1. Burn Surgery Basic Science Lecture General Surgery Kanene Ubesie, M.D. Virginia Commonwealth University (VCU) Burn Surgery Fellow

2. Objectives Burn pathophysiology, classification, and anatomy Non-operative and operative plans for burn wounds Initial burn evaluation and management Burn TBSA and resuscitation Thermal Burn Inhalation injury Electrical Burn Chemical Burn Frostbite

3. History of Burn Surgery 1940s: Early excision of burn to reduce mortality 1940s: Lund and Browder chart, Rule of 9s (G.A. Knaysi), Parkland formula (Charles Baxter and G. Tom Shires) 1947: First civilian US burn center at MCV by Dr. Everett I. Evans (Evans-Haynes Burn Center) 1960s: Zora Janzekovic developed the concept of tangential excision with an uncalibrated knife

4. Burn Epidemiology Common populations Very young Elderly Impaired Low socioeconomic groups Substance Abuse Trauma Nonaccidental Self-induced

5. Thermal Burns: Classification Dual layer skin Epidermis Keratinocytes Barrier (infection, toxins, UV, dehydration, thermal) Dermis Connective tissue, Mechanoreceptors, Glands, Lymphatics and Blood vessels Durability/Elasticity Papillary and Reticular Classification of Burns Superficial epidermal (1 st ) Partial thickness (2 nd ) Superficial Deep Full thickness (3 rd ) Muscle/Bone (4 th /5 th )

6. Thermal Burns: Classification

7. Burn Pathophysiology Zones of injury Zone of Coagulation Full thickness burn Necrotic Irreversible Must debride and graft Zone of Stasis Partial thickness burn Vasoconstriction/Ischemia Reversible Protect from - edema, infection, or poor perfusion Zone of Hyperemia Superficial epidermal injury Quickly heals without scarring Not included in TBSA

8. Thermal Burns: Initial Management ABCs!!!!!  Secondary Survey Stabilize and transfer to nearest burn center Burn Center Goal: early surgical excision and/or closure of burn wounds Systematic Approach Multidisciplinary team Psychosocial support Education Rehabilitation Reconstruction Criteria to refer to a burn center:

9. Thermal Burns: Initial Management

10. Indication for hospitalization Inhalation injury Large and/or infected wound Wound care and education Physical therapy Pain management Discharge planning Prognostic Factors >60 years of age Full thickness burn >40% TBSA Inhalation injury

11. Question: Name the zones of injury

12. Total Body Surface Area Rule of 9s More surface area for pediatric head 1% for the palm (tips to wrist) SAGE Lund & Browder

13. Burn Resuscitation: Parkland Formula Partial thickness and deeper Adult >20% TBSA Pediatric >10% TBSA 4 x kg x %TBSA Give half in the first 8 hours Lactated Ringers in the first 8 hours Maintenance fluid in pediatrics <20 Kg  D5 ½ NS No colloid until after at least 8 hours Titrate by UOP Adult – 0.5cc/kg/hr Pediatric – 1cc/kg/hr Over-resuscitation Compartment syndrome, pulmonary edema, swelling, ARDS

14. Non-operative Management of Burns Superficial epidermal to dermal wounds Daily dressing change Gently wash away fibrinous exudate and biofilm Debride large blisters Ointment Protective non-adherent dressing MOBILITY Decrease: edema, infection, pain, contractures

15. Non-operative Management of Burns: Antimicrobials Silver Sulfadiazine Broad spectrum, Pseudomonas and fungal Not very effective for Klebsiella, new resistance with Pseudomonas Soothing however does not penetrate eschar Can retard wound healing Reversible granulocyte reduction Mafenide Acetate (Sulfamylon) Cream and solution Broadest spectrum, all strains of Pseudomonas Painful – penetrates eschar Ears Metabolic acidosis – ventilator complications Silver Nitrate Staph aureus, E. Coli, Pseudomonas Activate with water (not NaCl) Hyponatremia, Hypochloremia, Methemoglobenemia Does not penetrate Eschar Stains black Sodium Hypochlorite (Dakins) Toxic to tissue if not diluted 0.025% - Pseudomonas, MRSA, Enterococci Mupirocin MRSA

16. Operative Management of Burns Full* thickness and deeper Early excision Better survival rates Shorter LOS Lower costs After 24 hours of initial management and within 7 days Stage every 2-3 days, 20% at a time Tangential vs Fascial Blood Loss Aesthetics Length of stay Allograft vs Autograft Cultured Epidermal Autograft

17. Operative Management of Thermal Burns Escharotomies Circumferential burns Fluid resuscitation Skin only Perform in anatomical position No benefit for digital escharotomies Can perform at the bedside with cautery

18. Question: What it the TBSA?

19. Question: Calculate Burn Resuscitation (20kg)# 12% TBSA

20. Burn: Inhalation Injury Significant increase in morbidity and mortality when combined with cutaneous burn History and exam Closed space Toxic fumes Facial burn Singed nasal/facial/scalp hair Soot Flexible laryngoscopy When to intubate Carbonaceous sputum below the vocal cords Respiratory distress or failure Altered mental status Hoarseness, wheezing, stridor Large burns undergoing resuscitation (>40% TBSA)

21. Burn: Inhalation Injury Carbon Monoxide (CO) poisoning Petroleum 200x higher affinity than oxygen to bind Hgb (carboxyhemoglobin) Most common symptoms: Nausea, dizziness, fatigue, headache Increasing altered mental status with increasing levels 100% FiO2 Hyperbaric

22. Burn: Inhalation Injury# Cyanide poisoning Natural/Synthetic compounds Structural fires Disrupts cellular oxidation  Lactic Acidosis CyanoKit (hydrocobalamin, Vit B12) Hypertension

23. Burn: Electrical Categories Low voltage, <1000V High voltage, >1000V Super-high voltage, Lightening Tissue injury Low voltage: localized, oral cavity High voltage: deep tissue and organ injury Lightening: Cardiopulmonary arrest, ruptured TMs Thermal injury Tetanic contractions Spinal fractures Concomitant injuries (Fall)

24. Burn: Electrical Work up Complete trauma evaluation Neurologic exam Ophthalmology exam Monitoring Telemetry Foley insertion Neurovascular exams Treatment Compartment Syndrome Fasciotomies Rhabdomyolysis UOP >100cc/hr Alkanalize Urine Rarely need mannitol

25. Question: Best, painless, colorless antimicrobial with the least side effect profile?#

26. Burn: Chemical Do not soak affected area Avoid neutralizing agents Liquid Alkali vs Acid Irrigate with water x30 minutes Powder Brush away Avoid water Hydrofluoric acid Severe hypocalcemia Irrigation and topical calcium gluconate are soothing Gold Standard treatment: Intra-arterial calcium gluconate over 4 hours Tar Remove with lipophilic solvent (Medi-Sol) Treat thermal injury

27. Frostbite Etiology Direct freezing or chronic exposure to extremely cold environment Pathologic process is provoked by repeat exposure Higher risk in patients with alcohol abuse, impairment, or psychiatric issues Treatment Removal from cold environment ABCs Elevation of affected limb and protect from further trauma Up to date Tetanus Correct hypothermia CONTINUOUS rewarming at room temperature Warm bath, 37-39C, 30 minutes Warm IVFs Narcotics Delay operative intervention until rewarming complete Do not rub/massage Do not unroof blisters

28. DONE!