AL-NAJAH UNIVERSITY

BURN INJURIES

MOHAMED HASAN
SAIFY
 Definition
 Burn is a wound caused by exogenous agent leading to
coagulative necrosis of the tissue.
– The mucosa of the upper GI system (mouth, esophagus, stomach)

can be burned with ingestion of chemicals

– The respiratory system can be damaged if hot gases, smoke, or

toxic chemical fumes are inhaled

– Fat, muscle, bone, and peripheral nerves can be affected in

electrical injuries or prolonged thermal or chemical exposure

– Skin damage can result in altered ability to sense.
 Burn Classification - Cause
 The primary cause of burn injury is exposure to
temperature +++ extremes

– Heat injuries are more frequent than cold injuries

– Cold injuries almost exclusively result from frostbite

 Electrical and chemical injuries constitute 5-10% of burn

injuries and are largely the result of occupational accidents
 Burn Classification - Depth
 Old terminology  New terminology
– 1st degree: only the – Superficial: only the
epidermis epidermis
– 2nd degree: epidermis and – Superficial partial
dermis, excluding all the thickness: epidermis and
dermal appendages dermis, excluding all the
– 3rd degree: epidermis and dermal appendages
all of the dermis – Deep partial thickness:
– 4th degree: epidermis, epidermis and most of the
dermis, and subcutaneous dermis
tissues (fat, muscle, bone, – Full thickness: epidermis
and peripheral nerves) and all of the dermis
Burn Classification - Depth
 Superficiel (first degree)
Epidermal tissue only.

Dry and red,blanches with pressure, no blisters.

Painful.

Healing within 7 days.

Unusual visible scar.

Sunburn, brief flame or flash.

Not considered in calculation of TBSA

 Superficiel partial thickness (2nd degree)

Epidermis and part of the papillary dermis.

Intact appendages : hair follicles, sweat glands, sebaceous glands

Pale pink, blanches with pressure, fine blistering.

Very Painful (exposed nerves).

Prevent wound progression.

Healing within 14 days.

Color match defect, hypertrophic scar.

Scald, short flash.

 Deep partial thickness (3d degree)

Epidermis, entire papillary dermis, down to reticular dermis.

Dark pink to blotchty red

 Painful or reduced/absent sensation.

Healing within 14-21 days.

Hypertrophic scar +++.

Surgery.

Scald, flame, oil or grease.

 Full thickness (4th degree)

Entire thickness and possibly deeper.

White, no blisters, may be dark

 Insensate .

No Healing .

Surgery+++.

Scald, flame, chemical, high voltage.

 Burn Classification - Extent
 Extent
– Burn injuries are also
classified in terms of the
percentage of the skin
surface injured (TBSA)
– A relatively simple, but not
totally accurate, method for
determining the extent of
injury is the rule of 9s
– The ABA classification
system describes burn
injuries as mild, moderate,
or major
Burn Classification – Extent
Lund & Browder
– Lund and Browder
 More accurate
 Children ++
 Divides body into
small areas
 Estimates proportion
each area contributes
 Takes more time and
effort to calculate
than Rule of Nines
method
 Pathophysiology of Burn
Injury
 Pathophysiology refers to the complex chain of
mechanisms that occur in the skin (local effects)
and in other organ systems (systemic effects)
when a burn injury occurs, as well as what
happens as the skin regenerates and heals
 Local effects
 Circulatory disruption at the site of burn .
 Occluded vessels = Blood flow decreases.
 Blood vessels thrombosis - necrosis.
 Three zones : coagulation-stasis-hyperemia
 Skin regeneration and scaring.
 Systemic effects
 Fluid shift :
 Initial vasoconstriction then dilatation .
 Leak of fluid into interstitial space.
 Third spacing syndrome.
 Decreased blood volume and blood pressure.
 Within 12 hours, continu up to 36 hours
 Systemic effects
 Fluid imbalances :
 As a result of fluid shift and cell damage .
 Hypovolemia.
 hyponatremia
 hyperkalemia.
 Metabolic acidosis.
 Hemococentration due to dehydratation.
 Systemic effects
 Fluid remobilization :
 After 24-36 hours .
 Capillary leak stops.
 Fluid shifts from interstitial into vascular space.
 Blood volume increases - diuresis.
 Body weight return to normal.
 hypokalemia.
 Systemic effects
 Cardiac :
 Decreased cardiac output
 Pulmonary :
 Respiratory insufficiency
 Respiratory failure
 Gastrointestinal :
 Decreased or absent motility
 Curling’s ulcer
 Curling’s ulcer
 Acute ulcerative gastroduodenale desease .
 Within 24h after burn.
 Reduced GI blood flow and mucosal damage.
 Treatement : H2 blockers, mucoprotectors and enteral
nutrition.
 Hemorrhage+++.
 Burn Treatment
– Respiratory care
– Administration of fluids
– Wound care (debridement)
– Pain control
– Plastic surgery (eg: skin
grafts)
– Monitoring for
complications
 Infections
 Cardiovascular
 Respiratory
– Massage & Physical therapy
massage video
– Posttraumatic stress
 Burn Treatment
 Pre hospital care :
– Stop burning process.

– Cool the burn wound.

– ABC (airway, breathing, circulation) check.

– Give oxygene.

– Elevate.

– Check for other injuries.

 Burn Treatment
 Hospital care :
– A: airway control.

