Burn

1. BURNS
Dr. Pranjal Rokaya
Resident General Surgery
KIST MCTH
5th Dec, 2022

2. CONTENTS
• INTRODUCTION
• CLASSIFICATION
• MANAGEMENT AND ROLE OF SURGERY
• SPECIAL CONSIDERATIONS
• SUMMARY

3. Introduction
• Burn injuries are a significant public health problem.
• Flame burns most common followed by scald burns.
• Scald burns among the pediatric population.
• Household injuries are most common.
• The average hospital stay : 13 to 60 days.
• Mortality: 4.5 to 23.5%, with the highest mortality among the flame burn
patients.

4. Classification

5. Classfication according to % TBSA involved
Mild - Partial thickness burns <15% in adult or <10%
in children.
- Full thickness burns <2%.
Moder
ate
- 2nd degree of 15–25% burns (10–20%
in children).
- 3rd degree between 2–10% burns.
- Burns which are not involving eyes, ears, face,
hand, feet, perineum
Severe - 2nd degree burns >25% in adults, in
children >20%.
- All 3rd degree burns of ≥10%.
- Burns involving eyes, ears, feet, hands,
perineum.
- All inhalation and electrical burns.
- Burns with fractures or major mechanical
trauma

6. Pathophysiology
• Thermal injuries cause coagulative
necrosis of the tissues.
• Areas of injury:
• Zone of coagulation
• Zone of stasis
• Zone of hyperemia

8. Systemic changes in Burn

9. Managing burn injuries
• Pre-hospital care:
• Removing from the source and stopping the
burning process, ensuring rescuer safety.
• Check for other injuries: ABC then rapid secondary
survey.
• Cool the burn wound but avoid hypothermia.
• Oxygen supplementation.
• Elevate the limbs.
• Pre-hospital wound care: clean dry dressing

10. Hospital care
• With the same principle as any other trauma case:
• A- airway control
• B- Breathing and ventilation
• C- circulation
• D- disability assessment
• E- exposure with environmental control
• F- fluid resuscitation

11. Major determinants of outcome
1. Burn surface area
2. Depth of burn
3. Presence of inhalational injury

12. Assessing Burn Size:
• Done in a controlled
environment, remove
any soot or debris, and
avoid hypothermia.
• “rule of nines” as a
rough guide.
• Open hand(palm +
extended finger)
Equal to 1% of TBSA

13. • In pediatric population the rule of
nine is too imprecise.
• “ The Lund- Browder chart”

14. Assessing depth of burn:
• From history and examination

16. Resuscitation
• Start if >10% in ped, and >15% in adults.
• RL in >2ys old and add 5% dextrose in <2yr old.
• Delay in resuscitation directs to poor outcomes.
• Relys on the establishment of IV access – short peripheral catheters in normal
skin preferred.
• Intraosseous access in children <6yr – if experience allows.
• Amount of fluids to be calculated by standard formulas.

17. • Standard formulas for fluid resuscitation
• 50% fluid in first 8 hrs then remaining 50% in subsequent 16hr from injury.
• Monitoring resuscitation: Urine output 0.5- 1.0 ml/kg/hr
• Tetanus prophylaxis is important in burns >10%.

18. Referral to burn center

19. Specific treatment of burns
• Inhalational injuries
• Dreaded injury in burn patients.
Recognition
History of being trapped in presence of smoke or hot gases.
Burns on the palate or nasal mucosa; loss of hair in nose.
Deep burns around mouth and nose
• T/t start with 100% O2 supplementation with facial mask.

20. Intubate if..
PaO2 Less than 60 mm Hg
PaCO2 More than 50 mm Hg
Pa02/Fi02 Less than 200
Respiratory or ventilatory failure Impending
Upper airway edema Severe

21. • Managing inhalation injuries
• Bronchodilators.
• Nebulization with:
• Heparin 5000-10000 units with 3ml NS every 4 hourly.
• N-acetylcysteine 20% , 3ml every 4 hours.
• Hypertonic saline – induces effective coughing.
• Epinephrine – decreases mucosal edema.
• Ventilatory support.
• Bronchoscopic removal of casts.

22. • Suspect pneumonia clinically if (any 2):
• New and persistent infiltrate/ consolidation/ cavitation
• Sepsis
• Recent changes in sputum/ purulence in sputum/ culture positive
• Start treatment accordingly and should cover common hospital-acquired
pathogens.

23. Wound care
• Consists of 3 stages:
• Assessment
• Management – thoroughly clean and debride then dressed with non
occlusive dressing.
• First degree wound:
• No dressing; use topical salves with antimicrobials
• Use oral NSAIDS
• Second degree wound:
• Superficial wound: daily dressing and topical antimicrobials

25. …contd
• Deep second-degree and third-degree wounds:
• Require excision and grafting for sizable burns
• Choice of initial dressing should be aimed at holding bacterial
proliferation in check and providing occlusion until the
operation is performed.

26. Surgery for acute burn wounds
Early debridement and grafting is the key.
• Early tangential skin excision and early grafting
• Decrease: hypertrophic scarring, joint contractures, stiffness
• Quicken rehabilitation.
• Excision:
• Skin graft knife or powered dermatome.
• Sharp excision with knife or electrocautery.
• Preserve as much viable dermis as possible.
• Remove all necrotic tissue in full-thickness burns.

27. • Techniques of excision
• Tangential excision
• Repeated shaving off of deep dermal burns with
dermatome until viable dermis reached.
• Depth: 0.005 – 0.010 inch
• Full thickness excision
Depth: 0.015- 0.030 inch
• Fascial excision
• Reserved for 4th degree/ infected wounds.
• Leaves permanent contour defects.

