Burns.pptx

Burns
Dr. Mohammad Masoom Parwez
Moderator: Dr. Swagata Brahmachari

Types of Burns
• Thermal injury
– Scald – spillage of hot liquids
– Flame burns
– Flash burns due to exposure of natural gas, alcohol, combustible liquids
– Contact burns – contact with hot metals/ objects/materials
• Electrical injury
• Chemical burns – acid/alkali
• Cold injury — frost bite
• Ionising radiation
• Sun burns

Classification of Burns
Depending on the Percentage of Burns
Mild (Minor):
• Partial thickness burns < 15% in adult or <10% in children
• Full thickness burns less than 2% TBSA
• Can be treated on outpatient basis
Moderate:
• Second degree of 15-25% burns (10-20% in children).
• Third degree between 2-10% burns.
• Burns which are not involving eyes, ears, face, hand, feet, perineum

Major (severe):
• Second degree burns more than 25% in adults, in children more than
20%.
• All third degree burns of 10% or more.
• Burns involving eyes, ears, feet, hands, perineum.
• All inhalation and electrical burns.
• Burns with fractures or major mechanical trauma

Depending on thickness of skin involved
First degree burn :
• epidermal burn alone
• present as erythema/redness only
• Typical example is sunburn
• very painful
• no blister formation
• resolves in 3-5 days without scarring

Second degree burn:
• involves epidermis and a portion of dermis
• further divided into superficial or deep
Second degree superficial: involvement of epidermis & papillary
dermis
• characterized by severe pain, hyperaesthesia and blister formation
• heals in 10-20 days with minimal scarring.

Second degree deep: or deep dermal burn
• involves epidermis, papillary dermis & a part of reticular dermis
• Wound is waxy white, soft & elastic
• heals in 3-5 weeks and usually causes hypertrophic scar
• danger of getting converted to full thickness due to infection or drying

Third degree burn: or full thickness burn
• involves the full thickness of skin, whole epidermis and dermis
• appears as tough, dry, inelastic, translucent & parchment like eschar
Fourth degree: Involves the underlying tissues— fascia, muscles, bones

Jackson Burn Wound Model
• Inner zone of coagulation: dead zone
• Outer zone of hyperaemia: reactive
zone of inflammation
• Middle zone of stasis: most important
zone, good first aid and wound
management significantly reduces
need of grafting

PATHOPHYSIOLOGY OF BURN SHOCK
Mechanism of thermal injury:
• Agent: Temperature & duration of exposure of the burning agent
• Host: Physical property of skin in the form of its thickness, water
content, pigmentation, presence of hair, oil, dirt all influence severity
of injury
• Environment: Temperature and humidity also determine the severity
of burn injury

Effects of Burn Injury
1. Shock due to hypovolaemia
2. Renal failure
3. Pulmonary oedema, respiratory infection, adult respiratory distress
syndrome (ARDS), respiratory failure
4. Infection by Staphylococcus aureus, beta haemolytic Streptococcus,
Pseudomonas, Klebsiella leads to bacteraemia, septicaemia. Fungal and
viral infections of dangerous types can also occur.
5. GIT: Hypovolaemia, ischaemia of mucosa, erosive gastritis—Curling’s
ulcer (seen in burns > 35%)

Effects of Burn Injury
6. Fluid and electrolyte imbalance
7. Postburn immunosuppression predisposes to severe opportunistic
infection
8. Eschar formation and its problems like defective circulation,
ischaemia when it is circumferential
9. Electrical injuries often cause fractures, major internal organ injury,
convulsions.
10. Development of contracture is a late problem. It leads to ectropion,
microstomia, disability of different joints, defective hand functions,
growth retardation causing shortening

Causes of death in burns
a. Hypovolaemia and shock
b. Renal failure
c. Pulmonary oedema and ARDS
d. Septicaemia
e. Multiorgan failure

BURNS-EXTENT & SEVERITY
Estimation of surface area
• Wallace Rule of 9
• Lund & Browder chart
• Rule of palm
• Berkow formula

Ten Commandments of Burn Management
1. Maintain circulation and blood pressure (shock management)
2. Maintain airway
3. Increase body resistance
4. Avoid bacterial toxemia
5. Avoid auto-toxemia
6. Watch for renal complications and multiple organ dysfunctions
7. Maintain nutrition
8. Abide by principles of biomechanical physiotherapy and rehabilitation
9. Attend to psychological, emotional aspects and counseling
10. Analyze factors for reducing mortality.

