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med n surg S2 > plastic surgery - burns > Flashcards

plastic surgery - burns Flashcards

1
Q

burns classifications

A
  • Thermal
  • Chemical
  • Electrical
  • Radiation
  • Cold Injury
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2
Q

thermal burns

A
  • Divided into scald, flame, contact and flash
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3
Q

scald burns

A
  • thermal burns
  • Scald most common type
  • Depth determined by temperature, duration of exposure and liquid viscosity
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4
Q

flame burns

A
  • thermal burns
  • Flame burn results in deep burns if clothes catches fire
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5
Q

flash burns

A
  • thermal burns
  • Flash burns injures exposed area and results in partial thickness burns
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6
Q

contact burns

A
  • thermal burns
  • Contact burns are deep but limited to contact area
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7
Q

burn effects

A
  • local
  • systemic
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8
Q

local effect

A
  • burn < 20% total body surface area
  • Jackson’s burn wound model
  • fluid resuscitation key
    (turn ischemic/intermediate to hyperaemia/outer zone if effective, if not = coagulation/inner zone)
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9
Q

Jackson;s burn wound model

A
  1. inner zone
    = zone of coagulation = coagulative necrosis (cell death)
  2. intermediate zone (ischema)
    = zone of stasis
    = damage to microcirculation
    = leads to schema
    = leads to necrosis if untreated
    = progression influenced by effective resuscitation (if resuscitation done effectively = zone of hyperaemia, if not effective = zone of coagulation)
  3. outer zone
    - zone of hyperaemia
    - cellular damaged cause release of inflammatory markers by capillary wall, white blood cells and plts
    = leads to vasodilation & increased permeability
    - ongoing fluid loss from circulation to interstitial space
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10
Q

systemic effect

A
  • burn > 20% total body surface area (TBSA)
  • Early excision & closure key
  • Result of systemic circulation of local inflammatory mediators (TNF, INF, Interleukins)
  • Affects all organ systems
    CVS – Hypovolaemia & myocardial depression
    Resp – Pulmonary oedema
    GI T – loss of protective function, hepatic dysfunction GUT – Renal impairment
    Immune – Suppression
    Nutrition - Catabolic
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11
Q

burn evaluation

A
  • Effective evaluation guides treatment plan
  • Follow ATLS principles
  • Airway–assess for inhalation injury
  • Adequate exposure (to calculate TBSA) but guard against hypothermia
  • Tubes – Two large-bore IV cannulas, ETT (endotracheal tube if inhalation injury), NGT (nasogastric tube - feeding), urinary catheter & baseline bloods
  • Adequate analgesia
  • Wound dressing–film dressing initially
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12
Q

burn depth classification tool

A
  1. 1st, 2nd, 3rd, 4th degree
  2. 1st degree - superficial
    2nd degree - partial thickness
    3rd degree - full thickness
    4th degree - involves underlying structure
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13
Q

1st degree superficial burns characteristics

A
  • dry, no blistering, no/minimal oedema
  • cause: flash flame, ultraviolet UV (sunburn)
  • colour: erythematous
  • painful
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14
Q

2nd degree - partial thickness burns characteristics

A
  • moist blebs, blisters
  • cause: hot liquid/solids, flash flame to clothing, direct flame, chemical, UV
  • colour: mottled white to pink, cherry red
  • very painful
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15
Q

3rd degree - full thickness burns characteristics

A
  • dry & leathery eschar until debridement, charred vessels visible under eschar
  • cause: hot liquids/solids, flame, chemical, electrical
  • colour: mixed white, waxy, pearly, dark, khaki, mahogany charred
  • little or no pain, hair pulls out easily
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16
Q

4th degree - involves underlying structure burns characteristics

A
  • same as 3rd degree, possible with exposed bone, muscle / tendom
    = dry & leathery eschar until debridement, charred vessels visible under eschar
  • cause: prolonged contact with flame/ electrical
  • little or no pain, hair pulls out easily (same as 3rd)
17
Q

3 TBSA tools

A
  • Wallace rule of nines (most common)
  • Lund Browder Chart
  • the Palmer rule
18
Q

