Burn Injuries

Epidemiology

• Tissue injury caused by thermal, electrical, or chemical agents

• Can be fatal, disfiguring, or incapacitating
• ~ 1.25 million burn injuries per year
• 45,000 hospitalized per year
• 4500 die per year (3750 from housefires)
• 3rd largest cause of accidental death
Risk Factors

• Fire/Combustion
• Firefighter
• Industrial Worker
• Occupant of burning structures
• Chemical Exposure
• Industrial Worker
• Electrical Exposure
• Electrician
• Electrical Power Distribution Worker
 Anatomy and
Physiology of Skin
Skin

• Largest body organ. Much more than a passive organ.

• Protects underlying tissues from injury
• Temperature regulation
• Acts as water tight seal, keeping body fluids in
• Sensory organ
Skin

• Injuries to skin which result in loss, have problems with:

• Infection
• Inability to maintain normal water balance
• Inability to maintain body temperature
Skin

• Two layers
• Epidermis
• Dermis
• Epidermis
• Outer cells are dead
• Act as protection and form water
tight seal
Skin

• Epidermis
• Deeper layers divide to produce the stratum corneum and also contain
pigment to protect against UV radiation
• Dermis
• Consists of tough, elastic connective tissue which contains specialized
structures
Skin

• Dermis - Specialized Structures

• Nerve endings
• Blood vessels
• Sweat glands
• Oil glands - keep skin waterproof, usually discharges around hair shafts
• Hair follicles - produce hair from hair root or papilla
• Each follicle has a small muscle (arrectus pillorum) which can pull the hair upright and
cause goose flesh
Burn Injuries
Burn Injuries

• Potential complications
• Fluid and Electrolyte loss  Hypovolemia (shock in severe cases)
• Hypothermia, Infection, Acidosis (due to decrease in body fluids)
•  catecholamine release, vasoconstriction
• Renal or hepatic failure
• Formation of eschar (black leathery skin)
• Complications of circumferential burn – COMPARTMENT SYNDROME (the
burn which will cover whole body part will compress on the compartments of
that body part leading to ischemia and necrosis of the muscle and the other
soft tissues) (eg: pressure on anterior compartment of forearm can lead to
necrosis of forearm and hand muscles and claw hand due to compression of
nerves and arteries)
Burn Injuries

• An important step in management is to determine depth and extent

of damage to determine where and how the patient should be
treated
• The following classification was given by Dupuytren.
Types of Burn Injuries

• Thermal burn
• Skin injury
• Inhalation injury
• Chemical burn
• Skin injury
• Inhalation injury
• Mucous membrane injury
• Electrical burn
• Lightning
• Radiation burn
Depth Classification

• Superficial
• Partial thickness
• Full thickness
Burn Classifications

• 1st degree (Superficial burn)

• Involves the epidermis
• Characterized by reddening
• Tenderness and Pain
• Increased warmth
• Edema may occur, but no blistering
• Burn blanches under pressure
• Example - sunburn
• Usually heal in ~ 7 days
Burn Classifications

• First Degree Burn

(Superficial Burn)
Burn Classifications

• 2nd degree
• Damage extends through the epidermis and involves the dermis.
• Not enough to interfere with regeneration of the epithelium
• Moist, shiny appearance
• Salmon pink to red color
• Painful
• Does not have to blister to be 2nd degree
• Usually heal in ~7-21 days
Burn Classifications

• 2nd Degree Burn

(Partial Thickness
Burn)
 Burn Classifications

• 3rd degree
• Both epidermis and dermis are destroyed with burning into SQ fat
• Thick, dry appearance
• Pearly gray or charred black color
• Painless - nerve endings are destroyed
• Pain is due to intermixing of 2nd degree
• May be minor bleeding
• Cannot heal and require grafting
Burn Classifications

• 3rd Degree Burn

(Full Thickness burn)
 Fourth degree burn

• Fourth-degree burns damage muscle, tendon, and ligament tissue,

thus result in charring and damage of the hypodermis.
• In some instances the hypodermis tissue may be partially or
completely burned away as well as this may result in a condition called
compartment syndrome, which threatens both the life and the limb
and the patient.
• Grafting is required if the burn does not prove to be fatal.
 FIFTH DEGREE

