Professional Documents
Culture Documents
Irene
Tangco,
MD
UST-FMS
Department
of
Surgery;
Plastic
and
Reconstructive
Surgery
th
(Magboo
C2015
Transcribed
From
Lecture
Notes
+
Schwartzs
Principles
of
Surgery,
9
Ed.)
Burn
Injury
is
a
Chronic
Disease.
Admission
Criteria
2
degree
burns
=
15%TBSA
Surgical
Critical
Care
3
degree
burns
=
5%TBSA
Keep
in
mind
the
functions
of
the
integumentary
system,
the
Burns
on
feet,
face,
hands,
perineum
more
difficult
to
complications
on
the
loss
or
impairment
of
these
functions
need
take
care
of;
if
not
treated
right
away,
may
cause
to
be
addressed.
deformity
and
significant
loss
of
function
Fluid
and
Electrolyte
Management/
Replacement
o Perineum:
greater
chance
of
infection
Infection
Control
Electrical
injury:
extent
may
not
be
easily
visible
Nutritional
Maintenance
(nutritional
requirements
Electric
current
may
have
gone
through
the
tissue
between
shoot
up)
hands
&
feet
(e.g.,
may
just
be
a
spot
in
the
hand
but
is
Cardiopulmonary
Support
really
extensive)
Wound
Care
(avoid
contractions)
Inhalation
injury:
burns
mucosa
down
to
the
lungs
edema
air
exchange
not
possible
DOB
Chemical
injury:
depth
cannot
be
assessed
at
once
Reconstructive
Surgery
Patients
<10
or
>50
y/o:
Cant
take
care
of
themselves
Skin
Grafts
and
Skin
Flaps
as
indicated
Those
with
additional
medical
conditions
(e.g.,
diabetes)
or
injuries
(e.g.,
fractures)
that
would
Rehabilitation
Surgery
compromise
the
patient
Involves
both
psychological
and
physical
function
The
Rule
of
Nines
Etiology
In
estimating
the
extent
of
Burns
(%
Total
Body
Surface
Area)
M>F
Infants
(<1yo)
Adult
(10yo
&
Above)
Scalds
(mainly
pediatric)
most
common
cause
of
burns
Head
&
Neck
18
9
60C
or
140F
(deep
dermal/full
thickness
in
3s)
One
Arm
9
9
Structure
Fires
Anterior
Trunk
18
18
Flammable
Liquids
/
Gases
(occupational)
Posterior
Trunk
18
18
Flash
burns
(mostly
dermal)
One
Leg
13.5
18
o Generally
heal
even
without
grafts
Perineum
1
1
o Cover
large
skin
and
upper
airway
areas
Dont
forget
that
we
normally
have
Two
Arms
and
Two
Legs
Electrical
Burns
In
computing
for
Children
(Age
1-9)
Open
Flames
(Fireworks/Explosives)
For
every
year
of
life:
-1%
from
head
and
neck
second
most
common
+0.5
%
for
every
leg
Chemical
Burns
-
disintegrate
skin
For
example:
a
3
year
old
will
have
15%
TBSA
corresponding
to
the
head
&
neck
areas,
18%
for
Two
Arms,
36%
for
the
Entire
Trunk,
and
15%
for
every
Leg
(30%
Emergency
Burn
Care
for
Two
legs),
the
1%
from
the
perineum
will
complete
the
TBSA
of
100%
Halt
Burning
Process
Immediately
o Extinguish
Flames
o Wash
copiously
with
Water
o In
Chemical
Burns:
Dont
put
Acid
versus
Alkali
or
Alkali
vs
Acid
Cardio-Pulmonary
Resuscitation
o Especially
in
electrical
burns,
as
it
may
stop
the
heart
Hemodynamic
Stabilization
O2
administration
(e.g.,
cases
of
CO
poisoning)
Room
Temperature
Water
Soaks
o Decrease
temperature
in
burnt
area,
so
injury
does
not
progress
Burn
Wound
Coverage
o To
avoid
further
fluid
loss
and
contamination
Note
possible
variabilities:
e.g.,
4.5%
if
only
the
anterior
or
posterior
surface
of
the
head
is
involved
(this
is
just
an
estimation),
1%
was
assigned
to
the
Hand
on
this
diagram.
