Burns

1. RECENT ADVANCES IN MANAGEMENT
OF BURNS
PRESENTED BY:Dr.SHYAM SUNDER REDDY
UNIT CHIEF:Dr.N.V.N REDDY SIR
ASSOCIATE PROFESSOR:Dr. LATCHU SIR
ASSISTANT PROFESSOR:Dr.MANJUSHA MAM
Dr.DEVENDER SIR
MODERATOR:Dr.PRIYANKA

2. BURNS
• Definition:
A burn is an injury to the skin or other organic tissue
caused by extremes of heat or cold,
chemicals,electricity,radiation or friction.

3. CLASSIFICATION OF BURNS

4. CONT…

5. ASSESSMENT OF BURNS
• Rule of Nine
• - Best used for large surface areas
.Rule of Palms
-Best used for burns <10% BSA
.LUND AND BROWDER CHART.

6. BURN % IN ADULTS: RULE OF NINES

7. LUND AND BROWDER CHART

8. PRE HOSPITAL CARE
. Ensure rescuer safety
. Stop the burning process:Stop,Drop,Roll
• Check for other injuries.
• A standard ABC(airway,breathing,circulation) check
followed by a rapid secondary survey.
• Cool the burn wound

9. HOSPITAL CARE
• A:Airway control.
• B:Breathing and ventilation.
• C:Circulation.
• D:Disability-neurological status.
• E:Exposure with environmental control.
• F:Fluid resuscitation.

10. FLUIDS FOR RESUSCITATION
• In chidren with burns over 10% TBSA and adults with
burns over 15% TBSA,consider the need for intravenos
fluid resuscitation.
• If oral fluids are to be used,salt must be added.
• Fluids needed can be calculated from a standard
formula.
• commomly used fluids are
• 1.crystalloid:Ringer Lactate
• 2.Hypertonic saline
• 3.Human albumin
• 4.colloids resuscitation.

11. • Parkland Baxter Formula
• Most widely used.
• Formula:
• Ringer lactate-4ml *kg body weight*TBSA
% Burned
•1/2 that total amt.given first 8 hours and
•1/4 that total amt.given each next 8 hours.

13. • ASSESMENT OF ADEQUACY OF FLUID REPLACEMENT
• Urine output is the most commonly used parameter.
• U/O>0.5-1.0ml/kg/hr
• Urine osmolarity is the most accurate parameter.
• CVP 5-10cm/H2O.
• U/O>2ml/kg/hr-sign of overhydration.

14. OVERRESUSCITATION COMPLICATIONS
• Poor tissue perfusion
• Compartment syndrome
• Pulmonary edema
• Pleural effusion
• Electrolyte abnormalities.

15. EVALUATION
• Infection of wound is a major cause of death after burns.
• Source of organisms :Both endogenous and exogenous sources.
• Bacteriology: The common organisms causing infections are
pseudomonas
aeruginosa,Escherichia,klebsiella,Proteus,Enterobacter and
Providencia.Staph aureus & group A streptococcus
pyogenes.
• Anaerobic infections are rare in burns wound.

16. • Classification of wound infection
• Non invasive
• The infection is limited to burn eschar.
• It may lead to early separation of eschar and increased
purulent discharge from the wound
• Invasive
• Defined as presence of organisms >1,00,000/gram of
tissue of the burn area and actively invading the subjacent
unburned tissues.
• This stage is reached if the burn wound remains
unproperly treated.

17. FACTORS PREDISPOSING
• Host risk factors.
• Infectious agents.
• Environment .

18. • Cliinical features
• These are general features and local signs at the site
of wound.
• General features
• 1.fever with chills.There may be hypothermia in gram
negative invasive sepsis.
• 2.Pulse is rapid and regular.it tends to become
thready in advanced stages od sespsis.
• 3.Intolerance to glucose load presensts as diarrhoea.

