LECTURE 5: BURNS & close small

complex wounds
BURNS: Current Concepts in Management 4. Rehabilitation, a. maintain range & Day 1 through
reconstruction & reduce edema discharge
Incidence reintegration b. strengthen &
USA: 1.1 million cases annually facilitate return to
45,000 hospital admissions society
4,500 deaths/year
Metro manila: 20,000/year Initial Evaluation
Metro Cebu: 3,000/year I. Primary Survey
A. Airway
Etiology B. Bleeding
Flame 40% C. Circulation
Scalding 30% D. Deformity
Chemical 10% E. Exposure
Contact 2%
Airway Evaluation & Protection
Mortality
Primary cause of death: Airway & Breathing
Systemic Inflammatory Response Syndrome (SIRS) Tracheotomy is contraindicated in patients with burns over
the neck because it carries a very high risk for mediastinitis,
Burning the largest immune organ which has a very high mortality rate.
Allgower, Spikes & Schonenberger, BURNS, Vol. 21, Suppl. 1, pp 5- Intubation is usually done rather than tracheostomy
549, 1995 CIRCULATION

Burning the skin... Vascular access & initial fluid support

The skin is the largest immune organ
Heat produdes coagulation of proteins on the surface of the Prevention of subsequent DEFORMITIES
burned skin, forming the LIPID-PROTEIN COMPLEXES
(LPCs) Multiple trauma issues

SKIN-immune system Incidence of EXPOSURE

EPIDERMIS
o Keratinocytes Prevention of hypothermia
o Langhans cells Vasoconstriction & hypovolemic shock
DERMIS
o Dendrocytes II. Burn Specific Secondary Survey
A. Burn History
SYSTEM INFLAMMATORY RESPONSE SYNDROME Nature/etiology of burn
Time of injury
HEAT Place: closed space/open area
Initial care
BURNS Medical history
Immunization
AICD Other healing deterrents

Multiple organ failure B. Physical Examination
Airway patency
Death Level of consciousness
Signs of inhalation injury
SIRS SEPSIS
Clinical Similar to sepsis Similar to sepsis Inhalation injury: clinical manifestations
Manifestations Facial injuries
th th
Time of onset 7 12 day First 72 hours post Singed nasal hairs
post burn burn Perioral burns
Focus of infection No identifiable focus With definite focus Tachypnea
Recommended Early debridement Antibiotics Hoarseness
management Anti-LPC agent Preventive measures
Stridor
Goals of treatment
Active bleeding
Survival
Concomitant injuries
Function
Cosmesis C. Initial wound evaluation
Depth of wounds
Overall management strategy
Extent of Injuries
Phases of Burn Care Presence of circumferential components
Phase Objectives Time
1.Initial Evaluation & Thorough evaluation 0-72 hours Depth of burn wounds
Resuscitation & accurate Superficial
resuscitation Partial-thickness (PT)
2.Initial wound Exactly identify and Days 1-7 o Superficial
excision & biologic remove all FT o Deep PT
closure wounds & achieve Full thickness
biologic closure
3.Definitive wound Replace temporary Day 7 - weeks
closure with definitive covers
Levels of Burn Injuries IV. Prevention of SIRS
Control of LPCs
Epidermis, Dermis/Corium, Subcutis, Muscles, tendons and fascia 1. Early surgical debridement
Normal none 2. Application of anti-LPC agents
Superficial epidermis
Superficial Partial Thickness epidermis, upper half of the Silver Sulfadiazine + Cerium Nitrate (Flammacerium)
dermis Anti-SIRS agent
Deep Partial Thickness epidermis, whole of the dermis Mechanism of Action: Cerium nitrate binds with the LPCs on
Full Thickness epidermis, dermis, subcutaneous the burn wound surface, thus preventing them from going
into general circulation, and causing SIRS
Superficial burns
e.g. Sunburn V. Infection Control
No hospitalization indicated 1. Systemic Antibiotics
No potential for infection 2. Topical Antibacterials
Linaments/salve e.g. aloe vera 3. Enteral Feeding
4. Surgical debridement of necrotic tissues
Partial-thickness burns 5. Anti-tetanus coverage
Full-thickness burns
VI. Burn Wound Care
Extent of burn injuries Intact blisters vs. Ruptured bullae
Early vs. Delayed debridement
Wallaces rule of nines Washing with NSS
Palm + Digits = 1% TBSA Topical antibacterials
Lund-Browder charts Dressing materials

