Surgery C - Burns and Plastics Flashcards
What is the immediate first aid for burns?
ABCDE + Analgesia, emollients, Keep patient warm.
Heat Burns Management
Remove person from source, irrigate the burn, water between 10 and 30 minutes, cover in cling film
Electrical Burns Management
Switch off power supply, remove person from source
Chemical Burns Management
brush any powder off then irrigate with water
Burn Depth
Explain 1st, 2nd and 3rd degree
1st Degree: Red and painful, superficial epidermal
2nd Degree (Superficial): Pale, pink, blanching, painful, blistered, partial thickness burns
2nd Degree (Deep), Mottled Cherry red, White, patches of non blanching.
3rd Degree: Dry leathery, White, brown, black in color, no blisters, no pain
How does negative pressure help burns
Negative pressure - can increase blood supply to encourage healing, used for larger wounds
What are the layers in the epidermis?
Stratum basale
Stratum spinosum
Stratum granulosum
Stratum lucidum
Stratum corneum
What are the layers in the Dermis
Papillary and
Reticular
What is the function of the skin?
- Provides a protective barrier against mechanical, thermal and physical
- injury and hazardous substances
- Retains fluid in the body / prevents loss of moisture
- Reduces harmful effects of UV radiation
- Acts as a sensory organ (touch, protective reflexes, reproduction)
- Temperature regulation
- An immune organ to detect and respond to infection
Burn – World Health Organisation definition
A burn is an injury to the skin or other organic tissue primarily
caused by heat or due to radiation, radioactivity, electricity,
friction or contact with chemicals. Thermal (heat) burns occur
when some or all of the cells in the skin or other tissues are
destroyed by: hot liquids (scalds) hot solids (contact burns), or
flames (flame burn).
What are the different types of burn injury?
- Flame: e.g. direct flame or clothing
- Scald: damage from contact with hot liquid
- Contact: damage from contact with hot or cold solid materials or surfaces
- **Chemical: **contact with noxious chemicals (acids or alkalis)
-
Electrical: conduction of electrical current through tissue (classified
as either low voltage or high voltage injuries) - **Radiant heat: **a nearby heat source such as radiator, sunburn
- Other/Miscellaneous: Cold burn/frostbite, ionizing radiation exposure
- Major burns are commonly associated with inhalation injury
What are the three zones of Jackson’s burn Zones
Zone of coagulation:
Zone of stasis:
Zone of hyperaemia:
Explain each zone in Jackson’s burn zones
- Zone of coagulation: irreversible
tissue loss due to coagulative
necrosis. - Zone of stasis: decreased tissue
perfusion. Tissue is viable but can
deteriorate to necrosis if no adequate
resuscitation. - Zone of hyperaemia: outermost zone
with increased tissue perfusion.
Tissue usually recovers in absence of
severe infection or severe tissue hypo
perfusion
Burns can result in?
oedema
hypovolemia
coagulability
inflammation
Which then leads to: viscosity and Increased capillary
permeability
Finally this leads to burn shock
What is required for burns of more than 15% of
body area in adults and 10% in children
Fluid resuscitation
What are some clinical assessments for burns
Total Burn Surface Area Assessment - Methods
*Palmar Surface area: 1%
* Wallace rule of nines
* Lund and Browder chart
* Mersey Burns App
What is Wallace rule of nines
to estimate the percentage of total body surface area burned.
Rule of Nines - The head represents 9%, each arm is 9%, the anterior chest and abdomen are 18%, the posterior chest and back are 18%, each leg is 18%, and the perineum is 1%.
What are the different types of Burn Depths
Superficial (Epidermal):
(Dermal)Superficial partial thickness burns:
(Dermal) Deep dermal injuries:
Full Thickness:
Explain Superficial (Epidermal) burns
No blistering. Epidermal burns are not included in TBSA calculations. Pink and painful. E.g. Sunburn.
What is Superficial partial thickness burns
salmon pink, blanching with blisters.
Very painful.
What is Deep dermal injuries
mottled cherry red colour that does **not **blanch -
blood is fixed within damaged capillaries in the deep dermal plexus.
Variable pain, but less painful than superficial partial thickness burns
What is Full Thickness Burn
A dry, leathery or waxy, hard wound that does not blanch
any typically white in colour and painless
What type of burn is this?
Epidermal Burn
-Erythema, Blanches to pressure, painful
What type of burn is this?
Superficial Dermal burn-Pale pink, mottled and bilstered, blanches, painful
What type of burn is this?
Deep Dermal Burn
-Cherry red, blistered, does not blanch, dull sensation
What type of burn is this?
