Surgical burns outcomes

1. WELLCOMEPATCH
17
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2. BURN INJURIES & ITS
MANAGEMENT
BY:MR
Samir Ismail
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4. GOALS
Prevent complications
Vital signs hourly
Assess respiratory function
Tetanus booster
Anti-infective
Analgesics
No aspirin
Strict surgical asepsis
 Prevent contractures-
physiotherapy
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5. DIFINTION
Physical trauma due to
effect of heat resulting of
various degrees of
coagulation of tissue protein
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6. CLASSIFICATION
According to the mechanism of injury
AETIOLOGY
1-Fire - flame , flash burn
2-Contact burn
3-Chemical
4-Electrical
5-Radition
6- Scalds -caused by liquid , steam

7. Classification of burn according to
mechanism of injury used as
indicator of out come and
hospitalization admission

8. BURNS
Results in 10-20 thousand
deaths annually
Survival best at ages 15-45
Children, elderly, and diabetics
have poor prognosis.
Survival best burns cover less
than 20% of TBA
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9. Burns are classified according
to the surface area involved
and according to the depth of
the burnt tissues.
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10. CLASSIFICATION ACCORDING TO
DEPTH OF INJURY
1- first degree burn :-
 There is minor epithelial injury of the
epidermis
 There is redness , tenderness and pain
 Blistering not occurs
 Tow point discrimination are intact
 Healing without scar
 Caused by flash and sunburn
 Blanching on pressure.

11. Radiation burns
 UV light
 X-rays
 sunlamps
 radiation therapy
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12. 2-Second degree :-
 Superficial partial thickness and deep partial
thickness , it tow type
 In this type some portion of the skin remain intact
allowing epithelial repair of the burn without skin
graft . Superficial partial
thickness involve the epidermis and superficial
dermis
 Heal in 2-3 wk without scaring

13. Deep partial thickness extent into deep
dermis
 The capillary refill is slow skin color is mixture of red
and white
 Heal within 3-6 week
 Sever pain.
 Vesicle formation.

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18. Third degree :-
 Is full thickness burn destroy both epidermis and
dermis
 The capillary network of the dermis is completely
destroyed
 burn skin is white
 Anesthetic skinno sensation
 Heal by contraction >1cmskin graft
l.

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20.  Causes scald – flame – chemical – electrical.
4 Fourth degree burn:
 It‘s full thickness burn destroy the skin and
subcutaneous tissue with involvement of fascia,
muscle , bone.
 It‘s due to prolong exposure to usual causes of 3rd
degree burn.

21. Fourth-degree burns
 epidermis, dermis and underlying tissue
 symptoms
 black skin
 no sensation
 example - flames
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22. Classification according to severity
of burn:-
1-Major burn:-
 Is partial thickness burn involving >25%TBSA in
adult or 20% in child <10yr or older than 50yr
 Full thickness burn involving >10%TBSA. burn
involving the ,face , eyes ,ears ,hand ,feet or
perineum that may result in functioning or cosmetic
impairment
 Burn complicated by inhalation injury

23. 2-Moderate burn :-
 Partial thickness burn of 15-25% in adult or 10-20%
in child
 Full thickness burn 2-10%without functional or
cosmetic problem

24. 3-Minor burn :-
Burn<15%in adult or 10%in child
Full thickness burn <2 % TBSA without functional or
cosmetic problem

25. Radiation burns
 UV light
 X-rays
 sunlamps
 radiation therapy
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26. CHEMICAL BURN
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27. Chemical burns
 strong acids
 strong bases
 solvents
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28. ELECTRICAL BURN
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29. ELECTRICAL BURN
 accidental electrical contact
 depend on:
 strength of electrical current
 duration of contact
 common causes : workplace injuries
 rare causes: lightning
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30. Thermal burns
 flames
 hot liquids
 hot objects
 gases
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31. BURN WOUND ASSESSMENT
Classified according to depth of injury
and extent of body surface area involved
Burn wounds differentiated depending
on the level of dermis and subcutaneous
tissue involved
1. superficial (first-degree)
2. deep (second-degree)
3. full thickness (third and fourth
degree)
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33. CLASSIFICATION
 Burn assessment as follow
1- According to the surface area:
A. In small burns the best measurement is to cut a
piece of clean paper the size of the patient’s whole
hands (digit and palm) which represent 1% TBSA
and match this to the area

34. B. In large burns the Lund
and Browder chart is useful
which maps out the
percentage TBSA of sections
of our anatomy

35. C. Rule of nine: which is
adequate for the first
approximation only it states
that each upper limb is 9%,
each lower limb 18%, the trunk
18% each side and the head
and neck 9%