19. • 4.Disorientation and unresponsiveness.
• 5.Hypotension,oliguria and paralytic ileus occurs in
late stage of illness.
• 6.The infection and its systemic manifestations
may lead to multiple organ failure.This is a grave
complication with high mortality.

20. Local signs in non invasive infections
1.Eschar separates rapidly
2.Profuse purulent discharge
3.Granulations remains pink
4.No changes are obseved in the unburnedviable
tissue

21. Local signs in invasive wound infection
1.Partial thickness burns gets converted into full
thickness injury
2.Focal or generalized violaceous dark brown or black
discolouration of wound.
3.Subeschar suppuration.
4.Hemorrhagic discoloration of subeschar fat
5.Rapid sloughing of burned tissue(eschar).

22. 6.Granulation tissue becomes pale,dry and
crusted.These degenerate and form “NEOESCHAR”
7.Purplish discoloration,edema and ulceration of
unburned skin at wound margin.
8.Development of Erythema gangrenosum.
9.Vesicle formation in healing partial thickness burns.
10.Failure to take graft.

23. DIGNOSIS OF BURN WOUND SEPSIS
• In addition to clinical features,the investigation which
can help in the diagnosis of burn wound sepsis
include:
• 1.Wound biopsy
• 2.Surface culture
• 3.Blood culture
• 4.Leukocyte count

24. PREVENTION AND TREATMENT
The control of infection is carried out by following
interventions
• 1.Topical medications.
• 2.Systemic antibiotics.
• 3.Surgical management of wound.

25. 4.Immunotherapy
5.Biological and synthetic skin substitutes
6.Nutrition

26. Topical medication
-topical therapy has decreased the infection rate of
wound significantly.
-to be effective should be started as early as possible
after the injury and changes are made according to
the condition of wound and bacteriologic reports.

28. Silver suphadiazine
- is the most commonly used topics agent in burn
wound.
- It is primarily bacteriostatic with wide spectrum of
activity.
- it decreases healing time in deep dermal
burns,prevent their conversion to full thickness and
reduces the incidence of invasive sepsis.

29. -Mafenide and silver nitrate have contributed
significantly in reducing sepsis in burns
-The existing invasiveness can be controlled by sub
eschar antibiotics and this technique results in early
separation of eschar.
-commonly gentamycin,tobramycin and kanamycin
are the drugs used in this modality.

30. SYSTEMIC ANTIBIOTICS
The use of systemic antibiotics can be either
prophylactic or therapeutic
Prophylactic
Antibiotics are used prophylactically immediately
before excision, post operatively after excision of burn
wound and at the time of skin grafting.

31. Therepeutic antibiotics
.The choice of antimicrobials and duration of
treatment is guided by clinical status,latest culture &
sensitivity of aorganisms colonizing the burn wound.
.Usually,broad spectrum antibiotics like
aminoglycosides and third generation cephalosporins
are used. And commonly used in combination.
.The antibiotic therapy if continued long,may lead to
emergence of resistant organisms and super infection.

32. Surgical management
The procedures used in the surgical manegement of
burns can be classisfied as follows:
1.Management of partial thickness burns:
(a)Tangential Excision and SSG.
(b)Tangential Excision and biological dressing.
(c)Superficial Escharectomy.

33. Tangential burn excision and SSG

34. 2.Management of full thickness burns:
(a)Escharotomy.
(b)Radical excision.
(c)Sequential excision.

35. ESCHARATOMY

36. Immunotherapy
A killed vaccine of corynebacterium parvum improves
antimicrobial defences and clinical trials indicate substantial
reduction(80%) in bacteremic episodes.
Levamisole, has a number of immunologic properties.
Phagocytosis is increased along with random
migration,chemokinesis, and chemotaxis of normal neutrophils.
Fibronectin acts as a circulating non specific opsonin
Cryoprecipitate infusion has been shown to replenish serum
levels of fibronectin and improves serum opsonic activity.