Immediate Care of the burn patient
Prehospital care
• Ensure rescuer safety
• Stop the burning process: Stop, drop and roll
• Check for other injuries
• Cool the burn wound: Cooling should occur for a minimum of 10 minutes
and is effective up to 1 hour after the burn injury
• Give oxygen
• Elevate: Sitting a patient up with a burned airway may prove life-saving in
the event of a delay in transfer to hospital care. Elevation of burned limbs
will reduce swelling and discomfort.

Hospital care
• Airway with C-spine Protection
a. Removing any burning agent, including chemicals.
b. Inspecting for singed nasal, facial and eyebrow hairs.
c. Looking for burns and edema around the head and neck.
d. Determining if there are circumferential burns to the chest which
may inhibit ventilation and require escharotomy.

Hospital care
Breathing
• Determine if the patient is moving air or not.
• Assessment of breathing includes:
a. Auscultating breath sounds,
b. Monitoring rate, depth and work of breathing, and
c. Monitoring for dyspnea and stridor.

Hospital care
Circulation
• appropriate vascular access: two veins with large caliber intravenous
catheters & initiate warmed fluids
• monitor heart rate and blood pressure
• initiate intraosseous infusion when unable to obtain vascular access
• Assess perfusion status by the following techniques:
a. Pulse check,
b. Capillary refill, and
c. Urinary output

Hospital care
Disability
• Detect if there are any manifestations of neurological deficits
Exposure
• total exposure of the patient to assess the severity of burns and initiate
treatment
a. Remove any burning agent, including chemicals
b. maintain a normal temperature by removing wet dressings and covering with
dry, sterile dressings
c. Begin re-warming the patient with blankets and warmed fluid. Ambient
temperature should be from 28° to 32°C (82° to 90°F).
d. Remove all jewelry

Additional Considerations for All types of Burn
Patients
Regardless of the patient’s age or type of burn, these treatment
considerations apply to all burn patients.
• Insert a gastric tube as directed by a physician.
• Monitor urinary output to assess fluid resuscitation by inserting an urinary
catheter and monitoring urine output (UOP) for amount and color.
• Electrical and inhalation injuries may require additional fluid during
resuscitation.
• Elevate the head of the bed 30 degrees.
• Elevate affected extremities.
• Administer a tetanus prophylaxis

Fluid resuscitation
• Correction of hypovolemic shock is essential and should be done as soon as
possible
• Main thrust remains to maintain intra vascular compartment, so that
cardiac output can be brought to normal
• Fluid of choice is Ringer Lactate
• In children with burns over 10% TBSA and adults with burns over 15%
TBSA, consider the need for intravenous fluid resuscitation
●● If oral fluids are to be used, salt must be added
●● Fluids needed can be calculated from a standard formula
●● The key is to monitor urine output

Parkland formula
Superficial burn/flame/scald:
• Adult: 2 x body weight x TBSA
• Child <14 yrs: 3 x body weight x TBSA
• Infant/ child <30kgs: 3 x body weight x TBSA with dextrose containing
maintenance fluid
• Half in 1st 8hrs and remaining half in 16 hrs
• Ideal urine output: 0.5-1cc/kg/hr for adults and 1-1.5cc/kg/hr for
children

Parkland formula
Deep burns/ electrical burns:
• Irrespective of age: 4 x body weight x TBSA
• and urine output 1-1.5cc/kg/hr
• Here if myoglobinuria is present, give fluids till myoglobinuria is cleared
In children maintenance fluid must also be given. This is normally dextrose–
saline given as follows:
●● 100 mL/kg for 24 hours for the first 10 kg;
●● 50 mL/kg for the next 10 kg;
●● 20 mL/kg for 24 hours for each kilogram over 20 kg body weight

Modified Brooke formula
• RL: 4 ml/kg/% burns in 24 hours (first half in first 8 hours)
• Colloid- none
Second 24 hours-
• Crystalloids- to maintain urine output
• Colloids- 0.3 ml to 0.5 ml/kg/burns in 24 hours

Evan’s formula
In first 24 hours-
• Normal saline 1 ml/kg/% burns
• Colloids 1 ml/kg/% burns
• 5 % dextrose in water, 2000 ml in adult.
In second 24 hours-
• Half of the volume used in first 24 hours.

