33BURNSBURNSDefDef..it is injury of the tissue caused by extremesit is injury of the tissue caused by extremesof temperature (heat or cold ) or chemicalsof temperature (heat or cold ) or chemicalsor ionising radiations.or ionising radiations.Basic pathophysiologyBasic pathophysiology.. involves two parts as compared to mechanical traumainvolves two parts as compared to mechanical trauma physical injury to tissuephysical injury to tissue Physiological injury to cells…..charing and precipitationPhysiological injury to cells…..charing and precipitationof protoplasm of cellof protoplasm of cellExternal skin burns are the most commonExternal skin burns are the most commonsurgical emergency.surgical emergency.
44Types and causesTypes and causes ThermalThermal due todue to FireFire Steam, boiling liquids……..calledSteam, boiling liquids……..called SCALDSSCALDS Blast, missile and fire arm injuriesBlast, missile and fire arm injuries ChemicalsChemicals ……acids, alkalis etc.……acids, alkalis etc. Ultravoilet raysUltravoilet rays…..sun burns…..sun burns Radiations….nuclear rays, radiation therapyRadiations….nuclear rays, radiation therapy Electricity currentElectricity current Mechanical friction injuryMechanical friction injury Burns commonly involve skin but can involveBurns commonly involve skin but can involvesubcutaneous tissue, muscle and bone even insubcutaneous tissue, muscle and bone even insevere cases.severe cases.
55 Skin …structure and functionsSkin …structure and functions AnatomyAnatomy SizeSize….Largest organ in body…with surface area….Largest organ in body…with surface area 1.7 sq. meters1.7 sq. meters ininadultadult Thickness…….? I do not know !.....any body knows it.Thickness…….? I do not know !.....any body knows it. Two layersTwo layers EpidermisEpidermis….5 layers of epithelial cells….5 layers of epithelial cells DermisDermis….2 layers…contain air follicles, nerve endings, blood….2 layers…contain air follicles, nerve endings, bloodvessels, fibrous tissue, sweat glands, sebaceous glandsvessels, fibrous tissue, sweat glands, sebaceous glands FunctionsFunctions Identity of a person or race, beautyIdentity of a person or race, beauty Physical barrier for microorganismsPhysical barrier for microorganisms Sweat glands regulate body temperature, excrete waste products,Sweat glands regulate body temperature, excrete waste products,hormones, cholesterol, electrolytes, etc.hormones, cholesterol, electrolytes, etc. Dermis prevents excessive fluid loss by evaporationDermis prevents excessive fluid loss by evaporation Sensory organSensory organ Vitamin D synthesisVitamin D synthesis Forensic importance……..fingerprintsForensic importance……..fingerprints
99 Factors determining the severity andFactors determining the severity andprognosis in burnsprognosis in burns Depth of burnDepth of burn Surface area involvedSurface area involved Age of patientAge of patient Site of burnSite of burn Associated injuriesAssociated injuries Type of burnType of burn Other associated disease factorsOther associated disease factors
1010 Depth of burns……classificationDepth of burns……classification Three degrees……Three degrees……according to thickness of skinaccording to thickness of skininvolvedinvolved Ist degree………..epidermis onlyIst degree………..epidermis only Second degree….epidermis and part of dermisSecond degree….epidermis and part of dermis Third degree…….epidermis and complete dermisThird degree…….epidermis and complete dermisSome authors mention 4 th degree burns for involvement of muscle, bone andSome authors mention 4 th degree burns for involvement of muscle, bone andsubcutaneous tissuessubcutaneous tissues First degreeFirst degree Involve epidermis onlyInvolve epidermis only Caused by sunlight or brief scaldingCaused by sunlight or brief scalding Tissue damage is minimalTissue damage is minimal Pain is predominant symptom as nerve endings getPain is predominant symptom as nerve endings getexposedexposed Burn skin is red erythematous,Burn skin is red erythematous, Healing occurs by epithelization in 5-10 daysHealing occurs by epithelization in 5-10 days Systemic effects like fluid loss are rareSystemic effects like fluid loss are rare
1212 Third degreeThird degree Involve epidermis, complete dermis andInvolve epidermis, complete dermis andextend into deeper tissuesextend into deeper tissues Characterized by dry, tough ,leathery surface,Characterized by dry, tough ,leathery surface,brown or black or whitish in colorbrown or black or whitish in color Blisters are absentBlisters are absent No painNo pain…..because pain receptors are…..because pain receptors aredestroyeddestroyed Tissues are dead and blood vessels areTissues are dead and blood vessels arethrombosedthrombosed
2121 Extent of burn surface…Extent of burn surface… ……calculated as percentage of body surface areacalculated as percentage of body surface area(BSA)(BSA) Determined byDetermined by rule of 9rule of 9 in adultsin adults Head and neckHead and neck =9%=9% Right armRight arm =9%=9% Left armLeft arm =9%=9% Chest& abdomen frontChest& abdomen front =18%=18% Chest & abdomen backChest & abdomen back =18%=18% Right lower limbRight lower limb =18%=18% Left lower limbLeft lower limb =18%=18% TotalTotal =99%=99%Where is one percent ?Where is one percent ? Different formula for children and infants.Different formula for children and infants.
