Undergraduate presentation about management of burn injury based on Bailey and Loves Short practice of Surgery

1. MANAGEMENT OF
BURN INJURY
DR.NOUSHIN NOWAR
INTERN DOCTOR,
DEPARTMENT OF SURGERY,JNNHAH,NOAKHALI.

2. BURNS
• In children- SCALDS caused by accidents with
kettles, pans, hot drinks and bath water
• In young males - Experimenting with matches and
inflamable liquids
• In adults- Electrical and chemical injuries.
Associated conditions such as mental
disease,epilepsy,alcohol and drug abuse may
present with burn.

3. ETIOLOGY
• Dry heat
• Flame
• Electric contact
• Chemical
• Frost bite
• Ionizing radiation

4. CLASSIFICATION
• Depending on the thickness of skin involved
• Superficial (first degree )
• Partial-thickness (second degree )
• Superficial partial-thickness
• Deep partial-thickness
• Full-thickness burns (third degree)
• Fourth degree

5. CLASSIFICATION
• Depending on the percentage of burns
(Burn severity classification)
Mild
• Partial thickness burns <15% in adults or <10% in children
• Full thickness burns <2%
• Can be treated on outpatient basis

6. CLASSIFICATION
• Depending on the percentage of burns
(Burn severity classification)
Moderate
• Second degree of 15 -25% (10-20 in children)
• Third degree 2-10%
• Not involving eyes, ears, face, hand, feet, perineum

7. CLASSIFICATION
• Depending on the percentage of burns
(Burn severity classification)
Major (Severe )
• Second degree burns more than 25% (>20%in children)
• All third degree burns of 10%or more
• Burns involving eyes, ears, face, hand, feet, perineum
• All inhalational and electrical burns
• Burns with fractures and major mechanical trauma

9. CLASSIFICATION
First degree
• Epidermis looks red
and painful
• No blisters
• Heals rapidly within
5 to 7 days by epithelialization without scarring
First degree burn

10. CLASSIFICATION
Second degree
• Affected area
looks red ,mottled
and painful
• Blister formation
• Heals within 14 to
21 days by
epithelialization
with scarring

11. CLASSIFICATION
Third degree
• Affected area is painless
and insensitive with
thrombosis of superficial
vessels
• Requires grafting
Fourth degree
• Involves underlying
tissues, muscles, bones

12. DEGREES OF BURNS

13. ASSESSMENT
• Assessing size
• Assessing the depth of a burn

14. ASSESSMENT
Assesing size
• Should be assessed in a controlled environment to avoid
hypothermia
• In smaller burns,
Just cut a piece of a clean paper of a size of patients
whole hand (digit and palm) which present 1% TBSA
and match this to the area burnt
Another accurate way of measuring the size of burns is to
draw the burn on a LUND AND BROWDER CHART

15. The LUND AND BROWDER CHART

16. ASSESSMENT
Rule of 9 (Wallace’s rule of 9)
• Each upper limb is 9% TBSA
• Each lower limb is 18% TBSA
• Torso 18 % each side
• Head and neck 9%
• Perineum 1%
• In children
• head and neck is 18% and
• lower limb is 13.5%each = 27%

17. ASSESSMENT
Rule of 9 (wallace’s rule of 9)
• Each upper limb is 9% TBSA
• Each lower limb is 18% TBSA
• Torso 18 % each side
• Head and neck 9%
• Perineum 1%
• In children
• head and neck is 18% and
• lower limb is 13.5%each
= 27%

18. ASSESSMENT
ASSESSING THE DEPTH FROM THE HISTORY AND
TIME
A.Superficial partial-thickness burns
• No deeper than the papillary dermis.
• Clinical features
• Blistering and/or loss of the epidermis.
• Underlying dermis is pink and moist.
• When blanched, capillary return is clearly visible
• Pinprick sensation is normal.
• Heal without residual scarring in 2 weeks.
• Treatment is non-surgical

19. ASSESSMENT
ASSESSING THE DEPTH FROM THE HISTORY AND
TIME
B.Deep partial-thickness burns
• damage to the deeper parts of the reticular dermis .
• Epidermis is usually lost.
• The exposed dermis is not as moist as that in a superficial burn.
• Fixed capillary staining
• Colour does not blanch with pressure
• Sensation is reduced and the patient is unable to distinguish sharp
from blunt pressure
• Takes 3 or more weeks to heal without surgery
• Leads to hypertrophic scarring

