3. PREAMBLE
• What are burns?
• What are the causes of burns?
• How are burns classified?
• How to treat a patient with burns?
• What are the complications of burns?
23. Look for ABC
• Airway
• Breathing
• Circulation
•Pre-hospital Care Hospital Care
24. AIRWAY
• Fire in a closed area
• Evidence of burns of face, mouth, lips, and neck
• Swelling of soft tissues of the airway leads to airway
obstruction
• Endotracheal intubation needed
BREATHING CIRCULATION
Hospital Care
25. Burns of the face
Cause swelling of the
airway with chances
of airway obstruction
Need endotracheal
intubation
26. • Heat damages upper airway
• Carbon monoxide damages lower bronchial tree and
lung parenchyma
• Require
• Oxygen
• Bronchodilators
• Steroids
• Intubation and ventilation
AIRWAY BREATHING CIRCULATION
Hospital Care
27. • Fluid lost from burn surface area
• Require rapid IV fluids
AIRWAY BREATHING CIRCULATION
Hospital Care
29. Requirement of IV
fluids is calculated
from percentage
area of burns
AIRWAY BREATHING CIRCULATION
Hospital Care
30. Wallace rule of nine
for calculating
percentage area of
skin burns
31. • Fluid calculation is done using Parkland formula.
• Fluid calculation by Parkland
formula
• 4cc / percent burn / kg body weight
of Ringer lactate is given in first 24
hrs
• Half of the fluid given in first 8 hrs.
• 1/4th fluid is given in second 8 hrs.
• 1/4th fluid is given in third 8 hrs.
AIRWAY BREATHING CIRCULATION
Hospital Care
Burns
What are burns?
What causes burns?
How are burns classified?
How to treat a patient with burns?
What are the complications of burns?
Definition of burns
It is an injury or damage caused by heat or sources producing heat leading to coagulation necrosis. Damage rarely occurs when temperature is below 45°C.
Coagulation necrosis
Coagulation necrosis is a type of cell death caused by ischemia or infarction. In coagulative necrosis, the architecture of dead tissue is preserved for at least a couple of days. The injury denatures lysosomal enzymes thus blocking the proteolysis of the damaged cells. The lack of lysosomal enzymes allows it to maintain a "coagulated" morphology for some time. Like most types of necrosis, if enough viable cells are present around the affected area regeneration will usually occur.
Various causes of burns are: 1. Dry heat: Fire 2. Wet heat: Hot liquids e.g. boiling water, tea, coffee etc. The injury is known as scald. These are usually minor burns. 3. Electric burns: Electric current
4. Chemical burns: Acids or alkali. It causes progressive damage because the agent remains in contact with the skin and chemical injury continues.
5. Irradiation: Radiotherapy given for cancer treatment.
Scald of the chest caused by boiling water
The skin consists of superficial layer (epidermis) and deep layer (dermis). There are appendages in skin like hair follicles, sweat and sebaceous glands. These lie in the dermis but project in epidermis as well.
Burns are divided into three degrees based on thickness of involved skin
1° burn: It is a burn involving epidermis only e.g. sunburn. 2° burn: It is a burn involving epidermis and part of dermis e.g. scalds
3° burn: It is a burn involving epidermis and full thickness of dermis e.g. flame, chemical and electric burns.
4o burn: It is a burn involving whole of skin as well as muscles and bones
1° burn: There is painful erythema of skin. It is tender to touch and blanches on pressure. It is of little clinical significance because water barrier of skin is not disturbed. Hence, it is not considered while estimating magnitude of burn injury and planning fluid replacement.
2° burn: It usually presents with painful blisters. When blisters rupture, the surface of burn appears red, shiny and wet (angry looking)
4° burn: It is painless because all cutaneous nerves are burnt. The burn surface appears dry, charred, grayish black in color.
1° burn: There is painful erythema of skin. It is tender to touch and blanches on pressure. It is of little clinical significance because water barrier of skin is not disturbed. Hence, it is not considered while estimating magnitude of burn injury and planning fluid replacement.
2° burn: It usually presents with painful blisters. When blisters rupture, the surface of burn appears red, shiny and wet
3° burn: It is painless because all cutaneous nerves are burnt. The burn surface appears dry, charred, grayish black in color.
1° burn: There is painful erythema of skin. It is tender to touch and blanches on pressure. It is of little clinical significance because water barrier of skin is not disturbed. Hence, it is not considered while estimating magnitude of burn injury and planning fluid replacement.
2° burn: It usually presents with painful blisters. When blisters rupture, the surface of burn appears red, shiny and wet
3° burn: It is painless because all cutaneous nerves are burnt. The burn surface appears dry, charred, grayish black in color.
