2.literary of Burn
2.literary of Burn
2.literary of Burn
TWAK SHAREERAM
The description of the anatomical structure of twak, the details about the
layers, thickness are variable in various texts in Ayurveda.
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Structure of skin
Skin is the largest organ of the body in both surface area about 20 square feet
and weight 12-15% of total body weight. Skin forms about 8% of the total body mass.
Its thickness ranges from 1.5 to 4mm according to its state of maturation, ageing and
regional specialization. The skin is thick about 5mm in sole of the foot, palm and
interscapular region. In the other area of body, the skin is thin.
Skin is the first line of defence against disease and bacterial invasion. Joseph
Lister said that, skin is also called as the best dressing of our body.
Layers of skin:-
A. Epidermis
B. Dermis
C. Subcutaneous layer
A.EPIDERMIS –
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As the new cells are produced, they push older cells to the surface of the skin
and the older cells become flattened, lose their cellular contents and begin
making KERATIN.
Eventually the keratin producing cells i.e. Keratinocytes which die and form a
tough, flexible water proof covering on the surface of the skin. The dead cells
shed or washed once in 14-28 days.
LAYERS OF EPIDERMIS:-
The last three layers are metabolically active through which cells are passing
and change their form and progressively differentiate. The most superficial
layer undergoes keratinisation or cornification.
The cellular progression from the basal layer to the skin surface takes 30 days.
The bricklike shape of keratinocytes is provided by a cytoskeleton made of
keratin intermediate filaments.
1. STRATUM CORNEUM –
It is the outermost layer of epidermis. It is otherwise called as horny layer. It
contains cells that are completely filled with keratin and melanin units.
Skin colour is only due to amount of melanin pigment. The melanocytes can
produce and transfer to the keratinocytes. It is called tanning of the skin due to
increased melanin production. The colour of skin reflected in this layer. Others
cells in the epidermis layer are melanocytes, Langerhans ‘cell, Markel cells.
Melanocytes are dendritic cells that distribute melanin pigment to
melanosomes and give the skin to its colour.
The Langerhans’ cells are dendritic in nature and are originate from bone
marrow. These cells are antigen- presenting cells.
Markel cells are derived from keratinocytes and play a role in mechano-
sensory receptors in response to touch.
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2. STRATUM LUCIDUM –
It is called the clear layer as it is highly refractive. It contains droplets of
eledin (clear intracellular protein) is transformed to keratin. Disease which
occurs due to localised overgrowth of melanocytes and melanin.
This layer looks like a homogenous translucent zone.
3. STRATUM GRANULOSUM –
4. STRATUM SPINOSUM -
5. STRATUM BASALE –
B. DERMIS -
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It contains thin dermal papillae (finger prints), sensory receptors, nerve cell
processes, Blood vessels, Hair follicles, Glands.
It consists of Irregular dense connective tissues. The dermis interlaced with
sensory nerve ending that mediate sensation of pain, heat, touch etc.
This is also called the ‘true skin’ because most of the vital functions of the
skin are performed here.
Layers of dermis:
Hair follicles, hairs, nails, sweat gland, sebaceous gland, mammary glands are
the appendages of skin.
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COLOUR OF SKIN –
i. Pigmentation of skin.
ii. Haemoglobin in the blood.
C.SUBCUTANEOUS LAYER –
All the appendages of the skin are responsible for the re-generation of the
epidermal layer. In full-thickness burn injury, all are damaged and re-generation of the
skin impaired and re-constructive surgery is mandatory.
1. Protective function.
2. Sensory function.
3. Storage function.
4. Regulation of body temperature.
5. Regulation of electrolyte imbalance.
6. Excretory function.
7. Absorptive function.
8. Secretory function.
9. Synthetic function.
AYURVEDIC REVIEW
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VEDIC PERIOD:
In Rigveda we get the references about dagdha vrana and its management
with ghee. In Atharva Veda (Kaushika sutra) 11/31, v/23 [27/14-20, 30/120].
In v-23, where we get dagdha vrana , which is due to fault during Agnikarma.
SAMHITA KALA:
Derivation –
The word Dagdha is derived from “Dhyate sma iti” means ‘that which burn’.
