Dr.

Moraya Alqahtani FRCSC

Dr. Moraya Alqahtani

 “We restore, repair, and make whole
those parts . . . which nature has given
but which fortune has taken away.”

Gaspar Tagliacozzi (1545-1599)

Dr. Moraya Alqahtani

 Outline
Hand: trauma and  Skin Cancer
REconstruction Maxillofacial Surgery
Reconstructive surgery
Soft Tissue Infections
Microsurgery
Pediatric Plastic 
Pressure Sores and Leg 
Ulcers Surgery
Cosmetic Surgery
•Wound Healing
•Burns

Dr. Moraya Alqahtani

Dr. Moraya Alqahtani
 Wound Healing
Inflammation 

Tissue attempts to stop bleeding (coagulation), 

remove necrotic tissue and debris

Early: PMNs (phagocytes) 

Late: Macrophages 

Dr. Moraya Alqahtani

 Proliferation 
Components- angiogenesis, fibroplasia, 
epithelialization

Predominant cell- Fibroblasts 

Formation of granulation tissue 

Dr. Moraya Alqahtani

 Wound Healing
Maturation 
Collagen cross-linking, 
scar maturation,
strength plateaus at 80%
of normal
Lasts 3 weeks to 1 year 
Equilibrium between 
collagen synthesis and
degradation
Wound contraction and 
remodeling

Dr. Moraya Alqahtani

Myofibroblasts
Responsible for wound contraction 
Contain microfilaments similar to smooth 
muscle cells
Implicated also in Dupuytren’s 
contracture

Dr. Moraya Alqahtani

 Hypertrophic Scar
Exuberant scar 
confined to margins
of original wound
Red, raised 
Responds to steroid 
injection, silicone
gel/pressure dressing,
scar revision once
mature

Dr. Moraya Alqahtani

 Keloid
Scar tissue overflows 
beyond wound margins
Common over upper 
chest, shoulder, earlobes
Pigmented skin 
Treatment- steroid, 
radiation, surgery
High recurrence rate 

Dr. Moraya Alqahtani

 How to achieve an aesthetic scar
Debride non-viable wound edges 
plan incisions along Langer’s lines 
Atraumatic technique 
Approximate, don’t strangulate edges 
Avoid tension on skin closure- use dermal sutures 
Choose finest suture possible for given wound 
Remove sutures in timely fashion 
Prevent infection! 

Dr. Moraya Alqahtani

 Lines of Relaxed Skin Tension

Dr. Moraya Alqahtani

Dr. Moraya Alqahtani
 Aims of burn care
Rescue Rehabilitate
Resuscitate Reconstruct
Refer Review
Resurface

Dr. Moraya Alqahtani

 Aims of burn care
Rescue Rehabilitate
Resuscitate Reconstruct
Refer Review
Resurface

Dr. Moraya Alqahtani

 Primary survey
Burn patient = Trauma patient 
A - Airway with cervical control 
B - Breathing 
C - Circulation 
D - Disability (neurological) 
E - Exposure with environmental control 

Dr. Moraya Alqahtani

 A: Airway
In-line cervical 
Options: immobilization when:
chin lift 
Mechanism suggests 
jaw thrust  C-spine injury
oropharyngeal 
Altered mental status 
airway
endotracheal  Distracting injuries 
intubation

Dr. Moraya Alqahtani

 Inhalational injury
Fire in enclosed space 
Full-thickness/deep dermal burns to 
face, neck
Singed nasal hair 
Carbonaceous sputum/particles in 
oropharynx

Dr. Moraya Alqahtani

 Burned airways
swell, so tube
early!

