BURNS BURNS

AND AND

BASICS OF PLASTIC SURGERYBASICS OF PLASTIC SURGERY

DR. ABDUL MAJID BHATDR. ABDUL MAJID BHATM.S., F.R.C.S. (ENGLAND)M.S., F.R.C.S. (ENGLAND)

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BURNSBURNSDefDef. .

it is injury of the tissue caused by extremes it is injury of the tissue caused by extremes of temperature (heat or cold ) or chemicals of temperature (heat or cold ) or chemicals or ionising radiations.or ionising radiations.

Basic pathophysiologyBasic pathophysiology.. involves two parts as compared to mechanical traumainvolves two parts as compared to mechanical trauma physical injury to tissuephysical injury to tissue Physiological injury to cells…..charing and precipitation Physiological injury to cells…..charing and precipitation

of protoplasm of cellof protoplasm of cell

External skin burns are the most common External skin burns are the most common surgical emergency.surgical emergency.

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Types and causesTypes and causes ThermalThermal due to due to

FireFire Steam, boiling liquids……..called Steam, boiling liquids……..called SCALDSSCALDS Blast, missile and fire arm injuriesBlast, missile and fire arm injuries

ChemicalsChemicals ……acids, alkalis etc. ……acids, alkalis etc. Ultravoilet raysUltravoilet rays…..sun burns …..sun burns Radiations….nuclear rays, radiation therapyRadiations….nuclear rays, radiation therapy Electricity currentElectricity current Mechanical friction injuryMechanical friction injury

Burns commonly involve skin but can involve Burns commonly involve skin but can involve subcutaneous tissue, muscle and bone even in subcutaneous tissue, muscle and bone even in severe cases.severe cases.

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Skin …structure and functionsSkin …structure and functions Anatomy Anatomy

SizeSize….Largest organ in body…with surface area ….Largest organ in body…with surface area 1.7 sq. meters 1.7 sq. meters in in adultadult

Thickness…….? I do not know !.....any body knows it.Thickness…….? I do not know !.....any body knows it. Two layersTwo layers

EpidermisEpidermis….5 layers of epithelial cells….5 layers of epithelial cells DermisDermis….2 layers…contain air follicles, nerve endings, blood ….2 layers…contain air follicles, nerve endings, blood

vessels, fibrous tissue, sweat glands, sebaceous glandsvessels, fibrous tissue, sweat glands, sebaceous glands

FunctionsFunctions Identity of a person or race, beautyIdentity of a person or race, beauty Physical barrier for microorganismsPhysical barrier for microorganisms Sweat glands regulate body temperature, excrete waste products, Sweat glands regulate body temperature, excrete waste products,

hormones, cholesterol, electrolytes, etc.hormones, cholesterol, electrolytes, etc. Dermis prevents excessive fluid loss by evaporation Dermis prevents excessive fluid loss by evaporation Sensory organSensory organ Vitamin D synthesisVitamin D synthesis Forensic importance……..fingerprintsForensic importance……..fingerprints

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Factors determining the severity and Factors determining the severity and prognosis in burnsprognosis in burns

Depth of burnDepth of burn Surface area involvedSurface area involved Age of patientAge of patient Site of burnSite of burn Associated injuriesAssociated injuries Type of burnType of burn Other associated disease factorsOther associated disease factors

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Depth of burns……classificationDepth of burns……classification

Three degrees……Three degrees……according to thickness of skin according to thickness of skin involvedinvolved Ist degree………..epidermis onlyIst degree………..epidermis only Second degree….epidermis and part of dermisSecond degree….epidermis and part of dermis Third degree…….epidermis and complete dermisThird degree…….epidermis and complete dermis

Some authors mention 4 th degree burns for involvement of muscle, bone and Some authors mention 4 th degree burns for involvement of muscle, bone and subcutaneous tissues subcutaneous tissues

