This document provides an overview of burns, including: 1. It defines burns and discusses their causes, including thermal, electrical, radiation, chemical and extreme cold injuries. 2. It covers the pathophysiology of burns, including how heat denatures proteins and causes coagulative necrosis of skin and tissues. 3. It describes burn classifications based on depth, extent, and severity, using systems like the Rule of Nines and Lund-Browder charts. 4. It outlines principles of burn management, including initial first aid, fluid resuscitation formulas, wound care, surgery, and prevention of complications.

1. Burns
MS BWALYA LECTURE NOTES

2. Outline/Objectives
• Introduction
• Anatomy
• Pathophysiology
• Classification
• Principles of management
• Complications and preventions
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3. Introduction-Definition
• A burn is coagulative necrosis of the skin or
other organic tissue primarily caused by heat
or due to radiation, radioactivity, electricity,
friction, contact with chemicals or even
extreme cold-frost bite.
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4. Introduction
• Caused by extreme of temperatures
• Duration of exposure also a factor
• Thermal (heat) burns occur when some or all
of the cells in the skin or other tissues are
destroyed by:
– hot liquids (scalds)
– hot solids (contact burns), or
– flames (flame burns).
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5. Introduction
• Deeper to skin includes;
– Muscle and tendons
– Subcutaneous fat
– Fascia
– Neurovascular bundles
– Bones
• Can also involve epithelial lining
– Oral cavity
– Airway
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6. Look out for additional injuries
• Head injury
• Fractures
• Chest
• Abdominal
• Spine
– Blast injury, high voltage injury, closed up
surrounding e.g. house
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7. Epidemiology
• An estimated 265 000 deaths world over every
year are caused by burns
• The vast majority occur in low- and middle-
income countries.
• Non-fatal burn injuries are a leading cause of
morbidity.
• Burns occur mainly in the home and
workplace.
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8. Causes
• Thermal heat
– Flames (danger of inhalation burns in closed
structures), hot water, hot foods, charcoal
• Electricity
• Radiation
• Chemical
• Friction
• Extreme cold
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9. Risk factors
• Poor social status; low and middle income
countries
• Sex; F>M, but lately equal
• Age; 5 years ( 11th cause of mortality among 1-
9 year olds)
• Occupation
• Epileptic
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10. Anatomy of skin
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11. Function of Skin
• Homeostasis
– Temperature regulation
– Fluid
– Electrolytes
• Immunity
– Innate ( mechanical barrier)
• Endocrine
• Excretory
• Identity/ race
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12. Pathophysiology
• Human body made up of cells, built up from
organelles composed of macromolecules
– Proteins, Carbohydrates, Fats
• Proteins: enzymes, pumps, adhesion molecules etc
• Heat denatures protein at temperature as low
as 42° degrees
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13. Pathophysiology
• Local effects
• Thermal injury causes coagulative necrosis to the
epidermis and the underlying tissues.
• These constitute local effects. The zone of coagulation
is surrounded by a zone of stasis which is surrounded
by a zone of hyperaemia.
• Cell death
• Release of inflammatory mediators
• Increased capillary permeability
• Microvascular Thrombosis
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KM

14. Pathophysiology
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15. Pathophysiology
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16. Classification of burns
• Done according to;
– Cause
• Flame, Scalds, chemical, friction, contact, etc
– Depth
• Thickness/ degree
– Extent
• Size
– Minor/Major
• Inhalational injury
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17. Burn classification
• Superficial/Erythema ( 1st degree)
– Involves epidermis only
– Eg sunburn
– Erthema and oedema of skin
– They are paniful
– Heal quickly within a week by re –epithelialization
with no scars
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18. Burn classification
(ii)Partial thickness burn-Second Degree
a. Superficial partial thickness
Involves epidermis and the papillary dermis
Red
Blistering, moist
Painful
Heal by epithelialization, complete by 14 days
Minimal or no permanent scars but can leave
discoloration
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19. 3/6/14 KM 18
• b. Deep partial thickness
• Involves epidermis, upper dermis and varying
degrees of lower dermis
• Pale, mottled appearance
• Fixed staining (no blanching)
• May be painful or insensate (depending on
depth)
• Heal by combination of epithelialization and
wound contracture
• May take weeks can leave significant scars and
contractures over joints depending on time
taken to heal

