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A friend, relative or stranger may rescue the victim of a serious burn accident.
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The decisions made and the treatment given at the scene of the accident – especially the quality of the first aid - has often had a profound effect on mortality and morbidity
(British Burns Association 2001, p. 17).
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Flame burns must be smothered.
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Cold water applied continuously over the burnt area relieves pain and limits the depth of the burn
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CHEMICAL BURNS
Contaminated clothing must be removed and copious quantities of running water applied to the area. Neutralizing agents need to be identified and applied accordingly.
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SCALDS pain.
Cold water can limit the extent of the damage and reduce the
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ELECTRICAL BURNS,
The patient may require CPR before attention can be paid to the injury. Unlike heat burns, these injuries do not spread and it is sufficient to cover the area with a clean cloth that has been soaked in clean cold water
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MINOR BURNS
These are defined as less than 10% surface area in a child or less than 15% in
an adult. If the injury is noncomplex these injuries are cleaned with chlorhexidine and covered with a bactericidal non-stick dressing.
The patient can rest at home and, depending on local circumstances, the dressings are changed every 2-3 days.
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MAJOR BURNS
These are injuries that involve 10% or more of the body surface area in children and 15% or more in an adult.
If the injury is complex the patient will be admitted to the burns unit or intensive care unit
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 Removal of victim from fire or agent
 Check airway
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Evaluation of associated injuries
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REMOVE THE VICTIM FROM THE FIRE
 Wrapping patient in a clean sheet or blanket
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Rolling the in on the ground or immersion into lake or river are not recommended because of possibility of massive contamination.
 Remove the victim from contact with electricity either by disconnecting the source or by using a non conductor to move the victim from the point of contact.
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Irrigating the affecting area with water( cold water for a period 15-20 min). in case of chemical burn
N.B. The use of cold water to
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Decrease pain
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Decrease inflammatory response
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Decrease exudation
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CHECK THE AIRWAY
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Insertion of oropharangeal airway, if the patient is unconscious and the tongue appears to be obstructing airway.
Insertion of an endotracheal airway in upper airway obstruction cases.
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Evaluation of associated injuries:
Rapid check of patient's thorax, upper and lower limbs and abdomen.
Observe fractures and dislocations.
Lock for head injuries.
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Resuscitation
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<20% oral fluid
20-50 % I.V. lines in un burned area
50-60 % or more two I.V. lines in burned and non burned
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Transportation
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The patient should be transported to the nearest medical facility
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Management in emergency room and triage
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Check airway and vital signs
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Re-evaluate the presence or absence of associated injuries.
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Evaluate total burn size
Triage.
Triage:
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Decision making with regard to admission or discharge (It is the process of determining the priority of patients' treatments based on the severity of their condition)
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Indications of some cases that need admission to hospital
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Burn larger than 15% of total body surface in adult or
10 % in children
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All burns which have a third degree.
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Burns of face, hands and perineum.
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All electrical and chemical burn.
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MODERN BURN CARE MAY BE DIVIDED INTO THE FOLLOWING 4
GENERAL PHASES:
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THE FIRST PHASE, initial evaluation and resuscitation, occurs on days 1-3 and requires an accurate fluid resuscitation and thorough evaluation for other injuries and comorbid conditions.
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THE SECOND PHASE, initial wound excision and biologic closure, includes the maneuver that changes the natural history of the disease. This is accomplished typically by a series of staged operations that are completed during the first few days after injury.
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THE THIRD PHASE, definitive wound closure, involves replacement of temporary wound covers with a definitive cover; there is also closure and acute reconstruction of areas with small surface area but high complexity, such as the face and hands.
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THE FINAL STAGE of care is rehabilitation, reconstruction, and reintegration. Although this begins during the resuscitation period, it becomes time-consuming and involved toward the end of the acute hospital stay.
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EPIDERMAL HEALING:
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Occur on the surface of the wound
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The intact epithelium attempts to cover an exposed wound through ameboid movement of cell from basal layer of surrounding epidermis into wound.
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The epithelial cells stops migration when they are completely in contact with other epithelial cells.
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After this contact inhibition - cells can begin to divide and multiply through mitosis.