First degreeFirst degree Involve epidermis onlyInvolve epidermis only Caused by sunlight or brief scaldingCaused by sunlight or brief scalding Tissue damage is minimalTissue damage is minimal Pain is predominant symptom as nerve endings get Pain is predominant symptom as nerve endings get

exposedexposed Burn skin is red erythematous,Burn skin is red erythematous, Healing occurs by epithelization in 5-10 daysHealing occurs by epithelization in 5-10 days Systemic effects like fluid loss are rareSystemic effects like fluid loss are rare

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Third degreeThird degree

Involve epidermis, complete dermis and Involve epidermis, complete dermis and extend into deeper tissuesextend into deeper tissues

Characterized by dry, tough ,leathery surface, Characterized by dry, tough ,leathery surface, brown or black or whitish in colorbrown or black or whitish in color

Blisters are absentBlisters are absent No painNo pain…..because pain receptors are …..because pain receptors are

destroyed destroyed Tissues are dead and blood vessels are Tissues are dead and blood vessels are

thrombosedthrombosed

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First degree burns

14142nd degree burns with…..blisters,( vesicals)

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Second degree burns

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Which degree burn is it ?

1919Full thickness 3rd. degree burns

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Extent of burn surface…Extent of burn surface… ……calculated as percentage of body surface area calculated as percentage of body surface area

(BSA) (BSA)

Determined by Determined by rule of 9 rule of 9 in adultsin adults Head and neckHead and neck =9%=9% Right arm Right arm =9%=9% Left arm Left arm =9% =9% Chest& abdomen frontChest& abdomen front =18%=18% Chest & abdomen backChest & abdomen back =18%=18% Right lower limb Right lower limb =18%=18% Left lower limbLeft lower limb =18%=18%

TotalTotal =99%=99%

Where is one percent ?Where is one percent ?

Different formula for children and infants.Different formula for children and infants.

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RULE OF NINE

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Accurate estimation of burned surface Accurate estimation of burned surface area is very important…because it is area is very important…because it is directly related to directly related to

severity , severity , prognosis,prognosis, fluid loss,fluid loss, metabolic changes and metabolic changes and patient managementpatient management

Rough estimation……….size of one palm of hand Rough estimation……….size of one palm of hand is equal to one % burn……….is equal to one % burn……….palm of patient not palm of patient not doctor or nurse…..!doctor or nurse…..!

24243– 4 % 2ND DEGREE BURN RIGHT ARM

Age of patient….Age of patient…. Burns of same specific depth and surface area Burns of same specific depth and surface area

inflict higher morbidity and mortality in infants inflict higher morbidity and mortality in infants below two years and elderly people above 60 below two years and elderly people above 60 yearsyears

Infants below 2 years have not well developed Infants below 2 years have not well developed immune system and have less resistanceimmune system and have less resistance

Older people above 60 years have other Older people above 60 years have other associated disease factors alsoassociated disease factors also

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Associated disease factorsAssociated disease factors Other associated disease factors increase Other associated disease factors increase

the morbidity and mortality in a burn patient the morbidity and mortality in a burn patient as compared to a normal person asas compared to a normal person as

Pulmonary diseasePulmonary disease DiabetesDiabetes Congestive heart failureCongestive heart failure Immuno -suppresive drugsImmuno -suppresive drugs Chronic use of steroidsChronic use of steroids Radiation therapyRadiation therapy ChemotherapyChemotherapy AnaemiaAnaemia

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Site of burnSite of burn

Burns involving some particular sites have Burns involving some particular sites have higher mortality and morbidityhigher mortality and morbidity FaceFace NeckNeck HandsHands Perineal areasPerineal areas Feet Feet

These are called These are called primary areas…..and primary areas…..and burns of these areas need hospitalization burns of these areas need hospitalization and special care. and special care. 2727

Associated injuriesAssociated injuries

Other associated injuries along with burns Other associated injuries along with burns increase mortality and morbidity asincrease mortality and morbidity as Inhalation smoke injuryInhalation smoke injury Fractures Fractures Head injuriesHead injuries Chest and thoracic trauma etc.Chest and thoracic trauma etc.

