PATHOPHYSIOLOGY OF BURNS Dr. Shiara Ortiz-Pujols Burn Fellow NC Jaycee Burn Center.
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Transcript of PATHOPHYSIOLOGY OF BURNS Dr. Shiara Ortiz-Pujols Burn Fellow NC Jaycee Burn Center.
Objectives
PART 1 Anatomy
Overview Causes of Burns Estimating Burns
(Depth & %) Categories &
Zones
PART 2 Physiologic
Implications Pathophysiology Resuscitation Post-Resuscitation Board Questions
Anatomy
Adult skin surface 1.5-2.0 m2 (0.2-0.3 in newborns); largest organ
Skin thickness 1-2 mm; peaks age 30-40; M> F
Functions include: protection from external environment maintenance of fluid/electrolyte homeostasis Thermoregulation immunologic function sensation Metabolic organ (i.e., Vit D synthesis)
Causes of Burns
Usually caused by heat, electricity, chemicals, radiation, and friction
Thermal burns are caused by steam, fire, hot objects or hot liquids. Most common burns for children and the
elderly Electrical burns are the result of direct contact
with electricity or lightning Chemical burns occur when the skin comes in
contact with household or industrial chemicals Radiation burns are caused by over-exposure
to the sun, tanning booths, sun lamps, X-rays or radiation from cancer treatments
Friction burns occur when skin rubs against a hard surface, e.g. carpet, gym floor, concrete or a treadmill
Effect of Heat
Temporal and quantitative 40-44C, enzymes malfunction,
proteins denature and pumps fail
> 44C, damage occurs faster than repair mechanisms can keep up with
Damage continues even when the source is withdrawn
Effect of Electricity
• Effects of current depend on several factors
- Type of circuit- Voltage- Resistance of
body- Amperage- Pathway of
current- Duration of
contact
• High voltage (>1000V) causes underlying tissue damage. Deep tissues act as insulators and continue to be injured.
• Resistance of various tissues from L→H: nerve, vessels, muscle, skin, tendon, fat, boneOhm’s Law- V=IR
• Damage more related to cross-sectional area which explains extremity injuries without trunk injuries.
Electrical Storms/Lightning
Burns are characteristically superficial and present as a spidery or arborescent pattern.
Cardiopulmonary arrest is common following lightning injury.
Coma and neurologic defects are also common but usually clear in a few hours or days.
Watch for tympanic membrane rupture
Usually lethal in 1/3 of patients.
World record for surviving lightning strikes is Roy C. Sullivan who was a park ranger from VA. Roy was struck 7 times from 1942-1977.
Effect of Chemicals
Acids and alkalis cause injury via different mechanisms.
Petroleum products can cause delipidation and depth of wound 2° tendency to adhere to skin
Acids: coagulation necrosis
denaturing proteins upon tissue contact
area of coagulation is formed and limits extension of injury
exception is hydrofluoric acid, which produces a liquefaction necrosis similar to alkalis.
Acid damaged skin can look tanned and smooth; do not mistake for a suntan.
Alkalis: liquefaction necrosis potentially more
dangerous than acid burns liquefy tissue by
denaturation of proteins and saponification of fats
In contrast to acids, whose tissue penetration is limited by the formation of a coagulum, alkalis can continue to penetrate very deeply into tissue
Can cause severe precipitous airway edema or obstruction.
Inhalation Injury
Heat dispersed in upper airways leads to edema
Cooled smoke and toxins carried distally Increased blood flow to bronchial arteries
causes edema Increased lung neutrophils –
mediators of lung damage – release proteases and oxygen free radicals (ROS)
Exudate in upper airways – formation of fibrin casts
Stages of Inhalation Injury
Stage 1 – acute pulmonary insufficiency Signs of pulmonary failure at presentation
Stage 2 – 72-96 hrs after presentation (ARDS picture) extravasation of water Hypoxemia Lobar infiltrates
Stage 3 – bronchopneumonia Early – Staph pneumonia (frequently PCN
resistant) Late - Pseudomonas
Grading of Burn Wounds
Mild: < 5% TBSA Moderate: 5-15% TBSA Severe: > 15% (95% of burns seen) May require Burn Unit care because of
potential for disability despite small TBSA (face, hands, feet, perineum)
Area of Burn – “Rule of 9s”
Note that a patient's palm is approximately 1% TBSA and can be used for estimating patchy areas.
