burn

1. BURN Presentation
Definition
A burn injury is a coagulative damage or destruction of
skin and/or its contents by
*Thermal
*Chemical
*Electrical
*Radiation energies or combinations

2. EPIDEMIOLOGY
Incidence varies greatly b/n cultures
Uk (popn. 65 million)
 175,000 burned pts/yr seek health care
 13,000/yr need hospital admission
 ~ 1000 have severe burns requiring fluid resuscitation.
 Half of them are <16yrs of age
USA
 1.1million burned pts/yr seek health care .
 45,000 require hospitalization
 4500 death
 Nearly ½ are smoking related due to substance abuse.

3. Ethiopian situation
1. A community-based study showed highest
incidence in children < 5
– Scald burn (59 %)
– Flame (34 %)
– Home (81 %)
2. A hospital-based study
– Scald 61.1 %
– 11.5 % died
In the 2015 MR for injuries was 84/100,000/yr;
injuries accounted for 4,981/yr/100,000

4. Con----
• Total death were 83,516; 13,550 death were
children <5yrs and 11,684 children
5-14yrs old
It is therefore important to pay attention and
take an action to address the burden of burn
injuries among children in Ethiopia

5. ETIOLOGY
At great risks are
♦ The very young
♦The very old
♦ Those whose ability to
protect themselves is impaired.
*Epilepsy
*Alcohol
*Drug abuse

6. Etio--
A. SCALD BURNS
●Scalds from hot water are most common cause of burn
●Depth is proportional to
– To,
– Duration of contact
– Thickness of skin.
eg. Water at 60 oc for 3 sec &at 69 oc for 1sec cause
deep dermal or full-thickness burn
● Immersion scalds are always deep, severe burns

7. Eti--
B. FLAME BURNS
●House fires
●Smoking related fires
●Improper use of flammable liquids
●Automobile accidents
●Ignition of clothing from stoves or space
heaters
●Fall into open fire

8. Etio--
C.FLASH BURNS
●Explosion of natural gas ,gasoline
& other flammable liquids cause intense heat
for a brief time
● Depth depends on the amount and type of
fuel
●Clothing, unless it ignites, is protective against
flash burns
●May be associated with thermal damage to
the upper airway

9. Etio--
D. CONTACT BURNS
●Result from contact with hot metals, plastic,
glass or hot coals
●Limited in extent & very deep

10. Etio--
E.CHEMICAL BURNS
●Caused by strong acids or alkalis
●Cause progressive damage until they are
inactivated by rxn with the body tissue or
diluted with water
●Acid burns may be more self-limiting than
alkali burns
●Chemical burns should be considered deep
dermal or full-thickness until proven
otherwise

11. Etio--
F. ELECTRICAL BURNS
●May be low-voltage or high-voltage
●3 mechanisms of injury :
i. Electrical current injury
ii. Electrothermal burns from arcing current
iii. Flame burn caused by ignition of clothes
●Deep destruction of muscles ,nerves & vessels –
myoglobinuria ATN
●The entry & exit wound is only the tip of the
iceberg

12. Pathophysiology
Heat causes coagulation necrosis of skin and
subcutaneous tissue.
↓
Release of vasoactive peptides
↓
Altered capillary permeability
↓
Loss of fluid → Severe hypovolaemia

13. Patho cont--
• Decreased cardiac output → Decreased myocardial function
↓
• Decreased renal blood flow→ Oliguria
↓
• Altered pulmonary resistance causing pulmonary oedema
↓
Infection
↓
• Systemic Inflammatory Response Syndrome (SIRS)
↓
• Multi Organ Dysfunction Syndrome (MODS).

14.  Burning pain .Hypothermia
 Blister formation .Sign of dehydration
 Red melted appearance .Sweating
 Decreased PR and RR .Unconsciousness
 Discoloration of the skin
 shock
Clinical manifestation

15. Estimation of BSA by
• Rules of 9
• Palm of the pt as 1%
• Lund & Browder charts
Extent of burn

16. Percent of body surface area burned
(Adults)

17. Extent of burn
• Lund and Browder charts are a more accurate
method of assessing burn extent
• Provide an age-based diagram to assist in
more precisely calculating the burn size

18. Percent of body surface area burned
(Children)

19. The Rule of Nines
 Heads of children
tend to be greater
than 9% of TBSA
 The lower extremities
tend to be less
than 18%

20. Classification of Burn Injuries

21. Classification by Depth of burn
Is proportional to
• To of causal agent
• Length of contact time
• Burning material

22. Classification by Depth of burn

23. Depth of Burn (Degree)

24. Burn depth categories

25. Depth of Burn (Degree)

26. TREATMENT OF BURN

27. TREATMENT OF BURN
• Focuses on:
 Adequate fluid resuscitation
 Nutritional support
 Wound management
 Rehabilitation

28. TREATMENT ….contd
FIRST AID
 Remove the person from further danger.
 Remove clothing.
 Irrigate the areas with water in copious amounts
 Scald, flame for 5min.
 Chemical injuries for 20-30 min
 Start life saving measures (if indicated).
 Cover the wound with clean towel.
 Management of associated injuries
 Transport to the nearby health facility.

29. Treatment …contd
Evaluation and management in the
emergency department
1. Primary survey.
ABCDEF
Airway, Breathing, Circulation
Check for life threatening injuries
2. Resuscitation
• Large bore intravenous line (if burn is greater than 10% to
15% of body surface).
• Start with lactated Ringer’s solution.
• Airway (endotracheal tube, if indicated) - humidified oxygen

30. Treatment …contd
3. Secondary survey - more thorough evaluation
• History
– Nature of injury (agent and circumstances)
– Time since injury
– Medical history, medication and allergies
• Examination: Rapid
– Check vital signs, weight
– Determine extent and depth of injury
– Rule out other injuries ,examine eyes.
– Look for circumferential burns on chest, limbs.
– Evaluate and treat inhalation injury (if indicated)

31. Treatment …contd
▫Collect blood samples :
Hct, x-match, electrolyte ,
BUN, glucose ,CBC
arterial blood gas analysis.
▫ Give analgesics and sedatives as indicated
▫ Give tetanus prophylaxis
▫ Calculate fluid needs and adjust infusion rate.

