Every information on burns

1. BURNS
CENTRAL UNIVERSITY PA STUDENT’S
TUTORIAL

2. OUTLINE
 CASE SCENARIO
 DEFINITION
 EPIDEMIOLOGY
 AETIOLOGY / RISK FACTORS
 ANATOMY
 PATHOPHYSIOLOGY/PATHOLOGY
 SIGNS AND SYMPTOMS
 CLASSIFICATION OF BURNS
 FACTORS THAT AFFECT THE DEGREE OF BURNS
 ESTIMATION OF EXTENT OF BURNS
 MANAGEMENT
 CRITERIA FOR REFERRAL
 COMPLICATION
 CAUSES OF DEATH IN BURNS

3. An 18 year old female sustained burns from a gas explosion in the
kitchen whilst cooking. The burns involved the entire chest up to
the umbilicus and the anterior part of both upper limbs. There
was presence of blisters and blanching of the areas of burns. The
incidence happened around 4pm but she was able to report to the
hospital at about 6pm.
 1.What is inhalational injury?
 2. What are the risk factors for inhalational injury?
 3. What are your differential diagnoses?
 4. Give one(1) reason each to support your differential
diagnoses? 5. How will you manage the lady

4. DEFINITION
Burns is defined as coagulative necrosis of the layers of the skin
and other tissues.
Or it can also be defined as damage to the tissue as a result of
injury by various aetiological agents such as thermal (dry and
moist heat), electrical, chemical ( acidic, alkaline, and organic
chemical) and radiation.
These agents causes coagulative necrosis of the tissues with the
exception of alkaline chemicals which causes liquefactive necrosis
with the ability for deeper injury.

5. EPIDEMIOLOGY
 Scalds which refers to injury resulting from moist heat has in
the last few decades overtaken flame burns as the common
type of burn injury in the west African sub region. These
injuries occur commonly as domestic accidents with children
and women constituting a majority of the casualties. Burns are
the fifth most common cause of non-fetal childhood injuries.
Commonest site of scald injury occur in the kitchen accounting
to about 50% with the 2nd most common been the bathroom e.g
water heaters.

6. Continuation.
 Outcomes for burn patients have improved dramatically over
the past 20 years, yet burns still causes substantial morbidity
and mortality. In the United States, approximately 1.25 million
people with burns present to the emergency department each
year. Among these 63,000 have minor injuries and an additional
6,000 sustain major burn injuries that require hospital
admission.

7. AETIOLOGY / RISK FACTORS
The causative agents of burns can be classified into the following:
 THERMAL BURNS
o Dry heat (flame, gas explosion & flash burns)
o Wet heat (hot water, hot soups & hot liquids)
 ELECTRICAL BURNS
o Flash burns, flame burns and contact burns.
o Low voltage < 1000Volts.
o High Voltage > 1000 Volts
o Type of current = AC/DC with AC being more dangerous

8.  CHEMICAL BURNS
o Acids (sulphuric acid, nitric acid)
o Alkalis (caustic soda, industrial cleaners, cement)
o Organic compounds (phenols, solvents, petroleum products)
 RADAITION BURNS
o Thermal radiation
o Radiofrequency energy
o Ionizing radiation
o Ultraviolet(UV) radiation- Sunburn

9. Risk factors
 Gender (Females). Higher risk for females is associated with
open fire cooking, or inherently unsafe cookstoves, which can
ignite loose clothing. Self-directed or interpersonal violence are
also factors.
 Age. Children are more vulnerable to burns. This is due to
improper adult supervision and child maltreatment.

10. continuation
 Socioeconomic factors. People living in low-and middle-income
countries are at higher risk for burns than people living in
higher income countries.
 Occupation that increases exposure to fire
 Alcohol abuse and smoking
 Use of kerosene as a fuel source for non-electric domestic
appliances.
 Inadequate safety measures for LPG and electricity.

