Cellular and Tissue Effects. Pathophysiology of the Burn Wound. Special Topics: Thermal Burns & Smoke Inhalation
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1 Special Topics: Thermal Burns & Smoke Inhalation MEDICAL RESPONDER AND RECEIVER SEMINAR; EXPLOSION AND BLAST INJURIES Pathophysiology of the Burn Wound The burn wound is the source of virtually all ill effects seen in the burn patient. Removal of the burn wound results in much improved patient outcome. Cellular and Tissue Effects Damage to the cells and tissue is a function of temperature and time. Sustained temperatures between 40C and 44C cause various enzymes to malfunction. Higher temperatures cause protein breakdown. 1
2 Cellular and Tissue Effects Zone of coagulation - Protein coagulation and cell necrosis * Zone of stasis - Cell initially viable, but blood flow compromised Zone of hyperemia - Minimal cellular injury, but increased blood flow and vasodilatation Zones of Injury DERMIS \ \ Zonao,Sta*l& i Zono of Hyparwnta _ j j Source Fellcune DV. Matte* Kt, Moo*«tt Trauma, 6th edition I*to//wymy.acmcsu'gery com Copy 'UJtit c The McGraw-Hill CompameC, Inc All HgtiU revcrvrd Systemic Effects Consumption of clotting factors and platelets Suppression of cellular immunity Myocardial depression * Pulmonary dysfunction * Hypermetabolism Fat and skeletal muscle catabolism Renal dysfunction 2
3 Primary Survey Airway: - Can deteriorate abruptly and rapidly - Airway obstruction due to progressive edema Breathing - Circumferential full thickness burns Lunginjury can affect oxygenation - Circulation - BP, Pulse, circumferential burns and third-spacing * Disability - Neurologic status may be affected due tomultiplecauses Exposure - Pay attention to hypothermia-induced stress Inhalation Injury - Upper airway burns $ Tracheobronchial injury - Lower airway burns Lungs -Toxic compounds Carbon monoxide Cyanide Ziad Kazzi 2012 Smoke Inhalation Smoke particles - Clinical manifestations: S3 Stridor, cough, shortness of breath Carbonaceous sputum, soot in airway, singed nasal vibrissae, facial burns - Can lead to rapid airway compromise - Surgical airway may be needed if oral intubation is not successful 3
4 Carbon Monoxide-Mechanism Binds hemoglobin to form carboxyhemoglobin that is unable to carry oxygen May inhibit to a certain degree cytochrone oxidase Carbon Monoxide-Clinical Most common presentation: - Flu-like illness CNS CV Carbon Monoxide-Labs Carboxyhemoglobin level (Arterial or Venous) Creatine kinase EKG, CXR 4
5 1Q0% Oxygen therapy Carbon Monoxide Hyperbaric oxygen therapy Long-term Effects Hydrogen Cyanide-Mechanism * Inhibits cytrochrome oxidase Cells are unable to use oxygen Anerobic metabolism prevails Lactate accumulates 5
6 CYTOlOi H3C =N / 5/ Im**" PPKpMt!P T- _ d,..*h--. 2H/3 Hyrdrogen Cyanide-Clinical Clinical: CNS -CV - Bitter almond: only 60% of population can detect it. - Cherry red skin, fundoscopic exami Hydrogen Cyanide-Labs -Lactic acidosis with a lactate > 7 mmol/l -Elevated venous 02 saturation >90% -Low 02 extraction when comparing a Venous P02 with and Arterial P02 6
7 Cyanide Antidote Kit AKA the Lilly kit Contains: -Amyl nitrite pearls -Sodium nitrite -Sodium thiosulfate I Tÿl! " : it J! V ' Hydroxocobalamin 5 g IV over 15 minutes May repeat dose if no response and patient is critically ill Adverse Effects of Hydroxocobalamin? * r ' * 2 7
8 History Secondary Survey Circumstances Cause mziad Kazzi 2012 <0 Secondary Survey * Duration of contact with flame Method used to extinguish the fire * Substances placed on the burns during pre hospital/bystander wound care Secondary Survey Setting - Indoors versus outdoors Associated trauma - Blast injuries Associated smoke inhalation 8
9 Past Medical History Comorbid conditions - Diabetes, renal failure, cardiovascular disease - Immunocompromised state - Previous disabilities and special needs AMPLE Allergies Medications Last meal Tetanus status Depth of Burn First degree Second degree or partial thickness - Superficial and deep Third degree or full thickness Fourth degree 9m tplder L l Hypcdermu'US 9
