Burns and Rehabilitation

1. Burns and Rehabilitation Detroit Receiving Hospital

2. Burn Incidence • The Numbers • How often? • How many injuries? • How many hospitalizations? • How many “major” injuries? • How many deaths?

3. Gender* • *Total N=126,642

4. Race/Ethnicity* *Total N = 126,642

5. Age Group* • *Total N=107,685 (Excludes Unknown/Missing)

6. Etiology* • *Total N=76,659 (Cases Where Etiology Was Included)

7. Place of Occurrence

8. Circumstances of Injury* *Total N=72,324 (Excludes Unknown/Missing)

9. Hospital Disposition* • *Total N=126,645

10. Conservation of body fluids Temperature regulation Excretion of sweat and electrolytes Secretion of oils that lubricate the skin Vitamin D synthesis Sensation Cosmetic appearance and sexual identity Burn injuries cause loss to some or all of these functions What are the functions of skin?

11. Types of Burn Injury • Thermal burns • Chemical burns • Electrical burns • Radiation burns

12. Thermal Burns • Two factors are related to the extent of thermal injury: • 1) Degree of temperature • 2) Length of exposure

14. Scald Burns • Common particularly in children • Accidental versus Abuse

15. Chemical Burns • Caused by exposure of the skin to noxious substances • Amount of tissue damage is dependent upon: • 1) Concentration of the agent • 2) Length of exposure • 3) Mechanism of chemical reaction

16. Chemical Burns • Caused by acids and alkalis • Chemical agents continue to cause injury until inactivated • 1) Inactivated by local tissue reaction • 2) Neutralized by external agent • 3) Diluted by water

17. Electrical Burns • Thermal injury incurred via electrical contact depends on: • 1) Type of current-AC more damaging • 2) Pathway of current • 3) Local tissue resistance • 4) Duration of contact

18. Electrical Burns • Death rate and voltage are variable • Electrical current follows a path of least resistance

19. Electrical Burns • Severity of injury can be deceptive • Complications often occur: • 1) Tetanic muscle contractions • 2) Fractures/ dislocations from falling • 3) Cardiac dysfunction • 4) Internal organ injuries

20. Radiation Burns • Occurs as a result of a local accident • Laboratory • Exposure to therapeutic radiation (cancer)

21. Dimensions of Burn Injury • Zone of coagulation (necrosis) • Zone of stasis • Zone of hyperemia

23. Degrees of Burn Injury • First Degree • Second Degree (Superficial and Deep Partial Thickness) • Third Degree (Full Thickness) • Fourth Degree (Subdermal)

24. First Degree Burns • Cell damage • Epidermis only • Perfect example: Classic sunburn • Red in color • Skin is dry • Delayed onset to pain • Desquamation=peeling • Heals spontaneously

26. Superficial Second Degree Burns • Cell damage • through epidermis and upper dermis • Epidermis completely destroyed • Mild-moderate damage to the dermis • Blisters are common sign=superficial 2nd degree

27. Superficial Second Degree Burns • Blisters removed for applying antibiotics • Bright red in color • Blanching occurs • Edema is usually minimal

28. Superficial Second Degree Burns • Extremely painful • Highly sensitive • Heals spontaneously • Color change from destruction of melanocytes • Scarring is minimal

30. Deep Second Degree Burns • Cell damage • Through epidermis • Deep layers of dermis • Mixed red or waxy white color • Surface is usually wet=interstial fluid • Edema is moderate

31. Deep Second Degree Burns • Painful • Sensation • Intact to pressure • Diminished to light touch • Healing occurs with scar formation and reepithelialization • Epidermal cells (follicular) assist with reepithelialization

32. Deep Second Degree Burns • Surgery or no surgery? • Spontaneous healing often results in: • 1) Thin epithelium • 2) Dry, scaly skin • 3) Decreased sensation • 4) Lack of thermoregulation

33. Deep Second Degree Burns • Healing in 3 to 5 weeks (if NO infection) • Wound care is critical to avoid conversion (getting worse to 3rd) • Hypertrophic scarring (raised scar, confined to area of wound) is common • Will still have hair follicles.

35. Third Degree Burns • Cell damage • Complete through epidermis • Complete through dermis • Characterized by eschar • Hair follicles completely destroyed • Nerve endings are destroyed- What is the result of this?

36. Third Degree Burns • Pain from surrounding areas that are only partial thickness burns • Characterized with complete vascular occlusion and edema • Occlusion of blood flow of even deep vascular branches • Distal pulses must be monitored, because edema can occuled.

37. Third Degree Burns • Highly susceptible to infection • Wound care is extremely important • No sites for new skin growth • Skin grafting is required

39. Fourth Degree Burns • Cell damage • Complete destruction tissues from epidermis to subcutaneous layers • Muscle and bone may be damaged • Occurrence • Prolonged contact with flames or hot liquids • Result of contact with electricity • Extensive surgical management=amputation

40. Extent of Burn Injury • Rule of Nines developed by Pulaski and Tennison • Segments are approximately 9 percent of total body surface area (TBSA) • Rapid assessment of TBSA injured

41. Extent of Burn Injury • Altered the percentages of body surface for children • Accommodates for growth body segments with age • Permits for higher accuracy • Feasibility in emergent care?

42. Wound Debridement • Purpose: • Remove dead tissues • Prevent infection • Promote revascularization/ epithelialization • Mechanical • Whirlpool (non-selective) • Sharp (selective) • Enzymatic • Santyl

43. Burn Wound Dressing Purpose: Comfort Maintain a moist, healing environment Protective barrier towards micro-organisims Debridement of eschar/necrotic tissue.

44. Burn Wound Dressing • Topicals: • Bacitracin (triple antibiotic) • Silvadene (inappropriate to be applied, outdated) • Gauze/Film • Xeroform • Aquacel Ag (gel Matrix)=great stuff, comes in rolls, has petroleum so wont stick • Acticoat Ag • Foam: • Aquacel foam • Mepilex=for ulcers/wounds

45. Burn Wound Dressings • Superficial burns • Use an occlusive dressing • Xeroform gauze=mosit, does not stick. • Dressing to cover • No need for antibacterial agent • Silvadene only used for minor burns

46. Burn Wound Dressings • Mild to Deep Dermal Burns • Most common treatment: • Use a topical antibacterial cream such as a triple antibiotic (Bacitracin) or Santyl (use till there less the 50-40% necrotic tissue) • Cover with a dry occlusive dressing once or twice a day (to absorb interstial) • Skin substitutes provide best protection • Ie: Alloderm, Epicel, Integra (~Shark Skin), Oasis (Pig Intestines) • More expensive

47. Burn Wound Dressings • Full Thickness Burn • Topical antibiotic cream for protection • Skin substitutes also used for coverage until surgery • Surgical excision and grafting

49. Surgical Management • Skin Grafting: • Autograft • Allograft (Homograft) • Xenograft (Heterograft) • Cultured epidermal autograft

50. Surgical Management • Skin Grafting • Extent and depth of injuries determine grafting needs • Donor site • Split-thickness skin graft (STSG)-take epidermis and top layer of dermis. • Full-thickness skin graft: