Burns: Assessment and Management

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Presentation on severe skin burns at a district hospital. Adaption is made for under resourced hospitals in developing countries.

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  • If you look at children only, you will see that the percentage of scald burns will come up to even 70%
  • If you look at children only, you will see that the percentage of scald burns will come up to even 70%

    Especially contact should be more investigated into the cause
  • Formula to calculate the amount of heat generated and hence the level of tissue damage is: 0.24 x Voltage2 x Resistance

    True high tension injuries occur when the voltage is more than 1000 V. There is extensive tissue damage and often limb loss. There is usually a large amount of soft and bony tissue necrosis. Muscle damage gives rise to rhabdomyolysis and renal failure may occur with these injuries. This type of injury needs more aggressive resuscitations and debridement than other burns. Contact with voltage greater than 70 000 V is invariable fatal.

    There is good evidence that if the patient’s electrocardiogram on admission is normal and there is no history of loss of consciousness, then cardiac monitoring is not required.
  • Judge neavi on (ABCDE)
    Asymmetry
    Border Irregularity
    Color
    Diameter (<6mm)
    Elevation

    Sunburns are caused by exposure to too much ultraviolet (UV) light. UV radiation is a wavelength of sunlight in a range too short for the human eye to see. UV light is divided into three wavelength bands — ultraviolet A (UVA), ultraviolet B (UVB) and ultraviolet C (UVC). Only UVA and UVB rays reach the earth. Commercial tanning lamps and tanning beds also produce UV light and can cause sunburn.

    Dark skin 'does not block cancer‘: http://news.bbc.co.uk/2/hi/health/5219752.stm

    Contrary to common perception, people with dark skin are more likely to die from skin cancer than those with fairer skin, warn US researchers. Although the disease is less common, when it does occur it is typically more aggressive and diagnosed later, which leads to more deaths, they explain.
    The Cincinnati University work is a warning to anyone who wrongly assumes skin tone makes some immune to cancers.
    Experts advise people of all races to protect their skin from sun damage.
    Misconception
    Lead researcher Dr Hugh Gloster said: "There's a perception that people with darker skin don't have to worry about skin cancer, but that's not true.
    "Minorities do get skin cancer, and because of this false perception most cases aren't diagnosed until they are more advanced and difficult to treat.
    "Unfortunately, that translates into higher mortality rates."
    He said it was true that the extra pigment in darker skin did afford some added protection against the sun's harmful UV rays and that darker skin is, therefore, less susceptible to sunburn.
    But he said this should not lull people with darker skin into a false sense of security.
    Dark skin has increased epidermal melanin which provides a natural skin protection factor (SPF) - a measure of how long skin covered with sunscreen takes to burn compared with uncovered skin.
    Very dark, black skin has a natural SPF of about 13 and filters twice as much UV radiation as white skin, for example.
    Sun protection
    However, health experts advise people to use sunscreen with an SPF of at least 15.
    Dr Gloster told a meeting of the American Academy of Dermatology in San Diego that doctors should make sure that all of their patients, regardless of race, use sunscreen and self-check for skin cancers.
    This study shows that even people with darker skin need to be aware of the signs of skin cancer
    Ed Yong, cancer information officer at Cancer Research UK
    Malignant melanoma, the most aggressive form of skin cancer, can present differently in different races.
    Fairer-skinned people may notice a change in a sun-exposed mole, whilst darker-skinned people might develop the cancer on areas protected from the sun such as the soles of the feet.
    There are over 70,000 new cases of skin cancer diagnosed each year in the UK, making it the most common type of cancer.
    Ed Yong, cancer information officer at Cancer Research UK, said: "This study shows that even people with darker skin need to be aware of the signs of skin cancer.
    "Although those most at risk of skin cancer are people with fair skin, lots of moles or freckles or a family history of the disease, it is also important for black people to check their skin regularly.
    "Black people are most likely to develop skin cancers on the palms of their hands or the soles of their feet.
    "Checking your skin for unusual changes is crucial as it can mean that the disease can be spotted earlier, when it is easier to treat."
  • Example of an alkalis that causes often chemical burns is cement.

    Some chemicals need to be treated with specific neutralizing agents:
    Chromic acid and Dichromate salts: rinse diluted sodium hyposulphite
    Hydrofluoric acid: apply or inject calcium gluconate 10%
  • Detecting these injuries is important as up to 30% of the children who are repeatedly abused die.

    Usually young children (<3 years) are affected.

    Abuse are more common in poor households with single or young parents.
  • In India, on a population of about 1 bilion, almost 800,000 hospital reported burn injuries (source BMJ).
  • Note how the <4 year old get 20% of all burns, while 5-14 year old get only 10% of all burns
  • Prognostic Burn Index: crude estimate of mortality involving adding age + TBSA has steadily improved to the point that a PBI score of 90-100 (predicting near certain mortality) now demonstrates mortality rates of 50-70% in adult burns.
  • It is only since the 1940’s that significant reduction in mortality (especially in children & young people) have been achieved in developed countries.

    Underhill and Moore identified the concept of thermal injury–induced intravascular fluid deficits in the 1930s and 1940s, and Evans soon followed with the earliest fluid resuscitation formulas in 1952. Up to that point, burns covering as little as 10-20% of total body surface area (TBSA) were associated with high rates of mortality. Through the 1970s, even a 30% TBSA burn was associated with nearly 100% mortality in older patients.
  • The shock with possibly also rhabdomyolysis can cause hypoperfusion, causing (multiple) organ failure.