Dr. Moraya Alqahtani

 B: Breathing
Bilaterally breath sounds 
Rate and depth of respiration 
High flow O2 at 15L (100%) using NRB mask 

Dr. Moraya Alqahtani

C: Circulation
BP, HR, colour of unburnt skin 
2 large bore I.V.s in unburnt skin 
Draw bloodwork 
Doppler exam of circumferentially burnt extremities 

Dr. Moraya Alqahtani

 D: Disability
Use Glasgow Coma Scale or AVPU method: 
Alert 
Responds to Voice 
Responds only to Pain 
Unresponsive 

Dr. Moraya Alqahtani

 The confused burn patient
If not initially alert, think of other causes: 
Associated head injury 
CO poisoning 
Substance abuse 
Hypoxia 
Pre-existing medical conditions 

Dr. Moraya Alqahtani

 E: Exposure/Environmental control
Remove clothing and jewellery 
Log roll for burn extent, concomitant injuries 
Dry sheets, blankets, Bair Hugger 
Use warmed I.V. fluids (37-40oC) 

Dr. Moraya Alqahtani

 Secondary survey
History 
Thorough physical examination 
Radiologic, laboratory studies 
Adjuncts 

Dr. Moraya Alqahtani

 History taking
Take on admission, prior to airway swelling: 
Past medical history 
Current medications, vaccinations (tetanus) 
Allergies 
Most recent meal 
Smoking habits –may affect ABGs 

Dr. Moraya Alqahtani

 Timing
When did the injury occur? 
How long was the exposure? 
How long was any cooling applied? 
When was fluid resuscitation 
initiated?

Dr. Moraya Alqahtani

 Mechanism
Type of agent (scald, flame, electrical, chemical) 
Circumstances of contact 
Treatment provided so far 
Concomitant injury risk (fall, MVC, explosion) 
Inhalational injury risk (enclosed space) 

Dr. Moraya Alqahtani

 Specific injuries
Scald Electric
Chemical voltage
type of liquid
recently  • type of chemical flash/arci
boiled ng
Solute in  contact 
liquid time

Dr. Moraya Alqahtani

Abuse
Think of it, check for it! 
Suspect in vulnerable 
populations: children,
elderly, special needs
Mechanism ≠ injury 
Other injuries (healing #s) 
Thorough documentation 

Dr. Moraya Alqahtani

Physical examination
Concomitant injuries 
Pre-existing illnesses 
Neurologic deficits 

Dr. Moraya Alqahtani

 Investigations
General Electric Inhalational
•CBC •12-lead ECG •CXR
•electrolytes •cardiac •serial ABGs
enzymes (follow
•urea, Cr ± CK, base excess)
•urinalysis myoglobin •COHb
•INR, PTT
•blood group
•glucose
Dr. Moraya Alqahtani
 Adjuncts to secondary survey

Universal precautions 
Regular vitals, pulse checks 
NG tube (>20% TBSA) 
Foley (monitor resuscitation) 
Analgesia (I.V. morphine) 
Tetanus 
Psychosocial assessment 

Dr. Moraya Alqahtani

 Assessment of burn severity
Burn area estimate vital to resuscitation 
Superficial burns not included, so depth 
assessment important

Dr. Moraya Alqahtani

 Assessment of burn area
Poorly done, even by experts 
Palmar surface 
including fingers = 1% (0.8%) TBSA 
small burns (<15% TBSA), large burns 
(>85%, count unburnt areas)

Dr. Moraya Alqahtani

Wallace
rule of nines

Large burns in adults 

Dr. Moraya Alqahtani

Lund & Browder charts

Most accurate method 

Corrects for age 
differences

Dr. Moraya Alqahtani

 Depth of a burn
A dynamic wound 
Requires frequent reassessment 
Determines need for surgical management 

Dr. Moraya Alqahtani

 Determinants of burn depth
Temperature of agent 
Duration of contact 
Thickness of dermis (thin in young, old) 
Blood supply (low BP, diabetics, cooling) 

Dr. Moraya Alqahtani

Classification of burn depth

Dr. Moraya Alqahtani

 Clinical assessment of burn depth
Superfici Superfici Deep Full
alSpontaneous
al partial Variable
healing
partial
Pin prick Brisk Brisk ,
Delayed Excision
None
bleeding
excision &
Sensation Painful Painful &
Dull grafting
None

