web gp burns workshop wang maitz

8/18/2019 Web GP Burns Workshop Wang Maitz

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Burn InjuryInitial Management and Surgical Approach

General Practice CPD

October 2014

Dr. Tim T. Wang BSc(Hons) MBBS(Hons) MRCS

Prof Peter K M Maitz AM MD FRACS

Burns Unit, Concord Hospital

University of Sydney, Australia

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T Wang & P Maitz IWSML Oct 2014 ©EMSB


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Burns Are Common



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Burns - Incidence

• 1% Australia and New Zealand per year

• 220,000 people per year

• 50% Restriction Daily Living Activities

• 10% Hospital

• 10% Severe Burns

©EMSBT Wang & P Maitz IWSML Oct 2014


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Burns Are Expensive / Impact for

Life



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Burns - The Cost

• Severe Burn - $400,000

• Rehabilitation

• Time off Work

• Loss of Earning Power

• Loss of Life Style©EMSBT Wang & P Maitz IWSML Oct 2014


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Burns Resus / First Aid



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Acute Resuscitation

• Primary Survey

A Airway, cervical spine

B Breathing, Oxygen

C Circulation

D Disability

E Exposure

F Fluids

• Secondary Survey

Tests, Tubes

X-Rays

Blood tests

History

Head to Toe Exam

First aid / Tetanus

Documentation

T Wang & P Maitz IWSML Oct 2014

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Burn wound ?• Cell damage starts at 41 Deg Celsius

• Coagulation of Protein > 50 Deg Celsius

• Depth of wound: Temperature, Duration

• Chemicals: ph, strength

• Electricity: voltage, entry-exit points



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Burns interfere with all 7 major Functions of Skin

• Temperature regulation

• Sensory interface

• Immune response

• Protection from bacterial invasion

• Control of fluid loss

• Metabolic function

• Psycho-social function



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Burns Are Dynamic



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Jackson’s Burn Wound Model

• Zone of Necrosis

• Zone of Stasis

correctresuscitation canpositively influencethis area

• Zone of Hyperaemia

Zone of Survival

Zone of Damage

Zone of Necrosis

Hyperaemia

Stasis

Coagulation


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Zone of Stasis

• Inflammatory mediators cause progression.

• Microvascular occlusion causes tissue

death and deepening of burn.

• Changes minimized by - prompt first aid

- early treatment



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Zone of hyperaemia

• Inflammatory mediators:-

vasodilatation & fluid loss

• Viable tissue• Major burn:-

whole body involved



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Burns First AidCool the Burn Wound

• Tap water 15oC (8

o-25

o)

• Flow, spray or sponging

• Application 20 minutes

• Water-gels or Hydro-gels may be useful

• No ice or iced water

• WATCH FOR HYPOTHERMIA



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Effectiveness of First Aid & Resuscitation

With First Aid No First Aid



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Burns Depth: Nomenclature



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Burn wound depth

• Superficial (first degree)

• Partial thickness (second degree)superficial partial

mid-dermal

deep-dermal

• Full thickness (third degree)



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Superficial (epidermal)

Burn• Redness, Painful, Dry• Spontaneous scar less healing within 7

days



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Partial Thickness superficial• Blister, Redness, Moist, Painful, Oedema• Reepithelialisation within 14 days with

minimal to no scarring



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Healing Mechanism of partialthickness wounds



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Partial thickness deep• Grey-white• Dry

• Little to no pain

• Reepithelialization with copious scarring over weeks (extensive collagen deposition)



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Burn wound depth

• Superficial (first degree)

• Partial thickness

(second degree)superficial partial

deep partial

• Full thickness(third degree)



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Full thickness• Dry, No pain, Clay like colour • No spontaneous wound closure possible

(except very small wounds)



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Do not count erythema!



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Rules of Nines


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Transfer guidelines ANZBA & ISBI Recommendations

Adults superficial burns,

partial thickness


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Burns PrognosisBaux score

Sum of Age in years

Plus

Area of burn in % TBSA< 80 good

80-100 life threatening

>100 death likely


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Estimation of Fluid Needs

• Burn extent - Rule of “Nines”

• Patient weight

• Calculation using formula



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First 24 hoursBurns >15% Adults >10% children

3 - 4 ml Hartmann Solution x

weight (kg) x % burn

in 24 hours

Children PLUS Maintenance with

4% dextrose in 1/2 normal saline



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Give HALF the calculated

volume in the first 8 hours &

the remaining HALF over the

subsequent 16 hours



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Monitoring Resuscitation

Urinary Output

Adults:- 0.5 ml/kg/hr = 30-50 ml/hr

Children (


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Capillary leak

• Responsible for fluid loss into extravascular space

• Occurs after every burn injury

• Extend depends on burn size and depth

• Temporary, sealing of epithelium followstime depended graph



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Burns of Special Areas

• Respiratory: respiratory support

• Perineal: catheterise

• Hands & feet: elevate

• Head & neck: secure airway



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Limb elevation

• Reduces swelling

• Reduces circulatory impairment

• Improves tissue perfusion

• Improves tissue nutrition



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Limbs: Signs of CirculatoryObstruction

• Loss of distal circulation

• pallor

• coolness

• absent pulse

• loss capillary refill

• decreased oxygen saturation

• Pain on passive extension

• Deep pain at rest



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Surgical Therapy in the Acute Phase

• Assessment of circumferential burns(extremities, chest): Escharotomies

• Electrical burns: conduction injuriesFasciotomies

Skin Biopsy for CEA culture

Excision and wound closure



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Escharotomy(Incision of burned tissue to release tension)

After Consultation with Burns Unit:

Can be performed without analgesia (local analgesia athealthy skin edges!) in ED, ICU, BU or theatres

• Chest: To allow respiratory movement

• Limb: To restore circulation in limb withexcess swelling under rigid eschar



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Initial Wound Treatment

• Prevention of Infection

• Pain control

• Creation of optimal wound healingenvironment

• Protection against secondary damage



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Management Burn Wound

• Wash wound (soap and water)

• Cover with clean dry cloth or

plastic film for distant transfer • NO topical antimicrobials unless

transfer delayed > 8 hours

• Elevating limbs reduces swelling



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Biobrane

Artificial Skin

• Xenograft: porcine collagen

• Nylon mesh with defined pores

• Indication partial thickness wounds(debrided full thickness wounds)



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Pre Hospital burn management• Simple, common sense and established

trauma approach (ABCDE)

• Assess burn wound: depth & extend• First aid: running water still best

• Simple wound care within first 24 hours

• Transfer according to guidelines



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Transfer guidelines ANZBA & ISBI Recommendations

Adults superficial burns,

partial thickness


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Take home messages• ABCDE – First aid / Tetanus

• Accurate assessment of burns area

• Appropriately Dress wound

• Do not debride• Refer to a burns unit when in doubt

• Big burns >15% Adults – iv fluids,analgesia, IDC, retrieve


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