Burns “Burnis atissue injury due to application of thermal energy in any form to the external or internal body surfaces" Classification: ‘Superficial partial thickness burn: Epidermis and dermis upto gaillary layer. Pink and moist. no or little fixed capillary staining. sensations normal. no treatment Deep partial thickness burn: not mosit, abundant fixed capillary stainingless sensations no treatment, hypertrophic scarring Full thickness burns: hard leathery, complete angesthesi Major determinants: Percentage of TBSA Presence of an inhalational injury Depth of burn Respiratory tre Circumferential burn Age less than 2 or more than 60 Complications: ‘Acute: hypovolemic shock, ARF , ARDS Delayed: Malabsorption, curling ulcers, compartment syndrome, infections, Late: scar, contracture , merjolin ulcer Severity Catagorization: Major burn: ‘Adults - Partial thickness more than 25% or deep more than 10% Children - Partial thickness more than 15% or deep more than 10% Moderateburn: Adult -Partial thickness 15 - 25% or deep <10% Children Partial thickness 10-15% or deep < 10% Minor Burn: Adult -Partial thickness <15% or deep <2% Children - Partial thickness <10% or deep <2% involvementManageme Prehospital: ‘Stop process ATLS Cooling if minor Oxygen Elevation of affected limb Circulatory resuscitation: if burn >15% TBSA, Parkland formula = %éage burn x body weight x 4 ml 1/2 in first 8 hours, rest in next 15 hours Mount yernon Formula : weight x % burn /2 ——- for 6 hours Treatment of Burn wound: Cleaning, dressing, excision [for full thickness] Iver sulfadiazine, silver nitrate, mafenide acetate, serum nitrate NSAIDs, Morphine n: >20% TBSA - NG tube Analgesi Energy balance and nutri Infection Prophylaxis Tetanus prophylaxis Physiotherapy , psychotherapy, nursing Gastric decompression: if want to travel Non-thermal Burn Injuries: Chemical injuries: Progressive damage. acid cause coagulative necrosis , alk liguifactive necrosis Remove clothing.Flush thoroughly with water. Electrical Burns Low tension, high tensionGrafts and flaps Graft - without blood supply , Flap - with own vascular bed Autograft: same person : feel i allograft: same species xenograft: different species Graft types: Split skin / Partial thickness graft -0.25 mm Full thickness graft Composite graft- having two ue Flap : Flap isa unit of skin and other viable tissues which is transferred from its original position to another site while maintai own blood supply through a pedicle Classification: According to blood supply: Random pattern flaps Axial pattern flaps According to location: Local Flap: Advancement flap zplasty Distant flap Free flap According to tissue type: flaps Muscle flaps Composite flapsBlood Transfusion Temperature : 2-4¢ Can be stored for 41 days with CPD-A1 Increase in potassium 1 me / day due to RBC destruction increased lactic acid and pyretic acid Less O2 and increased CO2 factors viable only for 24 hours One pint - 1 gram [0.8 mg] 7 ml/kg = 1 gram /dl Rate 40 drops/ min Platelet : can be stored at 22°C for 4-7 days Complications: 1) Transfusion Reactions Acute immune hemoh reaction Delayed hemolytic reaction Non immunogenic hemolytic Allergic Febrile reactions - within 24 hours Graft versus host jury 2) Overloading and CCF 3) Air embolism - 100 cc jon of ciseases 5) Potassium toxicity - give calcium gluconate , 25% d/w with insuli 6) Citrate toxicity - Ca gluconate 7) Metabolic acidosis 8) Hypothermia 9) Hyper ammonemia 10) Thrombophlebitis 11) Bleeding diathesis VY VV VY VV isease - within a month to immuno compromised bicarbs, salbutamolMassive Blood Transfusion : Replacement of a patient's totel blood volume in less than 24 hours Auto transfusion: Pre-deposite Blood salvage heemodilution DIC : Decreased PT, APTT, BT, protein C, protein S. Schistiocytes, thrombocytopenia , creased FDP , D-dimersAnaesthesia General Anaesthesia: Triad of unconsciousness, loss of pain, muscle relaxation Steps Induction : Inhalational [sevoflurane] , I/V [Propofol] Intubation : suxamethonium [1.5 mg/kg muscle relaxant] Maintenance : oxygen + nitrous oxide + sevoflurane + atracurium Monitoring Recovery : oxygen + neostigmine / atropine TIVA : Propofol + fentanyl only Complications: Related to intubation Related to drugs Related to respiration General complications Local Anaesthesia: > Ugnoceine 3mg / kg, 7 mg /kg with adrenaline , dont use if taking MAO inl TCA. lasts 1-2 hrs > Bupivacaine : Cardiotoxic, most potent > Prilocaine: methaemoglobinemia. Biers block surgery Complications: Local: Infection , hematoma Systemic: arrythmial lignocaine] , cardiotoxicity [bupivacaine] , mehamoglobinemia[prilocaine]Local Anesthesia Types: Infiltration: C/I infections, clotting disorders Topical. Plexus Block. Id Block. VVVVVYVY Epidural Pain Relief Blocking sites : NSAIDs, ibuprofen, diclofenic ranscutaneous Electric Nerve Modulation & perception : Opioids , diamorphine, fentanyl Pain Relief Ladder by WHO: Step 1: NSAIDs + paracetamol Step 2: NSAIDs + paracetamol + codeine Step 3: Paracetamol + NSAIDs + I/M morphine Step 4: Paracetamol + NSAIDs + /V morphine ulation, local anaestheticsGangrene & Amputation Macroscopic death of tissue is called gangrene. Causes: © Secondary to arterial obstruction © Infective © Traumatic Types: © Drygengrene- slow arterial occlusion * Wet gangrene - rapid arterial occlusion Gas gangrene - severe form Synergistic Gangrene: Gangrene due to mixed pattern of organisms Maleney's gangrene : Abdominal wall Fournier's gangrene : Perineal area Amputation: Removal of the whole or part of an arm / hand or aleg / foot. They are incicated when partor whole of the limb isdead, deadly or dead loss. * Dead: Gangrene, irreversible © Deadly : life threatening [wet gangrene, cellulitis, neoplasm, fistula] * Dead loss : severe trauma , contracture or rest pain Types of amputation: Toe : at the shaft of proximal phalanx Ray:: at neck of metatarsal Usfrance : disarticulation b/w metatarsal and tarsal bones Chopert : disarticulation of talonayicular and calcenocuboid joint ‘Syme: tibia and fibula divided above ankle Guillotine: at same level, without closure of skin . severe infection Below knee amputation: 8-12 cm from tibial tuberosity. fibula transected a bi tibia, Posterior flap 1 to 1.5 times diameter of limb Above knee amputation: For foot gangrene with skipped areas. Lenght of stump not less than 20cm and 12 cm proximal to knee joint igher thanWounds and Healing Abreak in the continuity of tissue is called wound. Categories: Abrasions avulsions - degloving injuries, Contusions Crushing injuries - necrotizing fasciitis , compartment and reperfusion syndrome Cuts Lacerations Missile wounds Puncturesand bites Rank & Wakefield's classification: Tidy wounds: sharp , clean edges. Untidy wounds: dirty , contaminated. debridement. Phases of Wound Healing: ° Proliferative /Regenerative / Reparative Phase: Epithelializ. © _ Inflammatory / Reactive Phase : Platelet plug and coagulation. Limits injury. 2-5 days n, fibroplasia, angiogenesis. 2 days to 3 weeks ° Maturational / Remodeling Phase: Matrix contraction . Scar tissue maturation. 3wk-2yr Types of Wound Healing: By Primary Intention : Approximation of clean edges. No complications By Secondary Intention: Contaminated, tissue loss By Tertiary Intention : Delayed primary closure : cleaning , ,debridement, closure after 3-7 days Secondary Suture: Open for morethan 10 daysInhibiting Factors: DIDNTHEAL Diabetes , Infection, Drugs, Nutrition , Tissue necrosis, Hypoxia, Excessive tension, Another wound, Low temperature Ulcer: A wound which is chronic Scar: A fibrous mark left on the skin after a surface injury or wound has healed is called scar Keloid: An abnormal scar that grows beyond the boundaries of the original site of skin injury. Hypertrophicscar: A widened or unsightly scar that does not extend beyond the original boundaries of the wound.Hemorrhage & Shock lypes of hemorrhage On the basis of vessel Arterial: Bright red, increasing and decreasing with pulse, spurting Venous: Darkred, steady , copious Capillary: Bright red, oozing On the basis of time Primary : At the time of injury or operation Reactionary : within 24 hrs, due to vasodilation or ligature slip Secondary: After 7-14 days, due to infection Site: External hemorrhage and internal