Estimation of Burn Wound Depth Initial assessment is often unreliable Ignore mild erythema when calculating
fluid requirements Pink areas that blanch are usually
superficial Deeper wounds are dark red, mottled or
pale and waxy Insensate areas are usually deep (3rd
degree or greater)
Factors Influencing Wound Depth Temperature and duration Thickness of skin (thin on eyelids, thick on
back) Age (children and elderly have
proportionally thinner skin in comparison to adults)
Vascularity Agent – oil vs water; acidic vs alkalotic Time to definitive care
Burn Zones
Circumferential zones radiating from primarily burned tissues, as follows: 1. Zone of coagulation - A nonviable area of tissue at the
epicenter of the burn
2. Zone of ischemia or stasis - Surrounding tissues (both deep and peripheral) to the coagulated areas, which are not devitalized initially but, 2° microvascular insult, can progress irreversibly to necrosis over several days if not resuscitated properly
3. Zone of hyperemia - Peripheral tissues that undergo vasodilatory changes due to neighboring inflammatory mediator release but are not injured thermally and remain viable
Categories of Burns – First degree
Burns are divided into 4 categories, depending on the depth of the injury, as follows: First-degree burns are limited to the epidermis. A typical sunburn is a first-degree burn. Painful, but self-limiting. First-degree burns do not lead to scarring and require
only local wound care.
Categories of Burns – Second degree
Second-degree burnspoint of injury extends into the dermis,
with some residual dermis remaining viable
Partial thickness or Full thickness those requiring surgery vs those which do
not
Categories of Burns – Third degree
Third-degree or full-thickness burns involve destruction of the entire dermis, leaving only subcutaneous tissue exposed.
Escharatomy Sites
Preferred sites for escharotomy incisions. Dotted lines indicate the escharotomy sites. Bold lines indicate areas where caution is required because vascular structures and nerves may be damaged by escharotomy incisions. (From Davis JH, Drucker WR, Foster RS, et al: Clinical Surgery. St. Louis, CV Mosby, 1987.)
Categories of Burns – 4th degree
- Fourth-degree burn is usually associated with lethal injury.
- Extend beyond the subcutaneous tissue, involving the muscle, fascia, and bone.
- Occasionally termed transmural burns, these injuries often are associated with complete transection of an extremity.
Physiologic Implications of Burn Injury Predictable changes Related to period of injury Can be anticipated
Pathophysiology of Burns
• Cell damage and death causes vasoactive mediator release:
• Histamines• Thromboxanes• Cytokines• Increasing capillary permeability causes edema,
third spacing and dehydration• Possible obstruction to circulation (compartment
syndrome) and/or airway
Resuscitation Period
“early ebb with late flow”; days 0-3 Hypodynamic, with need for close fluid resuscitation monitoring Massive, diffuse capillary leak 2° to inflammatory mediators;
abates 18-24 hrs after injury and volume requirements abruptly decline
leak can be seen in those with delayed resuscitation 2° systemic release of O2 radicals upon reperfusion
Extravascular extravasation of fluid, lytes, colloid molecules Other variables affect resuscitation: preexisting fluid deficits, delay
until treatment, inhalation injury, depth of wound Must reevaluate resuscitation progress and endpoints frequently;
do not just use a formula
Postresuscitation Period
Day 3 until 95% wound closure Hyperdynamic, febrile, protein catabolic state Tachycardia can be normal in burn patients Blood pressure may be hard to obtain due to
circumferential burns Release of more inflammatory mediators, cortisol,
glucagon, catecholamines, bacteria from wound High risk of infection and pain Remove non-viable tissue or close wounds to avoid sepsis Nutritional support essential Maintain and support body temperature with high ambient
temps and humidity
Recovery Period
95% wound closure until 1 year post-injury
Continued catabolism and risk of non-healing wound
Anticipate septic events, treat complications, and continue nutritional support
Pathophysiology of Electrical Burns Small cutaneous lesions may overlie extensive areas of
damaged muscle → myoglobin ARF. Monitor for at least 48 hours after injury for cardiopulmonary arrest May see vertebral compression fractures from tetanic
contractions or other fractures from a fall. Visceral injury is rare but liver necrosis, GI perforation, focal
pancreatic necrosis and gallbladder necrosis have been reported. Look for motor and sensory deficits—motor nerves are affected
more than sensory nerves. Thrombosis of nutrient vessels of the nerve trunks or spinal cord
can cause late onset deficits. Early deficits are direct neuronal injury.
Delayed hemorrhage can occur from affected vessels Cataracts may form up to 3 or more years after electrical injury Microwave radiation damages tissues via a heating effect.
Subcutaneous fatty tissue is often spared given its lower water content.
