Burns, forst bite, corrosion
1st Department of Surgery
University hospital of St. Anne
Brno

Thermal injuries
●Effect of heat
●Electricity, Radiation, Chemistry
●
●
●Time of exposure
●Type of energy

Mechanism of effect
●Dehydratation
●Formation of free radicals
●Denaturation of proteins (60 C´)
●Destruction of DNA mollecule
●Cellular membrane destruction
●Cellular death - apoptosis

Epidemiology and etiology
●1% of population per year
●97% ambulatory, 3% hospitalization
●
●40% children
●Hot fluids 60%
●Open flame 25%
●Electricity 3,5%
●Chemical burns 4%
●Radiation 1%

Types of burns
●Thermal injuries
●
●Electricity burns
●
●Chemical burns -corrosions
●
●Radiation burns

Types of burns –by depth of injury
●Grade I
●Grade II – Grade IIA
●              -  Grade IIB
●Grade III
●Grade 4

Grade I -  combustio erythematosa
●Injury to the epidermis, dermis intact
●Erythrema
●Pain (48hours)
●No scarrification
●Time of healing 3-6 days




Grade II -  combusti bullosa /vesiculosa/
●Grade II A
●Red undersurface of blister
●Capillary refill intact
●Healing time 7-14 days
●No scar /hyperpigmantation
●Grade II
●Purple/white undersurface of blister
●No capillary refill
●Healing time 21 days
●Scar
●
●




Grade III -  combustio escharotica
●Damage to all layers of skin
●Pale, vax-like skin
●Necrosis
●No pain – destruction of nerves
●Scar
●

Grade IV -  carbonation
●Destruction of deep underlying tissues /fascias, muscles, bones/





Jackson´s burn model
●1. central zone of coagulation (irreversibile)
●2. zone of stasis (partialy reversibile)
●3. marginal zone of hyperaemia (reversible)

Area of burns
●Estimation of burned area is vital for adequate treatment
●"Rule of hand (1%)"
●"Rule of 9"

Inhalation thermal trauma
●Airways damage
●Swelling/necrosis
●Airways obstruction!
●CO exposure!
●ARDS
●Rapid therapy!!!
●
●Secure airways early

How do I identify inhalation injury?






Barrier function of skin
●Altered in Grade IIB and higher
●Tissue necrosis
●Swelling, hypoxia
●Bacterial contamination and infection
●Typically Pseudomonas aeruginosa
●
●Sterile dressing, TAT, ev. ATB

Local damage
●LIRS... SIRS
●IL1,2, 6, 12, TNF alpha, Beta
●Histamine
●K+, myoglobin
●Pain
●Swelling
●Ischaemia
●Necrosis
●infection

General answer
●SIRS
●Period of shock (24-14 days)
●
●Acute period of burn dissease
●
●Period of reconstruction
●Loss of plasma, hemoconcentration
●Hypovolemia, AKI
●
●Toxines resorbtion
●Hypoproteinemia
●Infection, Curling gastric ulcer, liver dysfunction etc.
●




Treatment
●II. less than 10%
●III. Less than 2%
●II. 10-24%
●III. 2-10%
●II: over 25%
●III. Over 10%
●Special cases
●Burn unit
●Hospitalization
●traumacentre
●Ambulatory treatment

Special cases
●Head and face
●Perineum + genital
●Hands
●Circular burns of chest, neck
●Inhalation thermal injury
●Children under 2yo, II. Type over 5%
●Geriatric patients
●electricity

Treatment - goals
●Reduce local damage
●Prevent/treat general answer
●Prevent complications
●Reconstruct
●
●Proper treatment in proper time
●Technical help
●Pre-hospital help
●Acute care
●- symptomatic
●- supportive
●- surgical
●Reconstruction and rehabilitation

Symptomatic
●Stop burning process
●Analgesia
●Local hypothermia
●/cooling/
●Sterile dressing
●Prevention of hypothermy

Supportive
●Fluid resuscitation
●Oxygenotherapy
●TAT
●ATB?
●Urinary output
●A,B,C,D

Fluid resuscitation
●Min. 2 i.v. Lines
●ASAP
●Infants over 5%
●Children over 10%
●Adults over 15%
●Crystaloids, coloids? aminoacids
●Urinary output!!!
●Parkland formula
●RL 4ml x kg x %
●Brook formula 1:3
●(crystaloids:coloids)
●0,5/1,5 ml x % x ...kg
●Evans formula 1:1

Surgical
●Urgent care:
●Escharotomy
●Fasciotomy
●On-demand/ planed:
●Necrectomy
●Wound treatment







Necrectomy
●Surgical
●fascial vs. tangential
●Chemical
●40% benzoic acid
●40% salicyle acid
●Enzymatical -  less
●colagenase
●protease




Reparation, reconstructive surgery
●Plastic surgeons
●Dermo-epidermal graft
●Skin transplant
●Musculofascial flaps
●...
●Autotransplant
●Allotransplants
●Xenotransplants
●Synthetic materials
●(bovinne collagene, Synkrit...)







Frostbites - congelationes
●Effect of low temperrature
●Not neccesary below 0 C´
●Wind, wet
●Exposed skin
●Peripheral areas /acra/
●General state of patient

Types
●Frostnip
●Frostbite  - 1st Degree
                   - 2nd Degree
                   - 3rd Degree
                   - 4th Degree
●Non- freezing injury (Trench foot)
●Hypothermia
●

Frostnip
-mildest form of cold injury
-Initial pain, pallor, numbness
-reversibile, no tissue loss
-Th: rewarming

●Frostbite
●1st Degree:  hyperemia, swelling, no skin necrosis
●2nd Degree: clear blister formations, hyperemia, edema, partial-thickness skin necrosis
●3rd Degree: full-thickness and subcutaneous tissue necrosis, hemorrhage vesicle formation
●4th Degree: full-thickness skin necrosis + muscles, bones, gangrene
●




Trenchfoot
●endothelial damage, stasis, vascular occlusion
●Long-term exposure to wet conditions, temperatures just above freezing point
●Soldiers, sailors, fishermen…

●Trenchfoot
●Cold and numb tissue /24hours/ - due to arterial vasospasm
●progressing to hyperemia, pain, hysestesia
●Edema, blisters, redness, ulcerations
●Local infection, cellulitis, gangrena
●

Local and general answer
●Vasospasm
●Ischemia
●Swelling
●Necrosis
●Secondary complications
●Infections
●Sepsis
●Hypothermia  - less than 36 C´
●Mild  - 32-35C´
●Moderate – 30-32 C´
●Severe- less than 30C´
●Neurological problems
●Arytmia
●Cardiac arrest

Treatment
●Exposure!
●Re-warm
●Local/circulating water 40C´/
   (no dry heat, no rubbing!!!, pain management)
●Systematic – hot drinks, i.v. fluids
●Wound care
●Goal – prevent infection, preserve damaged tissue
●elevation, avoid opening clear blisters, imobilisation, TAT, ATB?
●

Corrosion -  chemical burns
●Exposure to acids, alkalies, petroleum products
●Acids -  coagulation
●Alkalies – colliquation (deeper penetration )
●Injury influenced by:
- Type, amount, concentration, time of exposure
●Treatment: rapid removal, neutralization(?), irriigation, sterile dressing, TAT, ATB?




Internal use of chemicals
●Accidental, suicidal
●Alkalies, acids /
●Hyperemia, flegmona, necrosis, ulcers, perforation… chroniicity - stenosis
●Dyspnoe, odynophagia, hoarseness, pain, laryngeal spasm, metabolic disorder
●GFS? PPI, NGT, irrigation, ATB, PEN
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●




Thank you