burns pp

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Published on January 4, 2008

Author: Melinda

Source: authorstream.com

Burns:  Burns Welcome to the burns module! Burns constitute a major global problem and are a leading cause of trauma deaths in children. Minor burns, if poorly treated, cause devastating complications with lifelong morbidity. Understanding how burns cause tissue damage and how the skin heals is vitally important in ensuring that the right diagnosis is made and the right treatment given. Typical burns from hot water in a child For information about the authors of this module, click here How to use this module:  How to use this module This self - directed learning (SDL) module has been designed for medical and other health care students. We suggest that you start with the learning objectives and try to keep these in mind as you go through the module slide by slide, in order and at your own pace. You should research any issues that you are unsure about. Look in your textbooks, access the on-line resources indicated at the end of the module and discuss with your peers and teachers. Finally, enjoy your learning! We hope that this module will be enjoyable to study and complement your learning about burns from other sources. Learning outcomes:  Learning outcomes By the end of the module, you should be able to: describe the structure of the skin outline the local and systemic effects of burn injury assess the size of burns accurately assess the depth of burns accurately and relate how this determines the way in which it heals classify burn injuries according to the type of treatment required (outpatient, inpatient or specialist care) Anatomy of skin (1):  Anatomy of skin (1) Epidermis Dermis The skin is made up of two layers, the outer layer (epidermis) and inner layer (dermis). Between the epidermis and dermis is the basement membrane which is semi permeable and acellular. It provides support, flexibility and regulates the transfer of substances across the dermal-epidermal junction. Under the skin is the subcutaneous layer which allows the skin to be loosely attached to the underlying fascia. It increases mobility and is especially important over joints. basement membrane Subcutaneous layer Anatomy of skin (2):  Anatomy of skin (2) Thickness of skin increases from birth until approximately 40 years of age, then it starts to thin again. It also varies over different parts of the body. The eyelid has a thin epidermis (~0.05mm). The palm and foot have a thick epidermis (>1.5mm). Click to Reveal Answers Which of the following areas do you think has a thin epidermis?: Eyelid Palm Foot Anatomy of skin – Epidermis (1):  Anatomy of skin – Epidermis (1) A protective barrier of stratified squamous epithelium consisting of 5 layers Stratum corneum: 20-30 rows of dead cells continually shed Stratum lucidum: 3-4 layers clear flat dead cells Stratum granulosum: Cells degenerating with production of keratin Stratum spinosum: 8-10 rows of cells that produce protein but can not duplicate Stratum basale: Columnar cells continually dividing, gradually migrating to surface EPIDERMIS There are three other cell types within the epidermis: melanocyte, Langerhan and Merkel cells Anatomy of skin – Epidermis (2):  Anatomy of skin – Epidermis (2) Other cell types within the epidermis: Melanocytes: Produce melanin pigment causing brown colouration of skin and protects skin from UV light damage Langerhan cells: Immune cells which help in defence. Situated in stratum spinosum, they help process and present foreign antigens to the immune system Merkel cells: Within the basal layer, close to hair follicles; involved in touch sensation Who do you think has more melanocytes (a), (b) or (c)? Click to Reveal Answers None of them! All racial groups have the same number of melanocytes, but dark skin individuals have more metabolically active cells which produce more melanin. (a) (b) (c) Anatomy of skin – Dermis (1):  Anatomy of skin – Dermis (1) The dermis consists of 2 layers: Papiliary dermis: The upper layer of dermis. It has extensions protruding into the epidermis called Rete pegs which also contain small capillary loops Reticular dermis: The lower layer of dermis. It is made up of collagen, elastin and ground substance as well as hair follicles, sweat and sebaceous glands Fibroblasts are the predominant cell type in the dermis and produce collagen and elastin which provide strength and flexibility to the skin. In addition, there are blood vessels, sebaceous glands, sweat glands, hair follicles, sensory receptors and fat cells. Anatomy of skin – Dermis (2):  Anatomy of skin – Dermis (2) There are other cell types and structures within the dermis: Myofibroblasts - contractile, important in healing of wounds Macrophages - derived from vascular leucocytes; phagocytic and stimulate fibroblasts Mast cells - contain histamine Lymphocytes - mediate immune function Sensory receptors Meisners Khause Ruffins Paccinian Texture Cold Heat Vibration & deep pressure Functions of the skin:  Functions of the skin Physical barrier Temperature control Immunity Sensation Vitamin D production Identity Remember P V I S I T ! Local effects of burn injury (1):  Local effects of burn injury (1) Summary of local effects: Cell death/disturbed function Release of inflammatory mediators Increased capillary permeability Microvascular thrombosis 1. Cell death/disturbed function Cellular function is disturbed when the temperature rises above 43oC. The higher the temperature and more prolonged the contact, the more cells die. An instantaneous full thickness burn occurs at a temperature of 700C or greater. Due to differences in skin thickness with age, at 55C, severe damage occurs after 10 seconds in a child and 30 seconds in an adult. Skin thickness is also reduced in older people and in certain conditions (e.g. steroid