For surgical residents presentation

1. Principles of Management of
Burns
By
Dr. Olofin K. E
Registrar Casualty Dept.
UATH
10/30/2023 1

2. Outline
• Introduction/Definition
• Epidemiology
• Anatomy of the skin
• Pathology/Pathophysiology of burns
• Classification/wound estimation
• Management
• Complications
• Prognosis
• Prevention
• Conclusion
• References
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3. Introduction/Definition
Definition:
Injury to living tissue arising from exposure to heat, friction, electricity,
radiation, chemicals or cold
• Non-fatal burn injuries are a leading cause of morbidity.
• 2/3 of all burns happen at home
• Burn injuries continue to be a major source of mortality and
morbidity in low- and middle-income countries of the world, of which
Nigeria is a part.
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4. Introduction
• Flame is emerging as the predominant cause of burns, and burn
injury is occurring increasingly away from the domestic setting.
• The severity of the injuries is also increasing.
• Several challenges militate against optimal care for burn victims.
• Burn injuries continue to contribute significantly to the burden of
disease in Nigeria.
• Avoidable complications are common and mortality remains high.
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5. Epidemiology
• 4.8% of trauma deaths in Nigeria
• 6.7% of surgically related deaths.
• In children, burns and scalds are the 4th commonest cause of
trauma < road traffic accidents < accidental falls < bites.
• Over 95% of fatal fire-related burns occurred in low- and
middle-income countries
• Chemical burns constitute 6.3% of burns in Enugu and 5% in
Ibadan
• Electrical burn injuries have an incidence of less than 1% in
children and 2.8-4.6% in all burn
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6. Epidemiology cont.…
• In India, over 1 000 000 people are moderately or severely burnt
every year.
• In Bangladesh, Colombia, Egypt and Pakistan, 17% of children with
burns have a temporary disability and 18% have a permanent
disability.
• Burns are the second most common injury in rural Nepal, accounting
for 5% of disabilities.
• In 2008, over 410 000 burn injuries occurred in the United States of
America, with approximately 40 000 requiring hospitalization.
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7. Anatomy of the skin
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The skin:
Largest organ
15% of total body weight
1.7 m2

8. Essential for:
• Thermoregulation
• Prevention of fluid loss by evaporation
• Barrier against infection
• Protection from environment provided by sensory information
• Others- social etc.
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9. Pathology of burns
• Fire/flames, Contact with hot liquids, hot/cold solid materials
induce cellular damage via transfer of energy directly leads to
coagulation necrosis.
• Chemical and electrical burns cause injury via cell membrane
damage in addition to thermal injury.
• Depth of Injury depends on 3 factors
1. Causative agents
2. Temperature at which skin exposed
3. Duration of Exposure.
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10. Pathology of burns
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11. Pathology cont.…
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12. Pathology cont.…
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13. Pathophysiology
Systemic Effects of Burns
1. Cardiovascular system
2. Renal system
3. Respiratory tract changes
4. Gastrointestinal tract changes
5. Central nervous system
changes
6. Hematological changes
7. Metabolic changes
8. Endocrine changes
9. Immune system changes
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14. Pathophysiology cont.…
Post Burn Metabolic Phenomena
Two Distinct phase of metabolic changes observed in post burns.
Ebb phase
• It occurs within the first 48 hours of injury
• Characterized by decrease in cardiac output, oxygen consumption
and metabolic rate, as well as impaired glucose tolerance
The flow phase
• These metabolic variables gradually increase within the first 5 days
post injury to a plateau phase
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15. Pathophysiology cont.…
Post Burn Squela
• Cardiac out put increases by 1.5 times
• Liver size increases by 225%
• Muscle protein is degraded much faster than it is synthesized.
• The net protein loss causes loss of lean body mass and severe muscle
wasting.
• 10% loss – Immune Dysfunction
• 20% loss – Decrease wound healing
• 30% loss – Increased risk of Pneumonia & Pressure sores
• 40% loss – Death
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16. Pathophysiology cont.…
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17. Classifications
-Depth -Types/ Source of energy - Extent
Depth
• Superficial
• Partial thickness
• Superficial
• Deep
• Full thickness
• Mixed
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18. Superficial burns
• old 1st degree
• Epidermis only
• Resembles Sunburn
• No blistering
• Capacity to heal
completely
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19. Superficial partial thickness
• Epidermal and papillary layers
of dermis involved
• Blister formation
• Rupture causes weeping moist
injury
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20. Deep Partial Thickness
• old 2nd degree
• through epidermis, into reticular
dermis
• Pale or Pink, moist, blisters, very
painful
• Some capacity to heal
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21. 10/30/2023 21