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Dryness is common
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DERMAL HEALING
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Scar formation occurs
Divided in to 3 phases: Inflammatory, Proliferative, Maturation a) INFLAMMATORYPHASE:
 begins at time of injury ends in 3-5 days. Characterized by inflammatory reactions, redness, warmth, edema, pain, decreased ROM.
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Initially there is decreased blood flow, platelets aggregate and Fibrin is deposited.
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Later Vasodilatation occurs, leukocytes infiltrate ,presence of macrophages, attracts Fibroblast.
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b) PROLIFERATIVE PHASE:
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Re-epithelialization occurs at the surface
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In deep wound Fibroblast migrates ,which synthesis Scar tissue.
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During this period of Fibroplasia, the tensile strength of the wound increases at a rate proportional to the rate of collagen synthesis.
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Wound contraction occurs
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Reduction in the number of Fibroblast
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Remodeling of collagen
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Collagen becomes more parallel in arrangements and forms stronger bonds
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If rate of collagen production exceeds breakdown then hypertrophic scar may result.
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Keloid is large firm scar that overflows the boundaries of original wound. It may lead to Functional and cosmetic deformities
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EARLY HOSPITAL MANAGEMENT (INCLUDING THE SHOCK PHASE)
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Maintenance of a clear airway
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Pain relief
Assessment of TBSA
Maintenance of fluid balance
Removal of adherent clothing
Covering of the Burns with sterile cotton dressings
Reassurance and explanation to the patient
Transfer to a burns unit or admission to an intensive care unit.
(Whether the person is sent to the operating theatre for shaving of burns and grafting depends on the depth of the burns, the age of the patient and whether the patient is fit for surgery.)
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Resuscitation
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Fluid replacement is administered over a 36-hour period (from the occurrence of the burn, not the time of arrival at hospital).
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The volume of plasma required by the burns patient is related to the TBSA and the size of the patient (Evans et al. 1952; cited by Settle 1986, p. 14).
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To calculate the volume of fluid required for resuscitation, the following formula is used (Muir and Barclay 1962):
mL of plasma = TBSA x age of patient.
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It varies according to the experience of the staff and facilities available.
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The two main themes are 'open' or 'closed'.
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OPEN METHOD
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This method leaves the wound exposed. If exudate is cleaned away regularly, the area dries out. Bacterial growth is inhibited and this method is used for areas that are difficult to dress, such as the
face. Healing of the epithelium tends to be slower than with the closed method.
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CLOSED METHOD
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The primary layer of dressing is non-adherent, for example petroleum jelly gauze. This is then covered with layers of absorbent cotton gauze, held in place by crepe bandages or net.
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With bandages securing the dressings the patient may be able to begin to
mobilize about the ward with the aid of the physiotherapist. Silver sulfadiazine is commonly used.
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When a hand is affected, a polythene bag containing chlorhexidine may be placed over the hand and bandaged to the forearm. The patient is able to regularly exercise the hand freely through full range of motion. The bag is changed daily or more frequently if indicated by large amounts of exudates collecting in the bag. The bag is changed to dry dressings at the nurse's discretion.
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ESCHARECTOMY
It is surgical removal of the dead, burnt skin by a method of excision or shaving.
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SKIN GRAFTING
Involves covering the open tissues with a layer of split skin.
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Z- PLASTY
Surgical correction of Scar contracture. It serves to lengthen a scar by interposing normal tissue in the line of the scar.
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Grafting is the closure of a burn wounds with skin tissue. The closure may be temporary or permanent depending on the tissue chosen.
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Involves covering the open tissues with a layer of split skin.
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Skin graft: It is nonvascular skin transfers may be divided into two groups.
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A) Split-thickness skin graft.
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B) Full-thickness skin graft
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Grafts are kept in position with petroleum jelly gauze and bandages, and splints can be applied to immobilize the joints adjacent to the grafts
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Skin is usually removed with a dermatome
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Indications for Skin Grafts:
1) To achieve temporary cover
A) Close an open wound
B) Prevent infection
C) Hasten initial healing
D) Prevent exposure of underlying structures
2) For definitive cover:
A) Provide permanent skin replacement which is supple sensate and durable.
B) To resurface areas of scarring or contracture.
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1. Auto graft: It is skin transferred from one area of the body to another. This should provide permanent cover.