2323 Accurate estimation of burned surfaceAccurate estimation of burned surfacearea is very important…because it isarea is very important…because it isdirectly related todirectly related to severity ,severity , prognosis,prognosis, fluid loss,fluid loss, metabolic changes andmetabolic changes and patient managementpatient management Rough estimation……….size of one palm of handRough estimation……….size of one palm of handis equal to one % burn……….is equal to one % burn……….palm of patient notpalm of patient notdoctor or nurse…..!doctor or nurse…..!
Age of patient….Age of patient…. Burns of same specific depth and surface areaBurns of same specific depth and surface areainflict higher morbidity and mortality in infantsinflict higher morbidity and mortality in infantsbelow two years and elderly people above 60below two years and elderly people above 60yearsyears Infants below 2 years have not well developedInfants below 2 years have not well developedimmune system and have less resistanceimmune system and have less resistance Older people above 60 years have otherOlder people above 60 years have otherassociated disease factors alsoassociated disease factors also2525
Associated disease factorsAssociated disease factors Other associated disease factors increaseOther associated disease factors increasethe morbidity and mortality in a burn patientthe morbidity and mortality in a burn patientas compared to a normal person asas compared to a normal person as Pulmonary diseasePulmonary disease DiabetesDiabetes Congestive heart failureCongestive heart failure Immuno -suppresive drugsImmuno -suppresive drugs Chronic use of steroidsChronic use of steroids Radiation therapyRadiation therapy ChemotherapyChemotherapy AnaemiaAnaemia2626
Site of burnSite of burn Burns involving some particular sites haveBurns involving some particular sites havehigher mortality and morbidityhigher mortality and morbidity FaceFace NeckNeck HandsHands Perineal areasPerineal areas FeetFeetThese are calledThese are called primary areas…..andprimary areas…..andburns of these areas need hospitalizationburns of these areas need hospitalizationand special care.and special care. 2727
Associated injuriesAssociated injuries Other associated injuries along with burnsOther associated injuries along with burnsincrease mortality and morbidity asincrease mortality and morbidity as Inhalation smoke injuryInhalation smoke injury FracturesFractures Head injuriesHead injuries Chest and thoracic trauma etc.Chest and thoracic trauma etc.2828
Type of burnType of burn Electrical and chemical burns may appearElectrical and chemical burns may appearminor externally but may involve moreminor externally but may involve moredamage to deeper tissuesdamage to deeper tissues Fire burns may damage more than scaldsFire burns may damage more than scalds2929
Management of burn patientManagement of burn patientMortality and morbidity can be reduced byMortality and morbidity can be reduced by Urgent attentionUrgent attention Proper assessment , ofProper assessment , of burned surface area andburned surface area and fluid requirementfluid requirement Consideration of high risk factors andConsideration of high risk factors and Appropriate treatmentAppropriate treatment RehabilitationRehabilitationManagement of severe burns need a specializedManagement of severe burns need a specializedBURN UNIT with skilled personnelBURN UNIT with skilled personnel3030
Management includesManagement includes Admit patient if indicatedAdmit patient if indicated Acute resuscitationAcute resuscitation CalculateCalculate burn surface area,burn surface area, degree of burn,degree of burn, site of burn and label a surface area diagram onsite of burn and label a surface area diagram onpatient record sheet.patient record sheet. Care of burn woundCare of burn wound Prevention of infectionPrevention of infection Nutrition of burn patientNutrition of burn patient Prevent and care of complicationsPrevent and care of complications Rehabilitation and physiotherapyRehabilitation and physiotherapy3131
Acute resuscitationAcute resuscitation Airway maintenanceAirway maintenance Large I / V cannulaLarge I / V cannula Fluid replacement therapyFluid replacement therapy Urinary catheter to monitor urine outputUrinary catheter to monitor urine output Central venous pressure lineCentral venous pressure line Monitor vital signsMonitor vital signs Tetanus toxoidTetanus toxoid Pain relief…Pain relief………I / V narcotic analgesics Morphine 0.1 mg / kg,I / V narcotic analgesics Morphine 0.1 mg / kg,Mepridine 1 mg / kg body weight.Mepridine 1 mg / kg body weight. Antibiotic prophylaxis in 2Antibiotic prophylaxis in 2ndndand 3and 3rdrddegree burns.degree burns.BURN PAIN IS SEVEREST TYPE OF PAINBURN PAIN IS SEVEREST TYPE OF PAIN 3232