32. Fluid Resuscitation
• Prevent burn shock& maintains adequate perfusion of
blood
• Calculate a pt’s fluid needs from the moment of burn
• Formula serve only as a standardized base line
• Fluid therapy must be individualized
• These formulae should be used only as guidelines

33. Fluid …cont
1. Parkland : 4ml x wt (Kg) x % TBSA burn
Ringer’s lactate
2. Evans  1ml x wt x %TBSA
3. Brooke  1.5ml x wt x %TBSA
4. Modified Brook  2ml x wt x % TBSA

34. Fluid….cont
This volume is then given at different rates
• ½ in  1st 8 hrs post injury.
• ½ in  next 16 hrs
• Next 24 hrs  give half of total
• Provide the daily maintenance requirement of 2-3lt on
top of the calculated amount .
• Patient monitoring during resuscitation
Clinical : PR,BP mental status, uop (30-35ml/hr)
Laboratory :Hct ( 40-45).

35. The parkland formula for fluid
resuscitation

36. Treatment …contd
Admit:
• Any burn over 15%(adults) & 10%(children)BSA.
• Special areas e.g. eye, face, hands, feet, perineum.
• Inhalation injury regardless of size of burn.
• Chemical & electrical burns
• Full thickness burns where grafting is indicated
• Children & elderly pts who require additional medical
or social support.

37. Escharotomy
• In constricting full thickness burns of limbs ,digits or
chest.
▫ To maintain or improve distal circulation
▫ To aid chest wall excursion
• Chest escharotomy at the anterior axillary line
• Extremity escharotomy

38. Escharotomy

39. Nutritional support
● Burn size is proportional to
*↑ in o2 consumption *urine nitrogen loss,
* Lipolysis, *weight loss
● If BSA burned >40%, lean body weight ↓ by 25% over the first 3 wks
(in absence of adequate nutritional support.)
● Pt with major burn needs high calorie in the form of
CHO (50%)
protein (20%)
fat (30%)
● Add vitamins & minerals

40. Route of administration
▫ Oral
▫ Parentral
▫ NG tube (earlier) used in TBSAB >20%
??start with in 6hrs,48hrs
●Decompression of stomach.
● Earlier paralytic ileus can be prevented.
● Mucosal integrity is preserved.
●↓Risk of bacterial translocation &
endogenous infection
● ↓ Catabolic response.

41. Curreri Formula
• Calorie requirement /24 hrs : Kcals /day
Adult  (25 x BW)+(40 x %TBSAB) .
Children  60/kg + 35% BSAB
• Protein requirement /24 hrs :
Adult  1g/kg + 3g%BSAB
Children  3g/kg + 1g%BSAB

42. Nutritional support
 BMD (butter milk diet)
*1lt of milk
*4egg
*3bannana
*50gm sugar
1ml of BMD  1Calorie
0.047gm protein
*Add vitamins (B, A,& D, C, ferrous sulpha

43. Care of the burn wound
Orthodox way of Mx of wound
 Daily washing
 Removal of loose dead tissue
 Topical application of saline-soaked dressings until they heal
by themselves or granulation tissue appear in the base of the
wound
 Protect recently healed tissues
 Prevent infection and if it is established, Rx it vigorously
 Skin graft over the granulating wound after 3-8 wks after
injury

44. Care of the burn wound
1. Minor burn injury - may be treated on an
outpatient basis
2. Moderate uncomplicated burn injury - should
be hospitalized
3.Major burn injury - should receive specialized
care such as provided by a Burn Unit

45. Principle of dressing
●Full thickness & deep dermal burns need
antimicrobial dressing
● Superficial burns need simple dressing
● An optimal healing envn’t can make a
difference to out come in border line depth
burns

46. Dressing Mx
i. Open (exposure) methods
◘In warm climate
◘ Encourages dry crust formation
◘ For superficial burns  Scalds
 Burns of pt’s face &neck
 Full thickness burns any where
◘ Large partial thickness burns except hands
◘ Can be modified by Vaseline gauze

47. Burn Complications
I. INFECTION
Predictors of infection :
●Burn size
● Age
● Inhalation injury
Site of infection in burn pts :
1.Wound infection
2. Pneumonia
3.Suppurative thromophelebitis
4. UTI

48. Infection control
Hand washing before & after touching each
pt.
Aseptic techniques for dressing & procedures
Environmental controls ,such as air filtration &
balanced ventilation
Microbiological screening of wounds ,nose
,throat ,perineum & axillae
Isolation of infected pts
Early nutritional support
Early excision of deep burns
Use of topical antimicrobials

49. Cont---
II. Curling ulcer
III. Contracture
Prevention
●Early excision and grafting
● Splintage
● Elevation of extremity
● Early physiotherapy
● Prevention of infection
IV. Marjolin’s ulcer, Hypertrophic scar, keloid
V. Ileus & acute gastric dilation

50. Rehabilitation
Goals of rehabilitation:
• Restore function
• Prevent contractures
• Return to normal activities
• Best aesthetic appearance possible
Modalities and techniques:
Positioning Active range of motion/exercises
Pressure Therapy Scar Management
Splinting Activities of daily living
Vocational training Documentation

51. BURN PREVENTION
Significant proportion of burns can be prevented
by
♦Implementing good health & safety regulations
♦ Educating the public

52. THANK YOU