BURN
Presented by:
Tasnuba Atique
Intern doctor
Surgery unit 5
Shaheed Suhrawardi Medical College and Hospital
Definition:


Burn may be defined as
a tissue injury due to
thermal application (heat
and cold), absorption of
physical e...
Prevalence:






Fire-related mortality rate is high in South-east
Asia: 11.6 deaths per 100,000 population per
year.
...
Risk factors:


Demographic:
 Age
 Sex
 Rural



and urban factors

Co-morbid conditions:
 Arthritis,

stroke
 Diab...


Socio-economic factors:
 Use

of open fire
 Wearing long, loose fitting clothes during cooking
 Use of open lamp
 S...
Causes of burn incident:











Scald- hot water, steam, cooking oil hot, hot
curry.
Flame burn
Contact with ...
Scald
Electrical burn
Entrance Wound: High
resistance of skin
transforms electrical
energy into heat, which
produces burns aroun...
Electrical burn
Exit Wound:
Current flows
through the body
from the entrance
point, until finally
exiting where the
body i...
Internal Injuries in electric burn

This worker was shocked by
a tool he was holding. The
entrance wound and thermal
burns...
Involuntary Muscle Contraction
This worker fell and
grabbed a
powerline to catch
himself. The
resulting electric
shock mum...
Chemical burn
Chemical burn
Chemical burn can
affect the eye
Chemical burn
Comments:A 22year-old man
employed in an
automobile battery
manufacturing
facility sustained
chemical burns
...
Chemical burn

Durjoy was made to drink acid
when he was a month old

A courageous acid attack
survivor provides a first-h...
Cold burn




Description: well demarcated
geometric red plaque with
discrete and confluent vesicles
and bullae
Comments...
Classification according to the
depth:
Epidermal burn
 Partial thickness- superficial (superficial
dermal)
 Partial thic...
Depth:








Epidermal burn: epidermis and very superficial
part of dermis
Partial thickness- superficial :
epidermi...
Tradititonally :
Cause:







Epidermal burn : sun burn, minor scald
Partial thickness- superficial : scald, minor flame
burn, contact...
Surface/colour:







Epidermal burn : dry, erythematous
Partial thickness- superficial : moist, reddish
colour with ...
Capillary return :





Epidermal burn: brisk
Partial thickness- superficial : brisk
Partial thickness- deep : sluggis...
Pain sensation:







Epidermal burn : burning sensation
Partial thickness- superficial : severe burning
sensation
Pa...
Healing time:





Epidermal burn : 3-7 days
Partial thickness- superficial : 10-14 days
Partial thickness- deep : 2-3...
First Degree
Sunburn
/epidermal burn
Second-degree burn of the hand
Second Degree/partial thickness Burn
Upper arm burn

121




Blisters show probable partial thickness burn.
Area without blister might be deeper partial
thic...
Deep Second Degree/partial thickness-deep Burn
Severe Hand/partial thickness-deep Burn
Third Degree/full thickness Burn on Finger
Full thickness burn:

Grounded sites of low-voltage injury
on the feet.

Electrical burns to the
hand.
Pathophysiology:









Most affected organ is skin –burn wound
Can also affect respiratory system- inhalation
inj...
Phases of thermal burn injury
Zones of Burn Wounds:






Zone of Coagulation
 devitalized, necrotic, white, no
circulation
Zone of Stasis ‘circulat...
Wound
excision until
fine punctate
bleeding
occurs
Inhalation injury:










Inhaled hot gases can cause supraglottic airway
burns and laryngeal oedema
Inhaled steam...
Inhalation
injury:
Role of nitric oxide
(NO) in the
pathophysiology of
smoke inhalation
injury.
Loss of hypoxic
pulmonary
...
American Burn Association Burn
Severity Categorization


Major burn injury
 Second-degree burn of > 25% body surface
are...
 Most

patients with the following:
 Inhalation injury
 Electrical injury
 Burn injury complicated by other major
trau...


Moderate uncomplicated burn injury
 Second-degree burn of 15–25% body surface
area in adults
 Second-degree burn of 1...


Minor burn injury
 Second-degree burn of < 15% body surface
area in adults
 Second-degree burn of < 10% body surface
...
Management:



Depends upon severity and presenting
complications
Burn management flow chart:
First aid/pre-hospital care
Primary survey

Secondary survey
Definitive care
First aid/pre-hospital care:







Ensure rescuer safety
Stop the burning process : Stop, drop and roll
Cool the bur...
Primary survey:






A=Airway maintenance and cervical spine
control,
look for airway clearance, apply cervical collla...




