BURN MANAGEMENT, BURN

1. ASSALAMUA’LAIKUM
AND
WELCOME

2. BURN MANAGEMENT -
AN OVERVIEW
DR. RAGHU NATH KARMAKER.
Resident phase –A .
Paediatric surgery, MMCH.

3. INTRODUCTION
● Burns affect more than 11 million people each year.
● 95% of burns occur in poor countries.
● 70% of those affected are children.
● Hospital admission– 0.1 million / yr.
● Attendance in DMCH in 2016 – 58,112 (OPD + Inpatient).
● Main causes– Flame burn 32%, scald 28%, and electric 27%.
● Average hospital stay– 1 - 1.5 d / % of burn.
● Mortality– 1,80,000 / yr.

4. WHAT IS BURN
A burn is a tissue injury from thermal (heat
or cold) application, or the absorption of
physical energy, or chemical contact.

5. CLASSIFICATION
A. ACCORDING TO DEPTH OF BURN WOUND:
1. Superficial / Epidermal (First degree)---
* Involves only epidermis.
* No skin breach.
* Erythematous and edematous.
* Painful.
* Subsides within 2-3 days.
* Requires no local or systemic antibiotics.
* Local application of emollient or soothing agents are
enough.
* Example—Sun burn.

6. CLASSIFICATION (CONTD.)

7. CLASSIFICATION (CONTD.)
2. Superficial dermal (second degree)---
* Involves epidermis and outer dermis (Papillary layer).
* Most dermal appendages are spared.
* Extremely painful, as free nerve endings are exposed.
* Blisters present and are usually large.
* Moist and pink underneath the blisters.
* Edematous.
* Slippery to touch.
* Capillary reaction present.
* Ends of hair follicles are visible giving a punctate appearance.
* Sensation intact.
* Heals within 10 – 14 days without scarring, if managed properly.
* Example– All scalds.

8. CLASSIFICATION (CONTD.)

9. CLASSIFICATION (CONTD.)
3. Deep dermal (second degree)---
* Involves up to deeper part of dermis (Reticular layer).
* Only bottom of sweat glands are spared.
* Hair falls out with gentle pull.
* Edematous.
* White in appearance.
* Pain diminished.
* No capillary refill.
* Some blister present and are usually small.
* Punctums present, but larger in size.
* Clotted dermal blood vessels can be seen.
* Heals in 6 – 8 weeks with formation of scar tissue.
* Example– Central areas of flame burn.

10. CLASSIFICATION (CONTD.)

11. CLASSIFICATION (CONTD.)
4. Deep / Full thickness (Third degree)---
* Involves the whole thickness of the skin with variable
depth of underlying tissue.
* Wound is dry, depressed and non edematous.
* No blisters.
* No pain.
* Leathery to touch.
* Can appear white, brown or black.
* Example– Electric contact burn.

12. CLASSIFICATION (CONTD.)

13. CLASSIFICATION (CONTD.)

14. CLASSIFICATION (CONTD.)

15. CLASSIFICATION (CONTD.)
B. ACCORDING TO AETIOLOGY:
1. Thermal–
a) Heat– i) Dry heat e.g. Flame burn.
ii) Moist heat / scald e.g. Boiling water, oil, liquid fat.
b) Cold e.g. Trench foot, frost bite, chill blain etc.
2. Physical energy--
a) Radiation e.g. UV ray, X-ray, Gamma-ray etc.
b) Contact burn e.g. contact with heated iron, metal etc.
c) Electric burn– * According to voltage–
i) Low voltage (≤ 1000 v).
ii) High voltage (> 1000 v).
iii) Extreme high voltage– Lightening strike.

16. CLASSIFICATION (CONTD.)
* According to mode of injury--
i) Electric Contact burn.
ii) Electric Flash burn.
iii) Flame burn.
3. Chemical burn—
a) Acids e.g. H2SO4, HCl, HF, HNO3 etc.
b) Alkali e.g. NaOH, KOH, household bleach,
cement, oven cleaner, fertilizers etc.
c) Other chemicals e.g. paints, insecticides etc.

17. ASSESMENT OF BURN AREA
1. Wallace Rule of 9s and rule of 7s–
* Most commonly used and most easy to memorize.
* Rule of 9s is used in adults and rule of 7s is used in case
of children.
* Rule of 9s— * Rule of 7s--
- Head and Neck- 9%. - Head and Neck- 28%.
- Ant. Trunk- 9x2 = 18%. - Trunk- 28%.
- Post. Trunk- 9x2 = 18%. - Upper limbs- 7x2 = 14%.
- Upper limbs- 9x2 = 18%. - Lower limbs- 14x2 =28%.
- Lower limbs- 18x2 = 36% - Genitalia- 2%.
- Genitalia- 1%.