20. Full thickness burns-Third Degree
• Both dermis and epidermis burnt.
• No blisters
• Skin appendages damaged.
• Look dull or dark.
• Pin prink sensation-negative (Insensitive)
• Eschar to the limb extremities may be present.
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21. Burn classification
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22. Superficial burns/Erythema
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23. Partial thickness superficial
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24. Partial thickness
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25. Partial thickness
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26. Burn classification-examination
Deep dermal with pale pink and white
patches, non blanching
Superficial partial
thickness showing pink
blanching
Full thickness, dry
white leathery
appearance
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KM

27. Electrical burns
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28. Electrical burns
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29. Burn size estimation
• Burns size
• Determination of the burn size estimates the
extent of injury
– Lund-Browder charts
– Rule of nines
– Rule of the palm
– Rule of sevens
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KM

30. Lund-Browder chart
These take account of the
patient’s age and provide a more
detailed mapping system for the
burnt area
AREA AGE 0 1 5 10 15 ADULT
A = ½ OF HEAD 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ 3 ½
B = ½ OF ONE THIGH 2 ¾ 3 ¼ 4 4 ½ 4 ½ 4 ¾
C = ½ OF ONE LEG 2 ½ 2 ½ 2 ¾ 3 3 ¼ 3 ½
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KM

31. 3/6/14 KM 30
 Whenyouareoncall,thept.comeswithburns.What3thingswouldyoutellthe
consultantonphoneaboutthept.?
a. The%ESTIMATEoftheburns:asthiswillhelpintheMxofthept.,whether
toadmitornotandexpectedcomplications
b. WhatCAUSEDtheburns-thiswillhelptellthedepthoftheburns
 Domesticburnsareusuallysuperficial
 Industrialburnsareusuallydeep
c. WhatTIMEdidthept.getburnt-thiswillhelpinfluidreplacementtherapy

32. 3/6/14 KM 31
rules
Estimate %
a) Wallace rule can either be
(i) Rule of 9 in adults
Head – 9%
Arm- 9%
Trunk- 18x2= 36%
Leg – 18%
Perineum- 1%
(ii) Rule of 7 in children
Head – 28%
Arm- 7%
Trunk – 28%
Perineum- 2%
Leg- 14%

33. 3/6/14 KM 32

34. Management

35. First aid treatment
• Safety for the rescuer
• Extinguish fire/switch off electricity
• Remove patient from the source of injury
• Chemical burns-copious water wash
• Cool water treatment
• Avoid causing further injuries to patient
especially cervical spine
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36. First Aid treatment
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37. Initial management
• A + cervical stabilisation=Airway
• B=Breathing
• C=Circulation
– Fluid resuscitation very important in the first
72hrs
• D=Disability GCS
• E=exposure, extent, electrolytes
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38. Initial management
• Primary re-evaluation; ABCDE
• Wash burnt surface area
• analgesia
• Catheterise patient
• Tatenus toxoid 0.5 mls IM single dose
• Secondary survey
– Detailed history
– Full physical examination
• Examine the entire patient in a warm environment
• Mind hypothermia
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39. End point of resuscitation
• Document findings
• Evaluation of burnt area to reach accurate
size
• Vitals normal for age;
– PR, BP, RR, capillary refill
• GCS
• Urine output
– 0.5-1.0mls/Kg BW/hr
• Keep patient warm
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40. 3/6/14 KM 39
• Intermediate [directed to the wound (open
or closed method)]
• Daily wound cleaning
• Silver sulphadiazine (flamazine)
• Wet soaks
• Sloughectomy/Escharotomy