    Cardiovascular:
    The capillary permeability is increased, leading to loss of intravascular proteins and fluids into the interstitial compartment.
    Peripheral and splanchnic vasoconstriction occurs which increases the cardiac afterload, decreasing the cardiac output
    Myocardial contractility is decreased, possibly due to the release of tumor necrosis factor alpha. Myocardial diastolic dysfunction may also be caused by myocardial oedema.
    These changes coupled with fluid loss from the burn wound result in systemic hypotension and end organ hypoperfusions.
    Administration of an inotropic agent (preferably those who do not cause vasoconstriction like dobutamine) is prefered above overloading a patient.

    Respiratory:
    Bronchoconstriction / RDS

    Kidney failure:
    Early renal failure after burn injury is usually due to delayed or inadequate fluid resuscitation, but it may also result form substantial muscle break down or haemolysis. Delayed renal failure is usually the consequence of sepsis and is often associated with other organ failure.

    Metabolic:
    As the basal metabolic rate increases up, the patient can easily end up in a catabolic state while he needs a anabolic state for recovery. There is even with small burn injuries an up to 3x increase in basal metabolic rate.
    As there is also splachnic hypoperfusion, you will need to give (early) aggressive enteral feeding to come to a anabolic situation while maintaining the gut motility.
    Even small burns can be associated with hyperpyrexia directly due to hypermetabolism.
    Management of the hypermetabolic response:
    Reduce heat loss by environmental conditioning
    Excision and closure of burn woud
    Early enteral feeding
    Recognition and treatment of infection

    Immunological changes:
    Non specific down regulation of the immune response occurs, affecting both cell mediated and humoral pathways.

    Local:
    Compromising constrictions
  • Do it early as you might not be able later
    You might need to intubate the patient
    Exact mechanism
    Type of burn agent
    How did in come into contact
    What first aid performed
    Which treatment started
    Risk of Concomitant injuries (such as fall from height, RTA, explosion)
    Risk of inhalational trauma (burn in enclosed space)
    Exact timing
    When did the injury take place
    How long was the patient exposed
    How long was cooling applied
    When was resuscitation started
    Exact injury
    Scalds:
    What was the liquid, was it (recently boiled)
    If tea of coffee: did it contain milk
    A solute in the liquid? (this raises the boiling temperature)
    Electrocution injuries:
    What was the voltage (AC/DC)
    Was it a flash or an arc contact
    Contact time
    Chemical:
    Type of chemical
    Suspicion previous injury / non-accidental burn
    Evasive or changing history
    Delayed presentation
    No explanation or an implausible mechanism given for the burn
    Inconsistency between age of the burn and age given by the history
    Inadequate supervision, such as child left in the care of inappropriate person (older sibling)
    Lack of guilt about the incident
    Lack of concern about treatment or prognosis
  • The reticular dermis is the lower layer of the dermis, found under the papillary dermis, composed of thick, densely packed collagen fibers, and the primary location of dermal elastic fibers.

    The papillary dermis is the uppermost layer of the dermis, intertwined with the rete ridges of the epidermis, composed of fine and loosely arranged collagen fibers.

    Stratum basale or Stratum germinativum is the deepest layer of the 5 layers of the epidermis. The basal cells of the stratum germinativum can be considered the stem cells of the epidermis. They are undifferentiated, and they proliferate. They create 'daughter' cells that migrate superficially, differentiating as they do so. The keratinocytes of the stratum germinativum undergo mitosis continually throughout the individual's life.

    In the stratum spinosum there are still connections between the keratocytes: which are desmosomal connections. The cells in the stratum spinosum produce and secrete bipolar lipids which prevent evaporation, helping to "water-proof" the skin. Keratinization begins in the stratum spinosum

    In the stratum granulosum the keratinocytes are now called granular cells, and contain keratohyalin and lamellar granules.

    Stratum lucidum is composed of three to five layers of dead, flattened keratinocytes.The thickness of the lucidum is controled by the rate of mitosis of the epidermal cells. In addition, melanocytes determine the darkness of the stratum lucidum.

    Stratum corneum: the outermost layer of the epidermis, composed of large, flat, polyhedral, plate-like envelopes filled with keratin, which is made up of dead cells that have migrated up from the stratum granulosum. From the Latin for horned layer, this skin layer is composed mainly of dead cells that lack nuclei.
    _______________________

    Keratinocytes form tight junctions with the nerves of the skin and hold the Langerhans cells and intra-dermal lymphocytes in position within the epidermis. Keratinocytes are essential immunomodulaters, maintaining the intergrity of the immune response by secreting inhibitory cytokines such as IL-4 and TGFβ when dormant, but when provoked, the keratinocytes will stimulate cutaneous inflammation and Langerhans cell activation via TNFα and IL-1β secretion.
  • Blue colored cells are viable, red cells are necrotic.

    Possible explanation for this scattered pattern: it might be that the higher water content of the superficial layers, and the cooling effect of surrounding air, cool superficial layers more quickly (water conducts heat easily).

    Some state that especially this thromboses of the deeper plexus is causing hypertrophy of the scar.

    Brans TA, et al; Histopathological evaluation of scalds and contact burns in the pig model. Burns 1994:20 Suppl 1:S48-51
  • Burns covering more than 15% of the total body surface area in adults and more than 10% in children warrant formal resuscitation.

    End point to guide fluid administration:
    Vital signs:
    BP, HR, Capillary refill
    Urine output:
    The end point to aim for is a urine output of 0.5-1.0 ml/kg/hour in adults and 1.0-1.5ml/kg/hour in children.
    Peripheral perfusion
    Gastric mucosal pH
    Serum lactate or base deficit
    Central venous pressure of pulmonary capillary wedge pressure
    Cardiac output:
    Oxygen delivery and consumption
  • The greatest amount of fluid is lost in the first 24 hours after the injury.