Agni
Sheetavarshaanila
Atitejasa
Ushnavataatapa
Indravajragni
Samprapti –
After contact the body parts with heat, blood gets vitiated along with pitta.
This causes severe pain and burning sensation.
Immediately there will be formation of blisters on that part and later on other
complications. Patients suffer from fever and thirst.
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According to Aetiology –
This is caused by the application of heat which is coming under the heading of
“Itharatha Dagdha”.
Ruksha Dagdha
Snigdha Dagdha
b. Ushnavataatapa dagdha
c. Atitejasa dagdha
d. Sheetavarshanila dagdha
e. Indravajragni dagdha
o According to depth –
A. Plustadagdha vrana -
There will be vivarna (Discolouration of skin) and atiplushyata.
B. Durdagdha vrana –
There will be sopha (Blister formation), paka, daha, teevra vedana.
C. Samyak Dagdha vrana –
Wound which is not deep seated (Anavagadha), colour like ripe palm fruit
(Talaphalavrana), and the morphology is well maintained (sushansthitam).
D. Atidagdha vrana -
The characteristics features are mamsavalambana, gatravislesa, sira-snayu-
sandhi-asthi vyapadana atimatra, jwara, daha, pipasa, murchha, vranasya
chirena ruhyati, vivarna.
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MANAGEMENT OF DAGDHA
PLUSTA DAGDHA –
Burn area should be burn again by agni and ushna veeryas medications. After
the fire contact the area becomes warmer and blood becomes liquefied.
So, warm water irrigation and drinking and cold water and cold therapy should
not be used in this burn.
DURDAGDHA –
In this type of burn both the ushna and sheeta chikitsa should be done. But
Ghee, Lepa and any medications should be sheeta veeryas.
SAMYAKDAGDHA –
ATIDAGDHA –
After the debridement of charred muscles all the cold management should be
advised.
Paste prepared of the powder of Shali and decoction of bark of Tinduki, mixed
with milk should be applied and covered that area with leaves of Guduchi and
Lotus.
Remaining treatment is to be followed according to the treatment described in
pittaja visarpa.
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Burn injury due to hot oil, ghee, and water etc. ruksha chikitsa should be
carried out.
DHOOMOPAHATA –
Swasa (Dyspnoea)
Adhmana (Tympanitis)
Kasa (Cough)
Chakhyusa paridaha (Burning sensation in eye)
Chakhyusa roga (Redness in eye)
Sadhumaka nishwasiti (Smoky air expired)
Ghreya annayatraveti (No perception of smell)
Rasana upahanyate (Tasteless)
Daha (Burning sensation)
Jwara (Fever)
Trishna (Thirsty)
Murchha (Unconsciousness)
Kshyabathu (Sneezing)
Sruti upahanyate (Deafness)
MANAGEMENT –
1. Vamana Karma should be done with sugarcane juice, ghee, milk, sugar etc.
2. Kavala graha with madhura, lavan, amla, tikta dravyas
3. Nasya
4. Pathyaahara sevana.
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ATITEJASA DAGDHA –
In this type of dagdha, usually patient doesn’t cure after a proper treatment.
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BURN
A burn injury is an injury to the skin or other organic tissue primarily caused
by heat or due to radiation, radioactivity, electricity, friction or contact with
chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity,
chemicals, as well as respiratory damage resulting from smoke inhalation, are also
considered to be burns. [W.H.O]
A burn injury is a tissue injury due to contact of heat in any form to the
external and internal body surface.
Burn wounds which remains unhealed for longer time either due to infection or
accumulation of excess proteases for 3 to 4 weeks. Burn wound transforming to
chronic wound if not properly managed.
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These injuries leave behind multiple deformities, ugly faces and crippled
hands. These are totally preventable by a little care. Burns are one of the most
devastating conditions encountered in medicine.
The injury represents an assault on all aspects of the patient, from physical to
the psychological. It affects all ages, from babies to elderly persons, and is a problem
in both developed and developing countries in the world.
Other risk factors include low socioeconomic status and unhealthy conditions.
