Page 1144 - TNFlipTest

PL22 Plastic Surgery
Burns Toronto Notes 2019
• earlyexcisionandgraftingisthemainstayoftreatmentfordeep/fullthicknessburns
• initialdressingshoulddecreasebacterialproliferation
• preventionofwoundcontractures:pressuredressings,jointsplints,earlyphysiotherapy
Other Considerations in Burn Management
Vascular Permeability and Edema Immunosuppression
Renal Failure (2o to􏰁Renal Blood Flow)
Figure 22. Systemic effects of severe burns
SEVERE BURN
Altered Hemodynamics (􏰁CO,􏰀SVR) Hypermetabolism
Progressive Pulmonary Insufficiency
Increased Gut Mucosal Permeability (GI Bleed Risk)
• nutrition
■ hypermetabolism: TBSA >40% have BMR 2-2.5x predicted
■ consider nutritional supplementation e.g. calories, vitamin C, vitamin A, Ca2+, Zn2+, Fe2+
• immunosuppressionandsepsis
■ must keep bacterial count <105 bacteria/g of tissue (blood culture may not be positive)
■ signs of sepsis: sudden onset of hyper/hypothermia, unexpected CHF or pulmonary edema,
development of ARDS, ileus >48 h post-burn, mental status changes, azotemia, thrombocytopenia,
hypofibrinogenemia, hyper/hypoglycemia (especially if burn >40% TBSA)
• GIbleedmayoccurwithburns>40%TBSA(usuallysubclinical)
■ treatment: tube feeding or NPO if there is a GI bleed, antacids, H2 blockers (preventative)
• renalfailuresecondarytounderresuscitation,drugs,myoglobin,etc.
• progressivepulmonaryinsufficiency
■ can occur after: smoke inhalation, pneumonia, cardiac decompensation, sepsis
• woundcontractureandhypertrophicscarring(outcomesoptimizedwithtimelywoundclosure,
splinting, pressure garments) and physiotherapy
Special Considerations
CHEMICAL
• majorcategories:acidburns,alkalineburns,phosphorousburns,chemicalinjectioninjuries • commonagents:cement,hydrofluoricacid,phenol,tar
• mechanismofinjury:chemicalsolutionscoagulatetissueproteinleadingtonecrosis
■ acids → coagulation necrosis
■ alkalines → saponification followed by liquefactive necrosis
• severityrelatedto:typeofchemical(alkaliworsethanacid),temperature,volume,concentration,
contact time, site affected, mechanism of chemical action, degree of tissue penetration • burnsaredeeperthantheyinitiallyappearandmayprogresswithtime
Treatment (General)
• ABCs, monitoring
• removecontaminatedclothingandbrushoffanydrypowdersbeforeirrigation
• irrigationwithwaterfor1-2hunderlowpressure(contraindicatedinheavymetalburns,suchas
sodium, potassium, magnesium, and lithium; in these cases, soak in mineral oil instead) • inspecteyes,ifaffected:washwithsalineandrefertoophthalmology
• inspectnails,hair,andwebspaces
• correctmetabolicabnormalitiesandtetanusprophylaxisifnecessary
• contactpoisoncontrollineifnecessary
• localwoundcare12hafterinitialdilution(debridement)
• woundclosuresameasforthermalburn
• bewareofunderestimatedfluidresuscitation,renal,liver,andpulmonarydamage
Table 20. Special Burns and Treatments
Acid Burn Hydrofluoric Acid
Sulfuric Acid Tar
Water irrigation, followed by dilute solution of sodium bicarbonate
Water irrigation; clip fingernails to avoid acid trapping; topical calcium gel ± subcutaneous injection of calcium gluconate ± 10% calcium gluconate IV depending on amount of exposure and pain
Treat with soap/lime prior to irrigation, as direct water exposure produces extreme heat Remove with repeated application of petroleum-based antibiotic ointments (e.g. Polysporin®)