Thermal injuries -plastic surgery

Mahajna MohammadSackler’s faculty of medicine , Tel-Aviv Uni; 2017

Thermal injuries

INTRODUCTION 

“ Concentrate all your thoughts upon the work at hand. The sun's rays do not burn until brought to a focus”

500K >50% 4K66%

33% 44% 26% 17%

Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.

American Burn Association White Paper. Surgical management of the burn wound and use of skin

Scalded :contact with hot liquids

Flame: superheated, oxidized air

Thermal 

Chemical  

Electrical  

Inhalation 

Radiation 

Cold exposure (frostbite)  

Depe

nds on

 :

 Jackson's thermal wound theory- 1947

ABC of burnsShehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10; 329(7457): 101–10; doi:  10.1136/bmj.329.7457.101

Lund-Browder — is the most accurate for adults and children (larger heads and smaller lower extremities) It takes into account the relative percentage of BSA affected by growth 

Rule of Nines — For adult assessment, the most expeditious method :

Each leg =18 % TBSA

Each arm =9 %TBSA

The anterior and posterior trunk each =18 % TBSA

The head =9 %TBSA

Palm method — used for irregular ,small or patchy burns 

The palm, excluding the fingers,  =0.5 % TBSA 

the entire palmar surface including fingers is 1 % TBSA in children and adults  Superficial burns are not included in the TBSA 

burn assessment.

Determination of burn size estimates the extent of injury. Burn size

is generally assessed by the “rule of nines”

Burn assessment

“Understanding is the first step to acceptance, and only with acceptance can there be recovery.” J.K. Rowling, Harry Potter and the Goblet of Fire

Stage 1 : Emergent phase

Stage 2 : Fluid shift-<24hr , peak at 8hr

Stage 3 : Hypermetabolic phase :days-weeks

Stage 4: Resolution phase : healing / scar formation

Initial assessment / treatment 

basic

Pre-hospital / initial treatment hospitalization

Specific injury 

e.g. inhalation

Airway and breathing support

Administer humidified oxygen at a rate of 10-12 L/min if signs of inhalation injury are present

A patient who is not breathing should be intubated and ventilated with 100% oxygen

Cooling : ↓ lactate production +acidosis,promoting catecholamine function and cardiovascular homeostasis

Remove clothing

Immerse wound in cold (1-5°C) water for 30m

Do not use ice water / ice directly to the burn wound

Local cooling of burns of < 9% of TBSA can for > 30 min relieve pain

Fluid resuscitation –burns >15% of TBSA may produce shock as a result of hypovolemia

Maintain IV access 

In children <6 years : intraosseous access in the proximal tibia until IV access is accomplished

Begin immediately with warmed fluid if possible

Cannulate burned skin if unburned skin is unavailable 

In adults: solution can be without glucose.

In children <2 yr  should receive 5%dextrose in lactated Ringer solution

Insertion of nasogastric tube (e.g Levin ,salem-sump,Andersen, Dobhof) is crucial : 

• Reduce intestinal ileus

• Prevent patient from air swallowing 

• Alleviates distention

Dobhof tube should be placed into the fist part of the duodenum to maintain caloric

intake

Recommendations for tetanus prophylaxis :

All patients >10% TBSA should receive 0.5 mL of tetanus toxoid. 250 units of tetanus immune globulin are also given If:

1. prior immunization is absent or unclear 2. the last booster dose was more than 10 years ago

Karyoute SM1, Badran IZ Tetanus following a burn injury.Burns Incl Therm Inj. 1988 Jun;14(3):241-3.

Admission to burn unit  Assets the need for intensive 

care unit

Wound care

Excision Escharotomies Coverage \ dressing

Basic support

Nutritional support Resuscitation

Consider location :e.g.

Fingers and toes should be wrapped individually 

separating the digits in order to prevent maceration 

and adherence

Wash + debride any open blisters

Steroids have no role in treating burn wounds.

The World Health Organization (WHO) recommends

debridement of all bullae and excision of all adherent

necrotic tissue

Decompressive escharotomy :Extremities at risk are identified either on clinical examination or on 

measurement of tissue pressures > 40 mm Hg.

With deep dermal and full thickness burns, the dermis can become stiff 

and unyielding, and this tissue is referred to as an eschar.

escharotomy

Fluid selection

• Resuscitation• Maintenance• Over-resuscitation

Desired fluid amount

Monitoring fluid status

Over-resuscitation

Fluid selectionHypertonic saline Colloids (e.g, albumin solution, dextran) Crystalloids or volume expanders

↓ net fluid intake ↓ edema, ↑ lymph flow

• significantly more expensive• should not be used in the fist 24 hours until

capillary permeability returned closer to normal

• Ringer lactate is typically used• lactate may reduce the incidence of 

hyperchloremic acidosis

Hypernatremia !!! Na <160 mEq/dL ↑ renal failure ↑ acute tubular necrosis ↑  hyper-chloremic metabolic 

acidosis

• Albumin use is controversial• The Cochrane group showed in a meta-

analysis of 31 trials that the risk of death was higher in burned patients receiving albumin compared with those receiving crystalloid. RR=2.40 : (cl 95% ,1.11 - 5.19). 

