PLASTIC SURGERY ARTICLE REFERENCE

WOUND CARE IN CASES OF SEVERE BURNS

ON ACUTE PHASE

Compiled by:
Dea Saufika Najmi G99142056
Riris Arizka Wahyu G99142065
Chendy Endriansa G99151012
Muhammad Al Amin G99121028

Supervisor:
Amru Sungkar, dr.,Sp.B,Sp. BP-RE
Introduction
Burns is an injury case often
faced by doctors, especially
in the ER. Severe burns can
cause severe morbidity and
degree of disability is
relatively high compared to
other causes of injury
Burns cause loss of skin
integrity and also raises very
complex systemic effects
caused by contact with a
heat source

The burn is usually

expressed by the degree of
Therefore, burns more
which is determined by the
appropriately managed by a
depth of burns. The severity
team consisting of specialist
of the wound depends on a
trauma surgeons
deeper, broader, and location
of the wound
BURNS

Wounds caused by
exposure to excessive
heat, chemicals, radiation,
or electricity leading to
damage of the tissue
 ETIOLOGY
 Thermal
exposure to flame or a hot object
 Chemical
exposure to acid, alkali or organic substances
 Electrical
result from the conversion of electrical energy into heat.
 Radiation
result from radiant energy being transferred to the body
resulting in production of cellular toxins

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CHEMICAL BURN

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ELECTRICAL BURN

6
BURN INJURY CLASSIFICATIONS
 Classified according to depth of injury and
extent of body surface area involved
 Burn wounds differentiated depending on
the level of dermis and subcutaneous
tissue involved
1. superficial
2. deep
3. partial thickness
4. full thickness

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4/1/2011
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 SUPERFICIAL BURNS

• Epidermal tissue only affected

• Reddened skin
• Erythema, blanching on pressure,
• Not serious unless large areas
involved
• Do not result in scarring
• i.e. sunburn, minor scald from a
kitchen acciddent

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10
 PARTIAL THICKNESS BURN
(Superficial)

• Involves epidermis and

papillary layer of dermis
• Intense pain
• White to red skin
• Blisters
• Spares hair follicles, sweat
glands etc
• Erythematous and blanch to
touch
• Very painful/sensitive
• No or minimal scarring 11
 PARTIAL THICKNESS BURN
(Deep)

• Involves the epidermis and

deep layer of the dermis
• Appears pale and mottled
• Fluid-filled vesicles –red, shiny,
wet, severe pain
• Hospitalization required if over
25% of body surface involved
• Contracture possible
• i.e. flame

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14
 FULL THICKNESS BURN
• Destruc tio n o f all skin layers
• Req uires im m ed iate ho sp italizatio n
• Dry, waxy white, leathery, o r hard
skin
• No p ain/ lo ss o f sensatio n
• Exp o sure to flam es, elec tric ity o r
c hem ic als c an c ause 3rd d egree
b urns

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16
TOTAL BODY SURFACE AREA
(TBSA)
 Superficial burns are not involved in the
calculation
 Lund and Browder Chart is the most accurate
because it adjusts for age
 Rule of nines divides the body – adequate for
initial assessment for adult burns

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LUND BROWDER CHART USED FOR
DETERMINING BSA

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Evans, 18.1, 2007)
RULES OF NINES
 Head & Neck = 9%
 Each upper extremity
(Arms) = 9%
 Each lower extremity
(Legs) = 18%
 Anterior trunk= 18%

 Posterior trunk = 18%

 Genitalia (perineum) =
1%

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 Local Response
THE THREE ZONES OF A BURN WOUND BY JACKSON

• the • characterized • characterized

Zone of stasis

Zone of hyperemia
Zone of coagulation

central, by vaso- by
constriction vasodilation
most and ischemia.
severely resulting
The tissue is from the
damage initially release of
area. The viable, inflammatory
cells in however it mediators
this area may convert
to coagulation
from
are as a cutaneous
coagulated consequence cells. Tissue
or necrotic. of the in this zone
Tissue in development typically
this zone edema, remains
infection, and viable
must be 20
decreased
debrided. perfusion
Local response

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SYSTEMIC CHANGES
• Decreased • Respiratory • Decreased or
cardiac output distress absent motility
syndrome • Curling’s ulcer
formation

Cardiac Pulmonary Gastrointestinal

• Increased of • Supression of
basal metabolic humoral and cell-
rate mediated
• Increase in core immune response
body temperature • Increased risk of
infection

Metabolic Immunologic 22
PHASES OF BURN INJURIES

Acute phase Sub Acute phase Advanced phase

• clinical shock • Accelerated • Hypertrophic scar
• external loss of metabolic rate • Keloid
plasma • Electrolyte and • Contracture
• loss of circulating chemical imbalance
red cells • Inflammation and
• burn edema Infection lead to
sepsis
• MODS

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Diagnosis
Physical Advanced
Anamnesis
Examination examination
• auto/alloanamnesis • Primary Survey • Laboratory studies
• Airway :CBC, serum
• Breathing electrolite,
albumine, ALP,
• Circulation
serum Carbon
• Disability Monoxide, urine
• exposure studies
• Secondary Surver • Chest X-Ray
(Head to toe) • CT-scan
• Local Status • ECG
• Renal function
(BUN and
creatinine)
• Bronchoscopy
Management
 Acute Phase:
a. Avoid contact with source of burning injury

b. Asess general condition : airway obstruction

blood pressure, conciousness
- if there’s any obstruction :
- if there’s shock : fluid resucitation immediately
without considering degrees of burn injury
- If patient’s not in shock condition : IV line in
accordance to fluid replacement needs
Fluid resucitation:
Parkland Formula (by Charles Baxter):
4m L × Patient's b o d y weig ht × T BSA = Vo lu m e to b e g iven in
the first 24 ho u rs

50% of this volume is infused in the first 8 hours, starting from the time of
injury, and the other 50% is infused during the last 16 hours of the first
day.