Appearan Red, Dry, grafting

Cherry red Dry,
ce glistenin whiter if large white,
g leathery
Blanching Yes, Yes, No No
to
Dr. Moraya Alqahtani
brisk slow
 Resuscitation regimens
Replace losses to maintain homeostasis 
Formulas ONLY GUIDELINES 
Monitor physiologic parameters 
Maintain tissue perfusion, prevent  depth 
Too little fluid = hypotension = renal failure, etc. 
Too much fluid = edema = tissue hypoxia 

Dr. Moraya Alqahtani

 A balancing act

Too little fluid Too much fluid

Dr. Moraya Alqahtani

 A balancing act

Too little fluid

Too much fluid

= edema
= tissue hypoxia

Dr. Moraya Alqahtani

 A balancing act

Too much fluid

Too little flu

= hypotension
= renal failure, etc.

Dr. Moraya Alqahtani

 Fluid shifts
First 8-12 hrs: ++ intravascular  interstitial shift 
Fast fluid boluses: no benefit ( hydrostatic P) 
Colloid: ? benefit acutely (++ capillary leakage) 
>15% TBSA in adults, >10% in children, elderly require formal 
resuscitation

Dr. Moraya Alqahtani

 Parkland formula
Total fluid requirement in first 24 hours =
4 mL x (TBSA (%)) x (body weight (kg))
50% given in first 8 hours FROM INJURY 
50% given in next 16 hours 

Dr. Moraya Alqahtani

 Pediatric resuscitation
Use Parkland formula + MAINTENANCE fluid 
For maintenance fluid, hourly rate of 
4 mL/kg for first 10 kg of body weight plus
2 mL/kg for second 10 kg of body weight plus
1 mL/kg for >20 kg of body weight
End point: urine output of 1.0-1.5 mL/kg/hr 

Dr. Moraya Alqahtani

 Electrical injury resuscitation
Fluid needs greater (= inhalational burns) 
9 mL x (%TBSA) x (kg) in first 24 hrs 
If myoglobinuria, may require bicarbonate infusion to 
alkalinize urine to pH > 8
End point: urine output of 1.5-2 mL/kg/hr 

Dr. Moraya Alqahtani

 Monitoring
Regimens just estimates, follow clinical parameters (urine 
output, BP, HR, RR)
Bloodwork q4-6h: CBC, serum sodium, base excess, lactate 
Invasive cardiac monitoring and splanchnic CO2 may give 
more accurate parameters

Dr. Moraya Alqahtani

 Initial burn wound management
Early transfer to burn centre (first 24 hours): 
Remove smoldering, non-adherent clothes 
No debridement or topical agents 
Clean, dry sheets, Bair Hugger 
Silver sulfadiazine or mafenide acetate cream 
bid

Dr. Moraya Alqahtani

Escharotomies and fasciotomies
At risk groups: 
Deep circumferential limb or truncal 
burns
High voltage electric injuries 
Delayed resuscitation 

Dr. Moraya Alqahtani

 Escharotomies and fasciotomies

Signs and symptoms: 

Cyanosis of distal unburnt limb skin 
Unrelenting deep pain 
Progressive paresthesias 
Progressive decrease, absence of pulse 

Dr. Moraya Alqahtani

Circumferential extremity burns

Dr. Moraya Alqahtani

Indications for Transfer to a Burn Unit
>10% BSA (2nd and 3rd deg) in age <10, >50 
>20% BSA ages 10-50 
>5% 3rd deg burns 
Burns affecting cosmetically important areas- hand, 
face, genitalia
Inhalation injury 
Electrical, extensive chemical burns 
Medical comorbidities 

Dr. Moraya Alqahtani

Depth of a Burn

Dr. Moraya Alqahtani

Depth of a Burn

Dr. Moraya Alqahtani

Escharotomy

Dr. Moraya Alqahtani

Escharotomy

Dr. Moraya Alqahtani

Dr. Moraya Alqahtani