5% Dextrose =D5W 0.45% NaCl = half formal saline 0.9% NaCl = normal saline Ringer lactate Hartmann’s  5% dextrose, normal saline = D5NS

Authors’ conclusions: 

Whether Hypovolemic or hypoalbuminemic

 there is no evidence that albumin reduces mortality when compared with cheaper alternatives such as saline. 

Human albumin solution for resuscitation and volume expansion in critically ill patients.Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi: 10.1002/14651858.CD001208.pub3.

Recommended amount

Another alternative method is the Rule of Tens depending on patient size: Estimate (TBSA) to the nearest 10 percent.

Multiply the percent TBSA x 10 = initial fluid rate in mL/hour for adults 40 to 80 kg.

> 80 kg, increase the rate by 100 mL/hour for every additional 10 kg of body weight.

Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.

Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE ;Burns. 2009 Feb; 35(1):4-1

Burn severity

Associated injury

comorbidities

age

Burn depthTBSALocation

Calculate amount needed

Start initial resuscitation

50% of the calculated fluid requirement is administered in the

first 8 hours

50% is given over the remaining 16 hours Evaluate response  adequate resuscitation 

achieved  stabilized

Change crystalloid to 5 % dextrose in (ie, 0.45%Nacl) +20 mEq of KCl per liter

Monitoring fluid status - Non-invasive methods

0.5 mL/kg / hr in adults 

1.0 mL/ kg/ hr in children

If urine output drops below 0.5 mL/kg/hr   a bolus of IV crystalloid (500 -1000 mL) 

↑infusion rate  by approximately 20 to 30 percent

Clinical signs of volume status: monitored every hour for the first 24 hours: heart rate

blood pressure

pulse pressure

distal pulses

capillary refill

 color and turgor of uninjured skin are

edema

Monitoring fluid status invasive methods (CVP/ Swan-ganz / Arterial BP /

SVV)

Evaluate response  stabilizedChange crystalloid to 5 % dextrose in (ie, 0.45%Nacl) +20 mEq of KCl per 

liter

unresponsive to resuscitation1) > 6 mL/kg X (X%) TBSA per 24 hours

2 )impending cardiac failure are present

Evaluate response

Invasive / non-invasive  

Swan-Ganz

Measure Co

If adeq Vol. but ↓ urine output

dopamine (5 µg/kg/min) may be used to increase renal perfusion.

Resuscitation related complication

CONCLUSIONS:Restrictive resuscitation is associated with increased AKI, without changes in infectious complications.

13 trials have indicated that as much as 50% of the edema observed in non-burned tissues.

In burns > 25% TBSA , capillary permeability is increased also in non-burned areas

Symptoms : Unproportioned Pain (early ,common finding)

 burning pain

Paresthesia (30m-2 hr;)

Examination findings Pain  

Tense compartment with a firm "wood-like" feeling

Pallor  (uncommon)

Diminished sensation

Muscle weakness (onset 2-4hr)

Paralysis (late finding)

ACS ∆ pressure = diastolic BP measured compartment ‒pressure

ACS ∆ pressure <20 to 30 mmHg indicates need for fasciotomy

(we use <30 mmHg)

J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture.Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD

References

Burns. 2006 Aug;32(5):529-37. Epub 2006 Jun 14.

American Burn Association White Paper. Surgical management of the burn wound and use of skin

ABC of burnsShehan Hettiaratchy, Initial management of a major burn: II—assessment and resuscitation; BMJ. 2004 Jul 10; 329(7457): 101–10; doi: 10.1136/bmj.329.7457.101

Karyoute SM1, Badran IZ Tetanus following a burn injury.Burns Incl Therm Inj. 1988 Jun;14(3):241-3.

Human albumin solution for resuscitation and volume expansion in critically ill patients. Albumin Reviewers (Alderson P, Bunn F, Li Wan Po A, Li L, Blackhall K, Roberts I, Schierhout G)1.Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001208. doi: 10.1002/14651858.CD001208.pub3.

Simple derivation of the initial fluid rate for the resuscitation of severely burned adult combat casualties: in silico validation of the rule of 10.Chung KK1, Salinas J, Renz EM, Alvarado RA, King BT, Barillo DJ, Cancio LC, Wolf SE, Blackbourne LH.

J Bone Joint Surg Am. 1994 Sep;76(9):1285-92.Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture.Heckman MM1, Whitesides TE Jr, Grewe SR, Rooks MD

Overview of the management of the severely burned patientAuthors:Gerd G Gauglitz, MMS, MDFelicia N Williams, MDSection Editor:Marc G Jeschke, MD, PhDDeputy Editor:Kathryn A Collins, MD, PhD, FACS

Sabiston textbook of surgery 19th;chapter19 : burns; David C Sabiston; Courtney M Townsend, Jr.; Philadelphia, PA : Elsevier Saunders, ©2012.

Burn resuscitation.Alvarado R, Chung KK, Cancio LC, Wolf SE; Burns. 2009 Feb; 35(1):4-1