Classification of severity of burnsClassification of severity of burns Major burnsMajor burns…………need admission to specialized burn unit withneed admission to specialized burn unit withskilled staffskilled staff Moderate burnsModerate burns….…..need admission to hospital ward.need admission to hospital ward Minor burnsMinor burns………….treated on out patient basis..treated on out patient basis.3333
Major burnsMajor burns…… ……must be admitted to a highly specialized burn unitmust be admitted to a highly specialized burn unit 22ndnddegree more than 25% in adultdegree more than 25% in adult 22ndnddegree more than 20 % in infants and elderlydegree more than 20 % in infants and elderly 33rdrddegree burns more than 10 %degree burns more than 10 % Burns involving primary sites… as face, ears, eyesBurns involving primary sites… as face, ears, eyes,neck, hands, perineum, feet,neck, hands, perineum, feet Patients havingPatients having inhalation injuryinhalation injury Electricity burnsElectricity burns Burns associated with otter injuries…fracture, headBurns associated with otter injuries…fracture, headinjury, chest trauma etcinjury, chest trauma etc3434
Moderate burns….Moderate burns….need admission to hospital wardneed admission to hospital ward 22ndnddegree burns 15-25% adultsdegree burns 15-25% adults 22ndnddegree burns 10-2-% childrendegree burns 10-2-% children 33rdrddegree burns 2-10%degree burns 2-10% 11ststdegree burns 30%degree burns 30% No associated injuryNo associated injury Minor burns…..Minor burns…..treated as outpatient basistreated as outpatient basis 22ndnddegree burns less than 15% adultsdegree burns less than 15% adults 22ndnddegree burns less than 10% childrendegree burns less than 10% children 33rdrddegree burns less than 2%degree burns less than 2% 11ststdegree burns less than 30%degree burns less than 30%3535
Fluid replacement and maintenance therapyFluid replacement and maintenance therapy many formulas……….remember one which you like and easy formany formulas……….remember one which you like and easy foryouyou Calculation of fluid requirementCalculation of fluid requirement Muir & Barckly formulaMuir & Barckly formula Parkland formulaParkland formula Evans . formulaEvans . formula Baxtar formulaBaxtar formula Basic requirement is adequate perfusion andBasic requirement is adequate perfusion andadequate urine out putadequate urine out put.. First 48 hours are critical for fluid therapy.First 48 hours are critical for fluid therapy. Urine out put is the best guide to know adequateUrine out put is the best guide to know adequatehydration ………hydration ……… 0.5 ml / kg / hr0.5 ml / kg / hr.. First fluid to be given is crystalloid solution…..like ringerFirst fluid to be given is crystalloid solution…..like ringerlactate, dextrose saline etc.lactate, dextrose saline etc.3636
Formula for fluid calculationFormula for fluid calculation First 24 hrs.First 24 hrs. 4ml / kg / % of burn = 24 hr requirement.4ml / kg / % of burn = 24 hr requirement. Give half in first 8 hrsGive half in first 8 hrs Next half in next 16 hrs.Next half in next 16 hrs.Hour to be calculated from the time of burnHour to be calculated from the time of burn Next 24 hrs…….Next 24 hrs……. Maintenance 2000ml andMaintenance 2000ml and Maintain urine out put 0.5.ml /hr.Maintain urine out put 0.5.ml /hr. Plasma is givenPlasma is given Blood may be needed in 3Blood may be needed in 3rdrddegree burns.degree burns. Check electrolytesCheck electrolytes3737
Care of burn woundCare of burn wound Cleaning with sterile salineCleaning with sterile saline Apply antibacterial ointments like silverApply antibacterial ointments like silversulfadizine or povidine iodine and dressingsulfadizine or povidine iodine and dressing Wound dressingsWound dressings Exposure methodExposure method……..no cover……..no cover Covered methodCovered method………cover with gauze………cover with gauze Primary excisionPrimary excision Debridement with proteolytic enzymes as …Debridement with proteolytic enzymes as …travasetravase Escharotomy……excision of dead tissueEscharotomy……excision of dead tissue Skin graftingSkin grafting3838
