Complete description of Burn

1. Dagdha Vrana (Burn Injury)
Dr. Alok Kumar
PhD, Shalya Tantra
NEIAH, Shillong

2. Burn
The injury caused by heat energy, leading to the coagulative necrosis of
tissue considered as burn wound.
The burn injury may be categories as :-
Non- Thermal burn
1. Electric burn
2. Chemical burn
3. Radiation burn
4. Cold burns
Thermal burn
1. Direct heat by flames, hot
metal, airplane crash or bomb
injury.
2. Scalds caused by moist heat
e.g. Hot liquid or steam

3. Thermal burn
• Mostly occurs in adults.
Scalds Burn
• Mostly occurs in minors as infants and
children accidentally.

4. Pathology of Burn
• Local changes
1. Severity of burn
2. Extent of burn
3. Vascular changes
4. Infection
• Systemic changes
1. Shock
2. Biochemical changes
3. Changes in blood
4. Systemic effect

5. Local changes
Severity of burn
The severity of burn is assessed on the basis of depth of tissue involve
in injury.
• First degree
• Second degree
• Third degree
One more classification
• Partial thickness
• Full thickness

6. First degree
• First degree of burn involves only the
superficial layer of epidermis. Here only
microscopic destruction occurs leading to
hyperemia and slight odema in skin. The
skin regenerate itself. There is no
problematic scarring.
• No active surgical management is required.

7. Second degree
• There is burn of entire epidermis layer leading to
formation of blebs or vesicles between epidermis
and dermis. Vesicle filled with serous, watery
discharge is diagnostic of 2nd degree burn.
• In Mild second degree burn the enough
epithelium is present including hair follicle and
sweat gland so they regenerate after healing so
grafting is not require .
• In severe second degree burn all skin appendages
are destroyed so resurfacing of wound is
required, i.e. grafting is necessary.

8. Third degree
• There is complete destruction of the
epidermis and dermis along with all dermal
appendages, leading to expose of muscles,
tendons and other structure.
• Skin grafting is mandatory to cover raw
surface area.

9. Extent of burn
• Before starting management we must to know
the amount of surface area injured in burn.
There are many formula in which Rule of 9 is
very popular for measurement of burn injury.
• This is applicable on the adults only for
children it may not applicable.
For Children For Adults

10. Vascular changes
• There is dilation of large vessels due to direct injury of
vessels wall and local liberation of histamine that
increases the blood flow to the injured part.
• Due to inflammatory changes in burn area the capillary
permeability increases in great extent so a large
amount of fluid exudate in blisters along with plasma
protein. Body losses a good amount of plasma protein
to cause hypoproteinemia in large body surface area
burn.
• Later on these blisters dried and forms the brown crust
which protects the wound.

11. Infection
• As we know the skin is our first line protection from infection, so in
second and third degree burn skin is destroyed so these burn always
have great risk of infection.
• Because of malnutrition, loss of plasma protein, blood volume and
anemia body’s defense mechanism become week to resist any
infection.
• Burn patient should kept in special design burn ward in sterilized
environment to protects from infection.

12. Systemic changes
• This most important effect of burn, parson may go into various shock
however hypovolemic shock is first followed by cardiogenic,
neurogenic and septic shock.
• Treatment should be start with keep in mind of Hypovolemic shock

13. Biochemical changes
• Electrolyte imbalance
• Hypoproteinemia

14. Changes in Blood
• Hemo-concentration due o loss of the serum in second and third
degree burn.
• Hb% may rises up to 15% in severe burn.
• Fall in eosinophil count during first 24 hr.
• Anemia is due to destruction of red cells in early post burn periods,
most in third degree burn.

15. Systemic effect
• There are various organs involved in severe burn…
• GIT
• Liver
• Heart
• Kidney
• Lungs
• Nervous system

16. Management of Burn
For convenient of understanding the management is classified as:-
• Treatment of shock
• General treatment
• Local treatment

17. Treatment of shock
• Immediate resuscitation starts with the assessment of extent of burn.
• Sedation
• Maintenance of airways
• Measurement of IV fluid
Parkland’s formula
• Half of the total must be infused in first 8hr and rest in next 16 hrs.
• IV infusion required on > 20 % of BSA in full thickness and >40% of BSA in
partial thickness burn.
Total fluid in ml for 24 hr = 4 X BSA(body surface area) involve X weight of body in Kg

18. General Treatment
It Includes
• Sedation / Analgesia
• Tetanus prophylaxis
• Prophylactic Antibiotics
• Nutritional support
• Gastric decompression
• Treatment of GI complications
• Escharotomy & fasciotomy

19. Escharotomy & fasciotomy
• This is required in third degree burn.
• Circumferential Third degree burn of limbs or
thorax may form an unyielding crust, known as
eschar.
• This eschar acts as tourniquet which may cause
compromised ventilation, venous obstruction.
• To reduce the tourniquet effect Escharotomy is
done.
• Sometime Escharotomy is not effective then
fasciotomy is required.
• Procedure should be done under GA.

20. Escharotomy & fasciotomy

21. Local treatment
1. First aid measure
2. Wound care
• Open method
• Closed method
3. Skin grafting
4. Physiotherapy and Rehabilitation

22. First aid measure
• Remove the patient from the
burn source of heat.
• Follow the STOP.

23. Wound care
• Once the resuscitation is complete, patient is stable now whole attention must
be paid on wound care.
• Patient must be kept in burn ward.
• Cleaning of wound, remove all devitalized tissue, blisters should be punctured
and over line skin remove, complete this procedure without anesthesia under
full aseptic condition and technique.
• Topical application of silver nitrate (.5%), silver sulphadiazine cream (1%)and
other antimicrobial solutions.
• The deep burn usually have eschar, if it is loose then remove other wise wait
and watch. Forcefully removal may cause severe pain and hemorrhage.
• Now further progress depends on surgeon choice
• Open or Close.