Diagram
taken
from
Schwartzs
1st degree 2nd degree: 2nd degree: 3rd degree Second
24
hours
Superficial Deep Dermal
Epidermis Dermis still intact (can still replenish itself); Entire thickness, epidermis to
Note
Urine
output
partial thickness burn dermis; no skin left o With
increased
Urine
output,
decrease
the
Load
Surgical debridement
Sunburn, Hot liquids, flames, Hot liquids, flames, Flame, immersion burns, scalds, o Very
little
urine
output,
continue
fluids
minor flash brief exposure to prolonged exposure high voltage electricity,
dilute chemicals to dilute chemicals concentrated chemicals Blood
Pressure:
Target
MAP
=
60mmHg
Pink Pink to bright red Dark red to mottled Pearly white, charred, parched
yellow white (dermis); (leathery)
Adults
can
be
given
D5
water
pinpoint areas live Colloid
containing
fluids
IV
hair follicles
Dry, no Bullae formation Smaller bullae, Dry, non-viable, adherent o Microvascular
permeability
already
reversed
blisters (epidermal layer ruptured or slightly epidermis, thrombosed vessels
raised), copious ruptured (black lines on skin surface); o 0.5
mL/kg
BW/%TBSA
affected
exudates viable tissue = bleeding areas
or
plasma
equivalent
Painful Painful because Decreased pinprick Anesthetic (no nerve endings),
nerve endings are sensation (less deep pressure sensation Note:
Children
has
less
capability
to
concentrate
intact on the painful); intact deep
deeper part of the pressure urine
skin
Soft, minimal Skin thickened by Moderate edema with Inelastic, leathery
o D5
water
0.45%
saline
Edema, edema, but pliable decreased elasticity
Superficial
exfoliation Inhalation
Injury
Heals Heals Heals in 3 weeks Non-healing
sponta- spontaneously in May have some Carbon
Monoxide
poisoning
neously in 5-21 days amount of scarring
2-3 days Has
200x
more
affinity
for
Hgb
compared
to
O2
Managemen Pain relief, Skin grafting for faster Remove eschar (dead tissue that
wont allow healing)x
Administer
100%
Oxygen
to
displace
bound
CO
t: lotion and Vaseline re-epithelialization
Vaseline Surgical and prevent extensive Mesh split thickness skin graft for Upper
Airway
Burns
(Tracheobronchial
tree)
debridement (looks scarring large areas (may have
raw, moist, with cobblestoning) PE:
dyspnea
Sheet graft no holes; for aesthetics
exudates) Mesh split thickness Fiber-optic
Bronchoscopy-
mucosa
is
blistered,
red
(face)
skin graft to expand Scalp thicker area where skin can
be harvested with preservation of Supraglottic
obstruction
follicles
Upper
airway:
bronchitis
suctioning
Lower
airway
burns
(Pulmonary
Parenchyma)
Fluid
Resuscitation
DOB
with
pulmonary
edema
sometimes
pneumonia
First
24
hours
CXR:
congestion
Parkland
Formula
Lactated
Ringers
Wound
Management
We
dont
give
D5
H2O
(Dextrose
containing
solution),
Debridement
(remove
necrotic
tissues)
because
burned
patients
have
very
high
sugar
levels
o Prevent
infections
Colloids
are
not
yet
given,
due
to
its
hypertonicity
o Irrigation/scrubbing
Children:
do
not
have
sufficient
glycogen
stores
to
maintain
o Surgical
removal
of
nonviable
tissues
an
adequate
glucose
level
in
response
to
the
inflammatory
Control
bacterial
proliferation
response;
They
need
more
fluids
than
the
adults
Adults:
- Wound
biopsy:
culture
and
sensitivity
4mL/kg
body
weight/%TBSA
affected
- Appropriate
antimicrobial
chemotherapy
(After
debridement)
Children
below
30kg:
4mL/kg
body
weight/%TBSA
affected
o Silver
sulfadiazine
Addendum
(Children
Above
30kg)
Most
popular,
Widely
available
Modified
Parkland
Formula
1%
in
water
miscible
base
These
additional
volumes
will
stack
on
top
of
the
initial
4ml/kg
BW
Gram
+/-
variable,
yeast
+
100mL/kg
for
the
first
10kg
Exposed
or
single
layer
Dressing
+
50mL/kg
for
the
second
10kg
Application
is
painless
+10mL/kg
above
second
10kg
Easily
applied
Wound
appearance
readily
monitored
Half
of
the
total
computed
volume:
given
within
the
initial
8
hours
Neutropenic
and
Cytopenic
Other
Half:
Given
over
the
last
16
hours
Limited
eschar
penetration
Eschar:
a
dry,dark
scab
or
falling
away
of
dead
skin
Still
combined
with
oral
antibiotics
*Sample Computations:
A 50kg 36-year old Female, presented with 2nd degree and 3rd degree burns on the Right Stainless
upper extremity, Right anterior leg and entire Right foot, and Right half of the anterior trunk o Mafenide