Full thickness burn
-White, does not blanch and has no sensation
What are the general management principles for burns
- First aid: stop the burning, 20 minutes of cool water, cling film
- ABCs and history including weight
- Early analgesia
- Cool the burn but keep the patient warm
- Assess Burn Total Burn Surface Area (TBSA)
- Assess Burn Depth
- Determine any Inhalation Injury
- Presence or absence of vascular compromise from
circumferential burns that may require urgent escharotomy or
even fasciotomy
Management principles for major burns
- Stop the burning process
- Airway management
- Circulatory management
- Relieve pain
- Keep the patient warm: high
risk of hypothermia - Assess area and depth of
burns - Instigate Fluid resuscitation
- Assess extremities and chest –
undertake escharotomies and/or
fasciotomies if needed - Tetanus prophylaxis
- Lines: peripheral, central, arterial,
catheter and NG tube (ICU) - Apply appropriate dressings
- Early excision and skin grafting
- Future reconstructive surgery
e.g.scar contracture releas
How do you decide where to treat a burn pt
In general terms
* Over 10% TBSA burns require
resuscitation - burn facilities
* Up to 40% TBSA burns cared
for in burn units
* Up to 100% TBSA burns cared
for in burn centres (such as
Whiston (adults) and Alderhey
(children)
How do you calculate the prognosis from a burn injury?
Age + TBSA >100 = poor
prognosis especially in presence
of inhalation injury
What is a Escharotomy
An escharotomy is a surgical procedure performed to allow greater circulation to that part of the body.
When is an urgent surgical
escharotomy needed
Circumferential burn of the limbs / chest or occasionally neck
What monitioring is necessary for pt who had escharotomy?
Remove rings, watches
Elevation of limb
Hourly monitoring:
- Skin colour
- Temperature
- Sensation
- Pain
- Capillary refill
- Peripheral pulses
How is fluid resuscitation calculated in a burn injury?
*Based on TBSA and weight of the patient
What are some resuscitation formula
- Resuscitation Formula including
- Parkland (Crystalloid) - MC
- Muir & Barclay (Colloid)
- Hybrid
Mersey Burns App for fluid volume calculations
Aim for Urine Ouput for burns patient
- Urine output is to be 0.5ml -1ml/kg/hr
- Children 1 -2 ml/kg/hr
Explain the wound management for burn pt
- Dressing care and dressing changes with antimicrobial agents (but not
systemic prophylactic antibiotics) is the key to good burn care,
supplemented by surgery for debridement, skin grafting and
reconstruction as required. - Systemic antibiotics are often required and based on the clinical
picture, swab results and blood culture - Staphylococcal and streptococcal colonisation are typical organisms
that are cultured up to and beyond day 5. - Pseudomonas infection is common after day 5, and has potential for
relatively early multi-resistance
What are some non burn skin loss conditions
Necrotosing Fasciitis
Steven Johnson Syndrome / Toxic Epidermal Necrolysis
(TENS)
Other forms of fulminant dermatological conditions
(erythroderma)
Examples of common soft tissue injuries?
- Lacerations (blunt trauma) and incised wounds (e.g. knife)
- Tendon injuries
- Nerve injuries
- Arteries and veins
- Amputations and nailbed injuries
- Special injuries and bites:
Important points in Lacerations?
Debridement and cleaning is key; wound closure is the second priority
Direct closure is typically possible, after that use the reconstructive ladder
Principles
Important point on tendon injuries?
Debridement and cleaning is key; tendon repair is the second priority
Extensor tendon repair is generally less complex; flexor tendon repair is more complex and these tendons
transmit tremendous forces. Principles of repair are suture-based tendon repairs, postoperative splintage, and
expert hand therapy
Important points on nerve injuries?
Neurotmesis is nerve transection, axonotmesis is partial nerve division, neuropraxia is bruising of a nerve
Divided nerves are typically repaired with microsurgery; most commonly injured nerves in the upper limb are
digital nerves to one or more fingers, median nerve and ulnar nerve.
Important points on arteries and veins injury
Injuries to blood vessels require surgery either to stop bleeding or to restore
Circulation and hence viability of a digit or limb. Vascular compromise in a digit or limb is a surgical emergency
requiring microsurgical repair
Important points on Amputations and nailbed injuries
Amputated limbs or digits are often salvageable. A single or multiple digits are the commonest amputations
and treatment requires either (a)microsurgical replantation or (b)revision amputation (informally called
terminalisation)
Replantation relies on a viable amputated part that has been stored and transported correctly (not in water or
direct contact with ice, but wrapped separately and then cooled in a container containing ice).
Nailbed injuries are most commonly crush injuries to the finger tips requiring cleaning and nail bed repair using
microsurgery, and only very occasionally wire fixation
Important points on Special injuries and bites:
Animal and human bites and other infected/dirty wounds need initial debridement, sometimes on more than one
occasion, antibiotics and definitive closure as necessary
What is Necrotising Faciitis
a rare bacterial infection that spreads quickly in the body and can cause death.