    Fast fluid boluses probably have little benefit as rapid rise in intravascular hydrostatic pressure will just drive more fluid out of the circulation.

    Much protein is lost through the burn wound, so there is a need to replace this oncotic loss. Although colloids do not have a proven advantage over crystalloids in maintaining circulatory volume (according to Cochrane), some schedules do introduce colloids after the first 8 as the capillary leak begins to shut down, whereas others wait 24 hours. Fresh frozen plasma is often used in children and albumin or synthetic high molecule weight starches are used in adults.

    Especially in children you should consider to add the daily maintenance fluids to this.

    Airway burns are associated with a substantially increased requirement for fluids. Reducing the fluid volume administered to avoid fluid accumulation in the lung, results in a worse outcome.
  • Any deep or full thickness circumferential extremity burn can act as a tourniquet.
    If there is any suspicion of decreased perfusion due to circumferential burn, the tissue must be released with escharotomies.
  • GCS or AVPU for assessment consciousness
  • paracetamol, non-steroidal anti-inflammatory drugs, tramadol, and slow release narcotics
  • With flammazine / Silver sulfadiazine you should also change the dressing every other day.
  • as epithelialisation progresses faster in moist environment
  • as epithelialisation progresses faster in moist environment
  • ‘large’ =>1cm
  • If primary closure is not possible:
    Skin grafts
    Flaps:
    Axial and random flaps
    Myocutaneous flaps
    Free Flaps
    Prefabricated flaps
    Transposition flaps (Z-plasty and modifications)
    Tissue expansion
  • Split-thickness skin grafts are also called Thiersch grafts. Full thickness grafts are sometimes called Wolfe grafts. Full thickness grafts are given when you want to avoid contractures.
    Thicker grafts give less contractures and are more durable.
    Grafts usually do not contain hairs and sweat glands.

    Grafts survive from imbibition of plasma from the wound bed as grafts by definition are lacking a blood supply.
    After 48h fine anastomotic connection are made, which leads to inosculation of blood
    Capillary ingrowths then completes the healing process with fibroblast maturation. Because only tissues that produce granulation will support a graft, it is contraindicated to use grafts to cover exposed tendons, cartilage or cortical bone. If the tendon still has a fine filmy sheet of paratenon, you can still graft it. If you cannot graft, you likely have to use a flap.
    → Imbibition wound plasma → anastomotic connections → capillary ingrowths

  • Early grafting is before the third day – following primary gafting
  • Microvascular transfer of tissue is called a free flaps.

    direct-cutaneous; musculocutaneous; perforator based; expanded flaps; microvascular transfer of tissues (free flaps)
  • Microvascular transfer of tissue is called a free flaps
  • To cover a deficit quickly:
    Advancement flap
    Rotation flap
    Bilobed flap
    Bipedicle flap

    To lengthen a contracture:
    Z-plasty
    Y-V-plasty
    V-Y-plasty
  • Full thickness burns of the beard area are reare because the hair follicles extend very deep here.

    The most common cause of failure to take is not keeping the graft still. So try to stop him talking and give him non-chewable food.
  • Emphasize on releasing the upper eyelid as the close the eye during the night.
  • Make sure nothing scratches the cornea, zelfs wimperharen geven cornea beschadiging.

    Contracture may develop, exposing his cornea: Conjunctivitis → exposure keratitis → corneal ulceration → perforation → infection of the globe

    If palpebral and ocular conjunctivae stick together, his movement of his globe will later be limited.

    If all or most of his eyelids have been destroyed, dissect the conjunctiva of both lids, free his orbiculris muscle and his tarsal plates, and cover his globes by suturing the remains of his lids together. Graft their exposed surfaces. Grafts take well on eyelids usually.
  • Full thickness burns of the digits need escharotomy
    After grafting you should not use the plastic bag method as the graft will float away. Instead use the dry air method or an occlusive dressing for 5/7, while using a splint to minimize movement so the graft can catch.
    Deep burns on the dorsal surface are difficult to treat: refer if possible
    Splint his hand with his MP joints flexed and widely abducted and forward of his palm = position of safety (75-8)
    Palmar burns:
    Splint his MP joints in 30 of flexion and his IP joints in 15 degrees of flexion
    If the joints of a patients hand are exposed:
    aim for an arthrodesis in the position of function (usually 30 degrees of flexion in his IP and MP joints)
    If one finger remains stiff consider amputating it
    If all fingers are damaged consider arthrodesis with dig 4+5 flexed as hooks for carrying, and his dig 2+3 mildly flexed so his thumb can grasp against it.
    If his bare tendons, bone, cartilage or joints have been burned, he will require specialistic treatment with skin flaps so refer him early.
    If not possible use the plastic bag method and graft as soon as granulation is visible
  • Dry method usually not suitable as it cracks will form.
    Occlusive dressing is not suitable as it will stiffen the hand much.


  • The burn injury destroys surface microbes except for gram positive organisms (mainly staphylococci) located in the depths of the sweat glands or hair follicles. Without prophylactic use of topical antimicrobial agents, the wound becomes colonized with large numbers of gram positive organisms within 48 hours. The moist, vascular burn eschar further fosters microbial growth.

    Gram negative bacterial infections result from translocation from the colon because of reduced mesenteric blood flow at the time of burn and subsequent insults. Furthermore, several immune deficits have been described among burns patients, including impaired cytotoxic T lymphocyte response, myeloid maturation arrest causing neutropenia, impaired neutrophil function, and decreased macrophage production. Burn area infection with gram negative organisms usually occurs on the 3rd to 21st day after the burn.

