Burn Management:

Past, Present and Future

Yefta Moenadjat

Introduction
Critical Burns Severe burn injury The most severe trauma ever The great constitutional disturbance Devastating injury Multifaceted injury

Hi mortality rate

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1. The formers: 1960s 1980s Concept of edema following burns injury Altering hydrostatic and osmotic pressures as well as physiologic fluid abnormality Capillary leaks 2448 hr Intravascular volume deficit (Burn shock) The role of histamine

Majno G, Palade GE. Studies on inflammation. I. The effect of histamine and serotonin on vascular permeability: An electron microscopic study. J Biophys Biochem Cytol. 1961; 11: 571 603

Burn management
1. The formers: 1960s 1980s Concept of edema following burns injury Acute renal failure Intravascular volume replacement Fluid and electrolyte is sufficient (Baxter, Parkland Hospital Dallas,1961) Vigorous crystalloid administration
Baxter CR. Fluid volume and electrocyte changes in the early postburn period. Clin. Plast. Surg. 1974; 1: 693.

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1. The formers: 1960s 1980s Concept of wound sepsis Ambroise pare (1510 1590, French barber surgeon): burns 1o 2o 3o

History of Surgery

Burn management
1. The formers: 1960s 1980s Concept of wound sepsis

History of Surgery

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1. The formers: 1960s 1980s Concept of wound sepsis Jakcson (1947): zone of coagulation, stasis and hyperemia

Jackson D. The diagnosis of the depth of burning. British Journal of Surgery. 1953;(40) 164:521632

Burn management
1. The formers: 1960s 1980s Concept of wound sepsis Wallace AB (1951, Bangour, Scotland): Rule of nine Lund and Browder (children)
Rosenthal SG, Zelman D, Valenti C, Song INC, Bromberg BE. In Vitro Evidence of A Burn Toxin. Plast Recon Surg. 1969; 43(4): 397-401 Allgwer M, Stdtler K, Schoenenberger GA. Burn sepsis and burn toxin. Ann R Coll Surg Engl. 1974 November; 55(5): 226235.

Burn management
1. The formers: 1960s 1980s Concept of wound sepsis Silver sulfadiazine: superior antimicrobial reduce sepsis

Wasiak J, Cleland H, Campbell F (2008). Wasiak, Jason. ed. "Dressings for superficial and partial thickness burns". Cochrane Database Syst Rev (4): CD002106. DOI:10.1002/14651858.CD002106.pub3. PMID 18843629.

Burn management
1. The formers: 1960s 1980s Concept of wound sepsis Burn toxin (Lipid Protein Complex)

Rosenthal SG, Zelman D, Valenti C, Song INC, Bromberg BE. In Vitro Evidence of A Burn Toxin. Plast Recon Surg. 1969; 43(4): 397-401 Allgwer M, Stdtler K, Schoenenberger GA. Burn sepsis and burn toxin. Ann R Coll Surg Engl. 1974 November; 55(5): 226235.

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1. The formers: 1960s 1980s Concept of burn team Multidisciplinary approach Team works

1. 2. 3.

Artz CP, Moncrief JA, Pruitt BA. Burns, a team approach. Philadelphia: WB Saunders & Co, 1979 Ward CG. Burn care: a multidisciplinary specialty. QRB Qual Rev Bull. 1979;5(7):2-3. Wolf SE, Herndon DN. Burn Care. Texas: Landes Bioscience 1999; 1-136

Burn management
2. The era of: 1980s 1990s Concept of wound sepsis Tangential excision Wound assessment Tissues preservation in contrast to aggressive dbridement Incidence of systemic inflammatory response syndrome (SIRS) and Multisystem organ failure (MOF)
1. 2. Janzekovic Z. The burn wound from the surgical point of view. J Trauma 1975 Baue AE, Berlot G, Gullo A (editors). Sepsis and organ dysfunction: Epidemiology and scoring systems, pathophysiology and therapy. Milano: Springer Verlag; 2000