28. • Escharotomy
• Deep 2nd degree or 3rd degree burns–
circumferential burns compartment
syndrome.
• Longitudinal incision -- lateral and medial
aspects.
• Improves venous outflowedema under the
unyielding eschar decrease.
• Reperfusion injury may occur after
escharotomy– ultimately may require
fasciotomy.

30. WOUND COVERAGE
• Autografts are the mainstay– split-thickness or full thickness.
• Various biologic and synthetic substrates: Integra, Alloderm.
• If full thickness burn >40% TBSA consider allograft and cadaveric skin too.

32. Preventing multiorgan failure
• Optimal resuscitation
• Early excision and early surgical management reduce chances of wound
infection.
• Perioperative antibiotics in severe burns.
• Timely replacement of IV sites.
• Observing closely for pneumonia and aggressive treatment.
• Early enteric feeding reduces septic morbidity and prevents gut barrier
dysfunction.
• DVT prophylaxis in patients not at risk of hemorrhage.

33. Attenuating hypermetabolic response
• Hypermetabolism directly proportional to the size of burn.
• O2 consumption
• Metabolic rate
• Urinary nitrogen excretion
• Lipolysis
• Weight loss
• 200% of the normal metabolic rate.
• Quick depletion of energy reserves– malnutrition– delayed recovery.

34. • Nonpharmacologic modalities
• Nutritional support– high protein and carbohydrate diet.
• Environmental supports– preventing hypothermia.
• Exercise and adjunctive measures– balanced physiotherapy for optimal
recovery and rehabilitation.
• Pharmacologic modalities
• Recombinant growth hormone
• Insulin-like growth factors.
• Testosterone analog oxandrolone

35. Treating late complications
• Hypertrophic scars
Pruritus, erythema, pain, thickened tight skin, and
even contractures
• Treatment
Nonsurgical therapies
compression garment, and corticosteroid.
Surgical excision and scar revision
Pulsed dye laser (PDL) and the ablative carbon
dioxide (CO2) laser.

36. • Joint Contractures
• Both wound contracture and scar
contracture prevent the range of motion
of a particular joint.
• Treatment
• Nonsurgical and surgical options
ranging from pressure garments and
splints to laser therapy and
contracture excision.

37. Electrical burn
• ELECTRICAL BURNS
• Low voltage (<1000V)
• Similar to thermal burn with less transmission to deeper
tissue and local damage.
• High voltage (>1000V)
• Various degrees of cutaneous burns
• Hidden destruction of deeper tissue
• Muscle sustains the most damage.
• Can be lethal immediately with associated cardiac arrhythmias
• Can also be associated with blunt traumatic injuries and
fractures.

38. Lichtenberg figures

39. • Initially acute trauma management.
• Continuous cardiac monitoring is required with pharmacological management.
• Treatment of wound is the key component.
• Early exploration and debridement of necrotic muscle may be required.
• Areas of questionable viability may need re-exploration after 48hrs.
• Early fasciotomy, sometimes nerve decompression and in some cases early amputation
of the affected limb.
• Injuries to vessels may be delayed and thus extend the necrosis even after initial
debridement.
Management

40. • Closure of the wound is paramount.
• Skin graft may suffice but may require flaps if bones and tendons are exposed.
• Vigorous fluid replacement diuresis is required to prevent acute kidney injury due to
myoglobin released in the circulation after muscle injuryobstructive nephropathy.
• Urine output: 2ml/kg/hr
• Delayed complications:
• Neurologic deficits– cortical encephalopathy, hemiplegia, aphasia brainstem
dysfunction.
• Development of cataracts even years after injury.
…Continued

41. Chemical burns
• Extent depends upon :
• Chemical nature of the agent
• Concentration
• Duration of contact
• Denaturation of proteins; formation of protein esters, Desiccation of tissue
• Early intervention is very important.
• A large amount of water required,
• Eg: 10ml of 98% H2SO4 dissolves in 12 litresof water

42. Alkali burns
• Usual chemicals: lime, KOH, NaOH, bleach, cement
• Usually deeper than acid burns.
• Cause burns by:
• Saponification of fat
• Massive extraction of water from cells
• Treatment
• Removal of the caustic agent and lavage with a large amount of water.
• Consider debridement in the operating room.
• Tangential removal until tissue iremoved is in at normal pH.

43. Acid burns
• Protein breakdown by hydrolysis: eschar, but the heat generated can still cause further
soft tissue damage.
• Treatment
• Lavage with a large amount of water
• Wound management is like any thermal burn, but wounds are deeper than the initial
appearance.
• Large amounts of industrial acid can cause electrolyte abnormalities, renal failure,
intravascular hemolysis, and pulmonary complications.
• Acidemia from ABG may require treatment with NaHCO3
• Hemodialysis

44. Summary
• Carry a significant burden as a public health problem.
• Injury is usually by coagulative necrosis and denaturation of tissue proteins.
• Initial management starts with same principle of acute trauma management.
• Early debridement and closure of the wound plays key role in the successful
management of burn injuries
• Proper nutritional, environmental and physical rehabilitation is very important for
the optimal recovery of patients.

45. References
• Williams NS, O‘Connell PR, McCaskie A, editors. Bailey & Love's Short Practice of Surgery: 27th
edition. CRC press; 2018.
• Townsend CM, Beauchamp RD, Evers MB, Mattox KL. Sabiston Textbook of Surgery. 20th Edition
• Schwartz’s Principles of Surgery. 11th Edition.
• SRB’s Manual of Surgey. 5th Edition.