acetate-
11.1%
in
water
miscible
phase
1. Compute for the Total Body Surface Area Burned.
Gram
+/-
Burned Areas Rule of Nines TBSA Designation
R Upper Extremity 9% 9% Has
very
good
penetration
of
eschar
Anterior Trunk: R HALF 18% (Entire Trunk) 9% 7%
hypersolubility
Reaction
R Leg: ANTERIOR 18% (Entire Leg) 9%
Not
commonly
used:
Carbonic
R Foot Just an estimate 1%
Total 28% anhydrase
inhibitors
can
produce
2. How will you manage the Fluid Resuscitation in this patient?
acidosis
Parkland Formula: 4mL/kgBW/%TBSA o Silver
nitrate
4mL x 50 kg x 28% 0.5%
aqueous
solution
5,600 mL LR solution
Give 2,800 mL over the first 8 hours Gram
+/-,
yeast
Give remaining 2,800 mL over 16 hours Occlusive
dressing
A 12 kg 3-year old Boy scalded on his Left lower extremity
Painless,
no
hypersensitivity
1. Compute for the Total Body Surface Area Burned. No
eschar
formation
3-year old = +0.5% per leg every year = 13.5 + 1.5 = 15% Causes
staining
on
linens
&
expensive
3. How will you manage the Fluid Resuscitation in this patient?
Modified Parkland 4 mL/kgBW/%TBSA + Additional fluid based on weight (rarely
used)
4mL x 12 kg x 15% = 720 ++ o Cerium
nitrate
100mL / first 10 kg = 100 mL x 10kg = +1000mL
50mL / second 10 kg = 50 mL x 2kg = +100 mL
Total : 720mL + 1000mL + 100mL = 1,820 mL (Give 910mL first 8, remaining 910mL 16)
Clinical
signs
of
burn
wound
infection
Hypermetabolism
nd Constant
until
the
burn
wound
spontaneously
heals
or
is
Conversion
of
2
degree
burn
to
full
thickness
closed
by
skin
grafting
necrosis
Nitrogen
loss
from
the
muscle
mass
is
significantly
affected
Focal
dark
brown
or
black
discoloration
of
wound
muscle
mass
is
lost
e.g.,
most
patients
thin
down,
no
matter
how
fat
they
were
Degeneration
of
wound
with
neo-eschar
formation
=
initially
and
muscle
mass
will
shrink
dead
tissue
expands
Cardiac
output
and
oxygen
utilization
doubles
Unexpected
rapid
eschar
formation
Ideal
daily
calorie
intake=
25
kcal/kg
BW
Hemorrhagic
discoloration
of
subcutaneous
fat
o 25
kcal/kg
BW
+
40
Kcal
%
TBSA
burned
o e.g.,
burned
px
10%
then
additional
Erythema
of
wound
margins
40
x
10
x
%
burned
TSBA
Erythema
gangrenosum
metastatic
septic
lesions
in
Enteral
feeding
advantageous
over
parenteral
feeding
unburned
tissue
INFECTION
AND
SEPSIS
Green
pigment
in
subcutaneous
fat
(e.g.,
Increases
in
incidence
with
increase
in
burn
size
Pseudomonas:
nosocomial)
Primary
cause
of
death
in
children
and
adults
(resuscitative
failure
in
elderly)
Highly
associated
with
inhalation
injury
prone
to
Electrical
Injury
pneumonia
w/
burn
injury
Tissue
damage:
electrical
energy
passes
through
the
o
Infection=
39 C,
WBC:
16000/mm
3
body
and
is
converted
to
thermal
energy
Sepsis
(immune
defense
of
the
body
is
broken
down)=
3
Hypothermia,
WBC:
5000-16000/mm
(coagulation,
necrosis
and
dessication
in
the
deep
tissues)
Infected
Burn
