BURN Surgery Notes

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PONS MD Notes

 At the ER? What questions will you ask?

Ano po nakasunog sa inyo?

Saan eto nangyari?

How to assess the patient at the ER?

ABCDEF

A-Airway
     Inspection: Check if the patient is gasping, abdominal breathing, alar flaring

     Can the patient tolerate room air or is the patient intubated

     Check if the patient can speak in phrases, full sentences

B- Breathing

Auscultate if the patient has clear breath sounds, check for decreased breath sounds

   If yes? Consider pneumothorax. If the patient is normotensive may do CXR , if positive for pneumothorax then do CTT

If patient is hypotensive with decreased breath sounds? May do needling(2^nd -3^rd ICS MCL) if positive proceed with CTT

C- Circulation

what is the most accurate way to check for circulation?

              Urine output is the most accurate way to check systemic circulation in burn patients

              Other ways to check-BP, CRT, pulses

     

             D- Deficits

             Check for GCS(Glasgow coma scale)

             Check for neurosensory deficits ( Review neuro PE)

           

            E-Exposure

           Open all the wounds

          Check for SPTs, DPTs, FTs

          Check for circumferential burns

          F-Fluids

FORMULAS           

Parkland’s Formula- uses a factor 2-6, Fluid of choice Ringers lactate

          Uses a factor of 2 for elderlies and those patients with cardiac disorders

          3- for children

          4-baseline for adults

          5-6 adjust the factor use base on urine output

When to use Parklands or when not to use it?

      Modified Brooke’s 0.5 D5

       Evans uses crystaloids at 1mL/kg/%TBSA plus colloids

       Slater uses ffp as a part of resuscitation

      Monafo high sodium(250meqs of Na, 150 lactate,100meq Cl)  reserved for cardiac patients

Formulas develop for Children

Shriners Cincinnati

Galveston

Choice of Fluids? Why is that so?

Crystalloids- readily available and cheaper than other alternatives

 e.g. Ringers lactate,saline,Hartmann solution

High volume of administration produces hyperchloremic acidosis

Increase neutrophil activation

Isomers of lactate increased production  of ROS

In vivo dilution of crystalloids causes of hypercoagulable state

Hypertonic solution –lower volume required  lead to hypernatremia and renal failure

Colloids- due to leaky status of the capillaries, colloids/plasma proteins leaks outside causing edema formation

What is Fluid Creep?

It is the over resuscitation more than what is predicted by the parklands formula which could lead to abdominal compartment syndrome

Stretegies to avoid it;

1.         Avoidance of early overresuscitation

2.         Use of colloid as a routine component of resuscitation or for rescue

3.         Adherence to protocols

EMERGENCIES OF BURN  

1.         Electrical Burn with compartment syndrome

2.         Burn shock

3.         Inhalational Injury

What are the components of burn shock?

1.         Distributive

2.         Cardiogenic

3.         Hypovolemic

Zones in Burn Wound

Zone of coagulation-avascular area, necrotic areas meant for excision/ debridement

Zone of stasis- salvageable area , sweet spot of resuscitation, over and under resuscitation may lead to progression of burn wounds

Zone of hyperemia- areas with erythema

How does and how long does  Burn wounds  Heal?

First degree burn -7days may apply lotions/moisturizers

2^nd degree burns

SPTs- heal approximately in 2-3 weeks, heal by? Epithelialization

DPTs-heal in 3-5 weeks resulting in hypertrophic scarring and contracture if not yet operated on

FT-heal by granulation

What is the cancer associated with burn?

Marjolins ulcer is an SCCA common sequelae of chronic burns

Dressing FAQs

How many gram of Silver in acticoat flex?

-100ug/mL water due to structure and sustained release, increased surface area

SSD- 3030ug Ag+/ gram

Silver nitrate 3180 Ag+/ mL water

Dressing causing metabolic acidosis due to inhibition of what enzyme? Answer: Mafenide acetate. Adverse effect: Inhibits Carbonic anhydrase leading to metabolic acidosis

For difficult to treat wounds like post irradiated wounds, what are the options?

Topical hemoglobin spray. MOA? Increase the availability of O2 in the vicinity, thus in theory contributes to faster wound healing

What is VAC? Vacuum Assisted Closure or commonly known as Negative pressure wound therapy

Indications:

1.         Exposed bone

2.         Exposed tendon

3.         Highly exudative abdominal wounds

Contraindications:

1.         Infected wounds

2.         Exposed major vessel

What is the ideal pressure for VAC? -100 to -150

Components of VAC

Sterile foam, ioban, suction catheter    

Why is the pressure intermittent? To stimulate further granulation

What is the molecular mechanism behind  VAC?