Improvement of incidence rate in the developing world through education and
prevention programmes or through indoor awareness programmes.
MECHANISM OF INJURY
SCALDS – About 70% of burns in children are scalds, also often in elder persons. It
FLAME – It comprises 50% of adult burns. They tend to be deep dermal or full
thickness burns.
An electric current will travel through the body from one point to another,
creating “entry” and “exit” points. The tissue between these two points can be
damaged by the current. It results from the conversion of electrical energy into heat.
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Electrical burn injuries are deep and most of them need urgent surgical attention.
Extent of injury depends on the types of current, the path way of flow and the duration
of current. Injury at the point of exit is more severe than the point of entry. Intervening
tissues may or may not be affected.
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Delayed Effects –
Most of the chemical burns are accidental and results from mishandling of
households cleaners industrial exposure. Chemical injuries may be of longer duration,
even for hours in the absence of appropriate treatment.
Chemical burns occur as a result of contact of the chemical with the skin.
Chemicals cause their injury by protein destruction, with denaturation, oxidation, and
formation of protein esters or desiccation of the tissue. Some chemicals may also get
absorbed into the tissues and causes systemic poisoning. In case of chemical burns it
is not only necessary to treat the injured parts but also requires keen observation to
identify the toxic effects during their treatment.
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ALKALI –
Alkalis, such as lime, potassium hydroxide, bleach and sodium hydroxide are
among the most common agents involved in chemical injury. Accidental injury occurs
in infants and toddlers exploring cleaning cabinets.
Massive extraction of water from the cells causes damage because of the
hygroscopic nature of alkali.
Alkalis dissolve and unite with the protein and it contains hydroxide ions,
these ions penetrate deeper into the tissue.
Treatment is immediate removal of the agent with lavage of huge volumes of fluid
and attempt to neutralize with weak acids. Cement [calcium oxide] burns are alkali in
nature, occur commonly and are usually work- related injury.
ACIDS –
Acid injuries are treated with copious amount of water like other chemical
injury. Acids induce protein breakdown by hydrolysis, which results in a hard eschar
that does not penetrate as deeply as alkali do. Formic acid injuries are relatively rare
and involve an organic acid used as a preservative.
Patients, who have sustained formic acid injury, electrolyte abnormalities are
of great concern with metabolic acidosis, renal failure, and pulmonary complications
being common.
All patients with hydrofluoric acid burns are admitted for cardiac monitoring,
with particular attention to prolongation of QT interval. Serum magnesium and
potassium are also closely monitored and replaced.
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In clinical practice burns are seen due to damage of skin during therapeutic use
of ionizing radiation. Alpha particles do little damage, since that can be absorbed by a
layer of clothing, paper or the outer layer of skin. Beta radiation tends to be superficial
as beta particles are unable to penetrate deep into the tissues.
These burns stimulate sunburn called as ‘Nuclear tan’. Gamma rays penetrate
deep into the tissues and cause more damage. Radiation burns are common in the
patients receiving ionizing radiation during the treatment of malignancies and the staff
who work unprotected.
Radiation burns usually heals very slowly and after healing the scars have
atrophic skin with underlying fibrosis. Healing may takes from three weeks to few
months. Ionizing radiation cannot be seen, felt or heard. A specialized instrument
Geiger counter is commonly used to measure the rate of radiation as roentgens per
hour (r/hr.).
COLD INJURIES
SYSTEMIC HYPOTHERMIA –
It is not commonly seen in our country except in northern part of the country
in winter. It can be result of general cooling of the body in a cold environment as the
cool air passes over the body there is heat loss by convection. The effect is aggravated
if the clothes became wet or there is associated wind. Intense shivering, difficulty in
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speaking, muscular rigidity, amnesia, slowing of pulse and respiration and later
unconsciousness, cardiac arrhythmia and ventricular fibrillation occurs. Death occurs
due to cardio-pulmonary arrest.
TREATMENT:-
First Aid: - Do not warm the patient too rapidly. It can cause ventricular
fibrillation. Remove wet clothing and wrap the patient in blankets. Move the patient to
warm environment as soon possible. Warm the patient with heat packs, warm water
bottles, warm air, radiant warmer etc. provide oxygen and monitor vital signs.