• Fluids used are normal saline, ringer lactate, Hartmann fluid, plasma.
• Ringer lactate is the fluid of choice
• Blood is transfused in later period (after 48 hours)
• First 24 hours only crystalloids should be given
• Sodium is assessed by formula:
• 0.52 mmol × kg body weight × % body burns, given at a rate of 4.0 to
4.4 ml/kg/hour

• After 24 hours up to 30-48 hours, colloids should be given to
compensate plasma loss (colloids are one which are retained in
intravascular compartment)
• Plasma, haemaccel (gelatin), dextrans, hetastarch are used
• Usually at a rate of 0.35-0.5 ml/kg/% burns is used in 24 hours

Colloid resuscitation
• Human albumin solution (HAS) is a commonly used colloid
• Proteins should be given after the first 12 hours of burn because,
before this time, the massive fluid shifts cause proteins to leak out of
the cells
• The most common colloid-based formula is the Muir and Barclay
formula:
●● 0.5 × percentage body surface area burnt × weight = one portion;
●● periods of 4/4/4, 6/6 and 12 hours, respectively;
●● one portion to be given in each period

Monitoring of resuscitation
• Urine output should be between 0.5 and 1.0 mL/kg body weight per
hour
• If the urine output is below this, the infusion rate should be increased
by 50%
• If the urine output is inadequate and the patient is showing signs of
hypoperfusion (restlessness with tachycardia, cool peripheries and a
high haematocrit), then a bolus of 10 mL/kg body weight should be
given
• patients should not be over-resuscitated and urine output in excess of
2 mL/kg body weight per hour should signal a decrease in the rate of
infusion

Wound management
Initial burn dressings
• Burn wounds are dynamic and change in appearance, particularly in the
first 48 hours
• the initial burn dressing should be one that can remain intact for 48 hours
and prevent infection
• Nanocrystalline silver dressings (eg Acticoat), slowly release silver, which is
toxic to microorganisms, to the burn wound bed
• apply a secondary dressing on top
–– wet gauze, followed by dry gauze and a bandage or adhesive dressing
–– this outer dressing can be re-moistened, allowing the dressing to continue
releasing silver ions for several days

Burn dressings after 48 hours
• After 48 hours, the silver dressing is removed and an assessment of
the burn injury is made
• Although silver dressings are toxic to bacteria, there is some in vitro
evidence that they inhibit keratinocytes and fibroblasts, which could
potentially prolong healing times
• Dressings that can be used after this time are:

Hydrocolloids (eg Duoderm [15 x 15 cm thin/thick]; Granuflex)
–– crosslinked adhesive dressings of gelatin, pectin and
carboxymethylcellulose
–– good for low/moderate exudating burns – contacts and holds
exudate as a gel inside the dressing
–– appropriate for all burn depths
–– water repellent and conformable
–– use thin hydrocolloids for paediatric dressings but thick
hydrocolloids for adults

• Foams (eg Allevyn [silver 10 x 10 cm]; Biatain [silver 10 x 10 cm];
Mepilex [silver 10 x 10 cm; plain 10 x 10 cm])
–– highly absorbent foam dressings suitable for highly exudating burns
–– available in plain and silver
–– absorb exudate well and therefore help to manage and prevent
hypergranulation and maceration
–– reduce requirement for dressing changes due to wet dressings

Alginates (eg Algisite M [10 x 10 cm]; Kaltostat)
–– highly absorbent, biodegradable dressings derived from seaweed
and contains calcium
–– use on moist granulating tissue or small superficial dermal areas of
burn
–– good for haemostasis if fragile/superficial bleeding
–– good for moderately-to-highly exudative sloughy wounds – becomes
a gel on contact with wound exudate
–– useful under a retention dressing such as Fixomull or Hypafix
need to soak with water or oil to remove alginates

• Hydrogels (eg Intrasite [8 g]; Hydrosorb [10 x 10 cm])
–– hydrophilic interactive dressings with very high water content
–– able to donate water to the burn and rehydrate dry eschar or
necrotic slough and absorb exudate also
–– good for dry or sloughy burns, which need some debridement
–– good for all burn depths but especially mid-dermal to deeper burns
–– no harm to granulation tissue or epithelialisation