Maintenance d o se is pro vid ed after the first 24 ho u rs.

100m l/kg : fo r the first 10kg
50m l/kg : fo r the seco nd 10kg
20m l/kg : every kilo g ram ab o ve 20kg
 Subacute-chronic phase

Clothing Cooling Cleaning Covering Comforting

•remove all •use flowing •remove dead •reduce heat •analgesic
burned water for 20 tissues loss and agent
clothes minutes, contamination
avoid
hypothermia
Wound Care of Severe Burn Injuries in
Acute Phase

Cleansing and
debridement
Use mild soap and water or with
chlorhexadine/normal saline washes

Most burn experts recommend

debridement of all blisters larger than 0.5
cm (reduce the risk of bacterial
colonization or infection)
 Culture swabs of all
wound beds  obtained
upon admission and
repeated serially to
monitor colonization.

Quantitative cultures to
diagnose wound invasion
 best obtained by tissue
biopsy
 First few hours colonized by gram-positive
bacteria
 Colonized by gut flora by 5 days

 Bacterial colonization does not require systemic

antibiotics but should be managed with early
debridement and/or excision, together with
appropriate topical and/or biologic dressings.
Dressing
 The selection of an appropriate dressing depends
on several factors :
- depth of burn

- condition of the wound bed

- wound location

- desired moisture retention and drainage

- required frequency of dressing changes

- cost
 The goals in selecting the most appropriate
dressing :
• providing protection from contamination
(bacterial or otherwise) and from physical
damage
• allowing gas exchange and moisture retention

• providing comfort to enhance functional

recovery
 Several layers of absorptive gauze and Kerlix cover
the wound  decrease evaporative water losses
 Minor burns can be managed with biologic
dressings, silver-coated dressings, or tribiotic
ointment covered with nonadherent gauze.
 Commonly utilized topical agents include:

- silver sulfadiazine (Silvadene)

- mafenide acetate (Sulfamylon)
- silver nitrate 0,5%
 Silver impregnated dressings (Acticoat, Aquacel
Ag, Mepitel, Mepilex)  has been developed to
provide antimicrobial coverage, adequate
humidity, and decreased trauma
 Biosynthetic subtitues (ex: Biobrane)  allow
faster re-epithelialization; use is limited due to
infectious complication
 Sufficient evidence exists recommending the use
of honey  acute wounds and for mild to
moderate superficial and partial thickness burns
due to :
 Anti-bacterial Activity

 Anti-inflammatory Properties

 Anti-oxidant Properties

 Anti-viral Properties
Surgical:
 Deep burns are also managed with surgical
excision and placement of xenograft, allograft,
autograft, or Cultured Skin Substitutes (CSS).
 Most experienced burn surgeons  Early wound
excision within the 1st to 7th day of injury
(attenuate the systemic inflammatory effects and
reduce the risk of sepsis)
Factors in appropriate timing for
burn wound excision and grafting
including:
- Age
- extent and depth of burn
- Comorbidities
- hospital resources
- physician preference
 Other studies:
- Most studies have shown that excision within
24 to 48 h after injury is associated with
decreased blood loss, infection, length of
hospital stay and mortality, and increased
graft take
- Due to prevent infection, excising the eschar
and covering the wound as early as possible
are critical.
 The standard for rapid and
permanent closure of full-
thickness burns is a split-
thickness skin graft from an
uninjured donor site on the
same patient (autograft) 
sufficient coverage without risk
of rejection
Patients with more extensive burns often require
temporary coverage with :
 allograft  tissue taken from a living/deceased
human donor
 xenograft  taken from a different species

 skin substitute

 dermal analog
Allograft and Xenograft
 Promote re-epithelialization and pre- pare the wound
bed for autograft, increasing the healing rate when
compared with traditional dressings
 Xenograft  superior choice for their increased safety
and reduced price
 A cadaver allograft  the best material for temporary
closure of excised wounds in extensive, life-threatening
burns and inadequate donor sites.
Allograft
Xenograft (pig origin)
Skin subtitutes and dermal analog

Broadly divided into :

 Epidermal substitutes  normally only a few cell
layers thick and lack normal dermal components
 Dermal substitues  include acellular matrices

- Alloderm (human origin)

- GraftJacket (human origin)

- Integra (Bovine/shark origin)

- Biobrane (Biocomposite dressing, nylon fibers

in silicone with collagen)
Cell-based techniques
 Reduce the amount of donor skin needed for
treatment of large burns
 Reducing the healing time of both the donor and
the burn sites
 Increasing overall graft success and scar quality

 More work is needed on cell-based coverage

options before widespread implementation can be
recommended.
 Culture-based options, such as:
- Epicel  use a small biopsy of the patient’s skin
to provide keratinocytes, expanded over 2 to 3
weeks into a confluent epidermal autograft
- ReCell  take a small biopsy of the patient’s skin
and prepare a mixture of keratino- cytes,
melanocytes, and stem cells in a liquid formula-
tion for spraying onto the excised burn wound
COMPLICATIONS
1. Acute phase
 External loss of plasma
 Clinical shock
2. Sub acute phase
 SIRS
 Sepsis
 MODS
 Acute Tubular Necrosis
 Gastrointestinal ; atrophy of mucosa, ulceration and mucosal
bleeding, bowel Motility decreases and ileus.
2. Advance phase
 Hypertrophic scar, keloid and contracture
PROGNOSIS
• Minor burns can heal 5-10 days without
scarring
• Moderate burn can be cured 10-14 days and
may cause scarring
• Major burns take over 14 days to recover and
will form scar tissue