Wallace rule of nines

A
  • divides body into 9
    head & neck: 9%
    anterior trunk: 18%
    posterior trunk: 18%
    left arm: 9%
    right arm: 9%
    left leg: 18%
    right leg: 18%
    genitalia & perineum: 1%
19
Q

Lund Browder Chart

A

includes % for adults as well as children

20
Q

Burn unit admission criteria

A
  • Partial Thickness burns >10%TBSA
  • Full Thickness burns
  • Burns involving special areas (face, hands, perineum, joints)
  • Special burns (Chemical, Electrical, Inhalational)
  • Burns with concomitant trauma
  • Burns with preexisting comorbid medical conditions
  • Extremes of age
  • Patient who will require special social, emotional or long-term rehab
21
Q

fluid replacement

A
  • TBSA helps calculate fluid replacement first 24hrs after burn
  • Parkland Formula (volume of Ringer’s lactate = 4mL x % TBSA x weight in kg) half = first 8 hrs / next 16 hrs
  • Ringer’s lactate used for adults
  • dextrose solution used for children 1ml mild, 2ml moderate, 3ml severe
  • Hartmann’s solution contains: Na131, Cl111, Lactate 29, K 5, Ca 2 mmol/l
  • Aim for urine output of 0.5ml/kg/h
  • Modify in children: add maintenance fluid as follows:
    100ml/kg for 1st 10kg body wgt
    50ml/kg next 10kg body wgt
    20ml/kg for remaining wgt
    Aim for urine output of 1ml/kg/h
22
Q

surgical care for burns

A
  • immediate
  • escharotomy & fasciotomy
  • Circumferential burn wound requires release
  • for limb perfusion
  • for respiratory function if interfered
23
Q

early excision & skin grafting

A
  • for deep burns
  • Popularized by Janezovic in the 70s’
  • Done within 3 days of injury
  • Increases survival
  • Decreased length of hospital stay
  • Reduces infection rates
  • Decreased risk of hypertrophic scarring
24
Q

wound closure

A
  • Refer to wound healing lecture
  • Superficial partial thickness burns will heal 3 weeks > Biobrane (to protect)
  • Deep partial thickness burns will require skin graft
  • Ideally full thickness graft better but limited donor site
    = Therefore reserved for post burn reconstruction
    = Split thickness graft gold standard
  • In large burns can wait for healing of donor site and reharvest
  • For deep burns and burns with exposed vital structures > Integra & graft or flaps
25
Q

burn reconstruction

A
  • Aim is to improve function, comfort and cosmesis
  • Start with prevention > early excision & grafting, positioning & splinting, early scar management
  • Potokar’s 5Ps > Problem/ Priorities/ Possibilities/ Perceptions/ Plan
  • Delay recon till scar maturity
  • Vancouver Scar Scale most commonly used scar assessment tool
26
Q

Scar assessment tool

A

VSS - Vancouver Scar Scale
1. vascularity
2. pigmentation
3. pliability
4. height

27
Q

surgical principles

A
  • Release extrinsic scar before intrinsic
  • Release from proximal to distal
  • Orient scar parallel to RSTL
  • Replace like with like (skin graft)
  • Follow subunit principle
  • Identify and protect potential donor site
28
Q

reconstruction ladder principles = will have recurrence of scar

A
  1. secondary intention
  2. primary intention
  3. delayed primary closure
  4. skin grafts
  5. tissue expansion
  6. local tissue transfer
  7. free tissue transfer
29
Q

scar management - scar formation

A

preventative therapy
* Prevents abnormal scarring
* Massage > scar pliability and remodels adhesions
* Silicone > scar occlusion & hydration,12hrs/day for 2 months starting 2 weeks post healing
* Pressure therapy > limit blood supply & increases apoptosis, 23hrs/day for 6 months

30
Q

scar management - established scar rx

A
  • Improves function and cosmesis
  • Intralesional steroids * Cryotherapy
  • Radiotherapy
  • Laser
    Remember above mainly follows surgical excision
    Refer wound healing lecture
31
Q

burn rehabilitation

A
  • Assist patient through recovery for better functional outcome
  • Should start when patient is admitted
  • Correct position > minimize contractures
  • Correct ROM > minimize deformity
  • Decrease oedema
  • Prevent loss of lean muscle mass
  • Prevent pulmonary complications > chest physio

med n surg S2 (18 decks)

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