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39. Full Thickness Burn
Partial Thickness Burn
White or black
Mottled red
Dry
Moist due to exudation of plasma
Possible visible thrombosed SC vessels
Blisters surrounded by erythema
Painless due to loss of terminal nerve
endings
Painful and sensitive
Granulation tissue formation and scar
separation starts after 3 weeks
Heals within 3 weeks

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41. CALCULATION OF BURNED BODY SURFACE
AREA
Calculation of
Burned Body Surface
Area
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42. TOTAL BODY SURFACE AREA
(TBSA)
Superficial burns are not involved
in the calculation
Lund and Browder Chart is the
most accurate because it adjusts
for age
Rule of nines divides the body –
adequate for initial assessment for
adult burns
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43. LUND BROWDER CHART USED FOR
DETERMINING BSA
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Evans, 18.1, 2007)

44. RULES OF NINES
Head & Neck = 9%
Each upper extremity (Arms) = 9%
Each lower extremity (Legs) =
18%
Anterior trunk= 18%
Posterior trunk = 18%
Genitalia (perineum) = 1%
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46. GOALS
Prevent complications
Vital signs hourly
Assess respiratory function
Tetanus booster
Anti-infective
Analgesics
No aspirin
Strict surgical asepsis
 Prevent contractures
Emotional support
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47. MANAGEMENT OF THE BURNED
PATIENT
 First aid:
 Stop the burning process:
 Flames from burning clothing or from burning
inflammable substances on the skin surface
should be stoped by wrapping the patient afire
blanket or any other readily available garment
such as the bystander's own clothing.
 With electrical burns it is important that any live
current is switched off, and with chemical burns
the first-aid worker must avoid contact with the
chemical. Burned or water-soaked clothing should
be removed.

48.  Cool the burn surface:
 Immediate cooling of the part is beneficial and
should continue for 20 minutes. With scalds,
irrigation with cold water under a tap is best and
many a child has had scald damage successfully
limited by pouring a readily available jug of cold
water or milk immediately over the scalded area.
Irrigation in cold water is particularly valuable for
chemical burns. Hypothermia must be avoided.
Don not uses ice or iced water. The burn should
then be wrapped in any clean linen ' and the
patient transported immediately to hospital.

49.  Fluid – major burn nil by mouth, get an I.V
going
 Emergency examination and treatment:
 The order of priorities in the management of major burn
injury is:
A: airway maintenance;
B: breathing and ventilation;
C: circulation;
D: disability – neurological status;
E: exposure and environment control – keep warm;
F: fluid resuscitation

50. GUIDELINES FOR MANAGEMENT
 Admit: criteria for admission
 Any burn over 10% in area extrem ages.
 IV fluids for burns over 15%.
 Burns in special areas face, neck, hands,
feet, perineum.
 Electrical burns any
burn with history of smoke inhalation.
 Chemical burns.
 Full thickness where grafting is indicated.
circumferential burn of thorax or extremities

51. S
 , co-existing major trauma or
significant pre-existing medical
conditions.
 At all ages2nd&3rd degree burns more than 20%.
 At all ages group 3rd degree brunt's 5_10%.
 Pregnancy.
 Burn incluk,de major joint
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52. ON ADMISSION:
 Get a history, include time and place of burn,
causing agent, details of the accident (can
provide clue to the depth of burn).
 Age of patient, weight, general health (heart,
lung, kidney).
 Ask for possibility of inhalation injury.
 Look for co-factors that can affect courses e.g.
drug addiction, immune , urine output since
injury.
 Medication given, tetanus status.
 The burn wound should never take precedence
over potential life threatening complications.

53. EXAMINATION
Estimate area of burn, how much is full
thickness.
Look for signs of respiratory burns.
Examine eyes.
Look for circumferential burns on
chest, limbs.
Complete full physical examination