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2. The era of: 1980s 1990s Concept of wound treatment Skin grafting Autografts Conventional Stamps Mesh graft Allografts Xenograft Cadavers

Burn management
2. The era of: 1980s 1990s Concept of wound treatment Skin grafting Autografts Conventional Stamps Mesh graft Allografts Xenograft Cadavers

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3. The era of Molecular Biology (1990s 2000s) Concept of burn shock Cellular hypo perfusion hypoxia oxidative stress Hypercatabolic stage of burns Burns >40%TBSA Hyperglycemia and insulin rsistance in burns
LeDoux D, Astiz ME, Carpati CM, Rackow EC. Effects of perfusion pressure on tissue perfusion in septic shock. Crit Care Med. 2000; 28: 27292732 Cuthbertson DP, Tilstone WJ. Metabolism during the postinjury period. Adv Clin Chem. 1969; 12: 1 55. Gosling P. The cellular, immune and metabolic response to trauma. Crit Rev Clin Lab Sci. 1998; 35: 59103. Sheridan RL. Editorial: A great constitutional disturbance. NEJM. 2001; 345(17): 1271. Pereira CT, Murphy KD, Herndon DN. Altering metabolism. J Burn Care Rehabil. 2005; 26(3): 194 199 Jeschke MG, Micak RP, Finnerty CC, Norbury WB, Gauglitz GG, Kulp GA et al. Burn size determines the inflammatory and hypermetabolic response. Crit Care. 2007; 11: R90.

Burn management
3. The era of Molecular Biology (1990s 2000s) Concept of burn shock Controversies of crystalloid vs. colloid in burns resuscitation (19952005) Controversies of albumin administration in critically ill (1998)

Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999 Jan;27(1):200-10. Gosling P. Review: Salt of the earth or drop in the ocean? A pathophysiological approach to fluid resuscitation. Emerg Med J. 2003; 20: 306315. Cochrane Injuries Group, Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH. Human albumin administration in critically ill patients: systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers. BMJ. 1998 Jul 25;317(7153):235-40.

Burn management
3. The era of Molecular Biology (1990s 2000s) Concept of inflammation SIRS and MODS The role of inflammatory mediators and anti inflammatory mediators

Spiess DB. Introduction to SIRS and MODS. J Cardiovasc Pharmacol. 1996; 27 (Suppl.1): vvii. Bone RC. Toward an epidemiology and natural history of SIRS (systemic inflammatory response syndrome). JAMA. 1992; 268: 345255

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4. The era of Molecular Biology (2000s 2007s) Advanced concept of molecular biology Oxidative stress and ischemia reperfusion injury

Dirksen MT, Laarman GJ, Simoons ML, Duncker DJGM. Reperfusion injury in humans: A review of clinical trials on reperfusion injury inhibitory strategies. Cardiovasc Res. 2007; 74: 343355. Girn HRS, Ahilathirunayagam S, Mavor AID, Vanniasinkam SH. Reperfusion syndrome: Cellular mechanisms of microvascular dysfunction and potential therapeutic strategies. Vasc Endovasc Surg. 2007; 41(4): 277293

Burn management
Hemodynamic monitoring Macro and microcirculation CVP, PAWP, MAP, toC AST/ALT, Blood ureum/creatinin RBG, serum lactate, BD, PCO2, SaO2, SvO2 SID, SIG

Gastric tonometry

Sublingual capnometry

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Hemodynamic monitoring Gastric tonometry and sublingual capnometry

Gastric tonometry

Sublingual capnometry

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Wound assessment

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Wound assessment

La Hei ER, Holland AJA, Martin HCO. Laser Doppler Imaging of paediatric burns: Burn wound outcome can be predicted independent of clinical examination. Burns. 2006; 32 (5): 550 553.

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Wound treatment

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Wound treatment

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Wound treatment

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Wound treatment

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Wound treatment

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5. The era of Stem Cells: future dimension

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Wound treatment: Tissue engineering

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Wound treatment: Tissue engineering

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Wound treatment: Stem cells

Thank you