Burn and Wound Management

Burn and wound management
C Balakrishnan, MD
Associate Professor
Division of Plastic Surgery
Wayne State University
Detroit, Michigan, USA
MOHC 2012, Grand Rapids, Michigan

Burn care and Wound care
No financial interest
Aim: Principles of Wound care principles,
Burn care and Reconstruction and
rehabilitation following burn injuries

Burn care and Wound care
Burn care and wound care – what is in

common?
Skin is the largest organ in the body
Local and systemic changes are best
studied for burns
American Burn Association, Am Academy
of Wound management, American College
of certified Wound specialists (CWS,
FCCWS)
Types of wounds
Acute wounds:
Acute thermal injuries (Burns, Frostbite)
Traumatic injuries
Chronic wounds:
Pressure sores
Radiation injuries

Burns

Cold injuries
Frost bite
Trench feet

American Burn Association criteria for
transfer to Burn unit
Major burns
Burns associated with inhalation injury
Burns of specific areas of the body – face,
hand, feet, perineum
Chemical injuries
Electrical injuries

Etiology of Burns
Causes :
Flame - damage from superheated, oxidized air
Scald - damage from contact with hot liquids
Contact - damage from contact with hot or cold
solid materials
Chemicals - contact with noxious chemicals
Electricity - conduction of electrical current through
tissues

Etiology of Burns
Incidence of work related burn injuries –
26.4 per 10,000 workers (Islam et al J T 2000)
Male – Construction and mechanical
Women – Service industry

Work force involved
Welders
Cooks
Laborers
Food service
Mechanics
Electrician
Fire fighters

Area involved
Hand, wrist – hot liquid

Eyes – chemical
Face flame, hot liquid
Contact burns
Firefighters – face and posterior neck

Etiology
Age groups - Younger cooks and food
service personnel
Depth – 1.3 per 10,000 deep
Associated trauma – Inhalation injury,
Fractures, Crush injuries

Psychological problems associated with
work related Burn injuries
Depression
PTSD
Anxiety disorders
Workers with electrical injuries had higher

psychological sequlae (19%)
JBCR 2011

Depth of injury
First degree - Injury localized to the epidermis

Superficial second degree - injury to the
epidermis and superficial dermis
Deep second degree - injury through the
epidermis and deep into the dermis
Third degree - full-thickness injury through the
epidermis and dermis into subcutaneous fat
Fourth degree - injury through the skin and
subcutaneous fat into underlying muscle or bone

Depth of burn

Depth of injury
Incineration Fourth degree

Physiology of depth of injury
Three zones:
zone of coagulation
zone of stasis
zone of hyperemia
This is similar for a pressure ulcer

Aim of management
To limit the injure to zone of coagulation

To prevent injury to zone of stasis
Management actually aims at preventing a
second degree or first degree burn to
becoming a deeperinjury

Burn size
Rule of nine
Charts

Chemical burns
Hydrofluoric acid - Calcium gluconate

Phenol - Ethylene glycol
Phosphorus - Copper sulfate

Chemical burns
Phenol – chemical peel Cardiac toxicity

Monitor EKG
Ethylene glycol

Electrical injuries

Electrical injuries
Muscle injury without skin damage

Myoglobinuria – treat to prevent renal
failure
Cardiac arrhythmia
Tetany, rupture of tendons
Neurological deficit
Saliva good conductor of electricity

Electrical Injuries
Impaired attention span
Memory problems (especially for short-term
anterograde verbal information
Persistent distress and frustration
Mood disorders - often characterized by
psychosocial difficulty and violent behavioral
outbursts, accompanied by a background of
generalized depression

Electrical injuries
Survivors of severe electrical injury have

been noted to exhibit abnormal
neuropsychologic findings several
years after trauma.
Late evaluation of patients with significant
electrical injury has suggested a common
constellation of symptoms involving both
cognitive and affective disturbances.

Systemic response to Burns
Inflammation and edema

Altered hemodynamics
Immunosuppression
Hyper metabolism
Decreased renal flow
Increased gut mucosal permeability

Principles of management
Burn Resuscitation
Early management
Wound care
Surgical management
Management of complications
Management of Psychosocial issues

Parkland formula
Parkland 4 ml/kg per % TBSA burn Total
fluid =4 x body wt x BSA
½ of which is given in first 8 hours from the
point of injury
Next half is given in the next 16 hours

Wound management
Escharotomy
Excision
Skin grafts
Flaps
Others

Escharotomy
Indications - Improve circulation

Fasciotomy

Wound care
Silver sulfadiazine
Mefenate acetate
Silver dressings

Wound care
Biological dressings Allograft (cadaver skin)

Xenograft
Placental membrane
Bilayered
Cultured epidermal cells

Wound healing Principles
Burn wounds are potentially contaminated

and needs debridement.
Clean wound with out coagulum heals
faster.
Epithlialization occurs from the cells
remaining in the dermis.