therapy). Local effects of burn injury (2):  Local effects of burn injury (2) 2. Release of inflammatory mediators Potent vasoactive mediators are released from the burn wound. These include vasoconstrictors and vasodilators, histamine, serotonin, kinins, prostaglandins and oxygen free radicals Thromboxane: causes platelet aggregation and microvascular thrombus formation Histamine: released by mast cells; causes increase in capillary permeability Prostaglandins: result in arteriolar dilatation Kinins: increases vascular permeability Serotonin: increases vascular resistance and venous hydrostatic pressure leading to oedema Oxygen free radicals: increase vascular permeability Local effects of burn injury (3):  Local effects of burn injury (3) 3. Increased capillary permeability When capillaries are damaged, they leak protein-rich fluid which results in oedema. Normal skin; normal capillary permeability Burn wound oedema with increased capillary permeability and protein leakage Local effects of burn injury (4):  Local effects of burn injury (4) 4. Microvascular Thrombosis Release of thrombogenic factors such as thromboxane, together with a hypovolaemic state cause sludging in the smallest blood vessels. This in turn leads to further tissue ischaemia, increased cell death and can cause extension of the depth and surface area of the burn. Area of burn increases due to sludging in blood vessels and ischaemia Systemic effects of burn injury (1):  Systemic effects of burn injury (1) When a burn is large (>20% of total body surface area), in addition to the local response, there is also a systemic response Vasoactive substances are released that act not just locally in the burned tissue, but in non-burned tissue as well. With large burns, the loss of circulating blood volume will rapidly lead to HYPOVOLAEMIC SHOCK, unless resuscitation is started Loss of circulating blood Vascular permeability Ischaemia Systemic effects of burn injury (2):  Systemic effects of burn injury (2) Click each box Respiratory system Cardiovascular system Renal system Haematological system Immune system Psychological system Gastrointestinal system Systemic effects of burn injury – psychological system:  Systemic effects of burn injury – psychological system Back Psychological Effects 1. Post traumatic stress disorders 2. Mood and anxiety disorders 3. Depression especially with facial disfigurement Social problems such as difficulty in sexual relations and social interactions Systemic effects of burn injury – respiratory system:  Systemic effects of burn injury – respiratory system Thermal injury to upper airway may result in mucosal swelling and obstruction Inhalation injury to lower airways may result in progressive pulmonary failure from ventilation-perfusion mismatch Beware: over aggressive fluid resuscitation can cause or exacerbate pulmonary oedema – especially in infants Respiratory system Back Systemic effects of burn injury – cardiovascular system:  Systemic effects of burn injury – cardiovascular system Circulating volume Venous return Cardiac output Peripheral vascular resistance Cardiovascular system Back Systemic effects of burn injury – immune system:  Systemic effects of burn injury – immune system Initial inflammatory phase increased circulating immunoglobulins activation of complement system elevated acute phase proteins Immune suppression phase decreased circulating immunoglobulins Immune system Back Systemic effects of burn injury – renal system:  Systemic effects of burn injury – renal system (1) Renal blood flow Glomerular filtration rate ADH production Aldosterone Na+ + H20 retention → generalised oedema Tubular dysfunction (± acute tubular necrosis) Beware: high-voltage electrical injury may be complicated by rhabdomyolysis and myoglobinuria Insert image of nephron Renal system Back Systemic effects of burn injury – gastrointestinal system:  Systemic effects of burn injury – gastrointestinal system Ulceration (stress ulcers) Ileus Bacterial translocation Cholestasis Liver dysfunction (deranged enzymes, decreased synthesis of clotting factors and proteins) Back Gastrointestinal system Systemic effects of burn injury – haematological system:  Systemic effects of burn injury – haematological system Anaemia, caused by … ↓ half life of red blood cells haemolysis Neutrophilia Thrombocytopaenia Haematological system Back Assessing total burn surface area (TBSA):  Assessing total burn surface area (TBSA) The area of this burn is about 3-5% of total body surface area. How much of the body surface area is burnt? There are several ways to assess the size of a burn. They all consider the burnt area as a percentage of the total body surface area and are supported by mapping the burnt area on a diagram. In the next couple of slides, we will be looking at the following methods of assessment: The rule of 9’s Lund and Browder charts Palm of hand Unburnt area Click to Reveal Answers Assessing TBSA - Rule of Nines :  Assessing TBSA - Rule of Nines This method divides the body into areas each of which equates to 9% of the total body surface area: the whole of one arm (anterior and posterior surfaces including the hand) is 9%, therefore 2 arms = 18% the entire head including face, scalp and neck is 9% anterior trunk is 18% posterior trunk including buttocks is 18% the whole lower limb (anterior and posterior surfaces, including the thigh, leg and foot) is 18%; therefore both lower limbs = 36%. This totals 99% with the perineum making the final 1%. Beware: this method is unreliable in young children. Assessing TBSA in children:  Assessing TBSA in children Why might the “rule of 9’s” be unreliable in children? Body proportions change with age. In a child, the head represents a much greater proportion of the total body surface area. Click to Reveal Answers Assessing TBSA - Lund and Browder charts:  Assessing TBSA - Lund and