burns management

1. BURNS MANAGEMENT

2. Outline
• Introduction
• Epidemiology
• Risk Factors for burns
• Classification
• Pathophysiology
• Management
• Comlications
• References

3. Introduction
Definition
• Complete or partial destruction of skin & other tissues caused by energy transfer
to these tissues.
The Skin
• Skin is a composite structure whose functions include:
 Acting as a physical barrier for infection control
Water & electrolyte balance
 Temperature regulation
Sensation
Waste excretion
Metabolic functions

4. Layers of the skin
• The skin consists of two layers with
different properties.
1. The covering layer/epidermis
• ectodermal in origin; has the capability
of complete regeneration hence burns
which are confined to the epidermis will
heal without scarring.
• Burns confined here: superficial burns
• Has 5 layers

5. 2. The dermis
• Provides strength and stability to the skin.
• Essential for elasticity, support and nutrients
for epidermis.
Has two layers:
Papillary dermis
• Basal layer of the epidermis encroaches into
this layer.
• Due to presence of these epidermal structures,
this portion of the dermis shows the property
of regeneration in combination with repair.
• Burns confined here: 2nd degree superficial

6. Reticular dermis
• This portion is devoid of epidermal elements & hence
has no property of regeneration and will always require
a reparative process.
• Burns involving this layer may develop hypertrophic
scars.
• Burns involving this layer: 2nd degree deep
Subcutaneous Layer/Hypodermis
• has fat, connective tissue, and neurovascular bundles.
• It functions as a cushion layer for the muscles, blood
vessels, and bone.
• Burns involving this layer: 3rd degree burns

7. Epidemiology
Mortality
• Burns are a global public health problem, accounting for an estimated 200-
300,000 deaths annually.
• In the USA, burn is the 4th cause of mortality necessitating medical attention for
about 2.5 million patients each year
Global inequities
• Majority of burn-related deaths (>90%) occur in LMICs
• Almost two thirds occur in the WHO African and South-East Asia regions.
• In sub-Saharan African countries the severity and mortality rate varies from one
country to another
• The average mortality rate in SSA is 17%, a death of 1 for every 5 burn victims. In
some countries, the mortality rate exceeds the average one. E.g. Togo 24.6%,
Malawi 27%.

8. Age
• Most studies identify children as being at the most risk for burns.
• Study done in Northern Ethiopia showed that the most commonly affected age group were
children<10 years of age
• Retrospective study by Oduor conducted at Nakuru PGH showed that pediatric burns largely
affected boys aged 0.5-2.5 years.
• The study further showed that scalds caused most burns (>90%)
• Mortality from burns higher in children-immature immune system & higher fluid requirements.
• Hence children are at a higher risk of hypovolemic shock and sepsis after burn injuries.
• Children with extensive burns require very close monitoring & would benefit from admission into
a dedicated pediatric burn ward
Burn location
Upper extremities and trunk most affected esp. among toddlers

9. Risk Factors
Include:
1. DEMOGRAPHICS
• Extremes of age
2. CO-MORBID CONDITIONS
• Diabetes, peripheral
neuropathy
• Dementia and other psychiatric
illnesses
•Stroke
3. SOCIO-ECONOMIC FACTORS
• Use of open lamps
• Use of open fire
• Substandard electric wiring
• Smoking, alcohol and drug abuse
• Storage of industrial chemicals in a
residential areas

10. Burns Classification
• Burns can be classified based on the following parameters:
Etiology
Depth of the burn
TBSA
Severity
Anatomical location

11. Based on etiology
1. Thermal burns
• Can be either due to heat or
cold.
A. Heat burns
• • Dry heat-flame burns, contact
burns
• • Moist heat-scalds (injury due to
contact with hot liquids)
B. Cold burns-frost bite
The extent of thermal injury
depends on:
• Temperature
• Amount of heat transferred
• Duration of contact
• Type of tissue injured

12. 2. Electrical Burns
• Occurs when passage of electrical current through the body.or
current of electricity arcs, causing flash burns from the intense heat.
• Voltage determines the extent of the damage. Voltage can be low, as
with the electricity in a house, or high.
• High voltage (>1,000 volts) • Low voltage
• Electrical burn injuries carry a unique risk of cardiac arrhythmias and
rhabdomyolysis with compartment syndrome.

13. 3. Chemical Burns
Caustic chemicals
 acids
 alkalis (more serious than acid burns due to ↑ penetration through liquefactive
necrosis).
4. Radiation
• Most commonly in the form of sunburns from ultraviolet radiation
• Can also occur from x-rays and other medical imaging or as a result of therapeutic
radiation.
5. Friction burns
• Occur when heat and mechanical disruption of tissue from contact with an
abrasive or rough surface.