22. Full thickness burn
• old 3rd degree (and 4th)
• Through epidermis, dermis and
connective tissue
• Appears waxy white, leathery gray or
charred black and dry and is not painful
• Has various colours
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23. 10/30/2023 23

24. Classification cont.…
Types/source
• Thermal: Contact, flame, Scald,
• Electrical- AC,DC
• Chemical
• Sun burn
• Lightening
• Radiation
• Laser
• Frostbite
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25. Classification cont.…
Extent
Assessment of extent of burn wound
• Rule of Nines:
• Quick estimate of percent of burn
• Lund and Browder:
• More accurate assessment tool
• Useful chart for children – takes into account the head size proportion.
• Rule of Palms:
• Good for estimating small patches of burn wound
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26. Rule of Nines
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27. Lund Browder Chart
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28. American Burn Association Severity Classification
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29. Management
Prehospital care
Principles
1. Ensure rescuer safety
2. Stop the burning process
3. Check for other injuries
4. Cool the burn
5. Give oxygen
6. Elevate
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30. Management
ATLS protocol
Primary survey
• Airway: Early recognition of airway compromise, intubation.
• Breathing: Pattern of breathing. Breathing?
• Circulation: vascular access, monitor device, blood pressure.
• Disability: other injuries; fractures, abdominal injury or
neurological deficit.
• Exposure: out of clothes, exposure of all orifices.
• Fluid resuscitation:
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31. Management cont.…
Secondary survey
Full history
• Biodata
• Cause of the burn
• Time of injury
• Place of the occurrence (closed space, presence of chemicals,
noxious fumes)
• Likelihood of associated trauma (explosion,…)
• Pre-hospital interventions
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32. Management cont.…
• Detection of the mechanism of injury.
• Consideration of abuse
• Possibility of carbon monoxide intoxication
Full examination
• TBSA, Burn depth, inhalational injury
• Concomitant injury, deformity, dx habitus
• Height and weight.
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33. Management cont.…
Indications For admission
• Major Burns
• Special areas- face, hand, perineum, joints, inhalational
• Poly-trauma
• Co- morbidities- DM, SCD, CVA
• Domestic abuse (slightest suspicion)
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34. Management cont.…
Investigations
• Electrolytes
• Blood gases
• Glucose
• Protein
• Haemoglobin (must be kept >12 g%)
• Bronchoscopy, X-rays
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35. Management cont.…
Goals of management
4Rs: revive , restore, repair and rehabilitate
• Maintaining body fluids & electrolytes
• Relieving pain
• Preventing/Treating infection
• Nutrition
• Early wound cover/ healing/surgery
• Rehabilitation
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36. Management cont.…
Fluid Resuscitation
• Goal- Maintain tissue perfusion
• Burns > 10% TBSA for children
• Burns > 15% TBSA for Adults
• Parkland, Brookes, Galveston, Shriners
• Crystalloids or colloids?
• Fluid monitoring
• Urine output, blood pressure ,central venous pressure, heart rate
• Urine output- 30-50ml/hr. 0.5 - 1.0 ml/kg/hr.
• Input/ output chart recorded hourly!!!
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37. Management cont.…
Resuscitation Formula’s
• total area
FORMULA CRYSTALLOID COLLOID
Parkland 4 mL/kg per %
TBSA burn
None None
Brooke 1.5 mL/kg/%
TBSA burn
0.5 mL/kg per
% TBSA burn
Galveston
(pediatric)
5000 mL/m 2
burned area +
1500 mL/m 2
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38. Management cont.…
Parklands
• Commonest
• 1/2 in first 8hrs post burn
• 1/2 in next sixteen hrs.
• Subsequently, Daily requirements plus ongoing losses after 24hrs
• Ongoing losses = 1cc/kg x TBSA
• Monitor urinary output!!! As determinant of adequate resuscitation
(except in ARF)
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39. Management cont.…
Pain management
• Pain- Hyperalgesia develops from exposed viable and growing nerve
endings
• Pain with time becomes learned and is psychological and difficult to
manage
• Pain is REAL to the patient
• IV injections not advised when burns exceeds 10% TBSA
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40. Management cont.…
Analgesics-
• Opioids- morphine(adults). Pethidine , PCM
• NSAIDS-
• Oral ketamine
• Anesthesia for dressings
• Psychotherapy, encouragement
• Good dressing techniques
• Soak dressings-shower
• Products- Non Adherent, Fewer intervals
• Early mobilization
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41. Management cont.…
Surgery
• Debridement
• Fasciotomy
• For compartment syndrome
• Escharoctomy
• Tangential excision + STSG
• Others as indicated
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42. Management cont.…
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43. Management cont.…
Burn Wound dressings
Principles:
• Full-thickness and deep-dermal burns need antibacterial dressings to
delay colonization prior to surgery
• Superficial burns will heal and need simple dressings
• An optimal healing environment can make a difference to outcome in
borderline-depth burns
10/30/2023 43

