Burn

Burn
(2020)
surgical club Red sea University RS(RSU)

 Prepared by:
 Dr: Aisha Omar Hamid 18
 Dr: Esraa Suliman 18
 Presented by:
 Dr: Amar Yahia
 Registrar of General Surgery
Surgical Club Red Sea University SC(RSU)11/7/2020

Function of skin :
1)It’s a barrier against invasion by micro-
organisms.
2)Prevent excessive loss of water from
body .
3) Regulation of body temperature by
sweet .
4) Formation of vitamin D .

Epidemiology
FACTORS STRONGLY ASSOCIATED WITH
MORTALITY AFTER BURN INJURY:
burn size of >40% (TBSA).
 patient age >60 years.
presence of inhalation injury .
One risk factor: 3% mortality rate; all three risk
factors: 90% mortality rate.

Etiology of burn:
Thermal injuries :
1) scalds caused by boiled liquids,
moist heat.
2) flam burn.
3) contact burn.
Electrical burn ( low or high voltage).

Chemical burns (acids or alkalizes).
Cold burns ( frost bite ).
Inhalation and respiratory burns; hot
gases affect (upper , lower ) airways .
Sun burns .
Radiation burns.

Cold burns ( frost bite )

Inhalation and respiratory burns

Sun burns

Radiation burns

PATHOPHYSIOLOGY OF BURN:
locally : the burn wound has three zones:
1) Zone of coagulative necrosis : area closest to heat
source.
2) Zone of stasis: area with damage to microcirculation
caused by local inflammatory mediators, resulting in
tissue hypoperfusion.
3) Zone of hyperemia : production of inflammatory
mediators secondary to burn injury results in widespread
vasodilatation and capillary leak.

Pathology of burn :
Extent and depth of burns:
1)Extent :
is percent of burnt skin surface area in relation to the
whole body surface area .
- This follow the “ rule of 9 “
In children need some modification; large size of head
comparison to the rest of body.

Extent of Body Surface Area
Injured
• RULE OF NINES,
• LUND AND BROWDER METHOD,
• PALM METHOD.

LUND AND BROWDER
METHOD
recognizes the percentage of TBSA
of various anatomic parts By
dividing the body into very small
areas and providing an estimate of
the proportion of TBSA regarding to
age of patient.

PALM METHOD
The size of the
patient’s palm is
approximately 1% of
TBSA.

- According to extent burn are classified into
percentage :
more then 30% of the body surface area .
1) Major burn
15– 30% in adult.
10-30% in children .2) Intermediate burn
less than 15% in adult .
less than 10% in children.3) Minor burn

(2) Depth:

 Fourth degree: Involves the underlying tissues—
muscles, bones.

surgical club Red sea University RS(RSU)1st degree burn

Second degree burn

3rd degree burn

fourth degree burn

Special type of burns:
1) Electrical burns :
❖ clinically 3 types of skin damage :
a) contact burns : occur at point of current enter and exist
from the body.
b) burn from current exist and re entry at adjacent part.
c) Thermal burns from irritation of clothing ; heat generated.

Electrical burns

2) Inhalation burn :
 Assessment of airway injury is important in burns :
• Presents with hoarseness or stridor.
• Inhaled burning gases can cause
upper airway burns and laryngeal edema.
• Smoke inhalation can cause chemical
alveolitis ,pulmonary edema , ARDS and
respiratory failure.

• Steam inhalation can cause damage to respiratory
epithelium and subglottic oedema.
• Carbon monoxide inhalation more than10% is
dangerous as it forms carboxyhemoglobin .
• Chest wall burn causes mechanical block of
ventilation – needs escharotomy .

• Airway burn may require early intubation or tracheostomy or
emergency cricothyroidotomy as a life saving method.
•High flow oxygen .
•Admission to hospital .

3) Chemical burn : “chemical agent “
- Severty determines by:
1. Strength agent .
2. Amount.
3. Duration skin contact.
4. Mechanism of action .

❖ Management :
1. All saturated clothes are removed .
2. Affected areas irrigated with huge amount of water .
4) Cold burn :
• Injury of tissue due to
exposure to cold .
• Example : frostbite.

Effects of Burn Injury :
1. Shock due to hypovolemia.
2. Renal failure.
3. Pulmonary edema, respiratory infection, (ARDS), respiratory
failure.
4. Infection leads to septicemia .
5. GIT: Hypovolemia , ischemia of mucosa, erosive
Gastritis
6. Fluid and electrolyte imbalance.

7. Postburn immunosuppression.
8. Eschar formation .
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.

11. Inhalation burn causes pulmonary edema,
respiratory arrest, ARDS.
12. Chemical injury causes severe GIT disturbances
like erosions, perforation, stricture esophagus
(alkali),pyloric stenosis (acid), mediastinal injury.