18. ASSESMENT
OF BURN
AREA
2. Rule of Palm– The
palmer surface of ones
hand equals about 1%
of his total body
surface area (TBSA).
Used for assessing
scattered burn areas.

19. ASSESMENT OF
BURN AREA
(CONTD.)
3. Lund and Browder chart–
* Most accurate.
* Difficult to memorize.
* Used in most burn centers.
* Body surface areas vary
with the age of the pt.
* During calculation of burn
surface area Erythema is not
included.

20. PATHOPHYSIOLOGY
* General response to burn injury occurs when—
Burn surface area is > 15 to 20% for adults or > 10% in
children.
* This generalized response is due to Inflammatory
reaction and neural stimulation.
* These include both local and systemic changes.

21. LOCAL CHANGES
* Occurs when the amount of heat absorbed exceeds body’s
compensatory mechanism.
* Protein degradation begins at 40° C, this is reversible if temp.
is lowered. Permanent protein denaturation starts at 45° C.
* The speed of tissue damage is dependent on time of exposure
and temperature—
45 - 51° C – within minutes.
51 - 70° C – within seconds.
> 70° C -- < 1 second.
* Local changes are explained by Jackson’s tissue injury
model.

22. ZONES OF BURN INJURY
Jackson has classified thermal burns in to three zones of injury.
These are—
1. An inner zone of coagulation necrosis– It
consists of cells irreversibly destroyed by heat.
2. An intermediate zone of stasis– This is the
target zone of fluid resuscitation. It consists of cells that are
damaged reversibly. Timely and adequate resuscitation turns
them back to normal but if resuscitation is delayed or
inadequate, they become irreversibly damaged. Increasing the
area of injury.
3. An outer zone of hyperemia– It represents area
of tissue reaction. Cells in this zone are completely healthy.

23. ZONES OF BURN INJURY (CONTD.)

24. SYSTEMIC CHANGES
A. Edema formation: Burn injury causes release of cytokines
and other inflammatory mediators causing peripheral vasodilation
and increased vascular permeability resulting in leakage of
plasma into the interstitial space and edema formation.
This decrease in blood volume leads to
hypovolemia. This hypovolemia, along with the effect of the
inflammatory mediators on the heart, large vessels and lungs
causes burn shock.
Maximum fluid loss occurs during the
first 8 hours post burn, followed by a sustained loss for the next 18
– 24 hours. After this the vascular permeability returns to normal.

25. SYSTEMIC CHANGES

26. SYSTEMIC CHANGES
B. Hemodynamic and cardiac changes: There is decreased
cardiac output due to the circulating myocardial depressant
factors, originating from the burn wound.
C. Hypermetabolic response: Marked and sustained increases
in catecholamine, glucocorticoids, glucagon and dopamine
secretion leads to acute hypermetabolic stress response. The
resting energy expenditure can rise to > 140% of normal. Muscle
protein is degraded resulting in loss of lean body mass (LBM).
10% loss of LBM--- Immune dysfunction.
20% loss of LBM--- Decreased wound healing.
30% loss of LBM--- Increased risk of pneumonia and pressure
sores.
40% loss of LBM--- Death.

27. SYSTEMIC CHANGES
C. Renal system: Decreased blood volume and CO result in
decreased renal blood flow, causing oliguria, which if left
untreated will cause ATN and renal failure.
D. Gastrointestinal system: The GI response to burn is
highlighted by mucosal atrophy, changes in digestive absorption,
and increased intestinal permeability. The best treatment to
alleviate mucosal atrophy is early initiation of enteral nutrition.
The liver function is also severely affected.
E. Immune system: There is global depression in immune
function. With burns > 20% of TBSA impairment of immune
function is proportional to burn size.