Nutrition in burn patientNutrition in burn patient Metabolic requirement increases 2-4 fold inMetabolic requirement increases 2-4 fold inburn patientsburn patients Proteins are lost in burn oozing fluidProteins are lost in burn oozing fluid Give adequate proteins and caloriesGive adequate proteins and calories Ant acids and H2 blockers are given toAnt acids and H2 blockers are given toprevent stress gastric ulcerations.prevent stress gastric ulcerations. Vitamins and iron may be givenVitamins and iron may be given Nutrition may be givenNutrition may be given orally ororally or tube feeding ortube feeding or parenteral feeding in critically ill and severelyparenteral feeding in critically ill and severelyburned patients.burned patients.3939
ComplicationsComplications Sepsis of burn wound…..pseudomonasSepsis of burn wound…..pseudomonas PneumoniaPneumonia Stress ulcers…….gastric and doudenum…calledStress ulcers…….gastric and doudenum…called....Curlings ulcersCurlings ulcers HypoxemiaHypoxemia Multi organ failureMulti organ failure Acute renal failureAcute renal failure Electrolyte disturbancesElectrolyte disturbances Respiratory failureRespiratory failure ScarsScars Keloid formationKeloid formation Post burn contracturesPost burn contractures Marjolin, s ulcer….squamous cell carcinoma in burnMarjolin, s ulcer….squamous cell carcinoma in burnscarscar 4040
Rehablitation in burn patientsRehablitation in burn patients Physical andPhysical and PsychologicalPsychological Pressure therapy for hypertrophied scarsPressure therapy for hypertrophied scars Active exercises to prevent contracturesActive exercises to prevent contractures Plastic surgical procedures for contracturesPlastic surgical procedures for contractures4343
Plastic surgeryPlastic surgery …….is the sub -specialty of surgery devoted.is the sub -specialty of surgery devotedto cosmetic and functional physicalto cosmetic and functional physicaldeformities.deformities. Common procedures usedCommon procedures used Local relaxing incisionsLocal relaxing incisions Skin graftsSkin grafts Skin flapsSkin flaps4444
Skin grafts……three typesSkin grafts……three types Split or partial thickness……Split or partial thickness…… .contain epidermis and part of dermis.contain epidermis and part of dermis Full thickness……Full thickness…… ……contain epidermis and full dermiscontain epidermis and full dermis Composite ……Composite …… .contain epidermis, dermis and sub cutaneous.contain epidermis, dermis and sub cutaneoustissue , cartilage or bone etc.tissue , cartilage or bone etc. ..4646
Split thickness or partial thicknessSplit thickness or partial thickness ……contain epidermis and part of dermis only , thickness …..contain epidermis and part of dermis only , thickness …..0.01-0.0250.01-0.025inches ,inches ,donner area heals by epithelization from basal skin cellsdonner area heals by epithelization from basal skin cellsSub classified asSub classified as thinthin medium andmedium and thickthick Thigh, buttock and abdomen are common donner sitesThigh, buttock and abdomen are common donner sites Advantages.Advantages... A large supply of donner areaA large supply of donner area Ease o harvesting….(preservation)Ease o harvesting….(preservation) Donner site for reuse in 14 daysDonner site for reuse in 14 days Decreased primary site scaring and contracturesDecreased primary site scaring and contractures Large donner area can be coveredLarge donner area can be covered DisadvantagesDisadvantages Cosmetic deformity at donner siteCosmetic deformity at donner site Decreased durabilityDecreased durability HyperpigmentationHyperpigmentation Increased secondary contracturesIncreased secondary contractures 4747
Full thicknessFull thickness …… contain epidermis and dermis in full.contain epidermis and dermis in full. Donner sites…supra clavicular fossa, post auricularDonner sites…supra clavicular fossa, post auricularsite, fore arm and groin. Donner site is closedsite, fore arm and groin. Donner site is closedprimarily.primarily. AdvantagesAdvantages Cosmetically superiorCosmetically superior Decreased secondary contractureDecreased secondary contracture Increased durabilityIncreased durability DisadvantagesDisadvantages Limited doner sitesLimited doner sites Large area grafts can not be taken.Large area grafts can not be taken. Composite graftsComposite grafts.. .contain full skin and sub- cutaneous tissue or.contain full skin and sub- cutaneous tissue orcartilage , or bone etccartilage , or bone etc.. 4848
FlapsFlaps……are portions of skin and sub cutaneousare portions of skin and sub cutaneousand or muscle tissue that are movedand or muscle tissue that are movedfrom one part of body to other alongfrom one part of body to other alongwith their vascular pedicle.with their vascular pedicle. Random pattern flapsRandom pattern flaps Axial skin flapsAxial skin flaps Fascio -cutaneous flapsFascio -cutaneous flaps Musculo -cutaneous flapsMusculo -cutaneous flaps Expanded tissue flapsExpanded tissue flaps4949