44. Management cont.…
wound dressing
• Regular intervals as determined by the need (not by staffing)
• Give analgesics I.V 30 mins before procedure ( or proceed with
psychotherapy)
• Layered removal of dressing
• Debride when required
• Clean with normal saline
• Dab dry
• Apply topical antibiotic
• Layered dressings applied systematically
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45. Management cont.…
Dressings can be occlusive or open
Benefits of occlusive dressing
• Protects against infection
• Reduces pain- nerve endings exposed to air is painful
• Providers a moist environnent for re-epithelisation
• Nursing care is easier/ not messy like open dressing
• Reduces need for frequent dressings with pain and pressure on
nursing personnel
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46. Management cont.…
Benefits of Open Dressings
• Easy , Quicker
• Dressing procedure less painful
• Cheaper
• Easy access to assess wounds for infection
• Great for hot tropical weather
• Difficult to move patient if extensive
• Messy on beddings
• More difficult to control hypothermia
• Requires strict control of environment, visitors
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47. Management cont.…
Dressing agents
Full-thickness burns and obvious deep dermal wounds
Nanocrystalline silver
• Silver sulphadiazine cream: 1%broad spectrum, not painful, yellow
pseudo eschar. Self limiting leucopenia
• Silver nitrate solution (0.5%)
• Mafenide asetate cream or 5% soln. Painful. Permeates eschars.
Carbonic anhydrase inhibitor causes acidosis
• Cerium nitrate
10/30/2023 47

48. Management cont.…
Superficial partial-thickness wounds and mixed –depth wounds
1. Exposure
2. Mefix
3. mepitel
4. Hydrocolloid
5. Biobrane
6. Amniotic membrane
• Bacitracin: chlorhexidine
• Povidone iodine
• Bactroban:Mupirocin – MRSA
10/30/2023 48

49. Management cont.…
Skin Substitutes
• Transcyte- cultured human fibroblasts in semi-permiable membrane
on nylon matrix
• Alloderm
• Integra
• CEA – cultured epithelial autograft
10/30/2023 49

50. Management cont.…
Blisters
To rupture or to leave?
• Controversial
• Blister fluid contains vasoactive mediators-
progression of the ischemic zone, and inhibit healing.
• The intact blister also serves as a physiologic dressing
• Blisters larger than several inches in diameter are
most likely to rupture and should be removed.
• Small blisters- Can leave
• Large blister- Rupture
• Blisters over joints- Rupture
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51. Management cont.…
Hydrotherapy Cart Shower
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52. Management cont.…
Nutrition
• Aim- Achieve a positive nitrogen balance
• Correct deficit
• Premorbid, pre referral
• Correct on-going losses
• Chronic catabolic state
• Maintenance
• Daily requirements
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53. Management cont.…
• Commence oral feeds as soon as possible
• Enteral feed superior to parenteral
• NGT in burns > 20% TBSA in children and > 30% TBSA in adults
• Manage Ileus
• Tight glucose control – esp ICU pts
• Protein – 2g/kg body wt/day
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54. • Curreri formula
• Sutherland
• Davies
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55. Management cont.…
Infection control
• Wash down on arrival
• Anti Tetanus prophylaxis
• Meticulous protocol in the burn unit
• Disciplined antibiotic use
• Early debridement and wound closure
• Nutrition
• Topical antibiotic dressing
10/30/2023 55

56. Electrical Burn
• Of all burns patients admitted, 3% to 5% are injured from electrical
contact.
• Electrical current enters a part of the body, such as the fingers or
hand, and proceeds through tissues with the lowest resistance to
current, generally the nerves, blood vessels, and muscles.
• The skin has a relatively high resistance to electrical current and is
therefore mostly spared.
• Heat generated by the transfer of electrical current and passage of
the current itself then injures the tissues.
10/30/2023 56