14. Based on Depth
• Traditionally, divided into degrees, 1st,2nd, 3rd & 4th
Points to note
1. Burn wounds are not usually uniform in depth and may have a
mixture of deep and superficial components.
2. A precise assessment of the depth of the burn wound may be
difficult initially as burn wounds are dynamic and can progress/convert
to deeper burn wounds, and as such may require several days for a
final determination.

15. 1st Degree
• Layer (s) affected- Superficial layers of
the epidermis
• Physical xstics- Erythematous (red skin),
dry, blanches on applying pressure and
refills rapidly, swelling, no blisters
• Pain & sensitivity- painful
• Healing- 3-6 days without scarring
• Management- Non-surgical
• examples-sunburns, minor scalds

16. 2nd Degree superficial (partial thickness)
• Layer (s) affected-Epidermis + Upper layers of
the dermis (papillary dermis)
• Physical xstics-Dermis is pink and moist,
blanches on applying pressure, blistering
(vesicles and bullae)
• Pain & sensitivity-Extremely painful
• Healing-1-3 weeks by re-epithelialization
(keratinocytes spared in the dermal structure)
with hypo/hyperpigmentation but no scarring.
• Management-Non-surgical
• Examples-Scalds, minor flame burn, contact
burn for a short time

17. 2nd Degree Deep (Deep partial thickness)
• Layer (s) affected-Epidermis + Deeper
layers of the dermis (reticular dermis)
• Physical xstics-Mottled skin with red
and/or white patches ,waxy dry, blistering
(vesicles and bullae), doesn’t blanch
• Pain & sensitivity-Minimal pain (painful to
pressure only)
• Healing-≥ 3 weeks with scar formation,
possible contractures
• Examples-Contact burn for a long time

18. 3rd Degree/Full thickness burns
• Layer (s) affected-Epidermis + dermis + subcutaneous tissue
• Physical xstics-Tissue necrosis with black, white or gray leather like
skin (eschar), dermis is dry, inelastic skin, no blistering, doesn’t
blanch, thrombosis of superficial vessels
• Pain & sensitivity-No pain
• Healing-Doesn’t heal by itself, contractures
• Examples-Chemical burns, electric burns

19. • 4th Degree/Sub-dermal
burns
• Layer (s) affected-Deeper
tissues; muscles,
tendons, bone, fascia
• Physical xstics-Charred
tissue

20. Based on Burn Severity
• The severity of a burn is determined by five major factors:
Depth of the burn
TBSA %
Areas of the body involved
Type of burn/burn mechanism
 Associated injuries

21. Mild Moderate Major
TBSA % and depth Partial thickness < 15% in
adults
Partial thickness < 10% in
children
OR Full thickness <2%
2nd degree 15-20 % in
adults
2nd degree 10-15 % in
children
OR 3rd degree 2-10-%
2nd degree > 20 % in
adults
2nd degree >15 in children
OR 3rd degree >10%
Type Isolated injury i.e. no
suspicion of inhalational,
chemical or electric injury
Non circumferential
Circumferential burns Known inhalational burns
Electric, chemical or
Circumferential burns
Location Burns which are not
involving eyes, ears, face,
hand, feet, perineum
Involves : Eyes, ears, face,
perineum, hands, feet
Associated Injuries - - Burns with fractures
Management or
disposition
In a physician’s office or in
the ED as an outpatient
Require admission to a
hospital but not a burn
center
Treated at a burn center

22. Pathophysiology of Burns
Effects of burns can be divided into two:
• 1. Local effects-Burns that do not exceed 25% TBSA
• 2. Systemic effects- burns >25% TBSA
• CVS • GIT • RESPIRATORY • RENAL • METABOLIC
Local Effects
Burn injury -Cellular proteins are denatured - Coagulative necrosis and thrombosis -
Release of vasoactive peptides (histamine, kinins, prostaglandins, serotonin)
Increased vascular permeability+ Platelet and leukocyte adhesion to endothelium.
The complement system is activated cytotoxic T cells increase, and the tissue
develops into an open site for infection + Denatured cell particles increase
intercellular osmotic pressure.

23. • Tissue damage is broken down into three zones, based on Jackson's model of burn injury.
1. Zone of coagulation
occurs at the point of maximum damage.
 It’s the area nearest to the heat source that suffers the most damage
irreversible tissue loss due to coagulation of the constituent proteins.
2. Zone of Stasis
• characterized by decreased tissue perfusion.
• The tissue in this zone is potentially salvageable.
• The main aim of burns resuscitation: increase tissue perfusion here & prevent any damage becoming
irreversible.
• Additional insults e.g. prolonged hypotension, infection, or edema—can convert this zone into an
area of complete tissue loss.