– B:breathing and ventilation.

– C: circulation.

– D: disability – neurological status.

– E: Environmental control ( heat loss).

– F: fluid resuscitation.
 Burn Treatment
 Hospital care :
 Circumstances surrounding burn injury.
 Past medical history.
 Medication, drug allergies, tetanus status.
 Dry weight.
 Height.
 Body surface area and nutritional needs.
 Burn Treatment
 Admission to a burn unit :
– Suspected inhalation injury.
– Require fluid resuscitation (15-20% TBSA).
– Hand, face, feet or perineum.
– Psychiatric or social background.
– Suspicion of non – accidental injury.
– Extremes of age.
– Electrical or chemical burn.
 Burn Treatment
 Inhalation injury :
 A history of being trapped in the smoke or gazes
 Lips, face, neck, ears,eyes.
 Cough, difficult swallowing.
 Expiratory sounds: wheeze, stidor.
 Flexible bronchoscopy.
 CO poisining.
 Burn Treatment
 Inhalation injury :
 Treatement :
 High-flow humidified oxygene
 Early intubation.
 Cricothyroidotomy;
 Fluid resuscitation

 If oral fluids salt.

 IV fluids if :

-Children over 10% TBSA.

-Adultes over 15% TBSA.

 Standard formula.
 Fluid resuscitation
 Parkland formula :
 TBSA * weight (kg) * 4 = volume (ml).
 Half this volume first 8 hours.
 The second half in the subsequent 16 hours.

 Assessement :
 Urine output (0.5-1 ml/kg/hr).
 Urine osmolarity.
 Most used

 Crystalloid : Ringer Lactate.

 Hypertonic saline.
 Human albumin solution.
 Colloid resuscitation.
 Complications

 Over resuscitation :

 Poor tissue perfusion.

 Compartement syndrome.
 Pulmonary edema.
 Pleural effusion.
 Electrolyte abnormalities.
 Treating The Wound

 Escharotomy :

 Circumferentialfull-thickness burns to the limbs.

 Mechanical block to breathing.

• Along medial or lateral surfaces.

• Avoid bony prominences.
• Avoid tendon, nerves and major vessels.
 Escharotomy
Uppe limb : midaxial, anterior to the elbow, avoid
ulnar nerve
 Escharotomy
Hand : midline in the digits.
 Escharotomy
Lower limb : mid- axial , posterior to the ankle,
avoid saphenous vein.
 Escharotomy
Chest :
 Treating The Wound
Debridement :
 Early debridement: (1-3 days) post burn.
o Interrupts and attenuates the systemic
inflammatory response and normalize immune
function.
 Tangential excision : 7 days post burn
Debridement
 Blisters

– Intact blisters : barriere to microbes.

– Moist environement more rapid

reepithelialization.
– More rapid angiogenesis.

– Rupture under contaminated conditions increase

infection rate.
 Analgesia

– Small burns : oral anesthesia.

– Large burns : intravenous.

– Contineous analgesia with oral tablets in the

subacute phase.
 Nutrition
• Extra feeding.

• NG tube if burns over 15% of TBSA.

• Acheiving healing.

• Stop the catabolic drive.

• Sutherland formula :

• Children :60 kcal/kg + 35 kcal % TBSA.

• Adultes:20 kcal/kg + 70 kcal % TBSA.

 Control of Infection
 Local sings:
 Excessive drainage with odor.
 Ulceration of health skin.
 Erythematous nodular lesions in unvolved skin.
 Coversion of partial thickness injury to full-thickness.
 Sloughing of grafts.
• .
 Control of Infection
 General sings:
 Altered level of consciousness.
 Changes in vital signs.
 Oliguria.
 GI dysfunction.
 Metabolic acidosis.
 Dresssing
 Standard dressing : petrolatum or wax
impregnated gauze
• Topical antimicrobial (silver sulfadiazin++)if:

• Partial to full thickness burn

• Large surface area involvement

• Contamination with foreign materials

• Immunodepression
 Surgical Treatement
 Early debridement and grafting +++.
 Deep and full-thickness wounds.
Burn Scars - Keloid
Burn Scars - Hypertrophic
Burn Scars - Contracture
Burn Scars - Contracture
Burn Scars - Nonraised
Skin Graft Scars
 Functional Limitations
 Acute Limitations
– Patients may experience delirium that precludes their

participation in treatment
– Edema, pain, bulky dressings, and immobilizing splints

impair the person's ability to perform usual daily activities

– Sleep is frequently disrupted

– Anxiety and fear can be present

 Functional Limitations
 Postdischarge Limitations
– The most frequent functional limitations

involve scarring and joint contracture

– Other functional sequelae may result in

permanent impairment
Rehabilitation Burn Treatment
 Postdischarge
– Wound care continues
– If there is a risk of hypertrophic scarring, or it
has already started, continuous pressure applied
to the area will prevent its progress
– Garments need to be worn 20 hours per day for
up to 1 year - uncomfortable, hot, and
unattractive
– Contracture control continues.
Rehabilitation Burn Treatment
 Postdischarge
– Reconditioning and strengthening exercises
begin
– Counseling is a possibility to work on
emotional difficulties that have resulted from
the burn injury
– Reconstructive surgery may be needed if the
functional or cosmetic limitations are not
responsive to rehabilitation treatment
THANK YOU