28. CATAGORIZATION OF BURN
Factors Minor burns Moderate
burns
Major burns
Partial
thickness burn
< 15% TBSA adults
<10% TBSA child
15-20% TBSA
adults
10-20% child
>25% TBSA adults
>20% TBSA child
Full thickness
burn
<2% TBSA 2-10% TBSA >10% TBSA
Preferred
treatment
environment
OPD patient General hospital –
Burn team
Specialized burn
care facility

29. SEVERITY ASSESMENT

30. ADULTS VS CHILD
A. Anatomical differences:
* Thinner skin– same temperature will cause a much
deeper burn.
* Increased surface to volume ratio– leads to rapid heat
loss.
* Shorter necks, smaller tracheal diameter, and larger
tongues– more at risk of airway obstruction.
* Narrower blood vessels– increased difficulty in
gaining I/V access.

31. ADULTS VS CHILD
A. Physiological differences:
* Rapid growth.
* A higher basal metabolic rate (BMR).
* Increased minute volume.
* Increased respiratory rate.
* Small blood volume.
* Poor renal tubular concentrating ability.
* Inability to handle fluid access.
* Immature blood-brain barrier.
* Limited hepatic glycogen reserve.
* Absent shivering response.

32. INITIAL MANAGEMENT
* Remove person from source of injury to prevent further damage.
* Extinguish flames.
* Remove burnt clothes and clothes saturated with causative agents
(hot liquids / chemicals).
* Check ABC – administer CPR.
* Apply copious amounts of running water to cool and irrigate affected
area (particularly acid & alkali). Cooling should be done with cold
running tap water at 8° - 15°C for 20 – 30 min. during period up to 3
hrs. from injury.
* Dry the burnt area with sterile gauze or clean laundered cloth.
* Cover wound with cleanest thing available.
* Asses and attend other injuries as per priority.
* Shift to appropriate center for further management.

33. ADMISSION CRITERIA

34. OPD MANAGEMENT
* Smaller, superficial burns.
* Take photo.
* Wound lavage with N/S.
* Wash with mild soap.
* Manage blisters – 1) Aspirate aseptically.
2) Debride, if ruptured or causing functional
impairment.
* Cover with moisture retaining non-adherent dressing.
* Keep face and difficult to dress areas open, apply ointment.
* If contaminated wound, topical antibiotic (1% SSD) dressing
* Instruct daily dressing change.

35. MANAGEMENT OF SEVERE BURNS
* Initial assessment following ATLS guideline—
A- Assessment of airway and control of cervical spine.
B- Breathing and respiration, O2 inhalation.
C- Circulation, establish IV line.
D- Disability, rapid neurological examination.
E- Exposure, remove clothing, brush off dry chemicals.
F- Fluid resuscitation.
* Asses burn area and depth.
* Draw blood sample.
* Give NG tube and catheter.

36. FLUID RESUSCITATION
* Should be started with Parkland’s formula--
- Calculates fluid for the 1st 24 hrs.
- Fluid of choice is Ringer’s lactate solution or Hartman’s
solution.
- Half of the calculated fluid should be given in the 1st 8 hrs.
and the remaining half in the remaining 16 hrs.
- 24 hrs. begin from the time of injury, not from the time of
arrival to the hospital.
- No colloids in 1st 24 hrs.
* Parkland’s formula: 4ml / kg / % of TBSA burn.

37. FLUID RESUSCITATION (CONTD.)
* Goals of fluid resuscitation:
- Restore and maintain adequate tissue perfusion &
oxygenation.
- Avoid organ ischemia.
- Preserve heat injured but viable soft tissue
- Minimize exogenous contribution to edema.

38. FLUID RESUSCITATION (CONTD.)
* Complications of over resuscitation:
- Compartment syndrome (5 Ps– Pain, Pallor, Paraesthesia,
Paresis, and Pulselessness).
- Pulmonary edema.
- Pleural effusion.
- Congestive cardiac failure (CCF).
- Electrolyte imbalance (Dilutional hyponatremia).
- Abdominal compartment syndrome (ACS). Sustained ACS
leads to Intra abdominal hypertension (IAH--Intra abdominal
pressure > 30 cm of H2O).

39. FLUID RESUSCITATION (CONTD.)

40. MAINTENANCE FLUID
* Additional maintenance fluid is also to be given in children.
* Maintenance fluid should be added for children < 30 kg body
wt. or < 10 yrs. of age.
* It should be given via a separate I/V line.
* It should be given as saline with dextrose.
* Maintenance fluid is calculated as follows—
> 4 ml / kg / hour for the first 10 kg of body wt. PLUS
> 2 ml / kg / hour for the second 10 kg of body wt. PLUS
> 1 ml / kg / hour for the subsequent body wt.
* The total calculated fluid is given over 24 hours.