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Type of burnType of burn Electrical and chemical burns may appear Electrical and chemical burns may appear

minor externally but may involve more minor externally but may involve more damage to deeper tissuesdamage to deeper tissues

Fire burns may damage more than scaldsFire burns may damage more than scalds

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Management of burn patientManagement of burn patientMortality and morbidity can be reduced by Mortality and morbidity can be reduced by

Urgent attention Urgent attention Proper assessment , of Proper assessment , of

burned surface area and burned surface area and fluid requirementfluid requirement

Consideration of high risk factors andConsideration of high risk factors and Appropriate treatmentAppropriate treatment RehabilitationRehabilitation

Management of severe burns need a specialized Management of severe burns need a specialized BURN UNIT with skilled personnel BURN UNIT with skilled personnel

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Management includesManagement includes Admit patient if indicatedAdmit patient if indicated Acute resuscitationAcute resuscitation Calculate Calculate

burn surface area, burn surface area, degree of burn, degree of burn, site of burn and label a surface area diagram on site of burn and label a surface area diagram on

patient record sheet.patient record sheet.

Care of burn woundCare of burn wound Prevention of infectionPrevention of infection Nutrition of burn patientNutrition of burn patient Prevent and care of complicationsPrevent and care of complications Rehabilitation and physiotherapyRehabilitation and physiotherapy

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Acute resuscitationAcute resuscitation Airway maintenanceAirway maintenance Large I / V cannulaLarge I / V cannula Fluid replacement therapyFluid replacement therapy Urinary catheter to monitor urine outputUrinary catheter to monitor urine output Central venous pressure line Central venous pressure line Monitor vital signsMonitor vital signs Tetanus toxoidTetanus toxoid Pain relief…Pain relief…

……I / V narcotic analgesics Morphine 0.1 mg / kg, I / V narcotic analgesics Morphine 0.1 mg / kg, Mepridine 1 mg / kg body weight.Mepridine 1 mg / kg body weight.

Antibiotic prophylaxis in 2Antibiotic prophylaxis in 2ndnd and 3 and 3rdrd degree burns. degree burns.

BURN PAIN IS SEVEREST TYPE OF PAINBURN PAIN IS SEVEREST TYPE OF PAIN3232

Classification of severity of burnsClassification of severity of burns

Major burnsMajor burns……

……need admission to specialized burn unit with need admission to specialized burn unit with skilled staffskilled staff

Moderate burnsModerate burns….…..need admission to hospital ward.need admission to hospital ward

Minor burnsMinor burns…………

.treated on out patient basis..treated on out patient basis.

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Major burnsMajor burns……

……must be admitted to a highly specialized burn unitmust be admitted to a highly specialized burn unit 22ndnd degree more than 25% in adult degree more than 25% in adult 22ndnd degree more than 20 % in infants and elderly degree more than 20 % in infants and elderly 33rdrd degree burns more than 10 % degree burns more than 10 % Burns involving primary sites… as face, ears, Burns involving primary sites… as face, ears,

eyes ,neck, hands, perineum, feeteyes ,neck, hands, perineum, feet Patients havingPatients having

inhalation injuryinhalation injury Electricity burnsElectricity burns Burns associated with otter injuries…fracture, head Burns associated with otter injuries…fracture, head

injury, chest trauma etcinjury, chest trauma etc

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Moderate burns….Moderate burns….need admission to hospital wardneed admission to hospital ward

22ndnd degree burns 15-25% adults degree burns 15-25% adults 22ndnd degree burns 10-2-% children degree burns 10-2-% children 33rdrd degree burns 2-10% degree burns 2-10% 11stst degree burns 30% degree burns 30% No associated injuryNo associated injury

Minor burns…..Minor burns…..treated as outpatient basistreated as outpatient basis