41. Long term
• Monitoring o Fluid replacement o Urine
output (0.5 - 1ml/kg/hr. hence catheterize the
pt.) o Temperature - spikes may indicate
infection.
• o Heart rate - rapid rate may also indicate
infection, or severe dehydration o Pulse rate o
Mental status o Edema
• Wound healing o Color o Pus o Slough
• Nutritional status
• Weight
• Skin fold thickness KM 40

42. Fluid resuscitation
• Parkland Formula
– Most widely used
Body wt x TBSA% x (2-4mls) = X mls
-1st give half of Xmls in the 1st 8hrs from time of burns event
-2nd give next half of Xmls in the next 16hrs
Important!!!
The above two formulae are only applicable up to and
including 40% burns. Thus, a pt. with 54% burns will be
considered to have 40% burns, for example. This ensures no
fluid overload The fluids used are Crystalloids, N-saline,
Ringer’s lactate or Hartmann’s solution
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KM

43. Barclay & Muir formula or leads
formula
• Body wt. x TBSA% = Xmls
2
• 1st give 4hrly in 12hrs X (4hr), X (4hr), X (4hr)
• Next- 6hrly in 12hrs X (6hr), X (6hr)
• Then – 12hrly in 24hrs X (12hr), X (12hr)
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44. Maintenance fluid in 24 hours
• For a Neonate - 120mls/kg b/wt.
• Up to 10kg - 100mls/kg b/wt.
• Between 10-20kg - 50mls/kg b/wt.
• More than 20kg - 20mls/kg b/wt.
• 5% dextrose is used for maintenance
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45. • Fluid/ blood
• If deep >20% = give blood
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46. CRITERIA FOR ADMISSION IN BURNS
1. Burns >20% bsa in adults
2. Burns >10% bsa in children & elderly >50
3. Electrical burns
4. Chemical burns [extensive]
5. Suspected child abuse burns
6. Inhalation burns
7. Special areas – face, hands, genitalia , major
joints
8. Concomitant trauma – trauma center first
9. Co-morbidities – cardiopulmonary, dm, epilepsy
10.>5% deep burns

47. TREATING BURNS
(1)Open method
• Clean & leave open
• Topical cream; flamazine cream
(2)Closed method
• Clean & dress wound for up to 10 days
(3)Mixed
• Clean and apply wet soaks
(4)Other methods Eg skin grafting
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48. Investigations
• CBC/FBC
• Electrolytes
• Creatinine, Urea
• Blood sugar level
• ECG-electrical burns
• ABGs
• CXR
• X-match; major
burns
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49. Escharotomy/ fasciotomy of chest
and arm-full thickness burns
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KM

50. Surgery
• Debridement
• Fasciotomy
• Escharotomy
• Skin grafting
• Flaps
• Pedicles
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51. Factors affecting healing
• Systemic
– Anaemia
– Infection
– Shock/hypotension
– Age
– Malignancy
– Smoking
– Co-morbidities
• Immunosuppression
• RVD, Steroids, Cytotoxics,
DM, malnutrition, renal
and hepatic failure
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52. Factors affecting healing
• Local
– Infection
– Foreign body
• Successful take depends on
– Good vascular bed
– No Infection: streptococcus, pseudomonas
– Good nutrition; early skin grafting
• Anaemia, Albumin,
– Well controlled co-morbidities
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53. Complications
EARLY
- Airway obstruction
- Oedema
- Hypovolemia
- Shock
- Hypoxia
- Breathing difficulties
- Hypothermia
- Hypoglycemia
- Electrolyte imbalance
INTERMEDIATE
-infection
-anaemia and malnutrition
-Compartment syndrome
-Renal failure
- Poor healing
LATE….
-contractures
-hypertrophic scar or
keloids
-nerve compression
Psychological effect –
cosmetic effect
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54. Complications
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55. Thanx…