24. 3. Zone of hyperemia
• In this outermost
zone tissue perfusion is
increased.
• The tissue here will
invariably recover
unless there is severe
sepsis or prolonged
hypoperfusion.

26. Systemic Response to Burns
• Occurs when TBSA>25%
Extensive tissue damage:
• 1. Release of cytokines and other inflammatory mediators (SIRS) •
↑vascular permeability → extravasation of protein and fluid from the
intravascular compartment to the interstitium→ generalized edema + ARDS
+ Hypovolemia shock with paralytic ileus
• 2. Immune dysfunction • Non-specific down regulation of the immune
response
• 3. Metabolic dysfunction & Hyper-metabolic state
• 4. Evaporative fluid loss

27. Effects on Resp System & Inhalational injuries
• Respiratory damage can occur with or without inhalational injury
• Inhalation-mediated injury occurs by:
direct heat injury to the upper airway, and
inhalation of combustion products/irritants into the lower airways
• This leads to:
direct mucosal sloughing (sloughed epithelial cells and debris),
edema,
accumulated secretions,
reactive bronchoconstriction, and
possible obstruction due to impaired ciliary clearance.

28. Effects on GIT
• Stress-induced gastric hypersecretion and susceptibility to mucosal
damage caused by splanchnic hypoperfusion can lead to acute
ulceration (Curling's ulcer).
• Mucosal atrophy, decreased absorption, increased gut permeability
• With this breach, translocation of bacteria and fungi occurs into
the blood, lymph, tissue, and organs

29. Other effects of burns
• Renal failure
• Infection (main culprits; staph aureus, beta hemolytic strep,
Pseudomonas, Klebsiella)
• Fluid & electrolyte imbalance
• Electrical burns-often associated with fractures, convulsions

30. Management
Points To Note
1. Many patients with burns also have ASSOCIATED INJURIES.
• E.g. in the case in burns occurring in the setting of: Motor vehicle crushes •
Explosions • Crush injuries • Falls e.g. in attempted escape
2. Respiratory distress in a burn patient may be due to a non-burn condition
e.g: • A pre-existing medical condition • A pneumothorax from an associated
injury • Metabolic abnormalities
3. In the pre-hospital and early hospital settings, prior to calculating the TBSA
burned, the initial fluid rates for patients with visibly large burns are based
on the patient’s age (ABLS 2018)*
• ≤ 5 years- 125 mls of RL per hour • 6-13 years- 250 mls of RL per hour • ≥
14 years- 500 mls of RL per hour

31. 4. Typically, the burns patient is initially alert and oriented.
If not, consider: • Associated injuries • CO poisoning • Substance
abuse • Hypoxia • Pre-existing medical conditions
5. Acute burns do not bleed. If there is bleeding, look for an associated
injury.

32. Pre-Hospital Care and Primary Survey
Pre-Hospital Care
1. Ensure rescuer safety
• The concept of body substance isolation
• includes use of gloves, eye wear, gowns and respiratory protection. Patients with
burns are at high risk for infection.
• The use of BSI devices also helps to protect the patient from potential cross
contamination from caregivers.
2. Stop the burning process
• Completely remove the patient’s clothing to stop the burning process
• Stop, drop, and roll technique to extinguish fires
3. Cool the area while avoiding hypothermia
4. Give oxygen

33. • Note:
• 1. Do not peel off adherent clothing
• 2. Take care to prevent overexposure and hypothermia
• 3. “Stop, drop, and roll”, although appropriate, can lead to
contamination of the burn with debris or contaminated water
• 4. Exercise care when removing any clothing that was contaminated
by chemicals
• 5. Once the burning process has been stopped, cover the patient
with warm, clean, dry linens to prevent hypothermia.

34. Primary Survey
• ABCDs
1. Airway and C-Spine Control
• Risk factors of airway obstruction
 Massive burns (↑burn size and depth)
Burns to the head and face
Inhalation injury
 Associated trauma
Burns inside the mouth

35. 2. Breathing
Components involved in effective ventilation
 Chest wall
 Diaphragm
 Lungs
Causes of Breathing Problems
Hypoxia-inhalational burns, poor chest compliance due to circumferential burns
CO poisoning
Cyanide poisoning
 Smoke inhalational injury
Direct thermal injury to the airway (from superheated steam [usually burns the
airway below the glottis] or ignition of inhaled flammable gases)
Circumferential burns of the neck and chest

36. Circulation
• Fluid resuscitation in burns is meant to replace ongoing losses from
capillary leak due to inflammation.
• Gaining IV access-establish at least 2 large bore gauge 16 iv
cannulas
• Fluid of choice-warmed isotonic crystalloids preferably RL
• Insert an indwelling urinary catheter in all patients receiving burn
resuscitation fluids, and monitor urine output to assess perfusion.

