Burn Management. Praz Patcha, MD 13 March 2014

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Georgina Gibbs
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1 Burn Management Praz Patcha, MD 13 March 2014

2 Epidemiology 500,000 / yr 40,000 to 60,000 requiring admission < 1% total injuries in US but $10.4 billion

3 Risk Factors Age Location Demographics Socioeconomics PREVENTABLE

4 Pathophysiology Local vs Systemic Local: Thermal injury causes coagulative necrosis temperature specific heat duration

5 Pathophysiology Local: Chemical, Electrical cause liquefactive necrosis additionally Classified by zone of injury (superficially)

6 Depth Classification

7 Depth Classification 1 st deg - epidermis PAINFUL, erythematous, BLANCH 2 nd deg superficial dermis PAINFUL, erythematous, BLANCH retained epithelial structures spontaneous reepithelialization

8 Depth Classification 2 nd deg deep dermis pale, painful to pin prick, DO NOT BLANCH reticular (deep) dermis reepithelialize from appendages severe scarring 3 rd deg into subcutaneous fat painless, eschar epithelialize from wound edges

9 Depth Assessment Clinical judgement Laser Doppler

10 Area

11 Systemic Pathophysiology Severe burns ( > 40% TBSA ) Severe inflammation Hypermetabolism Catabolic state Hyperdynamic circulation

12 Systemic Pathophysiology First 48h Ebb phase decreased CO decreased VO 2 decreased metabolism impaired glucose tolerance Then 48h to 5d plateau - Flow phase hyperdynamic circulation, hypermetabolism

13 Implicated factors IL-1, IL-6 TNFa plt-activating factors endotoxins complement cascade reactive O 2 spp. NO cascade coagulation cascade catecholamines glucocorticoids dopamine 5HT TXA2

14 Systemic Changes 2x insulin release but resistance so profound hyperglycemia up to 12 months post 10x to 50x plasma catecholamine / corticosteroid levels up to 3 YEARS post

15 Systemic Changes 1.5 x CO Myocardial O 2 consumption > marathoners Hepatomegaly 200% normal Thought to begin to resolve when wounds closed

16 Whoa.

17 Management ABC s (extra scrutiny on A) Remove the process (WITHOUT BECOMING A PATIENT) irrigate with room temp water (WITHIN 15 MIN) unless powder, then remove powder, then irrigate don t forget jewelry, belts, etc.

18 Early and Aggressive Resuscitation Parkland 24h IVF = Kg 4 ml %TBSA burned ½ in first 8h ½ in next 16h

19 Early and Aggressive Resuscitation Brooke 24h IVF = 2 ml kg %TBSA burned Colloid = 0.5 ml kg %TBSA burned

20 Resuscitation unimpaired renal function u/o end point otherwise hemodynamic endpoints otherwise doppler signals in extremities

21 Escharotomy

22 Dressings Protect exposed epithelium Occlusive to reduce heat loss Comfort Many options

23 Dressings

24 Early Wound Closure Why? Prevent zone of stasis from progressing to coag Remove cytokine cascade production Remove potential source of sepsis Tangential vs Fascial excision

25 Tangential Excision minimizes tissue loss, improving closure option reduces scar significant blood loss

26 Fascial excision 4 th deg easy planes, minimal blood loss significant defect, scar

27 Wound Closure Options STSG autograft FTSG autograft Cultured Epithelial autograft Dermal matrix Xenograft

28 Systemic Management Nutrition 1.33x basal Insulin anabolic, functional rehgh - anabolic Oxandrolone - anabolic Propranolol greatest reduction in myo O 2

Pediatrics Grand Rounds 1 June University of Texas Health Science Center at San Antonio. Management of Burn Wounds. Management of Burn Wounds

Pediatrics Grand Rounds 1 June University of Texas Health Science Center at San Antonio. Management of Burn Wounds. Management of Burn Wounds Management of Burn Wounds Management of Burn Wounds History of Burn Care Pathophysiology of Burn Lillian F. Liao, MD, MPH Division of Trauma and Emergency Surgery Department of Surgery UTHSCSA Acute burn