burn

• Causes of burn;• 1) thermal burn ; like flame and hot fluids• 2)electrical burn ; high or low voltage• 3) chemical burn ;acid or alkalie • 4) radiation burn ; appear after an incubation

period

• The shorter the wavelength the longer the incubation period e.g sunburn appear after one to two days while X –ray burn appear after few weeks

• Pathology • 1) local lesion • 2) constitutional response

• A) Local lesion; • 1) zone of irreversible heat coagulation ;• Its extend into skin and deep tissues depend

on duration of contact with heat• If it is deep and wide , it will lead to

destruction of RBCs and heat haemolysis

• 2) zone of reversible enzymatic changes ;• It is variable area surrounding the first zone in

which capillary permeability occurs by enzymatic change

• It results in escape of water and electrolytes and colloids into tissues

• It starts immediately after burn , reaches its maximum after 8 to 12 hours and decline till the end of 24 hours

• B)Constitutional effects ;1)Neurogenig shock

2)Oligemic shock

3)Liberation of ADH

4)Liberation of ACTH and adrenal corticoids

5) Acute tubular necrosis

Clinical assessment of burns

• 1) Assessment of depth • 2) Assessment of extent

Assessment of depth

• Significance of depth• It gives prognosis of local part and its

functions• It gives the degree of RBCs loss and heat

haemolysis• It affects prognosis of survival in extensive

burn

Classification according to depth

• 1) superficial burn ;• There is heat coagulation of epidermis only• Healing occur from survival deep layers within

2 weeks without scarring • At first there is erythema followed in few

hours by the development of superficial vesicles or bulla filled by serum

• 2)Deep burn ;• There are heat coagulation of all layers of the

skin .the destroyed skin separate as slough after about 3 weeks

• Healing will occur from periphery and there will be much scarring leading to contracture

• The skin is usually cyanotic red or dead white or greyish and is insensitive to touch

• After few days it become yellowish and central parts become dry and shrivel forming dark brown leathery slough .

• Deep to the slough and at its margin , a plane of separation appear during the third week

• Later the slough separate leaving an area of red granulation

• 3)Dermal burn ;• There is destruction of epidermis and superficial

part of dermis • Healing occur from the deeper layer dermis in 2

to 6 weeks with some residual scarring and disability

• It appear cyanotic or white skin identical to deep burn , then after 5 days thin slough separate and a characteristic stippled appearance

Assessment of extent

• Wallace Rule of nines ;• Head & neck 9%• Each upper limb 9%• Front of trunk 18%• Back of trunk 18%• Each lower limb 18%• Perineum 1%

Complications of burn

• 1) Neurogenic shock ; occur immediately after burn

• 2) Oligamic shock • 3) Infection ;the commonest organisms are

staphylococcus aureus and pseudomonas pyocyaneus

• 4) Toxemia ;more common after deep burn • 5)Suffocation

• 6)Contraction and disfigurement and keloid formation

• 7) Corneal ulceration and panophthalmitis• 8) Gangrene ; occur in circumferential burn • 9) Acute renal failure

Treatment

• 1) First aid treatment • 2) initial treatment during the first 48 hours• 3) treatment after the first 2 days

First aid treatment

• Extinguish the flames • In scalds rapidly cut off clothes• Wash the part affected by under running cold

water• Cover the burnt area with sterile guaze • Morphia to relieve pain• Transport to specialized center

Initial treatment during first 48 hours

• A) General treatment • Sedation • Antibiotic • I/V fluid therapy• -Parkland’s formula • % of burn x weight of Pt x 4 ml of Ringer

lactate

• Half amount of fluid given in the first 8 hours• Other half of amount of fluid given in the next

16 hours

• B) Local treatment • It is done only after the shock is controlled • 1) sterile toilet with normal saline or with

bland detergent like cetrimide-chlorhexidine solution

• In extensive burn anaesthesia may be necessary

• Dressing ; two methods• A) closed method ; • Put layer of flamazine (silver sulphadiazine )

then put tulle-gras then put hydrophilic cotton wall then put crepe bandage

• B) open method ;• The burn area is exposed and covered by thin

layer of antibiotic treatment

• Open method is suitable for face , head ,neck• Buttock in children , single surface of trunk