11. ANATOMY

12. Pathology
 The local consequence of exposure to excessive temperature is a
graded tissue injury radiating from the point of contact. The
Jacksonian model of three-dimensional concentric histopathological
zones apparently describes this. The zone of necrosis in the center is
irreversibly damaged. Next to this is the zone of ischemia or stasis
where vascular spasms and intravascular micro-thrombi result in
compromised perfusion with potential to progressive conversion to
tissue death. The outermost zone which is most remote from the
inciting agent is the zone of inflammation or hyperemia manifesting
with the classical signs of inflammation and expected to make
complete recovery in 7-10 days

13. continuation

14. PATHOPHYSIOLOGY
 Aside from the local effect of burn which results from heat transfer
and ischemia, large surface area burns are associated with systemic
physiologic derangements which are potentiated by mediators
liberated by the damaged tissue as well as neuro-endocrine organs.
These mediators activate inflammatory responses leading to increased
capillary hydrostatic pressure, generalized leakage of intravenous
fluid, electrolytes and proteins, decreased cardiac output and
suppression of the immune system. Major burn injury is therefore a
systemic disease affecting every system of the body irrespective of
remoteness from site of injury.

15. CONTINUATION
Systemic changes
 Oedema maximum at 18-24hrs
 Hypovolaemia
 Inhalational injury. Inhalation injury is most deserving of immediate
recognition and expeditious intervention.
 Renal changes
 Respiratory tract changes
 GI changes
 Central nervous system changes
 Haematological changes
 Metabolic changes

16. Inhalational injury
 The history is usually indicative of exposure to fire or smoke in a closed space
and the clinical features include facial burns, singed nasal vibrissae,
hoarseness, wheezing and the production of carbonaceous sputum and
probably loss of consciousness at the timeofinjury. Fibre-optic bronchoscopy
with its potential for enormous therapeutic benefits is the gold standard for
definitive diagnosis. Whereas heat is dispersed in the upper airways, the soot,
carbon monoxide, hydrogen cyanide and other toxic products of smoke reach
the bronchi and alveoli to evoke inflammatory changes. Increased vascular
dilatation and permeability lead to erythema, exudation and airway oedema.
This may cause patchy broncho-alveolar obstruction and impairment of
oxygenation. The ciliated epithelial cells are separated from the basement
membrane and there may be ulceration with consequent granulation tissue
formation. Proteins in the exudates coalesce to form fibrin casts, which
adhere to the bronchi and interfere with the function of the ciliated cuboidal
cells. Destruction of the ciliated cells lead to replacement with squamous
cells and scar tissue. There may thus be laryngeal obstruction, atelectasis,
respiratory infections, acute lung injury, acute respiratory distress syndrome
and respiratory failure.

17. Inhalational injury

18. CLASSIFICATION OF BURNS
 Partial thickness burns
o Superficial partial thickness burns
May be difficult to diagnose initially, Involves the epidermis and superficial
layers of dermis .Usually very painful . There are blisters (bullae) formation and
blanching- suggests viable dermis , Appears red or pinkish , Heals by 1-2 weeks
o Deep partial thickness burns
o Involves the epidermis and dermis. Relatively less painful with mottling. Heals
by 3-4 weeks

19. continuation
 Full thickness burns
o Involves epidermis, dermis, deep tissues, bones and nerves. Usually insensate
(not painful) with charring. May also appear waxy and
translucent/pale/white. Visible thrombosed veins beneath translucent skin is
characteristic. Heals by 2-3 months

20. Can anyone identify the degree of burns?

21. ?

22. ?

23. ?