    Finally, burns patients can incur hospital acquired infections common to other patients in intensive care units, including intravascular catheter related infections and ventilator associated pneumonia, with an overall incidence of infection higher than that of other patients in intensive care unit.

    Surface swabs and cultures cannot distinguish wound infection from colonisation. Wound biopsy, followed by histological examination and quantitative culture is the definitve method – though thime consuming and expensive, making it impractical as a routine.

    The reduction in mortality relies on a single study in which the patients were literally flooded with antibiotics.10 The 107 patients included (who had a mean of 19% full thickness burns) received a triple intervention including a systemic third generation cephalosporin for four days, oropharyngeal paste, and selective digestive decontamination with non-absorbable drugs (polymyxin, tobramycin, and amphotericin) until recovery. A significant reduction in mortality and early pneumonia was seen, but no significant difference in wound infection and an increase in late infection and bacterial resistance. Selective digestive decontamination is controversial because it has been shown to work only in settings with a very low incidence of resistant micro-organisms.

    Also topical antibiotics appeared not to be significantly reducing systemic infections; but they are commonly practiced as slows down the wound colonisation.

    Silver sulfadiazine
    Water soluble cream
    Advantages—Broad spectrum, low toxicity, painless.
    Affective aginast gram negative bacteria including pseudomonas
    Adverse effects—Transient leucopenia, methaemoglobinaemia (rare)
    Cerium nitrate-silver sulfadiazine
    Water soluble cream
    Advantages—Broad spectrum, may reduce or reverse immunosuppression after injury
    Adverse effects—As for silver sulfadiazine alone
    Silver nitrate
    Solution soaked dressing
    Advantages—Broad spectrum, painless
    Adverse effects—Skin and dressing discoloration, electrolyte disturbance, methaemoglobinaemia (rare)
    Mafenide
    Water soluble cream
    Advantages—Broad spectrum, penetrates burn eschar
    Adverse effects—Potent carbonic anhydrase inhibitor—osmotic diuresis and electrolyte imbalance, painful application
  • Symptoms of depression and anxiety are common and start to appear in the acute phase of recovery.

    Acute stress disorder and Post-traumatic stress disorder are more common after burns than other forms of injury

    Examples of no-drug approaches in pain management: relaxation, imagery, hypnosis, virtual reality

    Brief psychological counselling can help both depression and anxiety, but drugs may also be necessary. When offering counselling, it is often helpful to provide reassurance that
    symptoms often diminish on their own, particularly if the patient has no premorbid history of depression or anxiety. Drugs and relaxation techniques may also be necessary to
    help patients sleep. Informing patients that nightmares are common and typically subside in about a month can help allay concerns. Occasionally patients will benefit from being able to talk through the events of the incident repeatedly, allowing them to confront rather than avoid reminders of the trauma.
    Staff often make the mistake of trying to treat premorbid psychopathology during patients’ hospitalisation.
  • Skilled surgeons in well equipped hospitals can manage to do this with 30% of their burn patients
  • You can make small quantities of half strength saline by dissolving one teaspoon of salt in a liter of ordinary tap water.
    Learn what half strength saline should taste like and test its concentration by tasting it first.
  • In a patient’s skin is dry and dead, the underlying tissues can remain uninfected for several weeks, during which the patient’s fat liquefies.
    But if muscle is dead, infection occurs much more easily and a rise in temperature about the 10th day usually is indicative for this.
    Infection under and eschar is difficult to localize, but pain is a useful sign. When infection is further advanced, you may be able to feel a dry eschar floating in a pool of pus.
    If there is much dead muscle, beware of anaerobic infection, particularly gas gangrene and tetanus, and deslough early.

    Most desloughing is done piecemeal by the nurses as they dress the wound, especially if they apply saline soaks. One of the commonest mistakes is not to deslough a burn: as long as any slough remains, you cannot graft it
  • If you insist to give it to remove strep. pyogenes give a 5 day Penicillin course on admission, then stop it.

    Give systemic antibiotics if there are signs of systemic infections.

  • Children: he will grow, but the scar will not!
    Most contractures are due to burns on the flexor surfaces. The exceptions are the contractures of this wrist and fingers.

    As a generalist, you might need to decide to release contractures although it is actually a specialistic operation. Your nearest plastic surgeon will probably have a waiting list of a year long. While the child is waiting for a bed in a referral hospital, his contracture is likely to become an incurable deformity! Typically, in a good district hospital 2% of all operations done under general anesthesia should be for releasing contractures.
  • If possible, scrape away any excessive granulation up to a thin layer as a graft bed.
  • As large area as possible around the corners of the Z-plasty should be outside of the scarring tissue (if they would be inside the contracture area, they will likely not be flexible and not having proper blood supply.

    If there is no transverse slack tissue to start with, a Z-plasty will not work!
  • Z-plasties can be combined in a row to gain more effect

    The plasties can be touching or non-touching but in a row (creating one or several separate wounds)

    Remember the Z’s diagonal incision is transverse to the direction in which you want to gain the length.
  • Hypertrophic scarring results from the build up of excess collagen fibres during wound healing and the reorientation of those fibres in non-uniform patterns.

    Keloid scarring differs from hypertrophic scarring in that it extends beyond the boundary of the initial injury. It is more common in people with pigmented skin than in white people.

    Influenced by many factors:
    Treatment related: First aid; adequate resuscitation; positioning; surgical interventions; wound/dressing management
    Patient related: Compliance to rehabilitation program; motivation; age; pregnancy; skin pigmentation

    Applying pressure to a burn is thought to reduce scarring by hastening scar maturation and encouraging reorientation of collagen fibres into uniform, parallel patterns as opposed to the whorled pattern seen in untreated scars.