22ndnd degree burns less than 15% adults degree burns less than 15% adults 22ndnd degree burns less than 10% children degree burns less than 10% children 33rdrd degree burns less than 2% degree burns less than 2% 11stst degree burns less than 30% degree burns less than 30%

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Fluid replacement and maintenance therapyFluid replacement and maintenance therapy many formulas……….remember one which you like and easy for many formulas……….remember one which you like and easy for

youyou

Calculation of fluid requirementCalculation of fluid requirement Muir & Barckly formulaMuir & Barckly formula Parkland formulaParkland formula Evans . formulaEvans . formula Baxtar formulaBaxtar formula

Basic requirement is adequate perfusion and Basic requirement is adequate perfusion and adequate urine out putadequate urine out put..

First 48 hours are critical for fluid therapy.First 48 hours are critical for fluid therapy. Urine out put is the best guide to know adequate Urine out put is the best guide to know adequate

hydration ……… hydration ……… 0.5 ml / kg / hr0.5 ml / kg / hr.. First fluid to be given is crystalloid solution…..like ringer First fluid to be given is crystalloid solution…..like ringer

lactate, dextrose saline etc.lactate, dextrose saline etc.3636

Formula for fluid calculationFormula for fluid calculation

First 24 hrs.First 24 hrs. 4ml / kg / % of burn = 24 hr requirement.4ml / kg / % of burn = 24 hr requirement. Give half in first 8 hrsGive half in first 8 hrs Next half in next 16 hrs.Next half in next 16 hrs. Hour to be calculated from the time of burnHour to be calculated from the time of burn

Next 24 hrs…….Next 24 hrs……. Maintenance 2000ml and Maintenance 2000ml and Maintain urine out put 0.5.ml /hr.Maintain urine out put 0.5.ml /hr. Plasma is givenPlasma is given Blood may be needed in 3Blood may be needed in 3rdrd degree burns. degree burns. Check electrolytesCheck electrolytes

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Care of burn woundCare of burn wound Cleaning with sterile salineCleaning with sterile saline Apply antibacterial ointments like silver Apply antibacterial ointments like silver

sulfadizine or povidine iodine and dressingsulfadizine or povidine iodine and dressing Wound dressingsWound dressings

Exposure methodExposure method……..no cover……..no cover Covered methodCovered method………cover with gauze………cover with gauze Primary excisionPrimary excision

Debridement with proteolytic enzymes as …Debridement with proteolytic enzymes as …travasetravase

Escharotomy……excision of dead tissueEscharotomy……excision of dead tissue Skin grafting Skin grafting

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Nutrition in burn patientNutrition in burn patient Metabolic requirement increases 2-4 fold in Metabolic requirement increases 2-4 fold in

burn patientsburn patients Proteins are lost in burn oozing fluidProteins are lost in burn oozing fluid Give adequate proteins and caloriesGive adequate proteins and calories Ant acids and H2 blockers are given to Ant acids and H2 blockers are given to

prevent stress gastric ulcerations.prevent stress gastric ulcerations. Vitamins and iron may be givenVitamins and iron may be given Nutrition may be given Nutrition may be given

orally or orally or tube feeding or tube feeding or parenteral feeding in critically ill and severely parenteral feeding in critically ill and severely

burned patients.burned patients.3939

ComplicationsComplications Sepsis of burn wound…..pseudomonasSepsis of burn wound…..pseudomonas PneumoniaPneumonia Stress ulcers…….gastric and doudenum…calledStress ulcers…….gastric and doudenum…called

....Curlings ulcersCurlings ulcers HypoxemiaHypoxemia Multi organ failureMulti organ failure Acute renal failureAcute renal failure Electrolyte disturbancesElectrolyte disturbances Respiratory failureRespiratory failure Scars Scars Keloid formationKeloid formation Post burn contracturesPost burn contractures Marjolin, s ulcer….squamous cell carcinoma in burn Marjolin, s ulcer….squamous cell carcinoma in burn

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Post burn contractures

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Rehablitation in burn patientsRehablitation in burn patients Physical and Physical and PsychologicalPsychological Pressure therapy for hypertrophied scarsPressure therapy for hypertrophied scars Active exercises to prevent contracturesActive exercises to prevent contractures Plastic surgical procedures for contracturesPlastic surgical procedures for contractures

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Plastic surgery Plastic surgery ……

.is the sub -specialty of surgery devoted .is the sub -specialty of surgery devoted to cosmetic and functional physical to cosmetic and functional physical deformities.deformities.