24. FACTORS THAT AFFECT THE DEGREE OF BURNS
 Temperature of heat source
 Duration of exposure
 Consequent inflammatory response
 Skin thickness

25. ESTIMATION OF EXTENT OF BURNS
 Estimation of percent body surface area can be done using:
o Wallace’s rule of nine
o Lund and Browder chart
Wallace’s rule of nine
 Named after Dr Alexander Wallace, who first published the method
 The palm is 1% and may be used to estimate the extent of injury
 Usually a quick way of estimation although not accurate
 Wallace rule is preferred for adults

26. continuation
 Lund and Browder’s chart
o Created by Dr Charles Lund and Dr Newton Browder
o More useful for children
o Relatively accurate compared to Wallace rule
o Takes into consideration the age of the patient, i.e. the %BSA
decreases for the head region and increases for the extremities
as the child ages

29. continuation
 Superficial burns of 20% body surface area and above in adults or of
10% and above in children is considered major injury because the
associated fluid exudation in the first 48h post-burns may be severe
enough, to produce shock. Furthermore, burn wound infection easily
supervenes in such large areas of acute skin loss with a high risk of
septicemia. Major injuries of this nature should be admitted to
hospital. Similarly, 10% deep burns or above in adults and 5 % deep
burns and above in children also constitute major injury.

30. MANAGEMENT
The principle of management are to revive, restore, repair and to
rehabilitate the patient.
 First aid
 Resuscitation
 History
 Examination
 Investigations
 Treatment

31. FIRST AID
 This is the first and foremost care that must be given at the site/venue where the
burns took place
The following principles can be used as a guide
 FLAME BURNS
o stop the burning process, Call the National Fire Service on 192 and
national ambulance on 193. Take patient away from the source of flames.
Extinguish flames by rolling the patient on the bare ground i.e STOP,
DROP, ROLL. Remove all hot charred clotting/jewellery as quickly as
possible. If clothing is stuck, cut around the area. Lay the casualty down,
protecting the burned areas from contact with the ground if possible to
prevent contamination. Reassure and transport to hospital

32. Cooling the burn surface
 Cool with cold running water for at least 20mins
 Check for ABC while cooling and be ready to resuscitate.
 DO NOT use ice block or iced water. Extreme cold causes
vasoconstriction, it also deepens injury, risk of hypothermia.
 Cooling the surface of wound is an extremely effective analgesia
 Cover the injury with a clean gauze or non fluffy material to prevent
contamination
 A clean plastic bag or kitchen film may be used
 DO NOT put oil, shear butter or any creams on the wound

33. ACID BURNS
 Protect your hands and body
 Move the patient away from the source
 Prompt irrigation with copious water. Should be started within
10mins of contact with the substance
 Trim finger nails (some may hide in there)

34. ALKALI BURNS
 Less immediate damage than acid
 More long-term damage as they liquefy tissue and penetrate
more deeply
 Irrigate for longer period- at least 1 hour

35. ELECTRIC BURNS
 Don’t panic
 First switch off the power source (make sure you’re safe)
 Remove victim from power source with a non conductor (dry board or
wood/plastic)
 Clear airway
 Protect the cervical spine (usually for those who fell and hit the ground)
 Start CPR if needed
 Check for injuries
 Always call for help

36. COAL TAR/BITUMEN
 Rapid cooling
 Use of cooking oil
 DO NOT use any petroleum product e.g.- kerosene, petrol, etc.
which can cause tissue damage and systemic toxic effects

37. RESUSCITATION
 Before management of the burn wound can begin, the patient
should be properly and completely evaluated. Often, this is
brief effort, particularly in patients with small,uncomplicated
wounds. In those with larger burns evaluation of the wound is
often of secondary importance. As described by the American
College of Surgeon Committee on Trauma,evaluation of burn
patient is organized into a primary survey and secondary survey.

38. continuation
 Primary survey which involves the following systematic methodology.
o Timely resuscitation is important every burns patient
o This can followed as ABCDEF
o A - Airway maintenance and C- spine control
o B - Breathing and ventilation
o C - Circulation with bleeding control
o D - Disability and neurological status
o E - Exposure and environmental control
o F - Fluid resuscitation

39. FLUID RESUSCITATION
 Adults with more than 20% TBSA superficial burns and children
with more than 10% TBSA superficial burns or half the values
when the burns are deep require intravenous fluid replacement
to correct the plasma loss and prevent hypovolaemic shock.
 Various formulae used in administering fluids are only
estimates, the amount of fluid given should be guided by the
patient's response to treatment as determined by his general
condition (fluid overload, heart failure, kidney failure) and the
hourly urine output. (1-2ml/kg/hr for children).