FROST BITE –
Frost bite is the damage of the tissue caused by freezing. Skin and
subcutaneous tissues are at a risk of frost bite when exposure to cold air, liquids or
metals. Most cases of frost bites are seen in winter sports enthusiasts, climbers,
soldiers, homeless persons and those who work outdoors in cold climates. The risk of
frost bite increases with alcohol use and smoking.
The commonly affected parts are head, hand, feet, ear-pinna, cheeks, toes,
fingers and nose. When body parts are exposed to very cold air or liquids, there is
intense vasoconstriction. This leads to cutting down the blood supply in these parts.
The tissues are damaged because of combined effect of freezing and anoxia.
The ice crystals not only injure the cellular architecture but also disturb the
flux of electrolytes and water across cell membranes. Reflex vasoconstriction in the
extremities results in decreased capillary perfusion, which is aggravated by cold
induced hyper viscosity and a tendency to thrombus formation.
Clinical features –
Painful erythema,
Extreme pain,
Numbness of the exposed parts,
Loss of sensation.
The effected skin becomes white and waxy
Tissue necrosis occurs.
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A new method of classifying frostbite severity has been proposed: first degree,
leading to complete recovery; second degree, requiring only soft tissue amputation;
third degree, requiring bone amputation; fourth degree, requires major amputation and
effects systemic complications.
TREATMENT –
SUN BURN -
When exposed for sufficient length of time can cause damage to human skin
(At 400 C in 6 hrs. Human skin can sustain full thickness burn). During the summer
many areas in our country have ambient temperature above 400C. However there is
constant evaporative heat loss from the body due to sweating which effectively cools
the skin and protects it.
Clinical features -
If the patient arrives with acute burn patient should be examined for signs of
dehydration, presence of heat cramps, increased body temperature, shallow breathing,
tachycardia, presence or absence of perspiration, semi or unconsciousness.
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TREATMENT:-
If the skin is hot skin should be cooled immediately with cold water. During
transport wrap the person with wet cloth. Closed moist dressing with appropriate anti-
bacterial agent is recommended. Suitable antibiotic agent and other supportive
treatment should be carried out.
If there is the sign of associated heat stroke patient should resuscitated and
transported to the hospital immediately. Cooling of the body should be carried out
rapidly (to reduce hyperthermia to prevent cerebral damage.) use of ice-packs if
available will be useful during the transit. Continuous monitoring of vital signs is
mandatory. Intravenous fluid replacement should be started immediately as in case of
post burn dehydration.
Classification of burn
Burns are classified into five different causal categories and depths of injury.
Causes include injury from flame, hot liquids, and contact with hot or cold objects,
chemical exposure and conduction of electricity.
The first three induce cellular damage primarily by the transfer of energy and
lead to coagulative necrosis. Chemicals and electricity cause direct injury to cellular
membranes in addition to transfer of heat.
According to cause,
According to cause,
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Third degree – full thickness injury through the epidermis and dermis into the
sub-cutaneous fat.
Fourth degree – injury through the skin and sub-cutaneous fat into the
underlying muscles or bone.
Burn depth -
The depth of a burn depends on the degree of tissue damage. Burn depth is
classified according to the degree of injury in the epidermis, dermis, sub-cutaneous fat
and underlying structures.
First- degree burns do not result in scarring, and treatment is aimed at comfort
with the use of topical soothing salves, with or without aloe, and NSAIDS agents.
Second- degree burns are divided into two types: superficial and deep. All
second-degree burns have some degree of dermal damage, and the distinction is based
on the depth of injury into this structure. Superficial dermal burns are erythematous
and painful; blanch to touch, and often blisters.
Examples include scald injury from overheated bathtub water and flash flame
burns. These wounds spontaneously re-epithelialize from the retained epidermal
structures in the rete ridges, hair follicles and sweat glands in 7-14 days.