Burn Edema and Inflammation Generalized edema found in burns >
30% TBSA Heat directly damages vessels and
causes permeability Heat activates complement histamine
release and more permeability thrombosis and coagulation systems
+
Systemic Response to Burn Injury Accelerated fluid loss 2° leaky capillaries Host resistance to infection Multisystem Organ Failure Infections in burns <20% TBSA are well
tolerated. > 40% TBSA with infection has very low
survival rate Initially CO, subsequent hypermetabolic
state w/ doubling of CO in 24 – 48 hours
Select the true statements regarding the epidemiology of a burn injury
a. Scald burns are the most frequent forms of
burn injury.
b. Flame burns are the most frequent forms of burn injury admitted to burn centers.
c. Burn injuries are most common among adults
d. About 15% of pediatric burn injuries are attributed to abuse or neglect.
e. Burn-related deaths are highest among adults.
Select the true statements regarding the depth of burn
a. First-degree burns are physiologically important and therefore considered when calculating TBSA.
b. Second-degree burns always affect the epidermis and dermis of the skin.
c. Third-degree burns are very painful.
d. All first-degree burns heal within 2 to 3 days.
A 50 year-old man sustains a flame burn involving the entire upper left extremity, entire anterior trunk, genital area, and half of the left lower extremity. Approximately what percentage of the total body surface area is burned?
a. 24%b. 28%c. 37%d. 45%e. 30%
According to American Burn Association criteria, which of the following patients
should be referred to a burn center?
A. Second- and third-degree burns involving more than 20% of the total body surface area (TBSA) in patients younger than 10 or older than 50 years of age.B. Full-Thickness burns that involve 2% of the TBSA in patients of any age.C. Significant burns of the face, hands, feet, genitalia, perineum, or skin overlying major joints.D. Burn Injury in children with suspected or actual child abuse or neglect.E. Acute massive skin loss syndromes (e.g., Stevens-Johnson syndrome/toxic epidermal necrolysis, large traumatic de-gloving injuries)
All of the following are true regarding the Pathophysiology of thermal injury,
except?
A. Increased capillary permeability is due to direct
effect of heat and the liberation of vasoactive
mediators.B. Increased pulmonary vascular
resistance occurs during the immediate postburn period.C. Elevated thyronine (T3) and thyroxine
(T4) levels.D. Elevated interleukin-6 (IL-6) levelE. Decreased immoglobulin G (IgG) level
A 60-year-old, 80-kg man has sustained a second-
degree burn to 40% TBSA with a significant inhalation injury. He was admitted to the burn unit 30 minutes after the accident. According to the Parkland formula, resuscitation was started with lactated Ringer’s solution at 800 ml/hr. Six hours later the patient was found to be oliguric. What should be the next step in resuscitation of this patient?
A. Swan-Ganz catheter placement and measurement of pulmonary
wedge pressure.B. Trial of small dose of furosemideC. Low does of dopamine (2-3 ug/kg/min).D. Increase in volume of the lactated Ringer’s
solution infusion.E. Bolus of colloid solution
Which of the following statements is/are true regarding resuscitation of patients
with burn injury during the first 24 hours?
a. Parkland formula uses a balanced electrolyte solution & the fluid requirement is calculated as 3 ml/kg body weight per %TBSA burned.
b. Patients with 15% or more TBSA burn require intravenous fluid resuscitation.c. Adequate urine output implies hemodynamic
stability and adequate organ perfusion.d. Crystalloid resuscitation restores cardiac output
more rapidly than colloid alone.
e. Late pulmonary morbidity and mortality are higher in colloid-
resuscitated patients.
Match the items in two columns
Topical AgentsA. Sodium mafenide(Sulfamylon)
B. Silver nitrate 0.5%Solution
C. Silver sulfadiazine(Silvadene)
CharacteristicsA. Limited eschar
penetration, resistant organisms neutropenia, thrombocytopenia
B. Painful application, hyperchloremic reactions good eschar penetration
C. Hyponatremia, hypokalemia, hypocalcemia, methemoglobinemia
Which of the following statements is/are true regarding metabolism in
the burn patient?
a. Postburn hypermetabolism is mediated by catecholamine
release.b. IL-1 and IL-6 are elevated in burn injuries and enhance
the hypermetabolic response by increasing oxygen consumption.
c. Elevated core and skin temperature and lower core-to-skin
heat transfer are manifested in postburn hypermetabolism.
d. Increased blood flow to the muscles in the burned limb.e. The burn wound preferentially utilizes glucose by anaerobic glycolytic pathways despite increased blood flow to the wound.