Wound
Hallmark:
small
external
tissue
damage
but
with
high
Definitive
Treatment:
expeditious
wound
excision
likelihood
of
extensive
deep
tissue
damage
out
of
Most
acquired
infection
in
hospitalized
burn
patients
involve
organisms
that
originally
colonized
the
wound
proportion
with
the
visible
wound
C
&
S=
takes
about
3
days,
hence
the
use
of
empiric
Cardiopulmonary
arrest
as
electricity
passes
through
antibiotics
nerves
and
disrupt
electrical
activity
of
the
heart
o Do
culture
right
away
when
patient
gets
to
hospital
Acute
renal
Failure
An
identified
organism
is
treated
by
a
single
antibiotic
Nerve
deficits
(most
common?)
Tissue
damage
occurs
when
electrical
energy
is
converted
to
thermal
energy
Complications
Signs:
Cardiac
(arrhythmias
and
arrest)
Contracture
deformities
When
deep
2
or
3
burns
are
not
skin
grafted
Hypertrophic
scars
develop;
contract
that
area;
Wound
Management
Function
of
joints
impaired
Surgical
excision
of
burn
wound
Inability
to
flex
or
extend
Early
escharotomy
GI
Tangential
excision
Curlings
ulcer
(stress
ulcer)
Fascial
excision
(vascular
layer)
Antacids/histamine:
H2
antagonists
Wound
closure
Acalculous
cholecystitis
Skin
grafting
Acute
pancreatitis
Skin
flaps
Myocardial
infarction
Risk
for
wound
infection;
deeper
injury
Electrical
burns
Current
that
flows
to
the
body
mainly
affects
Biologic
Wound
Covering
the
conduction
mechanism
of
the
nerves
then
Limit
growth
and
proliferation
of
bacteria
on
the
the
muscles.
wound
surface
Prevent
wound
dessication
Other
things
that
we
use
for
Scars
Decrease
evaporative
water
and
heat
loss
Silicon
sheets
and
silicon
gel
Types:
Good
for
keloids
and
hypertrophic
scars
o Autograft:
most
appropriate;
comes
from
the
With
some
pressure,
it
can
soften
up
keloid
as
long
as
patient
it
is
not
so
thick
o Allograft:
cadaver
homograft
(in
NSS
with
Serve
to
realign
the
collagen
fibers
antibiotics,
not
formalin);
temporary
dressing,
Tissue
expander
works
well
to
keep
evaporative
losses
from
Silicon
bag
inflated
by
saline
overcoming
patient,
prevents
dessication,
Placed
under
normal
skin
to
expand
it
and
eventually
eventually
gets
rejected/sloughed
off
by
the
used
to
cover
adjacent
burned
areas
patients
immune
system
(about
5
days)
Remember:
there
should
be
an
underlying
viable
o Amnion:
only
for
2
degree
burns,
when
the
skin
is
blood
supply,
otherwise
the
grafted
skin
would
just
able
to
replenish
itself;
very
good
as
a
temporary
undergo
necrosis
dressing
because
it
keeps
the
body
fluids
in;
Random
flap
doesnt
allow
a
lot
of
exudation,
sheds
off
once
Certain
amount
of
skin
can
be
predicted
so
that
site
the
skin
is
healed
can
be
covered
o Xenograft:
e.g.,
porcaine
(from
pig
or
chicken):
Partial
Thickness
Skin
Grafts
anything
to
cover
the
wound
temporarily,
but
Full
thickness
skin
graft
for
joints
rejected
much
faster
than
the
allograft