D=Disability-Neurological
Look for alertness, response to vocal and
painful stimuli, pupillary reaction to light
E=E...








Calculate amount of IV fluid
Analgesia preferably with IV opoids (morphine)
Antibiotics if needed
Send blood...
Fluid therapy:




To calculate the amount of fluid required, we
need to know the extent of burns on the skin
surface.
T...
The rule of nine’s












An adult who has been burned, the percent of
the body involved can be calculated as...
The rule of
nine’s
Rule of 9s

ABA
Fluid therapy:


Resuscitation fluid requirement during first 24
hours using Parkland formula: Calculation:
ml/ kg/ % bod...






Resuscitation fluid requirement during second
24 hours:
Calculation: 0.5 ml/kg/% body surface area
burn colloid s...


Maintenance fluid for children:
the 1st 10 kgs- 100 ml/kg +
 For the next 10 kgs- 50 ml/kg +
 For the next 10 kgs upt...
Investigations to be sent:











CBC –Hb%, haematocrit, total count of WBC
Platelet count
Blood grouping and ...
Wound management


Conservative



Options for topical treatment of deep burns:
 1%

silver sulphadiazine cream
 0.5% ...
Debride blister using simple instruments
Medic debriding blister
After debridement
Silver sulfadiazene
Arm burn 4 days
Arm burn 7 days – note the exudate
pics

Soak silver dressings and gauze
in WATER (not saline).

Apply the
silver dressing.

Wrap with moist gauze.
Secure wi...
Foot burn
debridement

Before debriding
and applying cream,
clean entire foot
(including
toes and nails).
Hands

Dressings should not impede
circulation.
Leave tips of fingers exposed.
Keep limb elevated.
Secondary survey:
History of allergy, medications, past
illnesses and events related to injury
 Head to toe examination f...
Emotional support to patient
 Re-evaluation
 Proper documentation
 Transfer to nearest specialized burn unit

Definitive care:
Physiotherapy, splinting, pressure
garment
 Burn wound management


Escharotomy/Fasciotomy
 Skin graft...
Complication of burn:


Acute/early complications:
 Shock –hypovolumic or neurogenic
 Renal failure
 Acute respiratory...


Delayed complications:
 Wound infections
 Septicemia
 Protein-losing enteropathy
 Cerebral damage


Late complications:
 Hypertrophied scar
 Keloid
 Post-burn contracture
 Marjolin’s ulcer
Keloid
Keloid
Hands and feet


Fingers might develop
contractures if active
measures are not taken to
prevent them.
Contractures
Contractures
Contractures
Marjolin’s ulcer
Marjolin’s ulcer
Marjolin’s ulcer
Escharotomy - indications
Circulation to distal limb is in danger due
to swelling
 Progressive loss of sensation / motion...
Fasciotomy







Fascia = thick white covering of muscles.
Fasciotomy = fascia is incised (and often overlying skin)...
Skin graft:




A graft of skin detaches epidermis and varying
amounts of dermis from its blood supply in the
donor area...
Statistics of burn injury from burn unit,
Dhaka Medical College Hospital
Year

Admitted

Number of
death

Percentage
of de...
Reference:








Bailey & Love’s Surgery 25 th edition
CURRENT Diagnosis & Treatment Surgery
13edition
National gui...
Thank you
Burn
Burn
Burn
Burn
Burn
Burn
Burn
Burn
Burn
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Transcript of "Burn"