41. NUTRITION
* Early feeding can—
- Prevent gut ulceration.
- Prevent bacterial translocation.
- Reduce protein breakdown.
- Restore vitamins and minerals.
- Maintain strength for rehabilitation.
* The daily requirement for CHO, protein and fat should be –
CHO: 50%, Protein: 30%, and Fat: 20%.

42. OTHER MEASURES
* Antibiotics (Usually not needed for the first 5 days until there
is severe contamination).
* Analgesics, IV opioids are the choice followed by NSAIDs.
* Sedatives.
* Gastric anti-secretory agents.
* Tetanus prophylaxis.
* Encourage early feeding.
* Iron and Vitamin supplementation.
* Physiotherapy, should be started as early as possible.

43. WOUND MANAGEMENT
A. General--
- Cleaning and debridement of wound.
- Escharotomy / Fasciotomy, if necessary.
B. Specific—
- Open / Closed wound management.
- Purpose of closed dressing—
i) Absorption of drainage.
ii) Protection and isolation from the environment.
iii) Decrease wound pain.
iv) Psychological.

44. WOUND MANAGEMENT (CONTD.)
- Method of dressing—
1. After cleaning with normal saline apply a layer
of topical antiseptic agent.
2. Apply non adhesive material.
3. Cover with sterile gauze & cotton.
4. Apply a bandage with gentle pressure.
- Indications for dressing change—
i) Wound covered inadequately.
ii) Dressing soaked.
iii) Unexplained pain, temperature and smell.

45. WOUND MANAGEMENT (CONTD.)
Commonly used agents for burn wound dressing are—
1. 1% Silver Sulphadiazine (SSD).
2. 0.025% Sodium Hypochlorite (EUSOL).
3. 0.5% Silver Nitrate.
4. 3%, 6.5% or 8% Mefenamic Acid.
5. 10% Povidone Iodine.
6. 1% Gentamycin.
7. Mupirocin.
8. Antibiotic combination.
9. Hydrocolloids; Collagen sheet, dust or cream;
Amniotic membrane etc.

46. MONITORING
* Following parameters are commonly used in our context--
1. Blood pressure– Poor indicator.
2. Pulse rate and volume. 10. Core temp.
3. Peripheral O2 saturation. 11. Consciousness level.
4. Hourly urine output— 12. Capillary refill.
- 0.5 ml / kg / hr. in adults.
- 1.0 ml / kg / hr. in children.
5. Hb% and Hct. measurement.
6. S. electrolytes.
7. S. albumin.
8. S. creatinine.
9. Arterial blood gas analysis.

47. REHABILITATION
Rehabilitation means restoring the patient’s mobility and
ability to return to their daily life after injury. It comprises
correct positioning, splinting and exercise, as well as ongoing
support, reassurance and encouragement.
The key principles of rehabilitation programmes are—
* Minimizing swelling and edema,
* Preventing deformity (Correct positioning, splinting),
* Mobilizing,
* Maintaining function, and
* Treating long-term scarring problem.

48. PREVENTION OF BURN
* Never leave items cooking on the stove unattended.
* Turn pot handles towards the rear of the stove.
* Keep hot liquids out of reach of children and pets.
* Keep electrical appliances away from water.
* Test food temperatures before serving a child. Do not heat a baby’s
bottle in the microwave.
* Never cook while wearing loose-fitting clothes that could catch fire
over the stove.
* If a small child is present, block his or her access to heat sources
such as a stove, outdoor grill, fireplace and space heater.
* Before placing a child in a car seat, check for hot straps or buckles.

49. PREVENTION OF BURN
* Unplug irons and similar devices when not in use. Store them out
of reach of small children.
* Cover unused electrical outlets with safety caps. Keep electrical
cords and wires out of the way so that children don’t chew on them.
* If you must smoke, avoid smoking in the house and especially
never smoke in bed.
* Check your smoke detectors and change their batteries regularly.
* Keep a fire extinguisher in every floor of your house.
* Keep chemicals, lighters and matches out of the reach of children.
* Set your water heater’s thermostat below 120°F (48.9°C) to
prevent scalding. Test bath water before placing a child in it.

50. COMPLICATIONS OF BURN
Deep or widespread burns can cause many complications,
including—
1. Infection, leading to sepsis.
2. Low blood pressure.
3. Dangerously low body temperature.
4. Breathing problems.
5. Scarring and contractures.
6. Bone and joint deformities.
7. ARDS and respiratory failure.
8. Anoxic brain injury.

51. THANK YOU ALL