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After healing, these burns may result in some slight skin discoloration over the
long term. Deep dermal burns into the reticular dermis appear more pale and mottled,
do not blanch to touch, but remain painful to pinprick. These burns heal in 14-35 days
by re-epithelialization from hair follicles and sweat gland keratinocytes, often with
severe scarring as a result of the loss of dermis.
Third- degree burns are full thickness through the epidermis and dermis and
are characterized by a hard, leathery eschar that is painless and black, white or cherry
red. No epidermal and dermal appendages remain; thus, these wounds must heal by
re-epithelialization from the wound edges. Deep dermal and full thickness burns
require excision and skin grafting to heal the wound in time.
Fourth- degree burns involve other organs beneath the skin, such as muscles,
bone. This is the deepest and most severe burns. They are potentially life threatening.
These burns destroy all layers of skin, bones, muscles, and tendons.
Burn size-
In young children and babies, head and neck are 21% of TBSA, each upper
extremity are 10% of TBSA, anterior and posterior aspects of the trunk are 13% of
TBSA, each lower extremities are 13.5% of TBSA, buttocks are 5% and groin
assumed as 1% of TBSA.
The “rule of palm” is another method to estimates burn size of a burn. The
palm of the person who is burned (not fingers or wrist area) is about 1% of the body
and then transposes that measurement visually onto the wound for a determination of
its size. Use the person’s palm to measure the body surface area burned.
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RULE OF NINE
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Skin lesions begin to appear after a heat exposure between 450C. and 700C.
Origin of burns can be thermal, electric or chemical. Thermal burns constitute the
major group with an incidence of 80% and present specific profile.
Electrical burns show a special feature, with two different types of lesion.
Electrical passage burns show an entry point and an exit point, mostly found on the
hand, foot, and palm of the hand. Chemical burns often present a combination of
chemical toxic effects on skin and thermal consequences.
PATHOPHYSIOLOGY:-
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Topical antimicrobials are still the first choice in the local treatment, and the
most used agent is silver sulfadiazine ointment. Size of the burn is also critical.
Increasing percentage of injury in relation to body surface area increases the mortality.
In adult 20% burn is serious and 40% burn is very serious more than 60% burns is
many times fatal.
Severe burns more than 40% of the TBSA are typically followed by a period
of stress, inflammation and hyper metabolism characterized by a hyper dynamic
circulatory response with increased body temperature.
This hyper metabolic response to burn injury lasts for 12 months after the
initial event. Immediate post-burn patients have low cardiac output. However, 3-4
days post-burn the cardiac output is more than 1.5 times that of healthy people where
as in paediatric burn patients heart rates is 1.6 times those of non-burn children.
Post-burn muscle protein is degraded rapidly causing, loss of lean body mass
and severe muscle wasting, leading to decreased strength and failure in complete
rehabilitation. Protein degradation persists up to 1 year after severe burn injury.
Severely burn patients have a daily loss of nitrogen of 20-25gm/sq. of burned area.
Septic patients have a profound increase in metabolic rates and protein catabolism, up
to 40% more compared with those with burns of a similar size who do not develop
sepsis. Catabolic patients are more susceptible to sepsis because of change in immune
system.
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Diminished blood volume and cardiac output result in decreased renal blood
flow and glomerular filtration rate. Angiotensin, aldosterone, and vasopressin reduce
renal flow leads to oliguria, which if untreated will cause renal failure. Early
resuscitation decreases renal failure and improves the associated mortality rate.
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Aim of burn wound care – To restore form, function, and feeling (psychological and
emotional recovery).
First-aid care –
The patient must be removed from the source of injury. Care must be taken to
ensure that the rescuer does not become another victim. The heat sources should be
removed. Flames should be doused in cool running water or smothered with a blanket
or by rolling the victim on the ground. Carefully remove burn clothes and quickly
assess the extent of burn.
Clothing can retain heat, even a scald burn, and should be removed as soon as
possible. Adherent materials such as nylon cloth should be left on. Tar burn should be
cooled with water, but the tar itself should not be removed. Immersion with running
tap water should be done immediately for 20 minutes because water cools the burn,
relieves pain and replace the fluid loss, removes noxious agents, and reduces oedema
by stabilising mast cells and release histamine.