  1. 1. BURN Presented by: Tasnuba Atique Intern doctor Surgery unit 5 Shaheed Suhrawardi Medical College and Hospital
  2. 2. Definition:  Burn may be defined as a tissue injury due to thermal application (heat and cold), absorption of physical energy (electricity, ionizing radiation and friction) and chemical contact (acid and alkali).
  3. 3. Prevalence:    Fire-related mortality rate is high in South-east Asia: 11.6 deaths per 100,000 population per year. In Bangladesh, about 3,00,000 patients (166.3 per 100,000 population) get burnt every year. Death rate is 2.2 per 100,000 population, nearly 3000 deaths every year.
  4. 4. Risk factors:  Demographic:  Age  Sex  Rural  and urban factors Co-morbid conditions:  Arthritis, stroke  Diabetes, peripheral neuropathy  Dementia, confusion, forgetfulness and psychiatric illness  Alcohol and drug abuse
  5. 5.  Socio-economic factors:  Use of open fire  Wearing long, loose fitting clothes during cooking  Use of open lamp  Smoking  Use of mosquito coil in improper way  Substandard electric wiring  Familial disharmony and dowry  Easy availability of chemicals  Use of unsafe vehicles  Storage of industrial chemicals in a residential area
  6. 6. Causes of burn incident:          Scald- hot water, steam, cooking oil hot, hot curry. Flame burn Contact with hot objects Electric burns Chemical burn Friction Blast Extreme cold Ionizing radiation
  7. 7. Scald
  8. 8. Electrical burn Entrance Wound: High resistance of skin transforms electrical energy into heat, which produces burns around the entrance point (dark spot in center of wound). This man was lucky, the current narrowly missed his spinal cord.
  9. 9. Electrical burn Exit Wound: Current flows through the body from the entrance point, until finally exiting where the body is closest to the ground. This foot suffered massive internal injuries, which weren't readily visible, and had to be amputated a few
  10. 10. Internal Injuries in electric burn This worker was shocked by a tool he was holding. The entrance wound and thermal burns from the overheated tool are apparent Same hand a few days later, when massive subcutaneous tissue damage had caused severe swelling.To relieve pressure which would have damaged nerves and blood
  11. 11. Involuntary Muscle Contraction This worker fell and grabbed a powerline to catch himself. The resulting electric shock mummified his first two fingers, which had to be removed. The acute angle of the wrist was caused by burning of the tendons, which
  12. 12. Chemical burn
  13. 13. Chemical burn Chemical burn can affect the eye
  14. 14. Chemical burn Comments:A 22year-old man employed in an automobile battery manufacturing facility sustained chemical burns when a jar of concentrated sulphuric acid spilled on his back when an autorickshaw which he was driving collided with another
  15. 15. Chemical burn Durjoy was made to drink acid when he was a month old A courageous acid attack survivor provides a first-hand account of her horrific attack.
  16. 16. Cold burn   Description: well demarcated geometric red plaque with discrete and confluent vesicles and bullae Comments: A 10-year-old boy sustained an injury of the right ankle while playing football 4 days earlier. A topical refrigerant anesthetic spray was excessively applied from a short distance resulting in a cold induced injury.
  17. 17. Classification according to the depth: Epidermal burn  Partial thickness- superficial (superficial dermal)  Partial thickness- deep (deep dermal)  Full thickness 
  18. 18. Depth:     Epidermal burn: epidermis and very superficial part of dermis Partial thickness- superficial : epidermis, papillary dermis and part of reticular dermis Partial thickness- deep : both epidermis and dermis involved sparing skin appendages Full thickness : both epidermis and dermis including skin appendages are involved, may be with subcutaneous tissue, muscle or bone
  19. 19. Tradititonally :
  20. 20. Cause:     Epidermal burn : sun burn, minor scald Partial thickness- superficial : scald, minor flame burn, contact with hot object for short time Partial thickness- deep : scald, minor flame burn, contact with hot object for long time Full thickness : flame burn, severe scald or contact with hot object, chemical burn, electrical burn
  21. 21. Surface/colour:     Epidermal burn : dry, erythematous Partial thickness- superficial : moist, reddish colour with blisters Partial thickness- deep : moist, white slough, blisters, mottled Full thickness : dry, charred, whitish
  22. 22. Capillary return :     Epidermal burn: brisk Partial thickness- superficial : brisk Partial thickness- deep : sluggish Full thickness : absent
  23. 23. Pain sensation:     Epidermal burn : burning sensation Partial thickness- superficial : severe burning sensation Partial thickness- deep : burning sensation with variable severity Full thickness : painless
