الفهرس 
Epidemiology of burnOnly 14 pages are availabe for public view
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Abstract
Summary
Burn-related injuries are a major global public health problem. The risk
of burns is highest in low income and lower middle income countries. In
high income countries, an increased risk of burns is found in minority
populations, and in lower socioeconomic households. Flame/fire and
scalds are the most common type of burn in adults and children. Children
and elderly are at the highest risk of unintentional burns. While most
burns are unintentional, child abuse, deliberate self-burning and personal
violence are not uncommon. Approximately 90 percent of all burn-related
deaths occur in lower middle income (LMC) or low income countries
(LIC), while 3 percent occur in high income countries (HIC). For those
who survive the burn injury, there is the added burden of a permanent
disability and economic hardship for the victim and the family.
The local and systemic inflammatory response to thermal injury is
extremely complex, resulting in both local burn tissue damage and
deleterious systemic effects on all other organ systems distant from the
burn area itself. Although the inflammation is initiated almost
immediately after the burn injury, the systemic response progresses with
time, usually peaking 5 to 7 days after the burn injury.
A burn is defined as a traumatic injury to the skin or other organic tissue
primarily caused by thermal or other acute exposures. Cutaneous burns
are classified according to the depth of tissue injury. A thorough
estimation of burn size is essential to guide therapy. The extent of burns
is expressed as the total percentage of body surface area (TBSA). The
estimation of percent total body surface area includes partial-thickness,
full-thickness, and fourth degree burns. Superficial burns are not included
in the TBSA burn assessment. The most accurate method of assessment
of TBSA burn in children and adults is the Lund-Browder chart.
Multiple organ dysfunction syndrome (MODS) is a progressive disorder
that commonly occurs in acutely ill patients and exists in a continuum
with the systemic inflammatory response syndrome (SIRS) which affects
most patients with a severe burn, with or without an infection. The risk of
MODS increases with burn wounds >20 percent TBSA, increasing age,
Summary
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male gender, sepsis, hypoperfusion, and underresuscitation. Immediate
fluid resuscitation upon admission to the emergency department is the
fundamental approach to preventing acute kidney injury. Early renal
failure can occur as a consequence of underperfusion and
underresuscitation. A second period of risk occurs 2 to 14 days after the
initial resuscitation, and is most likely related to sepsis. Gut mucosal
atrophy occurs in the absence of intraluminal feeds and is another cause
of gastrointestinal failure after severe burn injury. Early enteral nutrition,
started 24 to 48 hours after burn injury, is one of the only therapies shown
to decrease this complication. Depression and post-traumatic stress
disorder (PTSD) are the most common psychologic problems, occurring
in 13 to 23 percent and 13 to 45 percent of patients, respectively.
Management of a patient with a severe burn injury is a long-term process
that addresses the local burn wound care as well as the systemic,
psychologic, and social consequences of the injury. The patients that
should be transferred to a burn center as soon as stabilized include:
Partial-thickness burns more than 10 percent of the total body surface
area (TBSA) and burns involving the face, hands, feet, genitalia,
perineum, and/or major joints. Concomitant burns and trauma (eg,
fractures) in which the burn injury poses the greater immediate risk of
morbidity and mortality.
If the trauma poses the greater immediate risk, the patient may be initially
stabilized in a trauma center before being transferred to a burn unit.
Physician judgment is necessary in these cases and should be in
conjunction with the regional medical control plan. Acute management in
the ICU includes continuation of respiratory support, fluid resuscitation,
cardiovascular stabilization, pain control, and local management of burn
wounds initiated in the emergency department. The goal of the ICU care
is to maintain end-organ perfusion and prevent burn shock. Inpatient
management focuses on wound healing, enteral nutrition, and
rehabilitation. Long-term management includes management of longterm
wound complications (eg, contractures), optimization of nutritional
support, and psychosocial support to return to work and for re-immersion
into society.
Summary
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The goal of reconstructive surgery for the burn patient is to restore
function then cosmesis. There are special challenges for reconstruction of
burns. A balance must be achieved between immobilization to allow for
skin grafts or tissue flaps to heal and mobilization to restore function.
Split thickness skin grafts (STSG) are more versatile than full thickness
skin grafts (FTSG) and are used to reconstruct large burn wound areas
and close donor flap sites. FTSG result in a more satisfactory esthetic
appearance due to their pliability. The use of dermal regeneration
templates (biosynthetic skin substitutes) has increased the number of
reconstructive options for burn surgeons.
The common purpose of these skin substitutes is to replicate the
properties of normal skin by adding a dermal component to the
reconstruction that is supplemented with a thin split skin autograft. Tissue
expansion is a technique that expands an area of skin in preparation for its
use as coverage of a burn defect or contracture. Tissue expansion occurs
by prolonged, gradual stretching of skin by inserting prosthesis into an
area of unburned skin immediately adjacent to the area to be covered.
Flap reconstruction is the ideal option if tissues are available. Flaps for
reconstruction can be classified according to circulation, composition,
contiguity, and contour.
STSG donor sites are managed intra-operatively by meticulous
hemostasis and infiltration of a long lasting anesthetic to provide longterm
postoperative pain relief. Covering the STSG donor site wounds
(DSW) with a hydrocolloid dressing when such products are available
because of the faster re-epithelialization. For clinical settings where
hydrocolloid dressings are not available, alternative dressings include
polyurethane film, alginate, or paraffin gauze. FTSG donor sites and flap
defects are managed by meticulous hemostasis and primary wound
closure, without tension. Facial transplantation procedure is a new and
controversial reconstructive technique that offers hope to patients with
severe facial burns, along with a lifetime requirement of
immunosuppressive therapy.