Wound therapy
Management of burn wounds can be
divided into three stages: assessment,
management, rehabilitation.
Rehabilitation starts early in management
Positioning and splinting
Stretching of joints

Surgical management
Primary excision
Early excision
Excision with Skin grafting
Excision with allograft
Excision with skin substitutes
Excision – Integra – Skin grafting
Excision with flap coverage

Surgical management
Immediate excision
Primary excision
Early excision
Delayed excision

Excision and grafting of the Burn wound
Early excision vs delayed

Outcome in Burns
Early, aggressive resuscitation regimens

including early excision and wound
coverage have improved survival rates
dramatically.
By decrease in Sepsis and Multi organ
failure

Outcome
Hypertrophic scar
Burn contractures
Amputations

Prevention of contractures!!!!
Think neck and chest are a single unit

when it comes to contracture
Hand splints
Position elbows and axilla
Knee brace
Prevent foot drop

Pressure garments
Pressure garments appear to help in :
reduce scar thickness/lumpiness
reduce scar redness
reduce swelling
relieve itching
protect newly healed skin/graft
prevent contractures/ maintain contours

Silicone gel sheets
The exact mechanism of action of silicone

in the prevention and management of
hypertrophic scars is unclear.
Influences the collagen remodeling phase
of wound healing
Soften, flatten and blanch the scar, making
it comfortable and improves appearance

Custom Compression Garments
25 mm of Hg
Constant use
Clear masks for face

Management of contractures
Serial casting
Surgical release
Post operative splinting

Lip deformity secondary to neck contracture

Complications of Hand Burns
Burn associated neuropathy

Reflex sympathetic dystrophy
Pain syndrome
Amputations and loss of parts

Hand burns - Principles
Early excision and wound coverage
Excision and skin grafting
Flap coverage of exposed bones and
joints

Cross finger flap

Radial forearm flap

DISTANT FLAPS -Abdominal flap

Abdominal flap

Amputation of digits / Fusion
DIPJs, PIPJs and possibly the middle

phalanges. – Try to preserve length
Both for toes as well as fingers.
The thumb amputation deformity is treated either
by pollicization or toe transfer.

Primary amputation
Electrical injuries
Contact burns

Complications of Hand Burns
Loss of parts Adduction contracture

Prevention of contracture by early
excision and soft tissue coverage
Soft tissue coverage of the knee joint following
burns. Canadian Journal of Plastic Surgery 2006;
14:163.

Elbow

Elbow

Elbow

Axillary contracture

Knee joint burns

Knee joint burns

Psychological problems associated
with work related Burn injuries
Depression
PTSD
Anxiety disorders
Workers with electrical injuries had higher

psychological problems (19%)
JBCR 2011

Occupational Burn injuries
Preventable?
Appropriate education
Work place training
PPE (Personal Protective equipment)
Safe work place procedures

Worker training
Worker illness and Injury prevention
programs
Reporting all injuries
First aids

Back to work programs
Can the worker return to previous
occupation
Is there any work place adjustments
required
Retraining

Classification of Chronic wounds
Pressure ulcers
Vascular insufficiency
Metabolic
Infections
Inflammatory disorders
Hematologic
Malignant
Miscellaneous

Pressure ulcers
Decubitous ulcers
Neuropathic ulcers
Contributing factors include Pressure,
Immobility, Shear, Moisture, Nutrition

Etiology - nomenclature
Pressure sore, decubitus ulcer, bedsore

Unrelieved pressure, altered sensory
perception, incontinence, exposure to
moisture, altered activity and mobility,
friction, and shear force.