37. Fluid Rates for resuscitation
• ATLS 2018 guidelines recommend the following:
2 ml of lactated Ringer’s x patient’s body weight in kg x % TBSA for
2nd and 3rd degree burns
3 mL x kg x % TBSA (pediatric patients)
4mL/kg/%TBSA for those with electrical burns.
One-half of the total fluid is provided in the first 8 hours after the
burn injury
The remaining one-half of the total fluid is administered during the
subsequent 16 hours

38. Note
1. formulas provide a starting target rate, subsequently, amounts of fluid given
should be adjusted based on urine output.
Urine output targets
• 0.5ml/kg/hr for adults
• 1ml/kg/hr for babies <30kgs
2. Recognize factors that affect the volume of resuscitation & urine output e.g.
inhalation injury, patient’s age, renal failure, diuretics, etc
3. Tachycardia-poor marker for resuscitation in the burn patient-other parameters
should be used
5. Avoid precipitous decrease of the IV rate by one-half at 8 hours- base the
reduction in IV fluid rate on urine output and titrate to the lower urine output rate.
6. Fluid boluses should be avoided unless the patient is hypotensive.

39. BALANCING RESUSCITATION
1. Under-resuscitation results in hypoperfusion and end organ injury.
2. Over-resuscitation results in increased edema, which can result in
burn depth progression or abdominal & extremity compartment
syndrome.
• Pulmonary edema
• Abdominal compartment syndrome
• Extremity compartment syndrome
• Intra-ocular compartment syndrome

40. Hospital Care and Secondary Survey
Admission Criteria for Burns
• Extent & depth of burn-Partial-thickness burns>than 15% TBSA in
adults & > 10% in children, 3rd degree burns in any age group,
circumferential burns to the limbs, neck or chest.
• Location of burn-face, hand & feet, perineum, major joints
• Type of burn-electrical, chemical, inhalational burns
• Case Hx-suspected non-accidental burns, concomitant trauma,
patients requiring special social, rehabilitative support
• Patient factors- extremes of age, pregnancy

41. Secondary Survey
Assessment of burn patients
A. The AMPLE Hx
1. Allergies and/or drug sensitivities
2. Medications currently used (including status of the patient’s tetanus immunization)
3. Past illnesses/Pregnancy
4. Last meal
5. Events/Environment-
time of the burn injury.
• Burns sustained within an enclosed space suggest the potential for inhalation injury and
anoxic brain injury when there is an associated loss of consciousness.
• Attempted suicide • Match the patient history to the burn pattern; if the account of the injury
is suspicious, consider the possibility of abuse in both children and adults

42. B. Assessment of the Burn Wound
1. TBSA%-superficial 1st degree are not included in TBSA assessment
• Rule of Nines (Adults)
Anatomic
Surface
%TBS
Head and neck 9%
Anterior trunk 18%
Posterior trunk 18%
Arms 9% each
Legs 18% each
Genitalia 1%

43. • Rule of Nines (Infants)
•
Anatomic Surface %TBS
Head & neck 18%
Anterior trunk 18%
Posterior trunk 18%
Arms 9% each
Legs 13.5% each
Genitalia 1%

44. • Lund-Browder Charts

45. Palm Method
• useful for irregular and patchy
burns & burns< 10% BSA

46. 2. Depth of the burn wound
• Initially difficult to assess due to the dynamic nature of burn wounds
• Techniques for assessment include:
• Clinical assessment-only accurate in 60-75% of cases
• Full thickness biopsy
3. Documentation
4. Labworks
• FHG • GXM• Arterial blood gas with HbCO (carboxyhemoglobin) • serum
glucose • Electrolytes• Pregnancy test in all females of childbearing age.