• Fifth-degree burns result in hypodermis being burnt off, leaving

blackened muscle, tendon, and ligament, with damage to compact bone,
and spongy bone.
• Fat, nerves, veins, arteries, arterioles, and venules have been destroyed
and the burn area is paralyzed as a result.
• Grafting or amputation is required, depending on the size of the burn
area.
• Sixth-degree burns leaving blackened bone and damaging marrow tissue,
these burns will definitely require amputation
• NEWER CLASSIFICATION
• A newer classification of "Superficial Thickness", "Partial Thickness"
(which is divided into superficial and deep categories) and "Full
Thickness" relates more precisely to the epidermis, dermis and
subcutaneous layers of skin .
• Is used to guide treatment and predict outcome.
Burn Injuries

• Often it is not possible to predict the exact depth of a burn in the

acute phase. Some 2nd degree burns will convert to 3rd when
infection sets in. When in doubt call it 3rd degree.
Body Surface Area Estimation

• Rule of Nines
• Adult

• Palm Rule
Body Surface Area Estimation

• Rule of Nines
• Peds
• For each yr over 1 yoa,
subtract 1% from
head and add equally
to legs
• Palm Rule
Burn Patient Severity

• Factors to Consider
• Depth or Classification
• Body Surface area burned
• Age: Adult vs Pediatric
• Preexisting medical conditions
• Associated Trauma
• blast injury
• fall injury
• airway compromise
• child abuse
Burn Patient Severity

• Patient age
• Less than 2 or greater than 55
• Have increased incidence of complication
• Burn configuration
• Circumferential burns can cause total occlusion of circulation to an area due
to edema
• Restrict ventilation if encircle the chest
• Burns on joint area can cause disability due to scar formation
Critical Burn Criteria

• 30 > 10% BSA

• 20 > 30% BSA
• >20% pediatric
• Burns with respiratory injury
• Hands, face, feet, or genitalia
• Burns complicated by other trauma
• Underlying health problems
• Electrical and deep chemical burns
Moderate Burn Criteria

• 30 2-10% BSA
• 20 15-30% BSA
• 10-20% pediatric
• Excluding hands, face, feet, or genitalia
• Without complicating factors
Minor Burn Criteria

• 30 < 2% BSA
• 20 < 15% BSA
• <10% pediatric
• 10 < 20% BSA
Thermal Burn Injury
Pathophysiology
• Emergent phase
• Response to pain  catecholamine release
• Fluid shift phase
• massive shift of fluid - intravascular  extravascular
• Hypermetabolic phase
•  demand for nutrients  repair tissue damage
• Resolution phase
• scar tissue and remodeling of tissue
Thermal Burn Injury
Pathophysiology
• Jackson’s Thermal Wound Theory
• Zone of Coagulation
• area nearest burn
• cell membranes rupture, clotted blood and thrombosed vessels
• Zone of Stasis
• area surrounding zone of coagulation
• inflammation, decreased blood flow
• Zone of Hyperemia
• peripheral area of burn
• limited inflammation, increased blood flow
Thermal Burn Injury
Pathophysiology

• Eschar formation
• Skin denaturing
• hard and leathery
• Skin constricts over wound
• increased pressure underneath
• restricts blood flow
• Respiratory compromise
• secondary to circumferential eschar around the thorax
• Circulatory compromise
• secondary to circumferential eschar around extremity
Inhalation Injury

• Anticipate respiratory problems:

• Head, Face, Neck or Chest
• Nasal or eyebrow hairs are singed
• Hoarseness, tachypnea, drooling present
• Loss of consciousness in burned area
• Nasal/Oral mucosa red or dry
• Soot in mouth or nose
• Coughing up black sputum
• In enclosed burning area (e.g. small apartment)
Inhalation Injury

• Burned or exposed to products of combustion in closed space

• Cough present, especially if productive of carbonaceous sputum
• Any patient in fire has potential of hypoxia and Carbon monoxide
poisoning
Inhalation Injury

• Supraglottic Injury
• Susceptible to injury from high temperatures
• May result in immediate edema of pharynx and larynx
• Brassy cough
• Stridor
• Hoarseness
• Carbonaceous sputum
• Facial burns
Inhalation Injury

• Subglottic Injury
• Rare injury
• Injury to Lung parenchyma
• Usually due to superheated steam, aspiration of scalding liquid, or inhalation
of toxic chemicals
• May be immediate but usually delayed
• Wheezing or Crackles
• Productive cough
• Bronchospasm
Inhalation injury

• Other Considerations
• Toxic gas inhalation
• Smoke inhalation
• Carbon Monoxide poisoning
• Thiocyanate poisoning
• Thermal burns
• Chemical burns
Chemical Burns