hemorrhage Blood Volume Measurement: Adult : 65 -75 ml /kg Child : 80-85 ml/kg Clenched fist size clot : 500 ml, Fracture of femur : 500-2000 ml Tachycardia is earliest sign of blood loss. 30% blood loss causes drop in BP Treatment: Arrest of hemorrhage: Pressure and packing Position Tourniquet Adrenalinesoaked gauze Bone wax Diathermy Surgical Ligation Main Artery Ligation Therapeutic embolizationReplacement of blood loss : Upto 20% by crystalloids. Then by transfusion Indications of CV Lin © Toguide fluid therapy in hypovolemia © For TPN © Monitoring of fluid therapy © Haemodialysis Shock: State of hypotension accompanied by hypoperfusion of the tissues caused either by decreased supply or inability of tissues to use oxygen sufficiently to meet metabolic requirement of the body Types: * Hypovolemic - blood loss orinadequate blood volume * Cardiogenic * Neurogenic * Septic © Vasogenic Stages of Hypovolemia: > Covert hypovolemia : 10-15% loss. no signs and symptoms > Overt hypovolemia : Reflex mechanism active. Tachycardia , palor , cold skin , tachypnea , no BP change > Decompensated hypovolemia : BP falls, Pulses impalpable, Bradycardia Goals: = CVP:6-12 mmHg = Urine output > 0.5 mi/kg/hr = Mixed venous saturation > 70%Surgical Infection Invasion of an organism , through the tissues following a break of local and systemic host defenses. Surgical Site Infection : Infection of surgical wound Types: © Superficial Incisional: Only skin or $/C tissue. Within 30 days, o Deep inci: deep soft tissue. o Organ/ space: within 30 days , or within 1 yr if implant present. SIRS: at least two of following should be positive o Hyperthermia / hypothermia o Tachycardia or tachypnea o WBC >12000 or <4000 Sepsis : Systemic disease caused by organisms or toxins in the blood Infection according to source: Primary : From community or endogenous Secondary : From operation theatre , ward Major wound infection : pus discharge , systemic signs, late return to home Minor wound infection : only pus discharge Classification of Surgical Wounds: Class 1 / Clean : no respiratory , GU or GIT breach Class 2 / Clean-contaminated: Respiratory , GIT , GU breach , minimal spillage Class 3 { Contaminated : GIT , GU , Respiratory breach, maximum spillage Class 4/ Dirty : Pus is found at site Therapy for 5-7 days with antibiotics if response is good Decisive Period : within 4 hrs of breach as during this period organisms growBrodie's Abscess : Formation of pus in the bone in chronic osteomyelitis. Ludwig's Angina : Cellulitis of submandibular and submental region with inflammatory edema of the mouth,Putrid halitosis is characteristic. Boil : Abcess of hair follicle due to pyogenic infection Carbuncle : infective gangrene of S/C tissue due to staph aureu! pathognomic Hidrade: Suppurativa: Recurrent abcess formation of the apocrine sweat glands in post puberty Paronychia : Infection of nail fold. Unguis Incarnatus: Ingrowing of toe nail. ribriform appearance isSterile Precautions Asepsis: Method of preventing contamination of wound and other sites by ensuring that only sterile objects and fluids come into contact with them. Anti-Septics: Chemicals used to kill microorganisms on the surface of skin and mucous membrane Decontamination: Eliminate or reduce vegetative forms of micro organisms and other unwanted materials Disinfection: A process intended to kill the micro organisms with exception of bacterial spores Methods of fection: Chemical Agents * Alcohol * Formaldehyde * 2% Glutaraldehyde [cidex] * 0.1% Sodium hypochlorite Physical Agents Low temperature steam : Drysteam at 73 °c for 20 min Boiling water : 100°c for 5 min Sterilization: Process of destroying all forms of microbial life including bacteria, viruses, spores, fungi Methods: © Steam [autoclay] : not suitable for heat sensitive objects. Temp 134°c for 3 min at 30 pound pressure OR 121°c for 15 min on 15 pound pressure Ethylene oxide: for heat and moisture sensitive materials Hot air ovens: for fine cutting edges instruments. Low tempsteamwith formaldehyde: dry steam + formaldehyde: at 73¢ Irradiation Paraceticaci oo0000 Denatures proteins , 50-56" cfor 12 min