57. Electrical Burn cont.…
• The muscle is the major tissue through which the current flows, and
thus it sustains the most damage.
• Injuries are divided into high- and low-voltage injuries. Threshold
being 1000v
• Low-voltage injury is similar to thermal burns without transmission to
the deeper tissues.
10/30/2023 57

58. Electrical Burn cont.…
• The syndrome of high-voltage
injury consists of varying
degrees of cutaneous burn at
the entry and exit sites,
combined with hidden
destruction of deep tissue .
• Address Cardiac derangement.
• The key to managing patients
with an electrical injury lies in
the treatment of the wound.
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59. Chemical Burns
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60. Management cont…
• Nursing care
• Physiotherapy
• Psychological care
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61. Complications
Early
• Hypovolemia/ Shock
• Acute renal failure
• Acute gastric erosion
• Compartment syndrome
• Gastric paralysis
• Anemia
• Sepsis
• Immunocompromised
• Severe weight loss
• Tetanus
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62. Complications
Late
1. Scarring
2. Hypertrophic scars
3. Keloids
4. Contractures
5. Myositis ossificans
6. Cataracts (electric)
7. Chronic Pruritus
8. Chronic/ recurrent ulcers
9. Malignancy –Marjolin's Ulcer
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63. Prognosis
Baux score
Expressed as % TBSA + Age
The score is a comparative indicator of burn severity, with a score over 140
considered as being un-survivable, depending on the available treatment
resources
Modified Baux score = body area affected + age of patient + 17
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.

64. 10/30/2023 64

65. Prevention
According to the WHO,
• Improve awareness
• Develop and enforce effective policy
• Describe burden and identify risk factors
• Set research priorities with promotion of promising interventions
• Provide burn prevention programs
• Strengthen burn care
• Strengthen capacities to carry out all of the above.
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66. First aid
What to do
• Stop the burning process by removing clothing and irrigating the
burns.
• Extinguish flames by allowing the patient to roll on the ground, or by
applying a blanket, or by using water or other fire-extinguishing
liquids.
• Use cool running water to reduce the temperature of the burn.
• In chemical burns, remove or dilute the chemical agent by irrigating
with large volumes of water.
• Wrap the patient in a clean cloth or sheet and transport to the
nearest appropriate facility for medical care.
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67. What not to do
• Do not start first aid before ensuring your own safety (switch off
electrical current, wear gloves for chemicals etc.)
• Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn.
• Do not apply ice because it deepens the injury.
• Avoid prolonged cooling with water because it will lead to
hypothermia.
• Do not open blisters until topical antimicrobials can be applied, such
as by a health-care provider.
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68. • Do not apply any material directly to the wound as it might become
infected.
• Avoid application of topical medication until the patient has been
placed under appropriate medical care.
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69. Conclusion
The treatment of burns is complex and require a multidisciplinary
approach
• Minor injuries can be treated in the community by knowledgeable
physicians.
• Moderate and severe injuries, however, require treatment in
dedicated facilities.
• Burn injury treatment depends on the depth and total body surface
area affected.
10/30/2023 69

70. Conclusion cont.…
• Early fluid resuscitation with adequate fluids and addressing
inhalation injury saves lots of life.
• Addressing wound comes second after initial resuscitation with
adequate covering of wound.
• Main aim of wound care is to protect body from infection and
hypothermia.
• Early wound excision and grafting prevents wound contracture.
• Primary prevention- Best bet.
• Prevent burns from occurring at all
10/30/2023 70

71. References
• Burns in Nigeria: a Review A.O. Oladele and J.K. Olabanji Ann Burns
Fire Disasters. 2010 Sep 30; 23(3): 120–127. Published online 2010
Sep 30.
• Bailey & Love's Short Practice of Surgery, 27th Edition 27th Edition
• Overview of the management of burns, Dr. Dafieware O.R
• Https://www.Who.Int/news-room/fact-sheets/detail/burns
• Ann burns fire disasters. 2010 sept 30; 23(3): 120–127.
• Grabb and Smith's plastic surgery seventh edition
• Principles and practice of surgery including pathology in the tropics
4th edition
• Principles and practice of burn care editor-in-chief sujata sarabahi
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72. •Thank you
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