Browder charts These take account of the patient’s age and provide a more detailed mapping system for the burnt area Assessing TBSA - Palm size:  Assessing TBSA - Palm size Another useful way, especially for small burns is to use the palm of the patient’s hand (with fingers extended). This equates to approximately 1% of the body surface area. Assessing TBSA - Unburnt area:  Assessing TBSA - Unburnt area In very large burns, it is often easier to measure the area of skin that is unburnt and then subtract this from 100%. Area of the body involved:  Circumferential burns of the limbs can cause distal ischaemia; of the chest, can compromise breathing Area of the body involved Not only is the surface area or size of burn important, but also the specific part of the body affected Face: Facial oedema can lead to airway obstruction. Scarring can cause significant psychosocial problems Perineum: problems with urogenital function and psychosexual Hands: Problems with feeding and hygiene Feet: Mobility problems Eyes: Burns to the eyes (especially chemical) can cause blindness. Depth of burn:  Depth of burn The depth of a burn determines its treatment and how long it takes to heal. For this reason, it is important to be able to assess the depth as: Superficial Partial thickness Superficial partial thickness Deep partial thickness Full thickness Depth of burn - Superficial (erythema):  Depth of burn - Superficial (erythema) Involves epidermis only: Painful Red No blistering Heals rapidly (reversible injury) No permanent scars Note that erythema is NOT included when assessing TBSA Depth of Burn – superficial partial thickness:  Depth of Burn – superficial partial thickness Patches of skin that would come off on cleaning Glistening moist red/pink appearance typical of superficial injury Typical hot water scald Involves epidermis and upper dermis: Red Blistering, moist Painful Heals by epithelialization Healing complete within 14 days Minimal or no permanent scars but can leave discolouration Depth of Burn - superficial partial thickness:  Depth of Burn - superficial partial thickness Blister Pin-point bleeding Pink surface; blanches on pressure Depth of Burn – deep partial thickness:  Depth of Burn – deep partial thickness Involves epidermis, upper dermis and varying degrees of lower dermis: Pale, mottled appearance Fixed staining (no blanching) May be painful or insensate (depending on depth) Heals by combination of epithilialization and wound contracture May take weeks to heal Can leave significant scars and contractures over joints depending on time taken to heal Deep dermal area, reddish with fixed staining Depth of Burn – full thickness:  Depth of Burn – full thickness Involves all of epidermis and all of dermis Dry, leathery (white, dark brown or charred) Insensate Heals by contraction Delayed healing Hypertrophic or keloid scars Leads to contractures Dry, leathery, charred appearance of a full thickness burn Circumferential full thickness burn:  Circumferential full thickness burn Typical position of hand in full thickness burns with metacarpophalangeal joints extended and interphalangeal joints flexed Black, charred skin Depth of Burn – mixed thickness:  Depth of Burn – mixed thickness Assess the depth of the burn in areas A, B and C Click to Reveal Answers Depth of Burn – Mixed thickness:  Depth of Burn – Mixed thickness Deep dermal with pale pink and white patches, non blanching Superficial partial thickness showing pink blanching Full thickness, dry white leathery appearance Classifying the patient:  Classifying the patient First you should assess the severity of the burn injury according to TBSA depth position presence of infection time since the burn presence or absence of inhalation injury Combine this information with patient factors: age associated injuries other medical problems nutritional status Finally consider social and family factors to classify the patient according to how and where to provide treatment. A guideline for patient classification:  A guideline for patient classification significant none other medical problems Specialist In-patient Out-patient Social / family factors nutritional status significant none associated injuries Extremes of age Adult or older child age Patient factors severe mild Absent inhalation injury Critical area Non-critical area position presence of infection depth TBSA Burn injury Factors Small Moderate Large Superficial Partial thickness Full thickness Absent Localised Systemic Normal Malnourished Able to care for oneself Unable to care for oneself Authors and reviewers:  Authors and reviewers Authors Welsh Centre for Burns and Plastic Surgery, UK Tom Potokar Consultant Plastic Surgeon Prakash Lohana SHO in Plastic Surgery College of Medicine, University of Ibadan, Ibadan, Nigeria Abiodun Alao Senior System Analyst Kemi Tongo Lecturer and Consultant paediatrician The School of Medicine, Swansea University, Swansea, UK David Lewis Learning Technologist Stephen Allen Reader in Paediatrics and Honorary Consultant Paediatrician We are very interested to receive feedback regarding any aspect of this module – especially if it helps us to improve it as a learning resource. Please e mail any comments to Tom.Potokar@swansea-tr.wales.nhs.uk For further information about the Partnership in Global Health Education, visit: http://www.medicine.swan.ac.uk/inthealth.html Back Sources of information:  Sources of information Some images have been adapted from CorelDraw clipart See www.interburns.org for more information End of Module Quiz:  End of Module Quiz Well done! Now that you have completed the burns module you may wish to try these questions to assess your learning. First, print-out the questions and write down your answers to each one. Then look at the answer sheet to assess your learning. Questions Answers

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