Active cooling removes heat and prevents progression of the burn. This is
effective if performed within 20 minutes of the injury. {sabiston19}
Ice water should not be used as intense vasoconstriction can cause burn
progression. Cooling large area of skin can lead to hypothermia, especially in
children.
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Initial treatment: -
Initially, burns are sterile. Focus the treatment on speedy recovery and prevention of
infections. In every burn cases, there must be administration of tetanus toxoids
injection. Except in small burn, debride all bullae.
Excise adherent dead tissue and after debridement, gently cleanse the burned
area with 0.25% of chlorhexidine solution and 0.1% of cetrimide solution. Apply
antibiotic cream (silver sulfadiazine). Dress the burned area with petroleum gauze
Daily treatment –
Change the dressing daily (at least two times). Remove dead tissue or loose
tissue then inspect the wound carefully.
Urine output is simple and well accepted methods of monitoring a fluid intake.
Good urine output indicates adequacy of visceral perfusion. Hourly nasogastric
aspiration is useful to guide the state of peristalsis.
High pressures are present in renal failure and low pressure indicates
inadequate resuscitation.
Blood pressure drops when the fluid replacement is inadequate for long time
and then the system compensates by peripheral vasoconstriction and increased heart
rate. Peripheral oxygen saturation (Sp02) indicates pulmonary gas exchange.
Haematocrit (PCV) if done frequently can guide rehydration of the patient.
Restlessness indicates presence of cerebral hypoxia.
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Following a burn injury there is a loss of body fluid from a burn wound. It is
seen in the form of blister fluid. Blister fluid contains water, plasma protein and
carbohydrates as main ingredients. In severe burn this results in a deficit in circulating
blood volume leading to oligemic shock.
The initial rate can be rapidly estimated by the TBSA burned multiplied by the
patient’s weight in kg and then dividing by 8. Thus, the rate of infusion for an 80 kg
man with a 30% of TBSA burned would be
Crystalloid resuscitation –
They are also less expensive and another reason is that large protein molecules
leak out of capillaries following burn injury. Isotonic crystalloids like normal saline,
Ringer’s lactate, 5% dextrose solution are freely available.
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Colloid resuscitation –
Hypertonic saline –
Hypertonic saline has been effective in treating burn shock for many years. It
produces hyperosmolarity and hypernatremia. This reduces the shift of intracellular
fluid to extracellular space. Advantages include less tissue oedema and a decrease in
escharotomies and intubations.
Various formulae have been suggested for fluid replacement in burn patient by
many workers in the field with successful outcome.
EVANS FORMULA –
One third of fluid is given in first 8 hrs. One third of the fluid should be given
in next 16 hrs. And one third in subsequent 24 hrs. He used half amount as crystalloids
and half of the amount as colloid in the form of dextran.
PARKLAND FORMULA –
Half the amount is transfused in first 8hrs. and remaining half in next 16hrs.
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Escharotomy –
This can be recognised by numbness and tingling in the limb and increased
pain in the digits. Extremities at risk are identified either on clinical examination or by
measurement of tissue pressures greater than 40 mm Hg. If vascular compromise has
been prolonged, re-perfusion after escharotomy may cause reactive hyperaemia and
further oedema formation in the muscles, thus making continue surveillance of the
distal extremities necessary. Increased muscle compartment pressure may necessitate
fasciotomy.
Inhalation injury -
There is increase blood flow in the bronchial arteries to the bronchi along with
oedema formation and increases in lung lymph flow. There are increased neutrophils
in lung releasing proteases and oxygen free radicals, which can produce conjugated
dienes by lipid peroxidation.
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CRITERIA VALUE
PaO2 (mm Hg) <60
PaCO2 (mm Hg) >50
PaO2/PaCO2 <200
Respiratory/ventilator failure impending
Upper airway edema Severe
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Initially for breathing and coughing exercises and for chest physiotherapy to
maintain clear airway, to improve air entry particularly when smoke inhalation is
suspected and later on to prevent chest complications, a physiotherapists may be
called to help. Later active or active assisted exercises under the supervision are
recommended to maintain range of movements of the joints of upper and lower
extremities and to maintain muscle bulk in order to sustain exercise tolerance later.