37. .Lithium has proven useful for treatment of
granulopoietic defect in other disease styates and may
be applicable in the future.
.The use of FFP in the burn patient has resulted in
icreases in neutrophil functionalchemotactic activity.
-This lends to the use of plasma exchange and
hemodialysis in severly burned patients.
.Pyran, a synthetic anionic copolymer increases
protection against bacterial and fungal infection.
.CP-46,665 a lipoidal amine,improves phagocytosis..

38. Enhancement of cell mediated immunity
.Defect in CMI in the burn patient are accurate
predictors of subsequent sepsis and mortality.
.The most expeditious means of avoiding CMI
depression may be to perform early excison of burn
tissue.
.Early excision and grafting may markedely improve
lymphocyte function.

39. -Cyclophosphamide, an alkylating antitumour
agent,which appears to be selectively inhibit
suppresser lymphocyte proliferation when used in low
concentration may prove to be useful.
-Histamines and prostaglandins are implicated
in the stimulation of suppressor T cells,both class
inhibitors may be effective in preserving delayed
hypersensitivity responses.
-Endotoxin may activate suppressor cells,the use of
polymyxin B,which will bind and inactivate endotoxin
may prove useful.

40. Other drugs that have offered immunologic
improvement include
a)IL-2
b)Indomethacin
c)TP-5(Pentapeptide derived from thymopoietin)
d)Vit A
e)Vit E

41. immunotherapy immunomodulation
Anti bacterial vaccines
Immunoglobulins
FFP
Cryoprecipitate
Nutrition
Corynebacterium parvum
.levamisole
.lithium
.Endotoxin
.Pyran
.CP-46,665
.H2 Receptor antagonists
.Prostaglandin inhibitors
.Cyclophosphamide
.Polymyxin B
.Thymosin
.Thymopoietin
Immuno–Activeagents

42. Skin substitutes
1) Biologic skin substitutes
a)Human allograft
b)Amniotic membrane
c)Xenografts
2) Synthetic skin substitutes
a)Synthetic bilaminate
b)Collagen based composites
-Biobrane
-Transcyte
-integra

43. 3)Collagen based dermal analogs
a)Dee-epithelized allograft
b)Alloderm
4)Cell culture derived
a)keratinocyte cell sprays
b)bilayer human tissue (apligraf)
c)polyglycolic or acid mesh (dermagraft)
d)cultured autologous keratinocytes
e)fibroblast seeded dermal analogs
f)epithelial seeded dermal analogs

44. Application of biobrane
Removal of biobrane

45. Transcyte

46. Integra Integra applied on skin

47. Nutrition
.High protein,high calorie and low fat diet is required
for burns patient.
.EARLY ENTERAL FEEDS throug NG Tube (TBSA
15%)
-tolerated in burn patients.
-preserve mucosal integrity.
-Reduce magnitude of hypermetabolic
response
.Parenteral when enteral is not tolerated

48. Sutherland formula
.Children:60 kcal/kg + 35 kcal% TBSA
.Adults:20 kcal/kg + 70 kcal % TBSA
Protein
1.5 to 2 g/kg protein/day

49. Future care of burn wound
(a)Enzymatic debridement:
-it will be effective in helping to differentiate the
partial and full thickness burn wound
-it should be painless with ease of appllication and
without any untoward toxic effects.
(b) Vaccines :
-jones et al developed vaccines against
pseudomonas.
-it may help in preventing septicemia due to
massive burn wound sepsis.

50. (B)Cultured skin:
-the biologists have cultivated cells into sheets
-the culture may start from patients own cell to avoid
immunologic problems.
-drawbacks are high cost and long time
(C)Topical oxygen:
-the susceptbility to infection increases if circulation or
oxygen delivery is decreased.
-in experiments,topical oxygen promotes healing
though thicker scar is produced.
-it needs further research to be used in extensive
burns,to prevent infection and reducing healing time.