Staging and risk factors
Pressure Ulcer Staging (depth & tissue type)
– Stage I Persistent redness (culturally
sensitive)
– Stage II Partial thickness skin loss
– Stage III Full thickness skin loss
(subcutaneous)
– Stage IV Full thickness skin loss (fascia)
Norton scale: Physical condition, mental condition,
activity, mobility, incontinence (score ≥ 12 is at risk)
Norton scale: Activity, mobility, sensory perception,
moisture, nutrition, friction, and shear

Pressure ulcers

Vascular insufficiency
Acute vascular
Chronic venous
Artherosclerosis
Lymphedema

Fx pelvis – SP embolozation

Lymphedema

Metabolic
Diabetes mellitus
Gout

Diabetes

Infected wounds
Bacterial
Fungal
Parasitic

Bacterial infections
Necrotizing fascitis

Bacterial infection

Inflammatory disorders
Pyoderma gangrenosa
Vasculitis
Necrobiosis lipodica diabeticorum

Hematologic disorders
Sickle cell disease

Polycythemia vera
Hypercoagulable states

Malignant ulcers
Marjolin’s ulcers
Primary cutaneous neoplasm
Metastic Cutaneous neoplasm
Kaposi’s sarcoma

Radiation associated wounds
Poor granulation
Rule out Cancer
? Hyperbaric

Radiation associated wounds
Can develop Angiosarcoma

Diagnosis by biopsy

Toxic drug ulcers
Extravasation injury
Paint gun injuries

Etiology of Chronic wounds
Nutritional deficiency
Tissue hypoxia
Infection
Metabolic
Malignant change
Immune compromise
Mechanical factors

Impaired wound healing – Intrinsic
factors
Ischemia
Infection
Foreign body
Smoking
Venous insufficiency
Radiation fibrosis
Repeated trauma
Malignancy
Impaired wound healing - Extrinsic
Nutritional deficiency
Diabetes mellitus
Chronic renal sufficiency
Steroids – reversed by Vit A
Chemo
Liver disease
Old age
Heredity
Hyperbaric oxygen
2.5 atmospheres for 2 hours
Tissue oxygen measured transcutanously.
Oxygen tension of 30 mmHg required for
normal cell division and wound healing.
Optimal oxygen requirement for nonhealing
wound is unknown.
Reinisch suggested that the beneficial effect of
hyperbaric oxygen is due to the
vasoconstructive property of oxygen, which
acts to close arteriovenous shunts and thus
improves capillary circulation
Categories of wound dressing
Absorbents – to control drainage

Impregnated dressings - Adaptic
Transparent dressing- Opsite
Foams
Hydrogels – DuoDerm Gel
Xerogels – Alginates, Sorbsan
Hydrocolloids – Cutinova, DuoDerm
Active dressing – hydrogel with antimicrobial
VAC system – subatmospheric wound healing
Biotherapy - maggots
Fetal wound healing
Contain few granulocytes

Increased turn over of matrix
Early gestation fetal skin heals by
regeneration or growth rather than scaring.
Extra cellular matrix rich in hyaluronic acid
Low hyaluronidase activity and increased
fibronectin production

Fetal wound healing
Highly organized collagen architecture

TGF – induces acute inflammation and
subsequent fibrosis in fetal wound
Collagen type III increased

Gene therapy
Two methods:
- Genetically engineered keratinocyte or
fibroblast to over express growth factor
genes
- Transfer of DNA directly by gene gun or
direct subcutaneous injection of DNA

Transplantation
Research to reality
Partial vs total face
Extremity

Thank you

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Burn and wound management

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Burn care and wound care – what is in

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Hand, wrist – hot liquid

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Workers with electrical injuries had higher

MOHC 2012, Grand Rapids, Michigan

First degree - Injury localized to the epidermis

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Incineration Fourth degree

MOHC 2012, Grand Rapids, Michigan

This is similar for a pressure ulcer

MOHC 2012, Grand Rapids, Michigan

To limit the injure to zone of coagulation

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Hydrofluoric acid - Calcium gluconate

MOHC 2012, Grand Rapids, Michigan

Phenol – chemical peel Cardiac toxicity

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Muscle injury without skin damage

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Survivors of severe electrical injury have

MOHC 2012, Grand Rapids, Michigan

Inflammation and edema

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Indications - Improve circulation

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Biological dressings Allograft (cadaver skin)

MOHC 2012, Grand Rapids, Michigan

Burn wounds are potentially contaminated

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Early excision vs delayed

MOHC 2012, Grand Rapids, Michigan

Early, aggressive resuscitation regimens

MOHC 2012, Grand Rapids, Michigan

MOHC 2012, Grand Rapids, Michigan

Think neck and chest are a single unit