Nutritional management:
Well-nourished patient with minor burn can withstand this loss by endogenous
supply of nutrients. However, in patients with moderate and major burn injury a
severe catabolic status develops. Those patients who have pre-existing mal-nutrition
cannot withstand this severe catabolic state.
Without adequate nutritional supports the burn patients rapidly lose weight and
show similar to prolonged starvation in short time. Enteral nutrition is usually
preferred to parenteral nutrition because of ease of administration, cost and it is much
less associated with complications.
Nutritional care of the patient should be started very early during the course of
treatment. Preferably on admission but at least within 48 hours of the burn injury
before the state of paralytic ileus has developed.
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management with indigenous drugs.]
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Whole proteins instead of Amino acids are available, cheap and convenient to
administer. When started early the body wasting is minimized, better immunological
status is achieved, healing time is reduced and overall recovery of the patient and the
period of hospitalization is greatly minimized.
Wound care –
After establishment of the airway and resuscitation, attention must be turned to the
wound. After assessment of extent and depth of the wounds, wound toilet and
debridement should be done. After the wound is dressed with an appropriate covering
it serves several functions.
Exposure/open method-
The wound is left open to dry. The necrotic tissue dries and forms an Escher. It
is the easiest methods but it is very uncomfortable, wound contamination occurs easily
and chances of septicaemia.
Closed method:
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 39
management with indigenous drugs.]
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adequate moisture, and comfortable to the patient. Extensive and deep burns will need
frequent dressing change.
ANTIMICROBIALS –
An untreated burns wound rapidly becomes colonized with bacteria and fungi
because of loss of normal skin barrier mechanisms. The antimicrobials are divided
into topical and systemic.
Topical antimicrobials:
This can be divided into two classes: slaves and soaks. Slaves are directly
applied to the wound with cotton and soaks are poured into cotton dressing on the
wound.
Systemic antimicrobials:
After burn wound excision, wound closure should be done. Various biological
and synthetic substrates have been used to replace the injured skin post burn.
Autograft from the uninjured skin remains the mainstay of treatment for many
patients. Because early wound closure using autograft may be difficult when full
thickness burn exceeds 40% of the TBSA.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 40
management with indigenous drugs.]
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Biobrane sheet is placed on the wound and becomes adherent in 24-48 hours
with dried wound transudate. This sheet becomes a barrier to moisture loss, and
provides a painless wound bed.
Biologic dressing includes xenograft from swine and allograft from cadaver
donors. This human skin performs the immunologic and barrier functions of the
normal skin. Thus, these biologic dressing are the optimal wound coverage in the
absence of normal skin.
BIOLOGIC DRESSING
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 41
management with indigenous drugs.]
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Laboratory findings –
Changes in blood-
Biochemical changes –
Electrolyte imbalance occurs in the form of low sodium chloride and high
potassium level in the blood. Hypoproteinaemia is due to excessive protein loss. There
will be rise in blood urea and creatinine level.
Rehabilitation –
Burn injury leaves behind many problems; physical, emotional and social.
Ideally the aim of rehabilitation should be to get the patient back to his/her original
occupation; child to go back to school, housewife to get to her home and kitchen and
worker to get back to his/her place of work.
Surgical rehabilitation:
In spite of all the care patient may develop deformities and disfigurement
leading to significant disability. There is enormous variety of these deformities. The
deformities of every patient and the requirement of their correction are different.
Surgical treatment cannot be standardized. Each situation may need a different
planning.
Psycho-social rehabilitation:
It should be start right from the beginning so that the patient is able to adjust
himself/herself to gradual and smooth recovery. There is a large variety of fear in the
patient’s mind. Fear of pain, uncertainty of recovery, development of ugly appearance,
disability. Both the patients and their relatives suffer from anxiety, due to various
problems associated with burn injury. The burn patients too need a lot of emotional
supports. It is necessary to make them understand that they should not lose their
proper concentration.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 42
management with indigenous drugs.]