Treatment after 48 hours

• High protein diet • High calories diet • If HB is low , we can give blood transfusion• Continue antibiotic • Dressing are not touched unless there are

fever or soaked

• Superficial burn will heal completely with 2 to 3 weeks

• In deep burn . After 2 to 3 weeks ,we excise the slough and the raw area is prepared to be covered with split or full thickness skin graft

Skin cover

A) permanent skin cover; 1) Free grafts• 2) Pedicle Flaps• 3)Free flaps • B) Temporary skin cover ;• 1) cadaver allograft • 2)Biobrane • 3)TransCyte

Free Grafts

• 1) Thin skin graft (Thiersch)• 2) Intermediate spit skin graft• 3) thick skin graft ( Wolf)• 4)Postage stamp

Thin skin graft

• It consists of superficial part of epidermis , this graft always takes because exudate is sufficient to maintain its nutrition until circulation invade it

• Disadvantages • 1) pigmentation • 2) contraction • 3)it does not bear pressure well

Intermediate split thickness skin graft

• It consists of epidermis and part of dermis • The success of taking the graft is less than

Thiersch graft• Less pigmentation ,less contracture ,less scaring • It is the most commonly used method in

grafting• It is taken by Humby skin graft knife or

electrical dermatome

Thick graft (Wolf)

• It consists of whole skin devoid of fat • It need optimum condition to be taken• Asepsis must be perfect• It is only used to cover small area which are

surgically clean• It does not become pigmented ,it does not

followed by contracture

Postage stamp graft

• A thin or split thickness skin graft is taken from donor site , then it divided into small squares and used to cover large granulation surface area

Pedicle flap

• The flap consists of skin and subcutaneous tissue

• It is mainly used for correction of contracture or in closure of defect or the formation of new cheek or nose

• It has an advantage over skin graft of maintain circulation through the pedicle, ensuring adequate nutrition until new circulation is developed

• Types ;• 1)one pedicle flap ;• sliding flap• swinging flap• distant flap• 2) Double pedicle flap ; used in repair wound of hand

by using this flap from abdomen • 3) Tubed pedicle flap ; used for distant transplantation

ex ; acromiopectoral flap for formation of cheek

Free flap

• A piece of skin and subcutaneous tissue with its related artery and vein are transplanted from one area to another area , using microvascular technique

Treatment of special types of burn

• 1) Burn of hand and foot ;• They can be placed in in plastic bags containing

antiseptic solution , this will exclude bacteria and allow free movement and maintain function

• 2) pulmonary burn ; there are liability of oedema of glottis and bronchial spasm

• Pt need humidified oxygen ,bronchodilator drugs• If not enough nasotracheal intubation or

tracheostomy

• 3)circumferential burn ;• In the limbs lead to ischemia and gangrene• In the neck and thorax may embarrass

respiration • Pt need escharotomy• If Pt develop compartment syndrom in limbs

Pt need fasciotomy

• 4) Electrical burn ;• It is localized and deep • It had entry and exit points It can lead to

arrythmia of heart

Wounds

• Types of wounds ;• 1) incised wound ;result from knife or sharp

objects• 2) lacerated wound; result from blunt objects

the edges and surface will contain devitalised tissues

• 3) crushed wound ; include all war wounds and RTA and industrial accident

• 4) wounds with skin loss

• Complications of wounds ;• 1)associated injuries ; artery ,nerve ,tendon ,

bone , viscera • 2)infections ; pyogenic ,tetanus, gas gangrene

Treatment

• 1) incised wounds ;• Primary suture if seen in the first 6 hours • Nerve and tendons repaired are also sutured • Blood vessel are repaired if big or ligated if

small • 2)lacerated wounds ; • a) early case (seen with in 6 hours )• wound excision and primary suture