Common procedures usedCommon procedures used Local relaxing incisionsLocal relaxing incisions Skin graftsSkin grafts Skin flapsSkin flaps

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Local relaxing incisionsLocal relaxing incisions

Z- plastyZ- plasty V-Y plastyV-Y plasty Transposition flapTransposition flap Rotation flapRotation flap

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Skin grafts……three typesSkin grafts……three types

Split or partial thickness……Split or partial thickness…… .contain epidermis and part of dermis.contain epidermis and part of dermis

Full thickness……Full thickness…… ……contain epidermis and full dermiscontain epidermis and full dermis

Composite ……Composite …… .contain epidermis, dermis and sub cutaneous .contain epidermis, dermis and sub cutaneous

tissue , cartilage or bone etc.tissue , cartilage or bone etc.

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Split thickness or partial thickness Split thickness or partial thickness ……

contain epidermis and part of dermis only , thickness …..contain epidermis and part of dermis only , thickness …..0.01-0.025 0.01-0.025 inches ,inches ,donner area heals by epithelization from basal skin cells donner area heals by epithelization from basal skin cells

Sub classified as Sub classified as thin thin medium and medium and thickthick

Thigh, buttock and abdomen are common donner sitesThigh, buttock and abdomen are common donner sites Advantages.Advantages...

A large supply of donner areaA large supply of donner area Ease o harvesting….(preservation)Ease o harvesting….(preservation) Donner site for reuse in 14 daysDonner site for reuse in 14 days Decreased primary site scaring and contracturesDecreased primary site scaring and contractures Large donner area can be coveredLarge donner area can be covered

DisadvantagesDisadvantages Cosmetic deformity at donner siteCosmetic deformity at donner site Decreased durabilityDecreased durability HyperpigmentationHyperpigmentation Increased secondary contracturesIncreased secondary contractures

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Full thickness Full thickness …… contain epidermis and dermis in full.contain epidermis and dermis in full. Donner sites…supra clavicular fossa, post auricular Donner sites…supra clavicular fossa, post auricular

site, fore arm and groin. Donner site is closed site, fore arm and groin. Donner site is closed primarily.primarily.

AdvantagesAdvantages Cosmetically superiorCosmetically superior Decreased secondary contractureDecreased secondary contracture Increased durabilityIncreased durability

DisadvantagesDisadvantages Limited doner sitesLimited doner sites Large area grafts can not be taken.Large area grafts can not be taken.

Composite graftsComposite grafts.. .contain full skin and sub- cutaneous tissue or .contain full skin and sub- cutaneous tissue or

cartilage , or bone etccartilage , or bone etc.. 4848

FlapsFlaps ……are portions of skin and sub cutaneous are portions of skin and sub cutaneous and or muscle tissue that are moved and or muscle tissue that are moved from one part of body to other along from one part of body to other along with their vascular pedicle.with their vascular pedicle. Random pattern flapsRandom pattern flaps Axial skin flapsAxial skin flaps Fascio -cutaneous flapsFascio -cutaneous flaps Musculo -cutaneous flapsMusculo -cutaneous flaps Expanded tissue flapsExpanded tissue flaps

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Taking skin graft

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Taking skin graft with a dermatome knife

Complications of graftingComplications of grafting InfectionInfection RejectionRejection Underlying seroma formationUnderlying seroma formation HyperpigmentationHyperpigmentation Contracture formationContracture formation Delayed healing of donner siteDelayed healing of donner site Improper colour matchImproper colour match

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Thank youThank you

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