

�Depth of Burn

–First degree: injury localized to the

epidermis

–Superficial second degree: injury

to the epidermis and superficial

dermis

–Deep second degree: injury

through the epidermis and deep into

the dermis

–Third degree: full-thickness injury

through the epidermis and dermis

into the subcutaneous fat

–Fourth degree: injury through the

skin and subcutaneous fat into

underlying muscle or bone

Normal Skin: physical barrier against

bacterial invasion, important role for

control of temperature, water and vitamin

D production

Pathophysiology of Burn (III)�Depth of Burn

–First degree:

painful, erythematous, and blanch to the touch, sunburn or minor

scalding burn, no scarring

–Superficial second degree:

erythematous, painful, blanch to touch, and often blister,

healing within 7-14 days with some slight discoloration

–Deep second degree:

pale and mottled, do not blanch to touch, but remain painful to

pinprick, healing in 14-35 days with severe scarring

–Third degree:

hard leathery eschar, painless and black, white, or cherry red in

color, healed by reepithelialization from the wound edges, skin

graft

Pathophysiology of Burn (IV)

critical area

Irreversible damage

Pathophysiology of Burn (V)

�Zone of Burn Area

–Zone of coagulation: the necrotic area of burn where cell have

been disrupted, irreversible damage

–Zone of stasis: the area immediately surrounding the zone of

coagulation, moderate degree of insult with decreased tissue

perfusion, either survive or go on to coagulation necrosis

(possible reversible), associated with vascular damage and vessel

leakage, thromboxane A2 present in high concentration-���� local

inhibitor: improve blood circulation

–Zone of hyperemia: vasodilatation from the inflammation

surrounding the burn wound, clearly viable tissue, healing

process, no risk for further necrosis

Pathophysiology of Burn (VI)

The Rule of Nine Burn Size

1

For Example,

70 Kg male,

Flame burn,

Second degree

Solution

•Arm; 9%

•Anterior surface

of right trunk: 9%

•Anterior surface

of right lower

limb; 9%

= 27%

Pathophysiology of Burn (VI)

Treatment of Burn

� Initial first aid

� Fluid therapy

� Wound Care

� Rehabilitation

Initial Treatment

�Prehospital

�Removed from the source of injury

�Always suspect to have inhalation injury���� 100% Oxygen

�All ring, watches, jewelry and belt should be removed

�Room temperature water can be poured on the wound within 15 minutes

of injury to decrease the depth of the wound

�Cold water should be avoided to preclude hypotherima

�Initial assessment: primary and secondary survey

�Initial wound care: only protection from the environment with clean dry

dressing

�Intravenous small dose of narcotic agent after full assessment

�Transport

Fluid Resuscitation

Rapid Calculation of

Initial Fluid Rate;

= (BSA X BWt/8)/ hr

80 Kg man with a 40 %

of burn;

= (40 X 80)/8 = 400ml/hr

Formula Calculation for first 24 hours

½

amount

�The

first 8

hrs

For Example,

70 Kg male,

Flame burn,

Second degree

Solution = 27%

Fluid during transfer;

(BSA x BWt/8)/ hrs

=(27 x 70/8)/ hrs

=236 cc/hr

Solution = 27%

Fluid during first 24 hrs;

= 4 cc/kg/BSA

= 4 x 70 x 27

= 7560 cc/ 24 hrs

The first 8hrs;= 7560/2

= 3780/8hrs

= 472.5 cc/hr

The next 16 hrs= 3780 cc/16 hrs

= 236 cc/hr

Escharotomy

Wound care I

Wound care II

Wound care III

Wound care IV

Excision and Skin Graft

+ Broad spectrum antibiotics

Snake Bite

� Snake: 3500 species in the world

� poisonous snake ; 10%

� In Korea, just three snakes have poison

– 살모사살모사살모사살모사 ( ; agkistrodon blomhoffii brevicaudus)

– 까치까치까치까치살모사살모사살모사살모사( agkistrodon saxatalis)

– 불독사불독사불독사불독사 (agkistrodon calaginosus)

� 국내국내국내국내사교상환자사교상환자사교상환자사교상환자: 년간년간년간년간 409.6명명명명– (심재한등심재한등심재한등심재한등: 한국산한국산한국산한국산독사의독사의독사의독사의생태학적생태학적생태학적생태학적특성특성특성특성및및및및독성독성독성독성, 고상빈도에고상빈도에고상빈도에고상빈도에관한관한관한관한조사조사조사조사연구연구연구연구. 환경생태의학회지환경생태의학회지환경생태의학회지환경생태의학회지 2:58-77, 1998)

