1. This document provides an overview of burns, including definitions, classifications, pathophysiology, assessment, fluid resuscitation guidelines, and complications. 2. Burns are classified based on etiology, anatomical depth and thickness. Full thickness third degree burns involve the entire dermis and are painless. 3. The pathophysiology of burns involves local tissue damage and systemic inflammatory responses that can lead to shock, organ dysfunction, and failure if not properly treated. 4. Assessment involves determining burn depth, size, and fluid resuscitation needs based on the Parkland or other formulas like Muir and Barclay that are calculated using weight and percent of total body surface area burned.

1. KABWE CENTRAL HOSPITAL
“BURNS”
Wisdom’s Lecture Notes
BANDA WISDOM CHILUFYA
MBChB (CBU)

2. Definition
Refers to coagulative necrosis of the
tissues caused by heat transferred from
the source to the body.
NB: frostbite is coagulative necrosis
caused by extreme degrees of cold

3. ETIOLOGICAL CLASSIFICATION OF BURNS
• Thermal burns: Flame and Scald burns
• Electrical Burns
• Chemical Burns
• Radiation Burns
• Inhalation Burns
• Friction Burns
• FRICET

4. ANATOMICAL CLASSIFICATION
1. First degree burns – erythema – redness –
sunburn – painful – n0 blister formation
[vesicle/bulla] – epidermis only
2. Second degree burns – blister formation – very
painful – damage to basement membrane –
epidermis & superficial dermis
3. Third degree burns – dermis – painless – aka
= full thickness burns
4. Fourth degree burns – subcutaneous tissue –
muscle & bone
A mixture is of the above is a common finding

5. Depending on thickness of skin involved
I. Partial thickness burns: It is either
first or second degree burn which is red
and painful, often with Blisters
II. Full thickness burns: It is third degree
burns which is charred, insensitive,
deep involving all layers of the skin.

6. Pathophysiology
 Heat causes coagulation necrosis of skin and subcutaneous
tissue.
 Release of vasoactive peptides
 Altered capillary permeability
 Loss of fluid
 Severe hypovolemia
 Decreased cardiac output
1. Decreased renal blood -Oliguria (Renal failure)
2. Altered pulmonary resistance causing pulmonary oedema
Infection
Systemic Inflammatory Response Syndrome (SIRS)
Multi Organ Dysfunction Syndrome (MODS).

7. JACKSON’S ZONES OF BURN

8. PHASE 1 = RAPID RESPONSE SYSTEM = NERVOUS
SYSTEM
• “Fight or flee”
• Governed by hypothalamus = autonomic
nervous system [sympathetic component]
• Release of adrenaline and noradrenaline
• Pupils dilate
• Heart rate rises
• Brain alert
• Airways dilate

9. PHASE 2 = LOCAL RESPONSE
• Initial response is vasoconstriction by the
catecholamine augmented by endothelin
= most potent vasoconstrictor known
• Soon this is replaced by vasodilatation
and increased vascular permeability at
injury site
• Principal vasodilators include nitric oxide,
prostacyclin, histamine, serotonin
• This allows for the extravasation of
inflammatory cells to come in to kill the invaders
and clean up the mess

10. PHASE 3 = ENDOCRINE RESPONSE
• Remember the bigger the insult or injury the bigger the
response
• Therefore limited injury will have no systemic
response
• The goal of all these responses is preserve
intravascular volume
• Any insult threatening intravascular integrity
HYPOTHALAMUS-PITUITARY-ADRENAL AXIS
• Low Bp is picked up by the baroreceptors =>
hypothalamus=>corticotrophin releasing hormone=>
adrenacorticotropin hormone=> cortisol & aldosterone=>
raises sensitivity of catecholamine & sodium
reabsorption

11. RENIN-ANGIOTENSIN-ALDOSTERONE AXIS
• Baroreceptors in the juxtaglomerular
apparatus=> renin=> angiotensinogen=>
angiotensin-1=> angiotensin converting
enzyme=>angiotensin-2=> vasoconstrictor
& stimulate aldosterone release by the
adrenal cortex

12. PHASE 4 – METABOLIC RESPONSE
• FIRST 72 HOURS-Glycogen catabolism Hyperglyceamic
state
• GLYCOGEN STORES=>400 gm =>100 IN LIVER & 300 IN
MUSCLE => EXHAUSTABLE IN 2-3 DAYS
• Catecholamine, cortisol, acth, glucagon & angiotensin 2
are potent stimulators of glycogenolysis
• These hormones inhibit insulin => hyperglycemia => pseudo
diabetic state
• B – PROTEOLYTIC PHASE
• After the exhaustion of glycogen stores the body switches to
the break down of proteins as a source of energy-Protein
stores are worth 2-5days

13. PHASE 4 – C – FAT CATABOLISM
• Fat stores are the major long term source of
energy for the stressed or starved human body,
accounting for 50-80% of the body’s energy
requirements.
• Break down products of fats=>fatty acids & glycerol
=> cori cycle => glucose & ketones
• Some tissues are able to use ketones as a source
of energy

14. ASSESMENT OF BURNS
1. Wallace rule of 9

15. RULE OF PALM
• “RULE OF THE PALM” = PATIENT’S PALM
IS APPROXIMATELY 1% OF THE BSA IN
BOTH ADULTS AND CHILDREN

16. Investigations
• FBC.
• U+E.
• If inhalation suspected: chest X-ray,
arterial blood gases, CO
• estimation.
• Blood group and crossmatch.
• ECG/cardiac enzymes with electrical
burns.

17. IN SUMMARY
1. ABCDE
2. Pain control
3. Tetanus prophylaxis
4. Secondary survey + % bsa + depth
5. Foley catheter
6. Fluid resuscitation => oral or intravenous
7. Proton pump inhibitors
8. Topical antibiotics
9. Daily wound care
10.Keep the room warm

18. Other General measures
• High protein diet
• Blood transfusion
• Physiotherapy
• The use of a cradle
• Always keep the patient warm

19. FLUID RESUSCITATION
1. PARKLAND FORMULA:-
1. 4ml x KG x % BURN AREA = MLS
2. Half is administered in first 8 hours
3. The next half is administered in the following 16
hours
• This formula or any formula is not cast in stone
and should be modified to achieve the desired
urine output
• Literature says don’t go beyond 8.4 liters.
Maximum percentage for fluid should be less
than 50%
• But in practice (30-40%)

20. 2. Muir and Barclay
• =(%BSA x Kg) /2
Fluids are given over 36 hrs. as follows
1st 12 hrs= 3 infusions at 4hrs interval
2nd 12 hrs= 2 infusions at 6hrs interval
3rd 12 hrs=1 infusion
Eg SLMO Phiri at Cavindesh sustains 20 burns, he
weight is 70 calculate his fluid requirement using
Muir and Barclay

21. 3. Modified Brookes
It calculates the deficity:
=2 X %bsa x kg.

22. CRITERIA FOR ADMISSION TO A BURNS
CENTER
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

23. Complications of burns
Early:
• Airway obstruction
• Shock
• Hypoxia
• RDS
• Hypothermia
• Electrolyte imbalance
• Infection
• Anemia
• Stress ulcers (Curling ulcers)
• Paralytic ileus
• Renal failure
• Compartment syndrome

24. Late complications
• Contractures
• Hypertrophic scar
• keloids
• Margolis's ulcer

25. Alex Comfort
English physician and sexologist
The idea of the human
responsibility of the doctor has
been present since medicine was
indistinguishable from magic.