13. DVT, pulmonary embolism, urinary infection, bed-
sores, severe malnutrition with catabolic status,
respiratory infection.
14. contracture itself like hypertrophic scar, keloid
formation.
15. Toxic shock syndrome: common in children.

Contracture
Severe contracture at
knee joint

Hypertrophic burn scar with
contracture neck
Keloid in the hand after
burn injury

Causes of death in burns
a. Hypovolemia and shock
b. Renal failure
c. Pulmonary edema and ARDS
d. Septicemia
e. Multiorgan failure (MODS ).
f. Acute airway block in head and neck burns

:Management of burn
 Frist aid :
•ABCDE
• Clothing should be removed.
• Cooling of the part by water at room temperature for 20 minutes.
 Indications for admission in burns:
• Any moderate and severe burns.
• Airway burns of any type.
• Burns in extremes of age.
• All electrical/deep chemical burns.

❖ Definitive Treatment :
• Admit the patient.
• Maintain Airway, Breathing, Circulation.
• Assess the percentage, degree, and type of burn.
•Chemoprophylaxis – tetanus toxoid; antibiotics.
• Sedation and strong analgesic IV e.g : pethidine.
• Patient in burns unit(ideally air conditioned) with barrier
nursing, sterile clothes, bed sheets with all aseptic
methods.

 Fluid resuscitation:
the amount and rate of fluid replacement are determined
by patient and the percentage of the total body surface
area injured .
❖ Formulas to calculate the fluid replacement:
1- Parkland’s Formula : Commonly used:
4 ml/% burn/kg body weight/24 hours.
Half the volume is given in first 8 hours, rest given in 16
hours.

• Ringer lactate is the fluid of choice.
• Administrated of blood is usually in major deep burn
start after 48 hours.
• We can calculated surface area by rule of 9 .
• First 24 hours only crystalloids should be given.
• After 24 hours up to 30-48 hours, colloids should be
given to compensate plasma loss.

Assessment of Adequacy of
Fluid Resuscitation
o Urinary Output
• Adult: > 1 ml/ kg/ hr
o Daily Weight
o Vital Signs
• Heart rate and blood pressure
• CVP
• Level of Consciousness
o Laboratory values

 Monitoring :
1) Monitoring the patient: Hourly pulse, BP, PO2, PCO2,
electrolyte analysis, blood urea, nasal oxygen.
2) Urine output: 0.5–1 ml/kg per hour in adults
and 1–1.5 ml/kg per hour in children.
3) C.V.P in critical cases.

Early care after resuscitative burn wound :
1) Escharotomy or fasciotomy ( in deep burn ) to
constricting eschars .
2) Cleaning : removing loose skin and initial
conservative debridement .
3) Topical antimicrobial .

Escharotomy

4) Wound dressing by two methods:
1. The wound leaved exposed (open method)
❖its advantages :
a) it is more comfortable to patient .
b) avoid need to dressing .
c) inhibit growth of bacteria .
d) burn involve one side of trunk or it on
(face/neck/perineum)

2. Covering the wound (close method)
• by bulky occlusive dressing 2-3 days .
( it depend state of burn wound ).

Late care of wound for deep burn :
Autologous skin grafting .
Biological dressing .
Prevention of contraction .

Prognosis of burn :
1) Burn factors :
1) Extent. 2) Depth. 3) Site .
4) Infection. 5) Type. 6) associated injury.
2) patient factors :
1) age . 2) concomitant diseases .
3) Treatment factors.

Principle of skin coverage :
1) Skin graft :
involves tissue that is completely detached from it’s
supply in the donor area and receives it new blood
supply from the base of the wound .
❖ Types :
1) Split thickness ( thriersch ) graft .
2) Full thickness ( wolfe ) graft .

Skin graft

Factor affecting skin grafting :
 Take :
1. Duration of take graft .
2. Vascularization it depend on patient it poorly perfused
e.g: DM or peripheral vascular diseases graft less
establish .
3. Wound bed .
4. Operative and dressing technique .

2) Flaps :
Tissues to be transferred from one site of the body to
another must maintain their blood supply for nourishment.
❖ Types :
1. Skin flap ( local / distant pedicle ).
2. Musculocutaneous .
3. Fasciocutaneus flaps .
4. Microvascular free flap .

Skin flap

3) Tissue expander :
Inflatable silicon implant .
The are placed subcutanous in collapsed state over
several weeks the expander is gradually inflated with
saline through a subcutaneous part the overlying skin is
gradually stretched to accommodate a larger area .

Tissue Expander

Referances
❑ General Surgery (Board Review Series) 1 st Edition
❑ SRB's Manual of Surgery, 3 rd Edition
❑ Schwartz's Principles of Surgery, 11th Edition
❑ Bailey & Love's Short Practice of Surgery, 27 th Edition
❑ Alkaaser Alainy

Burn

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