40. continuation
 There are two formulas for the estimation of the amount of fluid intake
for the first 24hrs that is modified Brooke and the Parkland formula, but
the most commonly used formula is the Parkland formula.
 The fluid of choice is ringers lactate, but normal saline, human plasma
protein fraction (albumin 4.5%) and dextran 110 may also be used.
 Modified Brooke formula is 2mls x TBSA x weight.
 Parkland formula is 4mls x TBSA x weight.
 50% is the maximal TBSA used even if the TBSA is more than 50%
 Half the calculated volume is given within the 1 st 8-hours from the time
of burns.
 The 2nd half of the calculated volume is given over the remaining 16-
hours.

41. continuation
 The normal daily fluid maintenance is added for children
 On the 2nd day (the 2nd 24hrs), half the total volume
calculated for the first 24hrs is given + the daily maintenance
fluid for children.
 In patients in whom depth of burns is deep with loss of red
cells, blood may be used as part of the requirement if necesary

42. Secondary survey
 History
o Cause of burns- rule out domestic violence in children.
How???
o Time of burns , Place of burns (whether in an enclosed
space) due to inhalational injury and carbon monoxide
intoxication.
o Ask of any complications if patient is conscious e.g.-
cough, difficulty breathing, chest pains, etc.
o Ask of any other injuries sustained (whilst trying to escape
or falling from a height). Helpful if patient is conscious
o Any chronic medical condition
o Current medications/drug history and allergies

43. Examination
 Head to toe examination- examine all systems
 This should not be limited to only the area of burns
 Look out for other injuries including fractures, abrasions
 Look out for possible signs of inhalational – singeing of hair in
nostril, soot around the nasal region and mouth, etc.
 Persons with facial burns should undergo a careful examination
of the cornea prior to the development of lid swelling that can
compromise examination.

44. Signs of inhalational injury

45. INVESTIGATIONS
 FBC- to be repeated weekly if patient on admission.
 Blood grouping and cross matching- if patient needs transfusion
 Sickling- routine if status not known
 BUE/CR – to assess renal function and electrolytes. Can be repeated on as
needed basis
 LFT- to assess protein and albumen levels. Can be repeated every 2 weeks or
as needed. May also indicate liver damage as a complication
 Random blood sugars
 CXR- if complications such as inhalational injury or pneumonia is suspected
 ECG- crucial in electrical burns

46. TREATMENT
 Analgesia
 Wound care
 Antibiotic therapy
 Prophylaxis for Curling’s ulcers
 DVT prophylaxis
 Tetanus prophylaxis
 Nutritional support
 Physiotherapy

47. Analgesia
 Paracetamol – available as oral, IV and suppository. Adults 500 mg – 1g 6-8hourly.
Children 6-12 years 250-500 mg 6-8 hourly.
 Ibuprofen Adults 200 – 800 mg 6-8 hourly. Children 10-15 mg/kg 6-8 hourly
/Diclofenac oral Adults 50mg 8 hourly or 100 mg 12 hourly. Children more than 12
years 50 mg 12 hourly. Not recommended for children less than 12
years./Naproxen EC oral Adults 250-500 mg 12 hourly. Children- not indicated.- not
recommended in severe burns due to Curling’s ulcers but can be used in minor
burns
 Tramadol- available as IV, IM and oral
 Morphine- available as IV, IM and oral
 Pethidine – available as IM or IV
 NB: the choice of analgesia will depend on individual patient factors

48. Wound care
 This is often done after resuscitation
 The wound is cleaned with water and antiseptic under sedation or adequate
analgesia
 Blisters can be left alone if patient will be transferred to a high centre
 Blisters can also be de-roofed to help estimate percentage body surface area
 All debris and devitalized tissue are debrided/removed
 Topical antibacterial creams can be used • Silver sulfadiazine (dermazin, silver
derma, flamazine) • Mupirocin (supirocin, bactroban) • Povidone iodine
 Wound is preferably covered with Vaseline gauze to prevent material from sticking
into the wound- exclude facial wounds Dressing- typical dressing for burns -
Vaseline gauze -Soff ban -Crepe bandage -Occasionally – POP application if
indicated