10 Burn Depth Estimation First degree: painful erythematous like a sunburn Partial thickness or second degree: painful, blisters, erythematous Full thickness or third degree: insensate, pale, without viable hair follicles, cadaveric/leathery consistency to palpation First Degree Burn *j 3 r " j / / fc j / /) Safes 10
11 Second Degree Burn &L _ Egg Explosion from Microwave Ls. Ziad Kazri 2012 (0 r: \ M Ziad Kaui
12 fr- ' ; Ziad Kazzi 2012 % r2012 t> mthird Degree Burn 12
13 , 10/2/2015 f VT. : *1 13
14 Burn Surface Area mestimation The patient's hand including fingers is approximately 1% of Total BSA Rule of 9 4.S >.9 9 &.. / tf v * W CJLL-) A r EH ; [ÿleg LEG TOTAL BURN RELATIVE PERCENTAGEOF BODY SURFACE AREA AFFECTED BY GROWTH ARE t TAGEO 1 TS 10 ~1S ADULT HIS fg-g-?- j 14
15 The Berkow Chart Tabic 30 3 Btrfcow chart Tor Estimation el Bum Size in children 3-* Y*4 Jppw arrr 4 Foot Assessment for Perfusion/Ventilation Circumferential full thickness burns -Extremity perfusion may be compromised -Ventilation may be compromised V, 1 ', 15
16 Special Consideration-Pediatrics Larger surface area of head More susceptible to hypothermia Moral support to patient and parents Fluid Resuscitation Fluid is determined by the severity of injury Amount of 2"a and 3ra degree burn Lactated ringers Initial fluid determined by parkland formula - 2-4cc/kg/%TBSA - 'A over the first 8 hours DO NOT BOLUS Titrate fluid to urine output cc/hour Fluid Resuscitation FORMULA CRYSTALLOID Parkland 4 ml/kg/%tbsa None burn Brooke Galveston (Pediatric) 1.5 ml/kg/%tbsa 0,5 ml/kg/% TBSA 2L burn burn 5000 ml/m2 None burned ml/m2 total NONE None Adapted from Feliciano 16
17 Maintenance Fluids Note that maintenance fluids need to be added in children to the Parkland formula. When using the Galveston formula, maintenance fluids are already included. Wound Care If the patient is to be transferred, cover the burns with sterile, dry, towels or sheets * Do not soak the burns or wrap with wet towels, this may induce hypothermia and worsen outcome. \ / Ziad Kazzi 2012 Q 17
18 Debridement -2S, Ziad Ka2Zi 2012 P Ziad Kazzi 2012 O 18
19 Job Well Done! 7tad Kÿy7i?017 (0 Antispectic scrub - Chlorhexidine versus Povidone-Iodine Cleansing Solution Ointments Silver preparations (e.g., silver sulfadiazine) - 5 mm layer every 24 hours * Sulfa allergy Staining of skin Silver nitrate (0.5%) - Can be used in sulfa allergy - less burn eschar penetration 19
20 Ointments Acticoat silver based dressing - No need for dressing change - Need for frequent application of silver nitrate Mafenide Acetate (Sulfamylon ) - Sulfonamide. Excellent antibiotic coverage - Cartilage Ointments Neosporin, Polysporin and Bacitracin are the most commonly used. Neosporin activity is due to the combination of three different types of antibiotics with different spectra: Bacitracin (gram-positive activity) Neomycin (gram-negative activity) Polymyxin B (gram-negative activity) Escharotomy- Indications Used to treat full thickness (third-degree) circumferential burns. Underlying tissues become constricted due to the eschar's loss of elasticity, leading to impaired circulation distal to the wound. The ability to ventilate a patient may be impaired by a circumferential chest burn. 20
21 10/2/2015 Escharotomy- Description H shaped incision ( hi r 21
22 \ V A Transfer to Burn Center Partial thickness burns >10% TBSA. * Burns involving the face, hands, feet, genitalia, perineum, or major joints. Third degree burns in any age group. Electrical burns, including lightning. Chemical burns. Inhalation injury. Burns in patients with pre-existing medical problems. Combination of burns and trauma. 22
23 *rr r, r T.r m P.. \ =% :: Questions or Comments? 23
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