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Social rehabilitation:
It is equally important after the patient is discharged from the hospital and gets
back to the society. If there are deformities, disfigurement or disabilities there is a
strong need of understanding from the other members of the family and the work
place. They should give encouragement to get the individual back into the normal
routine in spite of their shortcoming.
Endotoxins are liberated from gram-negative bacteria walls, and exotoxins are
released from both gram-positive and gram-negative bacteria.
Curling ulcer –
Only in 20% of the patients the disease may progress to frank gastric and
duodenal ulcers which usually become the first evident 96 hours after injury.
Curling’s ulcers are usually multiple and are found simultaneously in the stomach and
duodenum.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 43
management with indigenous drugs.]
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Acute pancreatitis –
This occurs in the patients with extensive burns with an incidence as high as
30% in those requiring treatment in intensive care unit. The peculiarity is that the
abdominal pain is often absent and this condition is only suggested by increasing fluid
requirement and new onset of hyperglycaemia. Treatment is nasogastric aspiration and
parenteral nutrition.
Myocardial infarction –
This may occurs in old burned individuals. Infarction usually occurs towards
the end of the 1 week after burn. It may be due to increased cardiac output at this time
exceeding the ability of the diseased heart to meet its own perfusion and infarction
occurs. All patients with major burns should be monitored electrocardiographically.
Pulmonary dysfunction –
Immunosuppression –
Skin grafting –
The goal of burn wound care is the timely closure of burn wound. It is the type
of skin graft surgery involving the transplantation of skin. The transplanted tissue is
called as a skin graft. It is done in extensive trauma, burns, wound. Skin graft is
employed after serious injuries when body skin is damaged.
It is of two types,
Thin layer is removed from a healthy part of the body like peeling of a potato.
Full thickness skin graft is risky.
The split thickness skin graft (auto graft) is directly applied to the area. During
the time interval between the eschar separation and the wound is ready for auto graft,
the open wound of granulation tissue can be temporarily covered with a heterograft or
homograft. This is called biologic or physiologic dressing.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 45
management with indigenous drugs.]
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This is the distinct from a graft, which does not have an intact blood supply
and therefore relies on growth of new blood vessels.
This is done to fill a defect such as a wound resulting from injury or surgery
when the remaining tissue is unable to support a graft, or to rebuild more complex
anatomical structures.
Classification:
I. Local flaps
II. Regional flaps
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 46
management with indigenous drugs.]
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Local flaps –
These are created by freeing a layer of tissue and then stretching the freed
layer to fill a defect. This is least complex types of flap. It includes advancement flaps,
rotation flaps, and transposition flaps, in order from the least to most complex.
With an advancement flap, incisions are extended out parallel from the wound,
creating a rectangle with one edge remaining intact. The rectangle is freed from the
deeper tissues and then stretched (advanced) forward to cover the wound.
A rotation flap is similar except instead of being stretched in a straight line, the
flap is stretched in an arc. The more complex transposition flap involves rotating an
adjacent piece of tissue, resulting in the creation of a new defect which must then be
closed.
Regional/interpolation flaps –
The freed tissue is moved over or underneath the normal tissue to reach the
defect to be filled with the blood supply still connected to the donor site via a pedicle.
This pedicle can be removed later on after new blood supply has formed.
E.X. DP for head and neck defect, TRAM for breast reconstruction.
Distant flaps –
These flaps are used when the donor site is far from the defect. Direct or tubed
flaps involve having the flap connected to both the donor and recipient sites
simultaneously forming a bridge.
This allows blood to be supplied by the donor site while a new blood supply
from the recipient site is formed.
Once this happens, the “bridge” can be disconnected from the donor site if
necessary, completing the transfer. This is the more complex types of flaps.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 47
management with indigenous drugs.]
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Tissue types –
Cutaneous flaps contain the full thickness of the skin and superficial fascia and
are used to fill small defects.
Fascio-cutaneous flaps add subcutaneous tissue and deep fascia, resulting in a
more robust blood supply and ability to fill a larger defect.
Musculo-cutaneous flaps further add a layer of muscle to provide bulk that can
fill a deeper defect.
[A clinical study on durdagdha w.s.r to second degree superficial burn and its 48
management with indigenous drugs.]