살모사살모사살모사살모사, 살무사살무사살무사살무사 ( )

Agkistrodon blomhoffii brevicaudus

까치까치까치까치살모사살모사살모사살모사Agkistrodon saxatalis, Korean-Magpie-Viperine-Snake

불독사불독사불독사불독사, 쇠살모사쇠살모사쇠살모사쇠살모사, 부독사부독사부독사부독사Agkistrodon calaginosus

Snake Bite

� In Korea, just three snakes have poison

– 살모사살모사살모사살모사 ( ; agkistrodon blomhoffii brevicaudus)

– 까치까치까치까치살모사살모사살모사살모사( agkistrodon saxatalis)

– 불독사불독사불독사불독사 (agkistrodon calaginosus)

– 출현시기출현시기출현시기출현시기: 4월월월월하순하순하순하순 ~ 11월월월월중순중순중순중순. 녹음기녹음기녹음기녹음기

– 골짜기풀밭골짜기풀밭골짜기풀밭골짜기풀밭, 돌무더기돌무더기돌무더기돌무더기, 경작지경작지경작지경작지

� 사독사독사독사독:

� 효소계효소계효소계효소계물질물질물질물질: phospholipase A, protease, endonuclease, L-

aminoacid oxidase, lecithinase, ATPase, DNPase, ribonuclease,

deoxyribonuclease, phosphomonoenterase, cholinesterase,

hyaluronidase, glycerophosphatase, 5-nucleotidase

� 비효소계물질비효소계물질비효소계물질비효소계물질: crotoxin(neurotoxin), crotamine(cytolysin),

proteolytic factor(hematoxin)

Snake Bite

� Phospholipase A: 세포막세포막세포막세포막파괴파괴파괴파괴, 용혈작용용혈작용용혈작용용혈작용, 췌장염췌장염췌장염췌장염

� Protease: 교상교상교상교상부위의부위의부위의부위의조직괴사조직괴사조직괴사조직괴사

� Hyaluronidase: 확산효소확산효소확산효소확산효소(spreading factor)

� Neurotoxin: Ach 유리유리유리유리억제억제억제억제, N-M junction 차단차단차단차단����호흡마호흡마호흡마호흡마비비비비, 심근마비심근마비심근마비심근마비

� Hematoxin: 적혈구적혈구적혈구적혈구세포막에세포막에세포막에세포막에직접직접직접직접작용하여작용하여작용하여작용하여용혈작용용혈작용용혈작용용혈작용,

항응고작용항응고작용항응고작용항응고작용

� Cytolysin: 조직세포의조직세포의조직세포의조직세포의파괴파괴파괴파괴및및및및기능억제기능억제기능억제기능억제 (뇌간세포에도뇌간세포에도뇌간세포에도뇌간세포에도작용작용작용작용), 혈관내피세포혈관내피세포혈관내피세포혈관내피세포파괴파괴파괴파괴, 신세뇨관의신세뇨관의신세뇨관의신세뇨관의상피세포상피세포상피세포상피세포파괴파괴파괴파괴, 백백백백혈구혈구혈구혈구적혈구의적혈구의적혈구의적혈구의파괴파괴파괴파괴

Snake Bite

� Identification of poisonous snake bite:

– 독사독사독사독사: 1-2개의개의개의개의독아독아독아독아자국자국자국자국, 비독사비독사비독사비독사: 한두줄의한두줄의한두줄의한두줄의차아자국차아자국차아자국차아자국

– 국소반응국소반응국소반응국소반응: 격심한격심한격심한격심한통증통증통증통증및및및및 압통압통압통압통, 조직괴사조직괴사조직괴사조직괴사및및및및피하피하피하피하출혈출혈출혈출혈, 수포형수포형수포형수포형성성성성

Snake Bite

Snake Bite

Snake Bite

Snake Bite

Snake Bite

Snake Bite

� 전신증상전신증상전신증상전신증상:

– 발열발열발열발열, 오심오심오심오심, 구토구토구토구토, 호흡곤란호흡곤란호흡곤란호흡곤란, 복통복통복통복통, 시야혼탁시야혼탁시야혼탁시야혼탁, 의식장애의식장애의식장애의식장애, 안검하수안검하수안검하수안검하수, 설사설사설사설사, 현기증현기증현기증현기증, 전신부종전신부종전신부종전신부종, 경부강직경부강직경부강직경부강직, 하혈하혈하혈하혈, 두통두통두통두통, 언어장애언어장애언어장애언어장애