54. Fluid resuscitation:
It is important at an early stage to
secure large bore intravenous
lines.

55. Pain management
Adequate analgesia imperative!
DOC: Morphine Sulfate
Dose: Adults: 0.1 – 0.2 mg/kg IVP
Children: 0.1 – 0.2 mg/kg/dose IVP / IO
Other pain medications commonly used:
Demerol
NSAIDs
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56. FLUID THERAPY
Occurs after initial vasoconstriction, then
dilation
Blood vessels dilate and leak fluid into the
interstitial space
Known as third spacing or capillary leak
syndrome
Causes decreased blood volume and blood
pressure
Occurs within the first 12 hours after the burn
and can continue to up to 36 hours
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57. COMMON FLUIDS
Protenate or 5% albumin in isotonic
saline (1/2 given in first 8 hr; ½
given in next 16 hr)
LR (Lactate Ringer) without
dextrose (1/2 given in first 8 hr; ½
given in next 16 hr)
Crystalloid (hypertonic saline)
adjust to maintain urine output at 30
mL/hr
Crystalloid only (lactated ringers)
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58. SKIN ASSESSMENT
Assess the skin to determine the size
and depth of burn injury
The size of the injury is first estimated
in comparison to the total body
surface area (TBSA). For example, a
burn that involves 40% of the TBSA is
a 40% burn
Use the rule of nines for clients whose
weights are in normal proportion to
their heights
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59. Parkland Formula
4 cc R/L x % burn x body wt. In kg.
½ of calculated fluid is administered
in the first 8 hours
Balance is given over the remaining
16 hours.
Maintain urine output at 0.5 cc/kg/hr.
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60. Parkland Formula
ARF may result from myoglobinuria
Increased fluid volume, mannitol
bolus and NaHCO3 into each liter of
LR to alkalinize the urine may be
indicated
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61. Assessing adequacy of
resuscitation
Peripheral blood pressure: may be
difficult to obtain – often misleading
Urine Output: Best indicator unless
ARF occurs
A-line: May be inaccurate due to
vasospasm
CVP: Better indicator of fluid status
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62. Assessing adequacy of
resuscitation
Heart rate: Valuable in early post burn
period – should be around 120/min.
> HR indicates need for > fluids or pain
control
Invasive cardiac monitoring: Indicated
in a minority of patients (elderly or pre-
existing cardiac disease)
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63. ANY QUESTION
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64. DRESSING THE BURN WOUND
After burn wounds are cleaned
and debrided, topical
antibiotics are reapplied to
prevent infection
Standard wound dressings are
multiple layers of gauze
applied over the topical agents
on the burn wound
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65. DIET
Initially NPO
Begin oral fluids after bowel
sounds return
Do not give ice chips or free
water lead to electrolyte
imbalance
High protein, high calorie
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66. DEBRIDEMENT
Done with forceps and curved
scissor or through
hydrotherapy (application of
water for treatment)
Only loose scar removed
Blisters are left alone to serve
as a protector – controversial
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67. SKIN GRAFTS
Done during the acute
phase
Used for full-thickness
and deep partial-
thickness wounds
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68. Lab studies
Severe burns:
CBC
Chemistry profile
ABG with carboxyhemoglobin
Coagulation profile U/A
 Type and Screen blood.
 CPK and urine myoglobin (with electrical
injuries)
12 Lead EKG
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69. Imaging studies
CXR
Plain Films / CT scan: Dependent upon
history and physical findings
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70. GENERAL COMPLICATIONS:

 Neurogenic Shock: immediately after burn &
last after 2 hrs.
 Olygogenic shock: occurs after several hrs
& manifested by Hypotension &
haemoconcentration due to loss of plasma,
Fluid & electrolytes & break down of
proteins.
 Anemia due to loss of RBCs.
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71.  Renal failure due to deposition of pigments in
the tubules due to hemolysis, anoxia following
shock leading to tubular necrosis.
 Liver failure due to focal necrosis resulting
from anoxia.
 Adrenal failure due to stress of burn &
anorexia of shock.
 Hypothermia due to disturbed skin
thermoregulation.
 A duodenal ulcer called Curling ulcer occurs in
the 1st part of the duodenum during the 2nd
weak of burn.
 Cardiac arrest &arrhythmia
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72. LOCAL COMPLICATIONS:
 Local loss of plasma → hypoproteinemia.
 infections.
 Edema of glottis → Suffocation & may require
tracheostomy.
 pulmonary complications following inhalation
of smoke.
 Nerve injuries → Loss of sensation.
 Vessels injuries → leading to gangrene.
 deformities of joints & muscles.
 Keloid formation (an ugly protruded scar).
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73. Circumferential burns of the
chest
Eschar - burned, inflexible, necrotic
tissue
Compromises ventilatory motion
Escharotomy may be necessary
Performed through non-sensitive,
full-thickness Escher
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74. Escharotomy incision on lateral and medial
surface. Incision must go through the entire
depth of the burn to allow tissue expansion
and a return of blood flow.

75.  Monitoring for the onset or progress of infection
should consist of:
 Routine temperature measurement.
 Frequent wound swab cultures.
 Wound inspection by an
experienced doctor or nurse at the
time of dressing change.
 Blood culture.

76. CURLING’S ULCER
Acute ulcerative gastro duodenal
disease
Occur within 24 hours after burn
Due
 to reduced GI blood flow and mucosal
damage
Treat clients with H2 blockers,
mucoprotectants, and early enteral
nutrition
Watch for sudden drop in hemoglobin
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ANY
QUESTIONS

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