21. ASSESSMENT
ASSESSING THE DEPTH FROM THE HISTORY
AND TIME
C. Full-thickness burns
• The whole of the dermis is destroyed
• Hard and leathery feel
• No capillary return.
• Often thrombosed vessels can be seen under the skin.
• These burns are completely anaesthetised: a needle
can be stuck deep into the dermis without any pain or
bleeding

23. CAUSES OF DEATH IN BURNS
• Hypovolaemia and shock
• Renal failure
• Pulmonary edema and ARDS
• Septicaemia
• Multi organ failure

24. MANAGEMENT OF BURNS
IMMEDIATE CARE OF THE BURN PATIENT
Pre-hospital care
• Ensure rescuer safety
• Stop the burning process.
• Check for other injuries. A standard ABC (airway, breathing, circulation)
check followed by a rapid secondary survey
• Cool the burn wound with tap water by continuous irrigation for 20
minutes
• Give oxygen. Anyone involved in a fire in an enclosed space should
receive oxygen
• Elevate

25. MANAGEMENT OF BURNS
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

26. MANAGEMENT OF BURNS
Hospital care
• A, Airway control
• B, Breathing and ventilation
• C, Circulation
• D, Disability – neurological status
• E, Exposure with environmental control
• F, Fluid resuscitation.

27. MANAGEMENT OF BURNS
Initial Management
• Clothing should be removed
• Cooling of the part by running water for 20 minutes
• Cleaning the part to remove dust, mud, etc
• Chemoprophylaxis—tetanus toxoid; antibiotics; local
antiseptics
• Covering with dressings by different methods
• Comforting with sedation and pain killer

28. MANAGEMENT OF BURNS
Definitive Treatment
• Admit the patient.
• Maintain airway, breathing, circulation (ABC).
• Emergency endotracheal intubation may be required in early
period
• Assess the percentage, degree, and type of burn.
• Keep the patient in a clean environment.
• Sedation and proper analgesia.
• Patient should be in burns unit (ideally air-conditioned) with barrier
nursing, sterile clothes, bed sheets with all aseptic methods.

29. FLUID RESUSCITATION
• IV volume must be maintained following a burn in
order to provide sufficient circulation to perfuse not
only the organs but also the peripheral
tissues,especially damaged skin
• IV resuscitation is appropriate for any child with a
burn greater than 10% and 15% for TBSA for adults
• If oral resuscitation is to be commenced then water
is given should not be salt free
• It is appropriate to give oral rehydration with a
solution such as DIORALYTE

30. FLUID RESUSCITATION
Formulas to calculate the fluid replacement
• Parkland formula (commonly used)
• This calculates the fluid to be replaced in the first 24
hours
4ml x TBSA (%) x body weight (kg) = volume (ml)
Half of this volume is given in first 8 hours
Second half is given in the subsequent in 16 hours
• Other formulas are Evan’s formula,Muir and Barclay
formula,Modified brook formula

31. FLUIDS USED
Crystalloid
• As effective as colloids for maintaining intravascular volume
• Less expensive
• Ringer lactate -most commonly used
• In children- Dextrose saline is given for maintainance
• 100ml/kg for 24h for first 10kg
• 50ml/kg for 24 hrs for next 10 kg
• 20ml/kg for 24 hrs for each kg above 20kg body weight

32. FLUIDS USED
Hypertonic saline
• Human albumin solution (HAS) is a commonly used colloid.
• Effective in treating burns shock for many years.
• Produces hyperosmolarity and hypernatremia
• Reduces shift of intracellular water to extracellular space
Advantages
Include less tissue oedema and a resultant decrease in
escharotomies and intubation

33. FLUIDS USED
Colloid resuscitation
• Plasma proteins are responsible for the inward oncotic pressure that
counteracts the outward capillary hydrostatic pressure.
• Without proteins, there will be oedema.
• Proteins should be given after the first 12 hours of burn because, before
this time, the massive fluid shifts cause proteins to leak out of the cells.
The most common colloid-based formula is the Muir and Barclay formula:
• 0.5 × percentage body surface area burnt × weight = one portion;
• periods of 4/4/4, 6/6 and 12 hours, respectively;
• one portion to be given in each period.