– 한국산한국산한국산한국산독사의독사의독사의독사의경우에는경우에는경우에는경우에는전신증상이전신증상이전신증상이전신증상이심하지심하지심하지심하지않음않음않음않음

– 빈혈이나빈혈이나빈혈이나빈혈이나황달은황달은황달은황달은오래오래오래오래지속됨지속됨지속됨지속됨

� 국소치료국소치료국소치료국소치료:

– First aid

� 독독독독이이이이전신으로전신으로전신으로전신으로퍼지기퍼지기퍼지기퍼지기전에전에전에전에현장에서현장에서현장에서현장에서실시하는실시하는실시하는실시하는응급처치로응급처치로응급처치로응급처치로한한한한시간시간시간시간이내에이내에이내에이내에시행함이시행함이시행함이시행함이좋음좋음좋음좋음

– Fixation: 사독의사독의사독의사독의전신화를전신화를전신화를전신화를막기위하여막기위하여막기위하여막기위하여교상부위를교상부위를교상부위를교상부위를고정함고정함고정함고정함

– Tourniquet: 임파액의임파액의임파액의임파액의흐름흐름흐름흐름만을만을만을만을막을막을막을막을정도로정도로정도로정도로느슨하게느슨하게느슨하게느슨하게장착장착장착장착

– Incision and suction: 교사후교사후교사후교사후 5분분분분내의내의내의내의경우경우경우경우사독의사독의사독의사독의 50%가가가가 제거제거제거제거됨됨됨됨, 30분분분분후에는후에는후에는후에는효과효과효과효과없음없음없음없음, 1 cm X 5 mm

– Excision: 교상후교상후교상후교상후 2시간시간시간시간이내에이내에이내에이내에점상출혈이점상출혈이점상출혈이점상출혈이있는피하조직을있는피하조직을있는피하조직을있는피하조직을광범위하광범위하광범위하광범위하게게게게제거시제거시제거시제거시 대부분의대부분의대부분의대부분의독을독을독을독을제거할제거할제거할제거할수수수수있음있음있음있음.

– Cryotherapy: 조직의조직의조직의조직의괴사만괴사만괴사만괴사만일으키며일으키며일으키며일으키며사독의사독의사독의사독의비활성화의비활성화의비활성화의비활성화의증거가증거가증거가증거가없없없없음음음음

Snake Bite

� First Aids

Snake Bite

� First Aids

Snake Bite First Aids (immobilization)

Snake Bite

� 전신전신전신전신치료치료치료치료– Anitvenin treatment:

� Important for systemic toxicity

� But, no cross immunity: polyvalent antivenin (?)

� Anaphylactic shock and serum sickness due to horse serum of antivenin

� 전신독성이전신독성이전신독성이전신독성이강하지강하지강하지강하지않는않는않는않는한국산한국산한국산한국산독사에서는독사에서는독사에서는독사에서는꼭꼭꼭꼭필요한지필요한지필요한지필요한지의문의문의문의문

– Steroid treatment

� Traditional treatment, but effective?

� Report of decreased incidence of serum sickness in antivenin treatment

– Adequate antibiotic treatment

– Tetanus toxoid

– Conservative treatment for renal failure, respiratory failure, DIC, liver failure

Human Bite

� 구강내구강내구강내구강내세균세균세균세균: Staphylococcus, Streptococcus, Anaerobic streptococcus, gonococcus, Vincent’s bacillus, fusiform bacillus, Spirochetes, Tetanus bacillus, Gas gangrene bacillus, Treponema pallidium

����이러한이러한이러한이러한균으로균으로균으로균으로오염되오염되오염되오염되었다고었다고었다고었다고생각하고생각하고생각하고생각하고치료치료치료치료함함함함

Human Bite

� 충분한충분한충분한충분한세척세척세척세척및및및및변연절제술변연절제술변연절제술변연절제술

� 광벙위광벙위광벙위광벙위항생제항생제항생제항생제치료치료치료치료

� Delayed wound closure: 6시간시간시간시간내에내에내에내에내원한내원한내원한내원한안면부의안면부의안면부의안면부의경우에는경우에는경우에는경우에는충분한충분한충분한충분한세척과세척과세척과세척과변연변연변연변연절제절제절제절제술술술술후후후후봉합할봉합할봉합할봉합할수수수수있다있다있다있다.

� 그러나그러나그러나그러나완전히완전히완전히완전히 avulsion된된된된귀나귀나귀나귀나코의코의코의코의조각은조각은조각은조각은다시다시다시다시이어주는이어주는이어주는이어주는것은것은것은것은거의거의거의거의성공하지성공하지성공하지성공하지못한다못한다못한다못한다.