47. 5. Radiological studies
• Patients who present with symptoms of ARDS • Patients who are intubated
• Patients suspected of having smoke inhalation injury • Other x-rays may
be indicated for appraisal of associated injuries.
6. Maintenance of peripheral circulation in circumferential extremity burns
• Rule out compartment syndrome:
✓ Pain greater than expected and out of proportion to the stimulus or injury
✓ Pain on passive stretch of the affected muscle ✓ Tense swelling of the
affected compartment ✓ Paresthesia or altered sensation distal to the
affected compartment

48. 7. Analgesia
Superficial burn-oral PCM or NSAIDS may suffice
Large burns-Iv opiates
IM route-avoided in large burns as absorption is unpredictable
Procedural pain- give short acting analgesics before dressing
8. Prophylaxis
Curling’s ulcer prophylaxis-PPIs or H2 antagonists
Tetanus prophylaxis
Antibiotic therapy-routine prophylactic antibiotic therapy not recommended

49. 9. Nutritional optimization
• Multivitamins • Zinc supplements • Iron supplements • High protein
diet
• Burn injuries are catabolic esp in the acute phase
• Early initiation of enteral feeding helps to control the hypermetabolic
response & reduce gut mucosal injury.
• Include nutritionists in care of these patients.
10. Supportive care- psychological support, physiotherapy

50. 11. Wound Care
Goals
to protect the wound surface
maintain a moist environment
 promote burn wound healing
limit burn wound progression
minimizing discomfort for the patient
• Aspects of wound care: application of antimicrobial agents, wound
coverage, escharotomies, debridement

51. A. Antimicrobial Agents
Topical Therapies for Burn
Wounds
I. Silver sulphadiazine.
Broad spectrum antibiotic and
antifungal
Mild analgesic,
No pseudomonal coverage
Mild inhibition to
epithelialization.
Doesn’t penetrate eschar.
II. Sulfamylon (mafenide acetate)
 Similar to silver sulfadiazine in its
sulfur properties.
 Pseudomonas and Enterococcus c
overage
 Can penetrate an eschar
 Metabolic acidosis, don’t use in
extensive wounds.

52. III. Silver Nitrate (0.5%)
Broad antimicrobial property
Stains linen, towel, clothing
Doesn’t penetrate eschar; causes methemoglobinemia.
IV. Bacitracin, neomycin, and polymyxin B ointments
Narrow antimicrobial coverage.
Used for smaller burns and superficial partial-thickness burns
Clear and painless

53. B. Wound Coverage
Choices for wound
coverage include:
• Wound dressings
• Skin grafts
• Skin flaps
I. Wound Dressings
Synthetic vs Biologic
Synthetic
-Vaseline impregnated gauze, duoderm,
opsite, biobrane, integra
Biologic-allografts, xenografts, amnion
 temporary cover for wound
 protect the wound from desiccation while
promoting re-epithelialization
 graft separates from the wound once it has
re-epithelialized.
 useful in children: applied only once,
decreasing the pain that typically

54. Synthetic dressings
For 1st and 2nd degree wounds-open vs closed methods:
-open method-apply SSD without dressing-used commonly for burns in the
face, head & neck
• Closed method-wounds dressed in 3 layers:
Non adhesive-petrolatum gauze, Vaseline gauze, Xeroform gauze dressing
Absorbent-gauzes
occlusive-crepe bandage
• The dressings: soothe & protect the skin

55. C. Escharotomies
• Eschar-charred, insensate, denatured,
full thickness, deep burns
• Circumferential eschar in the upper or
lower limbs, neck, thorax-create a
tourniquet effect-ischemia-gangrene
• May be thin or thick
• Thin-can be removed by serial dressing
• Thick-escharotomy-incisions made to
release constriction-restore distal
circulation
• Escharotomy-may cause heavy blood-
hence GXM prior and get blood ready for
transfusion

56. • D. Debridement
Early debridement of necrotic tissue recommended

57. Complications
Acute
Hypovolemia
Hypothermia
Renal failure
 Sepsis
 Shock
Pulmonary edema, ARDS, respiratory failure
Circumferential burns – compartment syndrome
Electrical burns-arrythmias, rhabdomyolysis

58. Chronic
• Contractures & their complications- Ectropion of eyelid causing
keratitis and corneal ulcer. ✓ Disfigurement in face. ✓ Narrowing of
mouth (microstomia). ✓ Contracture in the neck causing restricted
neck movements. ✓ Disability and nonfunctioning of joints due to
contracture.
• Hypertrophic scars & keloids
• Marjolin’s ulcers
• Chemical burns-esophageal strictures (if burns involve esophagus)

60. Summary
• Burns are a major cause of injury and death worldwide.
• 90 % of burns are preventable through public education, legislation and good
health and safety regulations.
• Burns are a socio-economic disease.
• The quality of care during the first hours after a burn injury has a major impact on
long-term outcome.
• Correct management of burns requires a skilled multidisciplinary approach
(general practitioners, burn surgeons, nurses, burn therapists, and other healthcare
specialists)
• Initial evaluation of the burned patient should follow the same initial priorities of
all trauma patients
• The main aims of burn care are to restore form, function and feeling

61. References
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