  24. 24. Healing time:     Epidermal burn : 3-7 days Partial thickness- superficial : 10-14 days Partial thickness- deep : 2-3 weeks Full thickness : skin grafting is needed, otherwise contracture, defomity and disability
  25. 25. First Degree Sunburn /epidermal burn
  26. 26. Second-degree burn of the hand
  27. 27. Second Degree/partial thickness Burn
  28. 28. Upper arm burn 121   Blisters show probable partial thickness burn. Area without blister might be deeper partial thickness.
  29. 29. Deep Second Degree/partial thickness-deep Burn
  30. 30. Severe Hand/partial thickness-deep Burn
  31. 31. Third Degree/full thickness Burn on Finger
  32. 32. Full thickness burn: Grounded sites of low-voltage injury on the feet. Electrical burns to the hand.
  33. 33. Pathophysiology:       Most affected organ is skin –burn wound Can also affect respiratory system- inhalation injury Infection from the burn site, lungs, gut, lines and catheters Malabsorption from the gut abdominal compartment syndrome Circumferential burns may compromise circulation to a limb
  34. 34. Phases of thermal burn injury
  35. 35. Zones of Burn Wounds:    Zone of Coagulation  devitalized, necrotic, white, no circulation Zone of Stasis ‘circulation sluggish’  may covert to full thickness, mottled red Zone of Hyperemia  outer rim, good blood flow, red
  36. 36. Wound excision until fine punctate bleeding occurs
  37. 37. Inhalation injury:      Inhaled hot gases can cause supraglottic airway burns and laryngeal oedema Inhaled steam can cause subglottic burns and loss of respiratory epithelium Inhaled smoke particles can cause chemical alveolitis and respiratory failure Inhaled poisons, such as carbon monoxide, can cause metabolic poisoning Full-thickness burns to the chest can cause mechanical blockage to rib movement
  38. 38. Inhalation injury: Role of nitric oxide (NO) in the pathophysiology of smoke inhalation injury. Loss of hypoxic pulmonary vasoconstriction and an increase in pulmonary vascular permeability results in ventilation/perfusion (V/Q) mismatch, which in turn results in decreased gas
  39. 39. American Burn Association Burn Severity Categorization  Major burn injury  Second-degree burn of > 25% body surface area in adults  Second-degree burn of > 20% body surface area in children  Third-degree burn of > 10% body surface area  Most burns involving hands, face, eyes, ears, feet, or perineum
  40. 40.  Most patients with the following:  Inhalation injury  Electrical injury  Burn injury complicated by other major trauma  Poor-risk patients with burns
  41. 41.  Moderate uncomplicated burn injury  Second-degree burn of 15–25% body surface area in adults  Second-degree burn of 10–20% body surface area in children  Third-degree burn of < 10% body surface area
  42. 42.  Minor burn injury  Second-degree burn of < 15% body surface area in adults  Second-degree burn of < 10% body surface area in children  Third-degree burn of < 2% body surface area
  43. 43. Management:  Depends upon severity and presenting complications
  44. 44. Burn management flow chart: First aid/pre-hospital care Primary survey Secondary survey Definitive care
  45. 45. First aid/pre-hospital care:      Ensure rescuer safety Stop the burning process : Stop, drop and roll Cool the burn wound : Cooling should occur for a minimum of 10 min and is effective up to 1 hour after the burn injury. Give oxygen : a fire in an enclosed space Elevation of burned limb
  46. 46. Primary survey:    A=Airway maintenance and cervical spine control, look for airway clearance, apply cervical colllar B=Breathing look for respiratory rate, chest movement, give oxygen C=Circulation look for pulse, blood pressure, capillary refill, control haemorrhage. Start fluid.
  47. 47.   D=Disability-Neurological Look for alertness, response to vocal and painful stimuli, pupillary reaction to light E=Exposure with Environment control remove all cothing and jewellery –wrap patient with blanket
  48. 48.       Calculate amount of IV fluid Analgesia preferably with IV opoids (morphine) Antibiotics if needed Send blood samples for base line tests Insert NG tube and catheter Prevention of early complications
  49. 49. Fluid therapy:   To calculate the amount of fluid required, we need to know the extent of burns on the skin surface. The rule of nine’s : A method for rapidly assessing the extent of burns on the skin surface- TBSA (total body surface area), which determines the amount of fluid required as replacement therapy
  50. 50. The rule of nine’s         An adult who has been burned, the percent of the body involved can be calculated as follows: Head = 9% Chest (front) = 9% Abdomen (front) = 9% Upper/mid/low back and buttocks = 18% Each arm = 9% (front = 4.5%, back = 4.5%) Groin = 1% Each leg = 18% total (front = 9%, back = 9%)