Nutrition in Burns
• All patients with burns should start oral feeds as soon as possible
• Oral fluids given should be 1/4th of daily normal requirement and this
should be slowly increased to normal daily requirement which should
include extra water loss from burn surface

Nutrition in Burns
• Protein should form 25% of energy requirement of burn patients
• 50% of energy requirement as carbohydrate
• Adults may be given 5 mg/kg/min and children 5-7 mg/kg/min
• In adults 4% and in children 2-3% of total energy requirement should
be met with fat
• Patient should be regularly weighed and patient must not be allowed
to lose weight for more than 5%

Nutrition in Burns
• Burns patients tend to develop low immunity both humoral and
cellular, therefore immuno-modulators are given to these patients
• A good protein diet containing Glutamine, Arginine and other
micronutrients like vitamins, iron, calcium, zinc, selenium, copper &
intravenous immunoglobulins especially IgG & IgM given to burn
patients has shown to improve their survival

Monitoring and control of infection

Deformities and Contractures
Causes of post burn deformities and contractures:
1. Loss of organ or tissue due to very deep burn
2. Loss of special organs like nose, ear, eye, eyelids, hands, feet, external genitalia
etc
3. Limbs are amputated due to vascular compromise, more common in electrical
burn
4. Delay in resurfacing of the raw area
5. Use of very thin split skin graft
6. Lack of use of Postoperative pressure garment and appropriate splints
7. Recurrent ulceration in the area of burn
8. Lack of physiotherapy and occupational therapy
9. Involvement of the muscles, tendons and joints

Prevention of Deformities and Contractures
An integral part of burn management
• active physiotherapy of all major joints and these joints should be kept in
optimum positioning
• Neck should be placed in slight extension without lateral rotation and in
alignment with the thorax
• Axilla should be kept at 90 degree abduction
• Shoulder in 10 degree flexion and neutral rotation
• Elbow should be kept in extension and mid prone position
• Wrist at dorsiflexion, MCP AT 90 degree flexion, IP joint at neutral and
thumb at abducted extended and opposed position

Treatment for Contracture
• Release of contracture surgically and use of skin graft or “Z” plasty or
different flaps
• Proper physiotherapy and rehabilitation is essential.
• Pressure garments to prevent hypertrophic scars.
• Management of itching in the scar using aloe vera, antihistamines
and moisturizing creams

Prevention of complication and rehabilitation
of burn victims
• Majority of contractures can be prevented if they are given splintage
and physiotherapy
• Gross deformation of hands and knees are because of not using
splints
• These contractures would require surgical correction in order to
restore optimum position
• Use of compression garment helps in reducing hypertrophy by
increasing local oxygen demand

Surgery in Burns
• Any deep partial-thickness and full-thickness burns, except those that
are less than about 4 cm sq, need surgery
• Burn of indeterminate depth should be reassessed after 48 hours
• For most burn excisions, subcutaneous injection of a dilute solution of
adrenaline 1:1 000 000 or 1:500 000 and tourniquet control are
important for controlling blood loss
• In deep dermal burns, the top layer of dead dermis is shaved off until
punctate bleeding is observed and the dermis can be seen to be free
of any small thrombosed vessels

RECENT ADVANCES
• Advanced technology, newer drugs and skin substitutes are the major
advances in burn care
ReCell (Avita Medical, UK): small samples of skin taken and suspension
of individual skin cell created.
• Within 30 mins, this sample can be sufficiently sprayed on an area 80
times larger than the sample tissue
StrataGraft (Stratatech corps, Madison): intended for more severe
burns.
• Mimics natural human skin with both dermal and epidermal layers
• Easily sutured or stapled and remain intact in the wound bed

Sources
• Bailey and Love Short Practice of Surgery, 27th edition
• Sabiston Textbook of Surgery, 20th edition
• Schwartz Principles of Surgery, 10th edition
• SRB manual of Surgery, 3rd edition
• Practical Handbook of Burns Management, Govt of India (MoHFW)
• Burn Clinical Practice Guidelines, Texas EMS Trauma Division
• Burn Dressings, FOCUS, AFP Vol 36, March 2017, Royal Australian
College of General Practitioners, 2017

Burns.pptx

More Related Content

What's hot

Similar to Burns.pptx

More from masoom parwez

Recently uploaded

Burns.pptx