4o degree burns
Treatment of Burns
Pre-hospital care
Hospital care
Treatment of Burns
Pre-hospital care
Pre-hospital care
The principles of pre-hospital care are:
Ensure rescuer safety. This is particularly important in house fires and in electrical and chemical injuries.
Stop the burning process. Stop, drop and roll is a good method of extinguishing fire burning on a person.
Check for other injuries. A standard ABC (airway, breathing, circulation) check followed by a rapid secondary survey will ensure that no other significant injuries are missed. Patients burned in explosions or even escaping from fires may have head or spine injuries and other life-threatening problems.
Cool the burn wound. This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury. Cooling should occur for a minimum of 10 minutes and is effective up to 1 hour after the burn injury. It is a particularly important first aid step in partial-thickness burns, especially scalds. In temperate climates, cooling should be at about 15°C, and hypothermia must be avoided.
Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen, especially if there is an altered consciousness level.
Elevate. Sitting a patient up with a burned airway may prove life-saving in the event of a delay in transfer to hospital care. Elevation of burned limbs will reduce swelling and discomfort.
Stop, drop and roll is a three step procedure that a fire victim should follow to minimize injury in the event their clothing catches fire.
Procedure:
Stop, drop and roll consists of three steps.
Stop – The fire victim must stop, ceasing any movement which may fan the flames or hamper those attempting to put the fire out.
Drop – The fire victim must drop to the ground, face down if possible, covering the face with their hands to avoid facial injury.
Roll – The fire victim must roll on the ground in an effort to extinguish the fire by depriving it of oxygen. If the victim is on a rug or one is nearby, they can roll the rug around themselves to further extinguish the flame.
Pre-hospital care
The principles of pre-hospital care are:
Ensure rescuer safety. This is particularly important in house fires and in the case of electrical and chemical injuries.
Stop the burning process. Stop, drop and roll is a good method of extinguishing fire burning on a person.
Check for other injuries. A standard ABC(airway, breathing, circulation) check followed by a rapid secondary survey will ensure that no other significant injuries are missed. Patients burned in explosions or even escaping from fires may have head or spine injuries and other life-threatening problems.
Cool the burn wound. This provides analgesia and slows the delayed microvascular damage that can occur after a burn injury. Cooling should occur for a minimum of 10 minutes and is effective up to 1 hour after the burn injury. It is a particularly important first aid step in partial-thickness burns, especially scalds. In temperate climates, cooling should be at about 15°C, and hypothermia must be avoided.
Give oxygen. Anyone involved in a fire in an enclosed space should receive oxygen, especially if there is an altered consciousness level.
Elevate. Sitting a patient up with a burned airway may prove life-saving in the event of a delay in transfer to hospital care. Elevation of burned limbs will reduce swelling and discomfort.
Treatment of Burns
Hospital care
In hospital check airway, breathing and circulation (ABC)
HOSPITAL CARE OF BURNS
Airway
Heat causes damage to upper airway (oral cavity, nasopharynx, larynx). History of fire in closed space or burns involving the mouth, lips and neck result in soft tissue swelling of the airways within hours of injury resulting in sudden airway obstruction.
Therefore signs of airway obstruction (cyanoses, stridor, tachypnea) should be looked for. In case of airway obstruction, endotracheal intubation or tracheostomy may be required.
HOSPITAL CARE OF BURNS
b. Breathing
Toxic chemicals like carbon monoxide present in smoke cause damage to lower bronchial tree and lung parenchyma.
Patient presents with hoarseness, stridor, wheezing and production of large amount of carbonaceous sputum. There is tachycardia, cyanosis and bronchospasm.
Patient requires humidified oxygen, bronchodilators, steroids and artificial ventilation.
HOSPITAL CARE OF BURNS
c. Circulation
The patient needs rapid intravenous fluid replacement to compensate for the fluid lost from burn surface area.
HOSPITAL CARE OF BURNS
c. Circulation
Maintain IV line with two large bore cannula. Since peripheral veins are usually not visible due to limb burns, venesection (cut down) is done in the arm or leg to start intravenous fluids.
HOSPITAL CARE OF BURNS
c. Circulation
Requirement of intravenous fluid replacement is calculated from percentage area of burns.
Percentage area of burns
It is calculated by Wallace rule of nine:
The body is divided into eleven parts and each part covers 9%, making it 11 × 9 = 99%. The remaining 1% is the perineum
Fluid calculation is done using Parkland formula.
4 cc per percent burn/kg body weight of Ringer lactate is given in first 24 hrs.
Half of the calculated fluid is given in first 8 hrs. 1/4th fluid is given in second 8 hrs.
1/4th fluid is given in third 8 hrs.
Time for giving I/V fluids commences at the time of injury and not at admission to hospital.