Severe, rapidly-progressive and life-threatening
soft tissue infection
What is the cause of Necrotising Fasciitis
group A streptococci +
anaerobes
Which condition has a higher incidence of Necrotising Fasciitis?
Diabeties
What is the Type of NF called where you get NF in genitalia
‘Fournier’s gangrene’
What does immediate management look like for NF patient?
Emergency debridement in
operating theatre needed –
minutes count
WHat is the classification used for compound fractures
Guistilo and Anderson classification
What is the UK Lower limb trauma guidelines (compound fractures)
Needs specialist centre - MDT ‘Orthoplastic’ approach
*Prophylactic IV Antibiotics
* Neurovascular status assessed and documented
*Exclude compartment syndrome and undertake fasciotomy if
required
*Early and thorough initial debridement with initial fracture
stabilization e.g. via external fixator
* Definitive soft tissue cover within 72 hours
What is the Signs of Compartment Syndrome
*Pain seemingly out of proportion to injury – exacerbated on
extension
*Pallor
*Paresthesia
*Pulselessness
Management for compartment syndrome?
Urgent Fasciotomy is limb-saving
What type of hand injuries doe plastic surgeons treat?
- Open fractures
- Tendons and ligament injuries
- Nerve injuries
*Arteries and veins
*Soft tissues
*Amputations
*Special injuries: bites, crush injuries and nailbed repairs, burns
What do cover in a hand injury hx
- Time of injury
- Place of injury
- Mechanism of injury
- Age
- Hand dominance
*Occupation - Previous injury
- Previous surgery
How do you examine a pt with hand injury?
- Look
- Feel
- Move
*Assess neurovascular function
*Assess motor e.g. grip strength, pinch grip, tendon continuity
*Special tests (e.g. Capillary refill, Tinel’s sign, Froment’s sign)
What is the Principles of hand fracture management
Imaging - X-ray
Debridement and washout of open fractures; antibiotics
Splintage or surgical fixation
Hand therapy
What is the reconstructive ladder?
The reconstructive ladder is the spectrum of closure options available for wounds, and in the mind of the reconstructive surgeon, closure should be achieved by the simplest effective technique.
Explain some reconstructive options?
Free flap
Pedicled flap
Random pattern flap
Tissue expansion
Full Thickness graft
Split thickness graft
Delayed Closure
Primary Closure
Dressings
What is primary closure
closing a wound with suture material primarily
What is delayed closure
allow a wound a reopen for a specific time before closing it again usuallty with suture materials
Skin grafts are classified according to its tissue origin. Explain these terms
Autograft -
Allograft -
Xenograft -
Autograft - coming from the patient themselves
Allograft - comes from the same species as the patient
Xenograft - Tissue from different species
What is a flap?
a unit of tissue which maintains its own blood vessels whilst being transderred from a donor site to a recipient site
WHat are the 3 broad types of flaps
random pattern, pedicled, free
What is the classification for flaps
Circulation - blood supply
Contiguity - donor site
Composition - type of tissue
What is STSG
Split thickness skin grafts
How is STSG classed
- Thin STSG: 0.008-0.012 inches mostly epithelium, thin reticular (elastin)
- Medium STSG: 0.012-0.018 in most commonly used
- Thick STSG: 0.018-0.030 in. almost like full thickness, used in certain application like face, flexion surfaces where contraction is minimal
Full thickness STSG would include which layers of the skin
Epidermis, Dermis and Hypodermis
What are the donor sites for FTSG
For Nose: preauricular, forehead
Cheek: Neck and supraclavicular
Hand: Groin
Usually flexion creases, areas of excess.
Look for color match and texture match
(pores, hair etc)
Explain the donor site healing
Basal cell layers in epidermal appendages dedifferentiate into basaloid morphology
Migrate into defect by diapedesis until “contact
inhibition”
Contact signal beginning re-differentiation into
Stratified Corneal Epithelium layers.
Site healing
What happens in the first 24-48hours
plasmatic imbibition
Nutrients and oxygen infiltrate through
capillaries <1mm away (thus the limitation on
thickness)
Fibrin bridges created: IMPORTANCE OF
COMPRESSIVE DRESSING
Site healing
What happens in the between 36- 48hours
Inosculation
Capillary buds sprout through the skin graft
and connect to pre-existing vascular channels
and create new one
Collagen bridges created
Contraindications for skin graft
Relative: flexion areas, constant shear and
friction
Non vascularized bed (bare bone), cancer, infection
Complications of the skin graft
Failure, or non-take
Hyperpigmentation (Thin STSG),
Hypopigmentation (Thick STSG)
Contraction
Meshed appearance
Dryness, scaling etc
What is the most common type of graft?
Meshed grafts