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2. Allograft (homograft): It is skin from another human (possibly a cadaver) is used. This provides only temporary cover until an auto graft is available.
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3. Xenograft (heterograft): This uses animal (e.g.) pig skin or porcine and is also only a temporary cover (donor- site).
N.B.
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- The most common way to close a deep burn wound after removal of eschar is with the use of non vascular skin transfers
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A) A split - thickness skin graft (STSG):
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Include the epidermis and any portion of the dermis.
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The Donor sites of the split thickness skin graft are generally obtained from the thigh, buttock, or abdomen.
B) Full thickness skin graft (FTSG):
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Includes the epidermis and entire dermis.
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All subcutaneous fat is removed from the dermis to improve the survival of the graft.
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The Common donor site includes the groin and the medial aspect of the
arm because the residual scar is hidden.

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SHEET GRAFT{ Skin is applied without alteration following harvesting from donor site usually in face, neck, hand}
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MESH GRAFT – When limited skin is available ,meshing of a graft consist of processing sheet graft that makes tiny parallel incision in a linear arrangement. This process permits Skin graft to be expanded before applying. Allow coverage of large area. Skin graft is held by sutures, staples, steri-strips.
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Pressure dressing facilitates
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DONOR SITE is the site where skin is taken {Thigh, Buttocks, back)
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(1) The split thickness graft undergoes secondary
(Late) contracture when it contracts as it heals, pulling the wound margins inward.
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(2) Both Types of grafts can be held in place with sutures, staples, or tape.
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(3) Meshing the graft is helpful in improving survival where moderate serous drainage is expected.
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(4) Where grafts may be exposed to shear forces, "tie
- over" dressing are useful.
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(5) Donor Site: Skin harvesting from the scalp in children can be recommended as first choice. The
Advantages, especially the rapid epithelialization and the lack of visible scars, over come the problems and the risks .
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The healing skin grafts can be divided into three phases.
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1. The first phase: the phase of serum imbibition begins immediately ,after placing the graft on the wound bed. Because there are no vascular connections, nutrients fluid supplied by
diffusion of serum from the bed. The graft is held in place only by weak fibrin and fibronectin bonds.
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2. Second phase: at 24-48 hours new capillaries start invading the skin graft making the phase of revascularization.
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3. Third phase: the phase of organization starts at 4-5 days when collagen linkages are made between the wound bed and the graft to create firm attachments.
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Factors Affecting Wound Healing:
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1. Age: affects wound repair. The rate of healing appears to slow with increasing age.
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2. Infection: infection lead to healing failures.
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3. Nutritional factors; nutrition is of extreme important factor for wound healing.
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4. Vitamins: vitamins are important for normal tissue repair as vitamin C, A, E, B, (Thiamine) and B2 (pantothenic acid).
Trace elements are metals: that are needed for enzyme function.
As iron, zinc, copper, manganese calcium, and magnesium. Shortages in trace elements may contribute to impair healing.
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6. Oxygen:
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Adequate blood supply is essential for healing. Oxygen is required to supply the energy for high metabolic needs healing wound.
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Poor vascularity essentially translates into hypoxia.
7. Diseases causing impaired wound healing:
Diabetes alters healing.
Chronic renal failure and liver failure lead to impaired healing
Malignancy lead to healing abnormalities
8. Other causes of impaired healing:
 Steroids drugs altered healing.
 Chemotherapy agents lead to impair healing.
 Radiations
 Drug that alter immune system
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Wound problems due to grafting on an inadequately prepared or unsuitable bed.
A vascularity.
Infection.
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Graft problems:
Early:
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Failure of take due to inadequate contact between graft bed. ( Inadequate fixation
(shearing)
Hematoma
Failure of take/graft lysis due to infection
Late:
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Avoidable scarring/contracture
Excessively expanded mesh graft
Graft insensate - Graft too thin for permanent cover
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Donor Site Problems:
Failure to heal Infection
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CIRCULATION: Provides a nutritive supply to graft
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INOSCULATION: Process by which direct connection is established between a graft and host vessels (within 72 hours)
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PENETRATION of the host vessel into graft site
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Initially , structural connections are Fibrous, Collagen is then laid down to secure the attachment of the graft.
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