• Usually associated with industrial exposure

• patient needS decontamination before treatment
• Burning will continue as long as the chemical is on the skin
Chemical Burns

• Acids
• Immediate coagulation-type necrosis creating an eschar though self-limiting
injury
• coagulation of protein results in necrosis in which affected cells or tissue are
converted into a dry, dull, homogeneous eosinophilic mass without nuclei
Chemical Burns

• Bases (Alkali)
• Liquefactive necrosis with continued penetration into deeper tissue resulting
in extensive injury
• characterized by dull, opaque, partly or completely fluid remains of tissue

• Dry Chemicals
• Exothermic reaction with water
Chemical Burn Management

• Definitive treatment is to get the chemical off!

• Begin washing immediately - removal the patient’s clothing as you
wash
• Watch for the socks and shoes, they trap chemicals
Chemical Burn Management

• Liquid Chemicals
• wash off with copious amounts of fluid
• Dry Chemicals
• brush away as much of the chemicals as possible
• then wash off with large quantities of water
• Flush for 20-30 minutes to remove all chemicals
Chemical Burn Management

• Do not attempt neutralization

• can cause additional chemical or thermal burns from the heat of
neutralization
• Assess and Deliver secondary care as with other thermal and
inhalation burns
 Chemical Burn to Eye Management

• Flood the eye with copious amounts of water only

• Never place chemical antidote in eyes
• Flush using LR/NS/H2O from medial to lateral for at least 15 minutes
• Nasal Cannula
• IV Ad Set
• Remove contact lenses
• May trap irritants
Electrical Burns

• Usually follows accidental contact with exposed object conducting

electricity
• Electrically powered devices
• Electrical wiring
• Power transmission lines
• Can also result from Lightning
• Damage depends on intensity of current
Electrical Burns

• Current kills, voltage simply determines whether current can enter

the body
• Ohm’s law: I=V/R
• Electrical CURRENT follows shortest path to ground
• Low Voltage
• usually cannot enter body unless:
• Skin is broken or moist
• Low Resistance (follows blood vessels/nerves)
• High Voltage
• easily overcomes resistance
Electrical Burns

• Severity depends upon:

• what tissue current passes through
• width or extent of the current pathway
• AC or DC
• duration of current contact
Electrical Burns

• Most damage done is due to heat produced as current flows through

tissues
• Skin burns where current enters and leaves can be almost trivial
looking
• Everything between can be cooked
• Higher voltage may result in more obvious external burns
Electrical Burns

• Alternating Current (AC)

• Tetanic muscle contraction may occur resulting in:
• Muscle injury
• Tendon Rupture
• Joint Dislocation
• Fractures
• Spasms may keep patient from freeing oneself from current
Electrical Burns

• Contact with Alternating Current can also result in:

• Cardiac arrhythmias
• Apnea
• Seizures
 Electrical Burns

• In addition to contact burns, patients can also develop flash burns

when the current arcs near them
• Flame burns may occur when clothing ignites after exposure to electrical
current
Electrical Burns

• Lightning
• HIGH VOLTAGE!!!
• Injury may result from
• Direct Strike
• Side Flash
• Severe injuries often result
• Provides additional risk to EMS provider
• Weather capable of producing lightning is still in the area
Electrical Burns

• Pathophysiology of Injuries
• External Burn
• Internal Burn
• Musculoskeletal injury
• Cardiovascular injury
• Respiratory injury
• Neurologic injury
• Rhabdomyolysis and Renal injury
Radiation Exposure

• Waves or particles of energy that are emitted from radioactive sources

• Alpha radiation
• large, travel a short distance, minimal penetrating ability
• can harm internal organs if inhaled, ingested or absorbed
• Beta radiation
• small, more energy, more penetrating ability
• usually enter thru damaged skin, ingestion or inhalation
• Gamma radiation & X-rays
• most dangerous penetrating radiation
• may produce localized skin burns and extensive internal damage
Radiation Exposure

• Radiation exposure may result in:

• external injury
• contamination
• incorporation injury
• combined injuries
Radiation Exposure

• Effect of Injury dependent upon:

• duration of exposure
• distance from the source
• shielding
• At risk for delayed complications
• STUDY PATHOLOGICAL CHANGES, COMPLICATIONS, CLINICAL
FEATURES AND MANAGEMENT OF BURNS FROM NOTES – BURNS
FROM TIDY’S PHYSIOTHERAPY