49. Antibiotic therapy
 Antibiotics are not routinely recommended in most adult burns where
contamination is not suspected
 All children with burns should however be placed on antibiotics
 All burns managed outside a burns unit may also consider antibiotics since
those environments are often not sterile
 The choice of antibiotics should be individualised
 Commonly used: Cefuroxime, metronidazole, flucloxacillin, clindamycin,
ceftriaxone, etc.
 When available, wound culture can be done to guide antibiotic choice

50. Prophylaxis for Curling’s ulcer
 Proton pump inhibitors are often used
o Omeprazole
o Esomeprazole
 Antacids may be added for symptomatic relief
o Magnesium tricilicate /Aluminium hydroxide mixtures (e.g.-
Nugel suspension)

51. DVT Prophylaxis
 For major burns with prolonged hospitalization
 Any of the following can be used if indicated and available
o Heparin
o Enoxaparin (Clexane)
o Dalteparin (Fragmin)
 They are usually given subcutaneous (SC)

52. Tetanus Prophylaxis
 Tetanus vaccine – can be given to those without previous
tetanus immunization history
 Human tetanus immunoglobulin- anti-tetanus serum(ATS)- if
available. NB-Give only after resuscitation
 Both are given IM

53. Nutritional support
 High protein diets recommended- eggs, beans, fish, etc.
 Parenteral amino acids if available – Astymin-3
 Dietician or nutritionist should be involved if available
 Add haematinics if no active infection ongoing- , Iron III
polymaltose, Ferrous sulphate, Folic acid, etc.
 Add Vitamin C to improve wound healing

54. Physiotherapy
 Starts right from the beginning of the burn injury
 Exercises to the underlying joints before each dressing
 Splinting when necessary
 Encouraging the patient to use affected limbs in every day
activities
 Mobilize out of bed as early as possible

55. CRITERIA FOR REFERRAL
 Burns more than 10% TBSA
 Burns involving the face, hands, feet, genitalia, perineum and major
joints
 3rd degree (full thickness) burns in any age group
 Electrical burns including lightening injury
 Chemical burns Inhalational injury
 Burns in patients with co-morbid medical conditions that could
complicate management, prolong recovery or affect mortality
 Burned children without qualified personnel or equipment for their care
 Burn injury in patients who will require special social, emotional and
rehabilitative interventions.

56. COMPLICATIONS
 Early complications of burns are the pathophysiological changes that would
affect every system of the body when the appropriate resuscitation is
inadequate or delayed.
 Hypovolaemic Shock
 Infections
 Gastrointestinal problems Acute gastric dilatation, Paralytic ileus, Curling's
ulcers, Liver damage
 Cardio-respiration problems Respiratory obstruction Tracheo-bronchitis
Pneumonia, atelectasis
 Genito-urinary problems Renal failure Cystitis, pyelonephritis, Calculi
 Vascularproblems Thrombophlebitis, Deep venous thrombosis Pulmonary
embolism
 Anemia Disseminated intravascular coagulation (DIC)

57. continuation
 Late complications of burns are usually related to consequences of
poor healing of the burn wound and include
 Unstable scars and chronic burn wounds.
 Burn scar hypertrophy and Keloids
 Burn scar contractures and deformities
 Dyschromic scars (hypo-, hyper-, & de-pigmentation)
 Burn Scar metaplasia and Marjolin's ulcers
 Loss of body parts.
 Psychiatric problems including PTSD

58. CAUSES OF DEATH IN BURNS
 Hypovolemic shock
 Renal failure
 Sepsis
 Laryngeal oedema/inhalational injury
 Curling’s ulcers --- upper GI bleeding/perforation