Which of the following can minimize metabolic expenditure in burn
patients?A. Nursing the patients at ambient
temperature below 30oC.B. Adequate analgesia and sedation.C. Early excision of the burn and complete
wound closure.D. Early diagnosis and treatment of
infection.E. Use of B-adrenergic blockers.
Select the correct statements regarding nutrition in burn patients.
a. The optimal calorie/nitrogen ratio varies between 150:1 & 160:1.b. Fat is the best source of non-
protein calorie.c. Glutamine deficiency results in
atrophy of gut mucosad. Long-chain triglycerides for
maintaining lean body mass.e. Overfeeding is associated with
hyperventilation.
Which of the following statements is/are true for invasive burn wound
infection?
a. Common in burns larger than 30% total body surface area.
b. Characterized by conversion of a partial-thickness burn to full-thickness burn.
c. Definitive diagnosis can be made if quantitative culture of the biopsy recovers more than 105 organisms per gram on tissue.
d. Incidence of Candida wound infection has increased owing to topical antimicrobial chemotherapy.
e. Topical antimicrobial agents have markedly decreased the incidence of invasive burn
wound infection.
Select the true statements regarding infection in the burn
patienta. Infection if the most frequent cause of
death in the burn patients.b. Cell-mediated immunity is not altered
in major burn injuries.c. Hematogenous pneumonia is the most
common pulmonary infection in burn patients.
d. Diminished granulocyte chemotaxis is an important factor in burn infection.
e. Suppurative thrombophlebitis can be a major source of sepsis.
Which of the following statements is/are true regarding administration of
antibiotics to burn patients?
a. Prophylactic systemic antibiotics are indicated in patients with extensive burns.b. With invasive burn wound sepsis,
systemic antibiotics should not be instituted before culture and sensitivity results are available.
c. Positive wound cultures should be treated with systemic antibiotics.
d. Antibiotics effective against anaerobic organisms are always indicated for burn wound sepsis.
e. Subtherpeutic serum antibiotic levels are common in burn patients.
Which of the following statements is/are true regarding burn wound
excision?
A. Excision is indicated for deep partial-thickness and full- thickness burn wounds.
B. Early excision and closure of burn wounds has been shown to reduce the incidence in invasive burn wound infection, shorten the hospital stay, reduce pain, and improve functional recovery.
C. Excision should be performed after successful fluid resuscitation.
D. Tangential excision involves sequential excision of the eschar down to bleeding, viable tissue.
E. Excision of more than 10% of TBSA single procedure is associated with significantly morbidity.
Which of the following statements is/are true regarding burn wound
closure?A. Split-thickness autograft is
contraindicated if wound culture is positive B-hemolytic streptococci.
B. Xenograft is the most frequently used and effective biologic dressing when an autograft is not available.
C. Allograft dressings promote bacterial proliferation.
D. Cultured autologous keratinocyte sheets can be used for permanent wound coverage with good results.
E. Dermal substitutes provide better temporary wound
coverage that biologic dressings.
Select the true statements regarding inhalation injury.
A. Presence of carbonaceous sputum is a specific sign of inhalation injury.
B Normal carbon monoxide level on admission excludes inhalation injury.
C. Chest radiography is sensitive for diagnosing inhalation injury.
D. Combined fiberoptic bronschosocpy and 133 Xe ventilation-perfusion lung scan has a diagnostic accuracy of more than 96%
E. Pulmonary infection is the most frequent cause of morbidity and mortality with inhalation injury.
Select the correct statements regarding electrical injury.
a. Depth of tissue injury is related to density and duration of the current flow.
b. High-voltage electric injury results in more severe injury to the trunk than the extremities.
c. Risk of acute renal failure is relatively high with an electrical injury due to myoglobinuria and underestimation of fluid needs.
d. Incidence of cholelithiasis is high in patients after electrical injury.
e. With a lightening injury cardiopulmonary arrest is common, and burns are characteristically superficial.
Which of the following statements is/are true regarding chemical
injuries?
a. Immediate wound care involves application of a neutralizing agent.
b. Acid burns cause liquefaction necrosis.
c. Alkali burns produce deeper injuries than acid burns.
d. Hydrofluoric acid burn is treated with local calcium gluconate gel.
e. Coal tar burn is best treated with immediate application of a petroleum-based ointment.
Select the true statements regarding post burn sequelae
A. All second & third degree burns produce permanent scarring.
B. The incidence of hypertrophic scar formation is less after excision and skin grafting than with wounds that heal spontaneously.
C. Hypertrophic scars are best treated by early excision and wound closure.
D. Basal cell carcinoma is the most common carcinoma in an old burn scar.