    Other options besides pressure application:
    Massage—Helps to soften restrictive bands of scar tissue, makes scar areas more pliable
    Silicone gel sheets (contact media)—Mode of action not known; possibly limits the contraction of scars through hydration, occlusion, and low molecular weight silicone
    Elastomer moulds (contact media)—Used to flatten areas of scarring where it is difficult to encourage silicone to mould effectively (such as toes and web spaces between them)
    Hydrocolloids (contact media)—As for silicone sheets, except that these may be left in situ for up to 7 days. Massage can be given through thin sheets
    Moisturising creams—Combined with massage to compensate for lost secretory functions of skin; protect against complications from skin cracking
    Ultrasound—Low pulsed dose aimed at progressing the inflammatory process more rapidly
  • Burns: Assessment and Management

    1. 1. Burns: Assessment & Management Dr Christian van Rij @ 8th and 15th April 2010
    2. 2. Structure Presentation Background • Definition/Causes • Epidemiology • Pathology Assessment • TSAB • Burn Thickness • Lab investigations Treatment • ATLS Approach • Skin Treatment • Special sites • Supportive Tx • African Adaption • Reconstructive Tx
    3. 3. Definition Burns Injury to the body surface caused by • Thermal • Electricity • Chemicals • Light / Radiation Flames 55% Chemical or Electrical 5% Scalds 40% Burn causes in the UK (2004)
    4. 4. Thermal Injuries • Flames: – majority in adult • Contact – object too hot / contact too long • Scalds – hot fluids and gases
    5. 5. Electrical Burns • Domestic current: – Alternating nature can cause arrhythmias • High tension injuries: – Mainly voltage determent (severe > 1000V) – Severe burns between entry & exit point • Flash injuries – No current through the body but heat from the nearby discharge cause superficial skin burns
    6. 6. UV-Radiation Burns • UV-Radiation damages DNA of superficial cells – Temporary damage – Benign alterations – Malignancies • Dark skin protects – But malignancies are later detected and often more aggressive
    7. 7. Ionizing Radiation • Can detach electrons from molecules – Penetrates deep → lesions deeper than skin only • Causes DNA damage / Acute Radiation Syndrome – If patient survives often cancers & birth defects
    8. 8. Chemical Burns • Burns tend to be deep as the corrosive agent continues until completely removed • Alkalis tend to penetrate deeper and cause worse burns than acids • Some chemicals need to be treated with specific neutralizing agents: – Chromic acid or Dichromate salts with Sodium Hyposulphite – Hydrofluoric acid with Calcium Gluconate 10% – But do not treat an alkali burn with an acid or vice versa!
    9. 9. Consider non-accidental injury Indicative are: • Injury pattern: – Burn of soles, palms, genitalia, buttocks, perineum or when only upper limps are affected – Symmetrical burns of uniform depth – No splash marks in a scald injury • History – Inconsistent story – Lack of guilt or concern
    10. 10. Epidemiology
    11. 11. DALY by Fires per 100,000 people WHO Disease and injury country estimates, 2009
    12. 12. Age Distribution Patients < 5 yr 20% 5-14 yr 10% 15-64 yr 60% > 65 yr 10% 2004 UK setting
    13. 13. Prognostication in major burns • Aggressive treatment for someone with a non- survivable injury is inhumane • A patient with a survivable injury should be treated as optimal as possible • Prognostic Burn Index: a very crude estimate of mortality involving adding age + TBSA – Not yet evaluated in a prospective large trial – Need to evaluate each patient individually
    14. 14. Main Determents of Mortality Death Increasing Burn Size Inhalation Trauma Increasing Age Infection
    15. 15. Burn patient Pathology
    16. 16. Jackson’s burn zones • Zone of coagulation • Zone of stasis: potentially salvageable • Zone of Hyperemia
    17. 17. Systemic Complications • When the burn reaches >30% of TBSA • Sites – Cardiovascular -> shock & electrolyte imbalances – Respiratory -> Bronchoconstriction / RDS – Metabolic -> 3x increase in basal metabolic rate – Immunological -> down regulation immune response – Local: compromising constrictions
    18. 18. Burn Assessment Anamnesis, TSAB, Burn thickness
    19. 19. History Taking • Do it early as later you might not be able • Exact mechanism • Exact timing • Exact injury • Suspicion previous injury / non-accidental burn
    20. 20. Total Body Surface Area Burned Superficial epithelial burned areas should not be included, it can be mentioned separately Three methods to make estimation of TBSAB: 1. Hand Surface 2. Wallace Chart: Rule of Nines 3. Lund and Browder Chart
    21. 21. TBSAB: Hand Surface Area • Surface hand palm & fingers is ± 0,8% – Bit smaller in morbid obese patients • For estimation of burns sizes: – Less than 15% TBSA, or – More than 85% TBSA ± 0,8% TBSA S.Hettiaratchy, R.Papini; Initial management of a major burn: II - assessment and resuscitation; BMJ 2004;329:101–3
    22. 22. TBSAB: Wallace Chart - Rule of 9s • Easiest to remember • Anterior & Posterior part of limbs together • Adapted version for children: Less accurate
    23. 23. TBSAB: Lund & Browder Chart • Bit more extensive but more accurate • Separate Anterior & Posterior percentages • Especially in children the best solution
    24. 24. Histology Skin Stratum Cornea Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale Epidermis Dermis Papillary region Reticular region Subcutaneous Tissue or Hypodermis
    25. 25. Burn Deepness: Superficial (epidermal) • 1st Degree • Brisk bleeding on pin prick • Painful • Caucasians: Red color • Africans: Darkening • Blanching on pressure with brisk return of color • Sometimes small blisters • No scar will develop