D. Laboratory & Radiographs TOPICAL ANTIBACTERIALS

Criteria for Hospitalization Silver Sulfadiazine (SSD)
Extremes of ages Silver Sulfadiazine + Cerium Nitrate
>15% TBSA PT injuries Mafenide Acetate (Mafylon)
>5% TBSA FT injuries Silver Nitrate
Involvement of primary areas Povidone Iodine
o Face Gentamycin
o Genitalia Others
o Joints
o Neck Surgical Debridement
Special burns Avulsion Technique
o Lightening Tangential Excision
o Chemicals Escharectomy
o Electrical Burn Wound Excision
Inhalation injury Extremity Amputation
Life-threatening associated injuries eg. Head injury
Presence of wound healing deterrent factores eg. Diabetes Sequential debridement
Psychiatric conditions Tangential excision
Close monitoring Done in partial-thickness burns
Excision of burn wound using a Humby knife or
III. Fluid Resuscitation dermatome, on tangent until a viable plane is reached
Burn formulas are used initially as basis for computation of Drawback: Bleeding
fluid requirement, but HOURLY URINE OUTPUT must be Escharectomy
considered subsequently. Removal/excision of the burn eschar
Done in full-thickness injuries
BAXTER-PARKLAND Formula Vs. Escharotomy releasing incisions on the eschar to
prevent vascular compromise
First 24 hours: Burn Wound Excision
Done for injuries deeper than full-thickness; entails
TFR = 4cc x kgBW x %TBSA excision of underlying subcutaneous fat, muscle or
fascia, even bone.
of total volume to be given in the first 8 hours ff burn injury; May constitute amputation of extremities in case of
remaining to be given in the next 16 hours severe injuries
Burn Wound Excision: amputation
Second 24 hours: Limb amputation

0.5 cc/kgBW/%TBSA VII. Nutritional Support

+ Ngt
D5W maintenance Parenteral nutrition
HIGH protein/carbohydrate
FLUID RESUSCITATION Vitamins A,B,C
Plain LRS given initially in the first 24 hours following burn Minerals zinc
injury; colloids may be given in the next 24 hours Surgical nutrition
In infants, D5 solutions are preferred since they lack High-protein, high carbohydrate diet
glycogen reserves. Vitamin supplements
Blood is not given in the first 48 hours, unless there is Commercially-prepared supplements
significant loss due to concomitant injuries
Colloids usually ordered also after 48 hours VIII. Rehabilitation
Physical
 Psychosocial
Occupational
TOTAL REHABILITATION
Goals: Secondary Survey
To restore the patients sense of general well-being Inspect for asymmetry and deformity
To restore patients pre-burn occupational capacity Palpation of entire craniofacial skeleton orbital rims, nose,
zygomatic arch, midface stability, mandible to detect any
BURN SEQUELAE irregularities or crepitation
Hypertrophic scars Investigation of facial nerve function
Unstable scars Evaluation of facial sensation: supratrochlear, supraorbital,
Deformities secondary to scarring infraorbital & infra-alveolar nerve distribution
Intranasal inspection for septal hematoma
COMPLICATIONS Ophthalmologic examination
Burn Scar contractures Malocclusion
Marjolins Ulcer
Burn syndactyly Assessment of Injuries
Soft Tissue Injuries
TEAM APPROACH Facial Bone Fractures
Concomitant Injuries
In medicine, rules are absolute, but results are variable. Facial Abrasions
-Celsus Lacerations
Animal/Human bites

Facial Soft Tissue Injuries

Disclaimer: Due to unfortunate technical problems the following notes Diagnostic studies
are incomplete, reading the book or other references is highly advised. Photographs
Precise inspection of injuries
LECTURE 6: TRAUMA Cleaning & Washing of wounds
Removal of foreign bodies
Common Causes of Traumatic Injuries Ant-tetanus coverage
Motorvehicular accidents
Aggravated Assaults Cleaning & Washing
Accidents like animal bites, falls etc Irrigation with saline solution
Sports Injuries Scrubbing & prying out of foreign materials to prevent
Motorcycle Accidents formation of traumatic tattoos
Surgical Debridement
Craniofacial Injuries
Principles of Repair
Initial Evaluation 1. Accurate primary treatment can prevent the need for
Primary Survey complex secondary reconstruction
Airway maintenance with cervical spine protection 2. Meticulous layered repair of the injury with identification of
Breathing & Ventilation severed glands, ducts, nerves
Circulation with hemorrhage control
Disability: neurologic status
Exposure/environmental control

A: Airway Control & Cervical Spine Protection

Check airway patency
Visual inspection of oral cavity, pharynx & larynx

B: Breathing & Ventilation

Auscultation
Chest radiograph
ABG measurement
Pulse oximetry

C: Circulation
Check for hypotension
Fluid replacement
Hemorrhage control

D: Disability
Neurologic exam
Skull radiographs
CT scan
Control of ICP
Medications

E: Environmental Control
Maintenance of warm ambient temperature following PE
Use of warm blankets
o Avoidance of hypothermia
 LECTURE 7: Cosmetic Surgery

Oriental vs. Caucasian

Blepharoplasty
Blepharochalasia
Dermochalasia
Baggy eyes

The aging face

Old
- presence of furrows
- Extra skin over eyelids dermochalasia
- Crows feet
- Perioral wrinkles
- Nasolabial folds
- Jaw??
- Turkey cobbler deformity

Rhytidectomy/Rhytidoplasty (Face Lift)

Augmentation, Mammoplasty

Cosmetic Procedures for the Aging Face

Rhytidectomy/Rhytidoplasty (Facelift)
Blepharoplasty (Removal of Eyebags)
Botox/Collagen injections

Other Cosmetic Procedures

Chin Augmentation
Neck Lift
Mastopexy (Breast Lift)
Breast Reduction
Abdominal Dermolipectomy

Reduction Mammoplasty

Abdominal Dermolipectomy
Tummy tuck

Suction-Assisted Lipectomy (Liposuction)

Body Sculpture (Body Contouring)