plastic surgery - burns

Question 1

burns classifications

Answer 1

• Thermal
• Chemical
• Electrical
• Radiation
• Cold Injury

Question 2

thermal burns

Answer 2

• Divided into scald, flame, contact and flash

Question 3

scald burns

Answer 3

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

Question 4

flame burns

Answer 4

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

Question 5

flash burns

Answer 5

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

Question 6

contact burns

Answer 6

• thermal burns
• Contact burns are deep but limited to contact area

Question 7

burn effects

Answer 7

• local
• systemic

Question 8

local effect

Answer 8

• 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)

Question 9

Jackson;s burn wound model

Answer 9

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

Question 10

systemic effect

Answer 10

• 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

Question 11

burn evaluation

Answer 11

• 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

Question 12

burn depth classification tool

Answer 12

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

Question 13

1st degree superficial burns characteristics

Answer 13

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

Question 14

2nd degree - partial thickness burns characteristics

Answer 14

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

Question 15

3rd degree - full thickness burns characteristics

Answer 15

• 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

Question 16

4th degree - involves underlying structure burns characteristics

Answer 16

• 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)

Question 17

3 TBSA tools

Answer 17

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

Question 18

Wallace rule of nines

Answer 18

• 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%

Question 19

Lund Browder Chart

Answer 19

includes % for adults as well as children

Question 20

Burn unit admission criteria

Answer 20

• 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

Question 21

fluid replacement

Answer 21

• 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

Question 22

surgical care for burns

Answer 22

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

Question 23

early excision & skin grafting

Answer 23

• 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

Question 24

wound closure

Answer 24

• 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

Question 25

burn reconstruction

Answer 25

* 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

Question 26

Scar assessment tool

Answer 26

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

Question 27

surgical principles

Answer 27

* 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

Question 28

reconstruction ladder principles = will have recurrence of scar

Answer 28

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

Question 29

scar management - scar formation

Answer 29

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

Question 30

scar management - established scar rx

Answer 30

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

Question 31

burn rehabilitation

Answer 31

* 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