    26. 26. Burn Deepness: Superficial Dermal • Superficial 2nd degree • Brisk bleeding on pin prick • Painful • Caucasian: Red color • Africans: Light Brown / Red • Blanching on pressure but with slow return of color • Blisters common • Sometimes Scars
    27. 27. Burn Deepness: Deep Dermal • Deep 2nd degree • Delayed bleeding on prick • Dull sensation • Dry red / bit white color • No blanching on pressure • No blisters • Gives scarring
    28. 28. Burn Deepness: Full Thickness • 3rd degree • No bleeding on pin prick • No sensation • Dry white color or Leathery • No blanching on pressure • Gives severe scarring
    29. 29. Burn Deepness: Overview Assessment Epidermal / Superficial / 1 Superficial Dermal / 2A Deep Dermal / 2B Full thickness / 3 Bleeding on prick Brisk Brisk Delayed None Sensation Painful Painful Dull None Appearance Red / Dark Bit whiter Cherry Red White leathery Blanching to pressure Yes, brisk return Yes, slow return No No When underlying muscles or bones are affected, sometimes this is called a 4th degree burn; but this is not official nomenclature.
    30. 30. Scald burns assessment is difficult • Non-scald burn: deepness extends in layers • Scald burn: give scattered pattern of deepness – Seems only superficial dermis is affected, but the deeper arterial plexus might already got thromboses Brans TA, et al; Histopathological evaluation of scalds and contact burns in the pig model. Burns 1994:20 Suppl 1:S48-51
    31. 31. Additional investigations • General Laboratory – Full blood count; packed cell volume; urea; electrolytes; clotting screen; blood group; crossmatch • Electrical injuries – 12 lead electrocardiography – Cardiac enzymes • Inhalational injuries – Chest x-ray – Arterial blood gas analysis
    32. 32. Advanced Trauma Life Support Approach Oxygenation and Circulation
    33. 33. Airway with cervical spine control • Inhalation of hot gases results in a airway at risk – Look for inhalation trauma indicators – Becomes oedematoes over next hours, especially after starting fluid resuscitation – Inspection Oropharinx by anaesthesist required – Indications for intubation: • Erythema or swelling of the oropharynx • Change in voice with hoarseness or harsh cough • Stridor, tachypnoea, or dyspnea
    34. 34. Breathing problems • Mechanical restriction due to chest eschars • Blast injury • Smoke as direct irritant to the lungs • CO inhalation results in Carboxyhaemoglobin • All patients should receive 100% O2 through humidified non-rebreathing mask at admission
    35. 35. Circulation: Fluid management • Resuscitation goal: – To maintain tissue perfusion to the zone of stasis – To achieve proper organ perfusion • How much? – Too little fluids causes poor perfusion & hypoxia – Too much fluids causes oedema which will again result in poor perfusion & hypoxia – Should be based on physiological parameters
    36. 36. Parkland Schedule for Resuscitation • 4ml (crystalloids) × TBSAB(%) × weight(kg) – Give 50% in the first 8 hours following the trauma – Give remaining 50% in the next 16 hours – High tension electrical & airway burns require more • Consider to add the daily maintenance fluid • Sodium chloride solution should be avoided as it can cause hyperchloraemic metabolic acidosis
    37. 37. Circulation: Escharotomy • Resuscitation can increase wound oedema and swelling beneath non-elelastic burnt tissue • Raised tissue pressure can impair circulation • Escharotomy may be required
    38. 38. Neurological Disability • Other trauma is often forgotten: – E.g. falling from height after high tension injury • Confusion can be due to: – Hypoxia – Hypovolemia – Head Trauma – Septicemia – Psychological shock
    39. 39. Pain Control • Burns are very painful • Combined analgesics reduces need for increasing narcotic doses for breakthrough pain • Don't give IM drugs if TBSAB > 10% as absorption is then unpredictable • Lorazepam has recently been found to lessen burn pain, largely by treating acute anxiety
    40. 40. Expose with Environmental control • Top to toe on front & back should be examined • Patients (children) become easily hypothermic – Will lead to hypoperfusion of the zone of stasis causing extension of the zone of coagulation
    41. 41. Treatment of the burned skin 1st aid to skin, skin toilet, grafting, strictures, keloid
    42. 42. 1st Aid to the burned skin • Skin cooling: – Remove all non-sticking clothing – Prompt irrigation with tap water for 20 minutes – Chemical burns require longer rinsing (up to 24h) – Do not use very cold water as it causes vasoconstriction worsening tissue ischemia – Prevent hypothermia
    43. 43. 1st Aid to the burned skin • Dressing – Helps relieve pain and keeps the area clean – Moist environment fastens wound healing – After 48h again, then every 3-4 days (unless soaked) • Types: – Continuously water soaked gauzes – Paraffin or Vaseline gauzes – Transparent Polyvinylchloride film – Silver sulfadiazine gauzes (only after wound assessment)
    44. 44. Epidermal burns • Analgesia usually only requirement treatment • Healing occurs rapidly within a week with regeneration from undamaged keratinocytes
    45. 45. Superficial Dermal Burns • Healing within 2 weeks by keratinocytes from the sweat glands & hair follicles • Progression to deeper is unlikely if the wound is kept moist • Elevate the affected limb for 48h
    46. 46. Deroofing Blisters: controversial • Pro Deroofing – Allows burn depth assessment – Blister fluid is a medium for bacterial growth – Blister fluid suppresses immunity (an in-vitro study) • Contra Deroofing – Intact blisters acts as a sterile stratum spongiosum • ‘Consensus’: large blisters to be deroofed