24. Open method
• The burn area is left uncovered and
topical antimicrobial agents are applied
12 hourly.
• A crust formed on surface to protect the
burn.
• Formation of crust depends on depth of
burn.
• It is suitable for head face and neck.

25. Close Method
• The wound is covered in three layer
• Inner= Non-adherent antiseptic with water based cream
• Middle = Ordinary sterile cotton gauze
• Outer = Cotton bandage
• If the burn wound becomes very much infected then,
treatment depends on extent and depth of burn.
• Systemic antibiotics may require, use after culture and
sensitivity.
• Selective antimicrobial solutions may be directly infused
on the wound site.
• If infection goes deep it may require surgical
debridement to drain.

26. Skin grafting
• Required when burn area is large in 2nd and 3rd
degree burn.
• The time of grafting is very important, it
should be done just after eschar formation.
The site must have good granulation tissue and
infection free.
• Improve healing and reduce disfigurement.
• Reduces evaporative water loss.
• Over the sensory nerve so reduces pain.

27. Physiotherapy and Rehabilitation
• As soon the patient is able to move, it must
be started that may reduce the contracture
formation on healing / fibrosis / scar
formation.
• Normal rage of joints movements are gain
with early movement.

28. Complications of thermal Burn
• Curling ulcers
• Acute pancreatitis
• Acute acalculous cholecystitis
• Superior mesenteric artery syndrome
• Non-occlusive ischemic enterocolitis
• Myocardial infarction

29. Injury to airway and lungs
• Physical burn injury to the airway
• Inhalational injury
• Metabolic poisoning (Smoke inhalation)
• Mechanical block on rib movement
Treatment
• The key of management of inhalation injury is history and early sign.
• First aid
• Intubation
• Ventilation support
• General Management of burn

30. Electrical Burn
• Electrical injuries are divided as low voltage and high voltage.
• Low voltage injuries causes, localized deep burn, they can cause
cardiac arrest through pacing interruption without significant damage
to myocardial tissue.
• High voltage injuries damage by flash (external burn) and conduction
(Internal burn).
• Myocardium may be damages without pacing interruption.
• Low voltage injury occur in domestic places with AC current, while
high voltage injuries happen in industrial places with DC current.

31. Treatment
• First aid.
• Resuscitation with fluid and oxygen.
• Careful orthopedic examination must be done.
• Conduction of current causes severe damage to subcutaneous tissue and
muscles , so myoglobin are generated that may causes renal depression. So
while resuscitation achieve high urine output should be first target.
• Severe acidosis is common in large electrical burn so bolus of bicarbonates
are required.
• Fasciotomy and exploration of muscles compartment for debridement and
sometime amputation becomes essential.

32. Chemical Burn
• There are about 70000 chemical being used in industry that may cause chemical
burn injury.
• There are two main aspects of this injury as first the physical damage of skin and
second is the poisoning caused by absorbed chemical.
• Most of injuries are either Acid or Alkali. Alkali are usually more dangerous than
acid specially if contact on eyes.
Treatment
• Lavage with plane water. (except…hydrofluoric acid with benzalkonium & phenol
with glycerol).
• The irrigation should continue at least for 30 min, in few cases may up to 24 hrs.
• Second step should be to identify the chemical and it’s concentration.
• Treat symptomatically. In case of extensive burns surgery may required.

33. Radiation Burn
• This injury can be divided in two parts
• Local
• Systemic
Treatment
• Localized radiation damage should be primarily treated with conservative, if
wound is there then excision and graft may recommended.
• Systemic or whole body radiation is mostly lethal, and results in slow
unpleasant death , so supportive management is recommended. In non-
lethal radiation patient may go under immune system dysfunction and may
damage the gut mucosa too. Symptomatic treatment is recommended.

34. Cold burns
• Cold burn is of two types. Our body has more resistant to cold burns
than the hot burns.
• Freezing injuries (frost bite)
• Non-freezing injuries (chilblain, trench foot, immersion foot)

35. Frost bite
• This is the freezing of tissue with formation of
crystals. Mostly occurs in soft tissue of hand, feet,
eras and nose. Extreme cold exposure leads to
necrosis due to freezing of extra/intracellular
content. Skin is relatively resistant than the other
tissue as nerves, muscles & blood vessels. Clinical
presentation depends on Severity of exposure. It is
of first, second, third and fourth degree.
• Treatment
• Conservative management include rapid exposure
to warm environment, surgery is rarely required.

36. Non-freezing injuries
• All conditions are similar types, occurs due to cold
damp weather with or without prolonged exposure
in cold water.
• Chilblain (localized, pain, erythema, itching in fingers,
toes or ear pinna)
• Trench foot ( occurs in soldiers who under goes
prolonged exposure to extrema cold water, leading to
circulatory disturbances predisposes by tight clothing or
ill fitted shoes.)
• Immersion foot ( occurs in shipwrecked person who
spent lot of time on waterlogged boats.)
• Treatment
• Conservative management is usually enough.
Chilblain
Trench foot
Immersion foot