34. MONITORING OF
RESUSCITATION
• The key to monitoring of resuscitation is urine output.
• Urine output should be between 0.5 and 1.0 mL/kg body weight per
hour.
• If the urine output is below this, the infusion rate should be increased
by 50 %
• If the urine output is inadequate and the patient is showing signs of
hypoperfusion (restlessness with tachycardia, cool peripheries and a
high haematocrit), then a bolus of 10 mL/kg body weight should be
given.
• Urine output in excess of 2 mL/kg body weight per hour should signal
a decrease in the rate of infusion.
• Haematocrit measurement is a useful tool in confirming suspected
under- or overhydration.

35. LOCAL MANAGEMENT
Dressings
• Paraffin gauze, Hydrocolloids, plastic films, vaseline
impregnated gauze or fenestrated silicone sheet or biological
dressings like amniotic membrane or synthetic biobrane.
Open method
• Silver sulfadiazine application without dressings commonly
used in burns of face, head and neck
Closed method
• with dressings . Done to soothen and to protect the wound,
reduce the pain, as an absorbent

36. TREATING THE BURN WOUND
Principles of dressings for burns
• Superficial burns will heal and need simple dressings
• Full-thickness and deep dermal burns need antibacterial
dressings to delay colonisation prior to surgery
• An optimal healing environment can make a difference
to outcome in borderline depth burns
• The choice of dressing can make the difference between
scar and no scar and/ or operation and no operation.

37. DRESSINGS
Options for topical treatment of deep burns
• 1% silver sulphadiazine cream
• 0.5% silver nitrate solution
• Mafenide acetate cream
• Silver sulphadiazine and cerium nitrate
1% silver sulphadiazine cream
• Broad-spectrum prophylaxis against bacterial
colonisation such as Pseudomonas aeruginosa and
methicillin-resistant Staphylococcus aureus. It causes
neutropenia.

38. DRESSINGS
0.5% silver nitrate solution
• Highly effective as a prophylaxis against Pseudomonas colonisation,
not as active as silver sulphadiazine cream
• It needs to be changed or the wounds resoaked every 2–4 hours.
• Causes staining of burnt area.
Mafenide acetate cream/sulfamylon
• Popular especially in the US, but is painful to apply. Causes acidosis.
Silver sulphadiazine and cerium nitrate.
• Cerium nitrate forms a sterile eschar ,when a conservative treatment
option has been chosen.
• To boost cell-mediated immunity in these patients.

39. DRESSINGS
Synthetic dressings in burn wound
• Vaseline impregnated gauze dressing prevents stiffness of eschar.
• Hydrocolloid dressing (duoderm) helps moist environment, proper
epithelialisation. It is useful in mixed deep burns. It is changed once in 3
days.
• Opsite -less expensive, less pain, creates moist barrier,no antimicrobial
effect,causes accumulation of exudates.
• Biobrane is collagen coated silicone sheet which gets adherent to wound
acting as barrier without any pain. No antimicrobial effect ,causes
accumulation of exudates. It is used for 2nd degree burns.
• Transcyte has similar features of biobrane. It contains growth factor
derived from cultured fibroblasts which promotes wound healing.
• Integra contains deeper collagen matrix as dermal substitute; Provides
complete wound cover. Scarring is reduced.

40. TREATING THE BURN WOUND
• Tangential excision of burn wound with skin grafting can
be done in 48 hours in patients with less than 25% burns.
• Usually done in deep dermal burn
• Dead dermis is removed layer by layer until fresh
bleeding occurs.
• Later skin grafting is done.
• Reduces the chance of secondary infection, the
hospital stay, and formation of hypertrophic scar or
contracture, the cost.