• b) neglected case ;• if seen after 6 hours , the wound is excised and if after

4 to 6 days the wound is clean , then delayed primary closure is done

• 3) Crushed wounds ; • Treated by wound excision only• After 4 to 6 days if wound is clean then delayed primary

suture• If the wound become infected ,then we treat the wound

from infection till it become clean then secondary suture

• 4)wounds with primary skin loss;• a ) if incised ; primary skin grafting• b) if lacerated ; wound excision and primary

skin grafting • c) if crushed ; wound excision and delayed

primary or secondary grafting

Skin and subcutaneous lesions

• Sebaceous cyst ;• It is a retention cyst due to obstruction of the opening

of a sebaceous gland by debris or fibrosis or inflammation

• Occur anywhere in the body but commonest to occur in face , scalp , scrotum

• Never occur in palm or sole• Usually solitary but may multiple in scrotum and scalp• It grows very slowly • It has punctum

• Complications of sebaceous cyst ;• 1)secondary infection• 2)pressure necrosis of overlying skin of scalp

causes fungation ( Cock ΄s peculiar tumor )• 3)baldness• 4)sebaceous horn• 5)sebaceous carcinoma• Treatment is surgical excision

Lipoma

• It is benign tumor arising from adult fat cell• May be single or multiple (Dircum΄s disease)• It is encapsulated • It has 2 capsules , a false capsule from the body and

true capsule which is part of tumor• It is tumor of adult life , rarely seen in children• Sites ; subcutaneous is the commonest site of

tumor ,subaponeurotic ,submucous ,subperiosteal, subserous ,intermuscular ,extradural , retroperitoneal which is a common to be liposarcoma

• Complications ;infection ,ulceration , calcification , compression of surrounding structures

• Treatment is enucleation between true and false capsules

Dermoid cyst

• It is formed due to persistence & and growth of epithelial cells under the skin

• Types ;• 1)Sequestration dermoid • 2)Implantation demoid• 3)Tubulodermoid • 4)Teratomatous dermoid • Treatment is excision

Squamous cell carcinoma

• Occurs in the skin or any area covered by squamous epithelium like mouth , tongue ,oesophagues , etc

• In the skin it is commonest at junction of mucocutaneous junction

• In the face the commonest site is the junction of the outer and middle thirds of lower lip

• More common in male than female • More common in fair skin& blond people

• Naked eye appearance ;• Nodule • Ulcer with everted margina• Cauliflower mass• Diffuse infiltrating type • Fissure

• Sq. cell .ca spread mainly by lymphatic or by direct spread

• Treatment by • 1) irradiation • 2) surgical excision

Basal cell carcinoma ( rodent ulcer)

• It arise from basal cells of skin or hair follicle cells • Growth is very slow • Naked eye appearance ;• nodular• ulcer• cystic• pigmented • fire -field

• More common in male• The edge of the ulcer is rolled in edge • Regional lymph node are never affected by

secondaries but when they are enlarged , this is either infection ( firm ,tender nodes) or epitheliomatous changes occurred ( hard nodes)

• Treatment ;• 1) irradiation • 2 ) surgical excision

Melanoma

• It is pigmented tumor arise from melanocytes• It may benign or malignant• 1)Benign (Mole or Nevus )• it is painless localized pigmented area that

may be flat or raised , may be present since birth or appear later , may be hairy or hairless , occurs in skin & nail bed & uveal tract & genitilia

• 2)Malignant melanoma• May occur spontaneously or on top of benign

mole , in the later case malignancy is suspected by rapid growth & pain & increase vascularity & increase pigmentation or depigmentation

• Spontaneous malignant melanoma is common in palm ,sole , nail bed , uveal tract of eye , axilla , genital area

• Highly malignant tumor that spread by lymphatic or by blood to liver or brain

• C/P• rapidly growing black swelling which is

painful ,ulcerated , itchy , bleeding is common • Treatment ;• excision with wide safety margin of skin and

uderlying fascia • amputation if arise from nail bed