 By subjecting the wound under intermittent stress production of growth factors such as VEGF, PDGF, FGF are stimulated.

 By subjecting the wound to negative pressure exudates are removed which contains excess inflammatory agents, metalloproteinases and cytotoxic agents.

Other uses of VAC;

In open   abdomen that is difficult to close

In grafted wounds in order to keep the graft adherent to the wound

What are stages of graft take?  

Imbibition- occurs within the 24-48 hours where the graft obtains its nutrition and oxygen from the wound thru passive diffusion.

Inosculation- occurs after 48 hours characterized by kissing of the newly formed capillary buds

Early revascularization- at 72 hours  new vascular connections are made. At this point GSO can be done if we are suspecting infection

What causes graft site loss?

1.         Hematoma

2.         Seroma

3.         Infection- critical count 10⁵  CFU/gram of tissue

4.         Shearing- prevented with splinting

5.         What are microorganisms are the exception to the rule, even though  their amount <1 b="">0⁵  CFU/gram of tissue can lead to graft site loss?

a.          MRSA

b.         Pseudomonas

c.          Group B streptococcus

Whats the difference between primary contraction vs secondary contraction?

Primary contraction- the immediate coiling the graft due to its elastin content

FTSG> STSG

Secondary Contraction- late event which arises due to increased activity of the fibroblast

Mesh STSG> STSG> FTSG

What is the best donor site for the STSG of the face?

Back

What is the best donor in terms of cosmesis and the amount of pilosebaceous unit?

Scalp

What are the components of the pilosebaceous unit?

a.          Hair follicle

b.         Sebaceous gland

c.          Sweat gland

d.         Apocrine gland

e.          Dermal appendages

In theory, when can you reharvest from a previous donor site(STSG)?

2 weeks

What is a reconstructive ladder?

This is guide use by the plastic surgeons in their reconstruction

From lowest to highest

1.         Delayed primary closure

2.         Primary closure

3.         Skin graft

4.         Local flap

5.         Regional flap

6.         Free flap

What is the thickness  of various skin grafts?

Thin STSG 0.15–0.3 mm

Intermediate STSG 0.3–0.45 mm  

Thick STSG  0.45–0.6 mm

How to dress skin grafts?

It depends on location

At the chest, trunk or pelvis it is dressed with tie over dressing or bolster dressing

For extremeties it is dressed with circumferential dressings.

Nutrition questions

What is the best protein for burn patients? Whey protein

Differentiate Whey from Casein?

Whey is absorbed fast

Casein is long acting best for atheletes

What is permissive underfeeding?

Study showed that with decreased feeding compared to the standard have less incidence of infection given that the feeding is a high protein diet

BURN Surgery

How to do escharectomy in the hand?

Identify the peak points of the digit. For the thumb incision is at the ulnar side. From index finger to ring finger incision should be done at the radial side

How to do fasciotomy of the upper extremity?

In the thigh and leg? Release at the medial and lateral aspect of the leg.

How many compartments in the leg? 4

Anterior

Lateral

Deep posterior

Superficial temporal

Landmarks

Tibial spine

Lateral Incision

Lateral 1 fingerbreath in front of the fibula, maintain anterior to the fibula to avoid damaging the superficial peroneal nerve

Medial incision -1 fingerbreath below the palpable medial edge of the tibia

Differentiate escharectomy vs escharotomy

Escharectomy is the process of removing the eschar thru sharp debridement

Escharotomy is incising directly into the eschar to relieve the tourniquet effect of circumferential full thickness burns

Aesthetic unit of the face

SPLINTS

Functional hand splint?

Thumb abducted, Wrist  30 deg extended, MCP 45-50  flexed

Dynamic Hand splint

For rehab excises , practice finger extensions

Sugar thong splint designed for genital surgeries where the goal keep bilateral lower extremity separated

Log leg splint

JAQ favorites?

What causes compartment syndromes in burns?

Circumferential full thickness burns

high voltage electrical burns

trauma  

What are the composition of various IV fluids?

 

Dressings

What are the adjuncts for difficult wounds?

Hemoglobin spray

Can we combine MEBO and Ganulox? NO Mebo an oil based product will decrease the availability of surface oxygen in the wound

 Copyright of the Notes owned by PonsMD