  51. 51. The rule of nine’s
  52. 52. Rule of 9s ABA
  53. 53. Fluid therapy:  Resuscitation fluid requirement during first 24 hours using Parkland formula: Calculation: ml/ kg/ % body surface area burn in 1st 24 hours  ½ of the calculated fluid should be infused during the 1st 8 hours  1/4th in the next 8 hours and the rest 1/4th in the next 8 hours  3-4  Nature of the fluid: crystalloids, preferably Hartmann’s solution; 0.9% NS if it is not available.
  54. 54.    Resuscitation fluid requirement during second 24 hours: Calculation: 0.5 ml/kg/% body surface area burn colloid solution + 5% DA (rate maintained to get 0.5-1.5 ml/kg/hour urine output) Nature of the fluid: colloid solution (plasma or plasma substitue) + 5% DA (Dextrose in aqua)
  55. 55.  Maintenance fluid for children: the 1st 10 kgs- 100 ml/kg +  For the next 10 kgs- 50 ml/kg +  For the next 10 kgs upto 30 kg- 20 ml/kg  For   Nature of fluid: 4% glucose in ½ strength (0.45%) normal saline Volume of fluid requiremetn in children in 1st 24 hours is:  Resuscitation fluid + maintenance fluid
  56. 56. Investigations to be sent:         CBC –Hb%, haematocrit, total count of WBC Platelet count Blood grouping and cross matching Serum creatinine, Urea Random blood sugar Serum electrolytes Serum albumins Chest X-ray
  57. 57. Wound management  Conservative  Options for topical treatment of deep burns:  1% silver sulphadiazine cream  0.5% silver nitrate solution  Mafenide acetate cream  Serum nitrate, silver sulphadiazine and cerium nitrate
  58. 58. Debride blister using simple instruments
  59. 59. Medic debriding blister
  60. 60. After debridement
  61. 61. Silver sulfadiazene
  62. 62. Arm burn 4 days
  63. 63. Arm burn 7 days – note the exudate
  64. 64. pics Soak silver dressings and gauze in WATER (not saline). Apply the silver dressing. Wrap with moist gauze. Secure with mesh, gauze, or tape.
  65. 65. Foot burn debridement Before debriding and applying cream, clean entire foot (including toes and nails).
  66. 66. Hands Dressings should not impede circulation. Leave tips of fingers exposed. Keep limb elevated.
  67. 67. Secondary survey: History of allergy, medications, past illnesses and events related to injury  Head to toe examination for associated injuries  Tetanus prophylaxis 
  68. 68. Emotional support to patient  Re-evaluation  Proper documentation  Transfer to nearest specialized burn unit 
  69. 69. Definitive care: Physiotherapy, splinting, pressure garment  Burn wound management  Escharotomy/Fasciotomy  Skin grafting   Rehabilitation
  70. 70. Complication of burn:  Acute/early complications:  Shock –hypovolumic or neurogenic  Renal failure  Acute respiratory distress syndrome  Respiratory failure  Pneumonia  Laryngeal oedema  Acute GIT ulcer: Curling ulcer  Hypothermia  Multiple organ system failure (MOSF)
  71. 71.  Delayed complications:  Wound infections  Septicemia  Protein-losing enteropathy  Cerebral damage
  72. 72.  Late complications:  Hypertrophied scar  Keloid  Post-burn contracture  Marjolin’s ulcer
  73. 73. Keloid
  74. 74. Keloid
  75. 75. Hands and feet  Fingers might develop contractures if active measures are not taken to prevent them.
  76. 76. Contractures
  77. 77. Contractures
  78. 78. Contractures
  79. 79. Marjolin’s ulcer
  80. 80. Marjolin’s ulcer
  81. 81. Marjolin’s ulcer
  82. 82. Escharotomy - indications Circulation to distal limb is in danger due to swelling  Progressive loss of sensation / motion in hand / foot.  Progressive loss of pulses in the distal extremity by palpation or doppler.  In circumferential chest burn, patient might not be able to expand his chest enough to ventilate, and might need escharotomy of the skin of the chest. 
  83. 83. Fasciotomy      Fascia = thick white covering of muscles. Fasciotomy = fascia is incised (and often overlying skin) Skin and fascia split open due to underlying swelling. Blood flow to distal limb is improved. Muscle can be inspected for viability.
  84. 84. Skin graft:   A graft of skin detaches epidermis and varying amounts of dermis from its blood supply in the donor area and is placed in a new bed of blood supply from the base of the wound, or recipient area. Type of Graft:  Thin split-thickness  Thick split-thickness  Full-thickness
  85. 85. Statistics of burn injury from burn unit, Dhaka Medical College Hospital Year Admitted Number of death Percentage of death 2004 1020 183 17.94 2005 3276 289 8.82 2006 4615 362 7.84 2007 8081 374 4.63 2008 9128 443 4.85 2009 11112 480 4.31
  86. 86. Reference:      Bailey & Love’s Surgery 25 th edition CURRENT Diagnosis & Treatment Surgery 13edition National guideline to burn management www.wikipedia.org www.mtpsa.com
  87. 87. Thank you
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