plastic surgery - burns Flashcards
1
Q
burns classifications
A
- Thermal
- Chemical
- Electrical
- Radiation
- Cold Injury
2
Q
thermal burns
A
- Divided into scald, flame, contact and flash
3
Q
scald burns
A
- thermal burns
- Scald most common type
- Depth determined by temperature, duration of exposure and liquid viscosity
4
Q
flame burns
A
- thermal burns
- Flame burn results in deep burns if clothes catches fire
5
Q
flash burns
A
- thermal burns
- Flash burns injures exposed area and results in partial thickness burns
6
Q
contact burns
A
- thermal burns
- Contact burns are deep but limited to contact area
7
Q
burn effects
A
- local
- systemic
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)
9
Q
Jackson;s burn wound model
A
- inner zone
= zone of coagulation = coagulative necrosis (cell death) - 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) - 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
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
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
12
Q
burn depth classification tool
A
- 1st, 2nd, 3rd, 4th degree
- 1st degree - superficial
2nd degree - partial thickness
3rd degree - full thickness
4th degree - involves underlying structure
13
Q
1st degree superficial burns characteristics
A
- dry, no blistering, no/minimal oedema
- cause: flash flame, ultraviolet UV (sunburn)
- colour: erythematous
- painful
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
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
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
- secondary intention
- primary intention
- delayed primary closure
- skin grafts
- tissue expansion
- local tissue transfer
- 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