    47. 47. Deep Dermal burns • Most difficult to assess: reexamine after 48h • Lower density of skin adnexae → slower healing • Associated with contractures / keloid • Excise to a viable depth in cosmetic/large areas • Dress non-adhesively and elevate
    48. 48. Full Thickness Burns • Spontaneous healing only from edges • Necrosis should be excised • If primary excision and closure is not possible: – Grafts or Transposition flaps
    49. 49. Skin Grafting • Type of graft: – Meshed thin/thick split graft – Full thickness (pinch) graft – Thicker is better for graft site; but worse for donor site • Grafts have no blood supply – Do not graft where no granulation can occurs; like cartilage, bone or naked tendon
    50. 50. Skin Grafting Technique
    51. 51. Skin Grafting Technique
    52. 52. Skin grafting as a priority Make the mistake of grafting too often instead of too little If you wait too long: – Granulation tissue will be older making grafts take less well – Prolonged fibrosis will give worse scars and contractures Consider priority areas first
    53. 53. Flap translocations • The transfer whole thickness skin with intact blood supply • Flaps should be considered – If very quick closing of the skin deficit is crucial – If reconstruction of underlying structures is needed – If at the site split skin grafts are unlikely to take
    54. 54. Flap Types • Free Flap – The blood supply is isolated, disconnected, then reconnected at a remote site • Perforator Flaps: – Flaps in which tissues are isolated on small perforating vessels that run from major vessels to supply the surface • Composite Flaps: – Composed of various tissues and transferred together; often skin with bone or muscle
    55. 55. Flap Types • Random Flap: – Local transposition ignoring blood vessel paths – Length to width ratio not more than 1 ½ :1 • Axial Flaps: – Local transposition respecting blood vessel paths – Longer flaps with length to width ratio of 6:1 • Pedicled or Islanded Flap – Have a very narrow base around stalk of supplying vessels around which it can be rotated
    56. 56. Random Flap subtypes • Advancement flap • Rotation flap • Bilobed flap • Bipedicle flap • Z-plasty • Y-V-plasty Often used for contraction release
    57. 57. New Developments • Cultured epithelial autografts – Can be applied as suspension after one week, or – As sheet after three weeks – Can be combined with a mesh grafts to improve cosmetic results • Vacuum-assisted closure • Skin traction techniques
    58. 58. Special Sites Face, Ears, Hands and Feet
    59. 59. Facial skin burns • Clean face with diluted chlorohexidine bd • Apply cream (such as liquid paraffin) every hour • Sleep with pillows to minimize oedema • Men: shave daily • Use unmeshed skin grafts only • Priority: Eye lids must be able to be closed
    60. 60. Covering the cornea is an emergency Options: 1. Fill cornea temporarily with CAF ointment 6h 2. Make relaxation incisions (esp. for upper lid) 3. Early inlay split skin graft 4. Temporary tarsorrhaphy Caution: • Do not use steroids • Do not apply gauzes to the cornea (it rubs)
    61. 61. Burns to the Cornea • Examine the cornea early (swelling comes quick) – Usually the cornea is not burned but eyelids only – Use fluorescein to look for ulcers • Treatment corneal burn: – If hazy cornea: apply CAF and atropine eye drops – If punctae or canaliculae are damaged: pass a style or indwelling suture through them to keep them open – If palpebral & ocular conjunctivae stick together: separate them with a glass rod
    62. 62. Ear burns • Inflammation of the cartilage can occur when the skin has already healed • Symptoms: acutely painful, red and tender • Necrotic cartilage will infect and slough; taking down the finely shaped skin
    63. 63. Removing necrotic cartilage • Incise outer border ear • Remove any non resilient yellow cartilage • Reexamine after 24h to remove new necrosis • Keep it moist with saline • Don’t bend cartilage
    64. 64. Burned Hands • Dorsal hand burns are complicated • Refer burned tendons, bone, cartilage and joints • Exposed joints usually require amputation or arthrodesis (in a functional position) • Thick burns to finger often need escharotomy • Excising/grafting hand/foot burns is a priority!
    65. 65. Burned Hand or Feet • Raise his hand high to minimize oedema • Moist plastic bag method best way of dressing – It keeps the fingers moist, mobile, painless – Daily wash his hand and apply antiseptic like silver • Physiotherapy and splinting in position of safety are needed to prevent stiffening & contractures – Dynamic splinting or night splinting
    66. 66. Supportive Treatment Antibiotics, Nutrition, Psychology
    67. 67. Systemic Antibiotic Prophylaxis • Meta-analysis could not really confirm benefit: – Only proven benefit with huge quantities of triple Tx – Prophylaxis before surgery might be beneficial • Burn units: known for Resistance development → Systemic antibiotics only for established infections with the smallest spectrum possible → Topical antimicrobials are advised Avni T, Levcovich A, et al; Prophylactic antibiotics for burns patients: systematic review and meta-analysis. BMJ 2010;340:c241c
    68. 68. Nutritional importance • Prevent catabolic state: an anabolic state is required for healing • (Small) injuries can triple basal metabolic rate – Associated with hyperpyrexia • Splachnic hypoperfusion decreases absorption and motility
    69. 69. Management hypermetabolic response • Reduce heat loss by environmental conditioning • Ensure quick closure of wounds • Early recognition and treatment of infection • Early enteral feeding
    70. 70. Physiotherapy • Elevation, Splinting and Exercises improve outcome very significantly • Needs to start on day one, given on daily basis • Splinting essential to prevent contractures