41. Surgical treatment of deep burns
• Deep dermal burns need tangential shaving and split-skin
grafting
• All but the smallest full-thickness burns need surgery
• The anaesthetist needs to be ready for significant blood loss
• Topical adrenaline reduces bleeding
• All burnt tissue needs to be excised
• Stable cover, permanent or temporary, should be applied at once
to reduce burn load

42. SURGERY FOR THE ACUTE BURN WOUND
• Any deep partial-thickness and full-thickness burns,
except those that are less than about 4 cm2, need
surgery.
• Any burn of indeterminate depth should be
reassessed after 48 hours.

43. TREATING THE BURN WOUND
Escharotomy
• Circumferential full-thickness burns to the limbs require emergency
surgery
• The tourniquet effect of this injury is easily treated by incising the
whole length of full-thickness burns.
• This should be done in the mid-axial line, avoiding major nerves ,
adequate blood should be available for transfusion if required.
• Management of the burn wound remains the same, irrespective of the
size of the injury.
• Full thickness burns and deep partial-thickness burns that will require
operative treatment will need to be dressed with an antibacterial
dressing to delay the onset of colonisation of the wound.

44. ADDITIONAL ASPECTS OF
TREATING THE BURNED PATIENT
Analgesia
• Paracetamol/NSAIDs in superficial burns
• IV opiates for large burns
• IM shouldn’t be used in burns over 10%
• Short acting analgesia before dressing
Energy balance
• Burns patients need extra feeding. It should start within 6 hours of the injury
to reduce gut mucosal damage
• Nasogastric tube -in burns over 15 % of TBSA
• Burn injuries are catabolic in the acute episode.

45. ADDITIONAL ASPECTS OF
TREATING THE BURNED PATIENT
Monitoring and control of infection
• Patients with major burns are immunocompromised
• They are susceptible to infection from many routes
• Sterile precautions must be rigorous
• Swabs should be taken regularly
• A rise in white blood cell count, thrombocytosis and increased
catabolism are warnings of infection
• Control of infection begins with policies on hand-washing and
other cross-contamination prevention measures.

46. ADDITIONAL ASPECTS OF
TREATING THE BURNED PATIENT
Nursing care
Physiotherapy
Psychological

47. MINOR BURNS/OUTPATIENT
BURNS
Local burn wound care
Blisters
• Whether to remove blisters or leave them intact has
been the subject of much debate.
• Some says it acts as a medium for bacterial
growth.blister fluid depresses immune function, slowing
down chemotaxis and intracellular killing
• Conversely, other authors advocate leaving blisters
intact as they form a sterile stratum spongiosum.

48. MINOR BURNS/OUTPATIENT
BURNS
Local burn wound care
Initial cleaning of the burn wound
• Washing the burn wound with chlorhexidine solution is ideal
• Dressings with a non-adherent material, such as Vaseline-
impregnated gauze ,left in place for 5 days. Silver sulphadiazine
1% is most commonly used
• Healed after 7–10 days.
• Avoid in pregnant women, nursing mothers and infants <2
months of age because of the increased possibility of kernicterus
in these patients.

49. MINOR BURNS/OUTPATIENT
BURNS
Local burn wound care
• The aims of dressing -decrease wound pain ,protect and isolate the
burn wound.
• First layer is Vaseline gauze or another non-adherent dressing.
• Then, gauze is wrapped around with sufficient tightness to keep the
dressing intact, but not to impede the circulation.
• This is further wrapped with bandage.
• Bulkiness of dressings depends upon the amount of wound
discharge.
• Burn of Hands - dressings should be minimised so as not to impede
mobilisation and physiotherapy.

50. MINOR BURNS/OUTPATIENT
BURNS
Local burn wound care
• Synthetic burn wound dressings are popular
• Duoderm or hydrocolloid dressings are not bulky,
help in healing and can be kept in place for 48–72
hours. They provide a moist environment, which
helps in re-epithelialisation of the burn wound.

51. HEALING OF BURN WOUNDS
• Burns that are being managed conservatively should be
healed within 3 weeks
• If there are no signs of re-epithelialisation in this time, the
wound requires debridement and grafting
Infection - use combination of topical and systemic agents.
Consider Debridement and skin grafting .
Itching -Antihistamines, analgesics, moisturising creams, aloe
vera and antibiotics
Traumatic blisters - Non-adherent dressings usually suffice;
regular moisturisation is also useful

52. Thank You