    71. 71. Nursing Tasks • Positioning • Regular dressings • Encouraging exercises • Encouraging proper feeding • Psychosocial support • Monitoring • Administering drugs
    72. 72. Psychological characteristics Challenges • Pain • Anxiety (acute stress / PTS disorder) • Depression • Sleep disturbance • Increase of premorbid psychopathology • Grief Treatments • Drug management of anxiety, depression sleeplessness and pain • Brief counselling • Teach non-drug approaches to pain management
    73. 73. Staring “The way we choose to interpret and perceive stares will influence our ability to cope with them” “By strengthening our social skills, we can overcome the challenge of looking different” “Remember, you are in control and not the person staring: become conscious of your own behavior” Why people are staring Compassioned Concern Curious Overwhelmed by trauma Rude Amy Acton, burn survivor, www.phoenix-society.org
    74. 74. Adaption to our Africa Setting Non-specialized staff, Limited equipment and drugs
    75. 75. Patient Case
    76. 76. 4 possible approaches 1. Early excision followed by – Dressing and early grafting, or – Flap Application 2. Occlusive dressing 3. Air dried dressing 4. Soaked dressing Commonly practiced in well resourced and specialized settings (discussed above) Advocated for an under-resourced or non-specialized setting
    77. 77. 1: Early Excision and grafting • Excise necrotic tissue (within 3/7) and graft it directly (within 3/7) before it becomes infected • You must be sure the burn is full thickness • Severe bleeding is the main danger – Have adrenalin injections and transfusion at hand
    78. 78. 2: Occlusive Dressing
    79. 79. 2: Occlusive Dressing • For non full thickness burns • Dressing burn wound >2cm thick – Sealing the wound to prevent bacteria reaching it • Assuming the burn made the wound sterile, and • Dressing is applied aseptically immediately, and • Wound fluids are absorbed before reaching the surface – Leave undisturbed and new skin has grown after 10/7 ! Done badly this dressing is a disaster !
    80. 80. 3: Open / Air-dried method
    81. 81. 3: Open / Air-dried method • A dried crust is an effective barrier – Air will dry the wound and is barely contaminative – Use bed cradles as clothes & flies contaminate – Wound fluids must be removed to get a dry crust – Regular application of povidon iodine is advocated • If an eschar / slough needs to come off, you might change to soaked dressings • Be aware of hypothermia
    82. 82. 4: Water Soaked Dressing • Put gauzes over the wound and keep it constantly wet with half strength saline hourly – Pouring from a jug with a Macintosh under the burn – Immersing the burn in a (daily refreshed) bucket • Patient should exercise while immersed for 20 minutes bd • Sloughs on a deep burn will usually separate on the 12th day and be ready for grafting on the 15th to 17th day
    83. 83. 4: Water Soaked Dressing • Advantages: – Reduces hospital time compared to the dry method – Is painless, easy and cheap – Suitable for superficial as well as deep burns – Eschars will turn to Sloughs and will separate early • Disadvantages: – Not easy on the thorax in adults – Difficult to combine with splinting – Caution for hypothermia
    84. 84. Slough and Eschars • Slough & Eschars: a thick layer of dead tissue: – Sloughs are moist, soft and stinking – Eschars are dry, hard and dark • Eschars can impair circulation → Escharotomy • Eschars can protect against infection • If infected they should be removed directly: – under an antibiotic cover – if bleeding is excessive, consider removing in stages
    85. 85. Other considerations for adaption • Systemic Antibiotics – Also in Africa no evidence of a prophylactic benefit – Resistance development is not less common, while – Spread of resistant bacteria is much more likely due to limited isolation • Blisters – Some argue that “due to less hygienic environment you should also keep larger blisters intact”
    86. 86. Reconstruction Surgery Contractures and Keloids
    87. 87. Contractures
    88. 88. Preventing Contractures • Prevent full thickness burns • Make grafting joints a priority – Graft early on a thin layer of granulation to prevent extensive (contracture forming) fibrosis – Use unmeshed full thickness grafts at joints – Place grafts across the joints • Splinting is effective against grafting – But it can stiffen a joint if applied 24h – Serial casting are not effective for burn contractures
    89. 89. Skin expansion
    90. 90. Incision Releases for wide contractures
    91. 91. Z-Plasty for narrow contractures
    92. 92. Z-Plasties combined to gain effect
    93. 93. Y to V Plasty
    94. 94. Hypertrophic / Keloid Scarring • Keloid: hypertrophic scarring outside area burnt • Influenced by many factors • Pressure garments are the primary intervention • Other options: – Special contact media (e.g. silicone gel) – Moisturizing creams – Massage – Surgery
    95. 95. Following up a burn survivor • Healed burns will be sensitive; are often dry/scaly and may have pigment changes • Use moisturizer cream • Sun protection for 6-12 months • Pruritis is common: – Massage with aqueous creams like Aloe Vera – Antihistamines and analgesics can help • Psychological / Social assessment
    96. 96. Questions and Discussion What can we implement/improve at our Hospital?
    97. 97. References • ABC of Burns; – BMJ Books; 1 Ed.; 2005; ISBN: 978-0727917874 • Emergency and early management of burns and scalds – Enoch S; BMJ 2009;338:b1037 • Prophylactic antibiotics for burns patients: systematic review and meta-analysis; – Avni T, et al; BMJ 2010;340:c241 • Primary Surgery; Volume Two; – King M; Chapter 58; 1st ed; 1993 • Bailey & Love’s Short practice of Surgery: – Williams N; Chapter 28-29; 25th ed; 2008

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