The document discusses anatomy and physiology of the skin, types of burns, burn classifications, burn depth assessment, burn management, and burn complications. It describes the three layers of skin - epidermis, dermis, and hypodermis - and their functions. It classifies burns as superficial, partial thickness, or full thickness depending on the depth of tissue damage. Burn management includes wound care, fluid resuscitation, antibiotics, surgery, and physiotherapy. Complications can be immediate, early, or late and include shock, infection, organ failure, contractures, and cancer.

1. BURNS AND COLD INJURIES
Dr. Milkah O. Angachi
BCM 229

2. ANATOMY AND PHYSIOLOGY OF THE SKIN
• The skin is the largest organ of the body with
a total area of about 20 square feet.
• It creates a barrier between the external
environment and the internal organs.
• A protective cover for the deeper structures
and a barrier for entrance of organisms.
• It regulates temperature through the activities
of sweat glands.

3. The skin consists of three layers
• The epidermis is the thin outer layer contains no blood vessels and relies
on the dermis for its nutrients and waste removal. It is made up of
• Basal cells and squamous cells- continually work to rebuild the surface of
the skin.
• Langerhans cells involved in immune response
• Merkel cells makes the skin sensitive to touch.
• The dermis is the thickest of all 3 layers. It is made up of
• A papillary layer and a reticular layer.
• Collagen and elastin are produced by fibroblasts to provide structure to
the skin.
• Blood vessels, lymph vessels, hair follicles, sweat glands, sebaceous (oil)
glands and nerve endings are within the layer.
• The hypodermis or subcutaneous fatty tissue lies beneath the dermis.
• This layer is made up of fat, or adipose tissue.
• It helps to conserve the body’s heat and protect the organs of the body.

4. FUNCTIONS OF THE SKIN
• Protects the body from heat, sunlight, injury and
microbes infections.
• Regulate and maintain a constant body
temperature. Blood flow to the skin’s surface
allows the heat to escape.
• Sweating when body temperature is greater than
37°C.
• Helps to control fluid loss by preventing the body
from losing water and electrolytes.
• Getting rid of waste substances through the
sweat glands

5. FUNCTIONS OF THE SKIN Ctn’
• Sensations of touch, heat, and cold- Nerve
receptors in the skin monitor the
environment by sensing cold, heat, pain and
pressure.
• These nerve receptors are more
concentrated in our fingertips.
• Storing water, fat and Vitamin D

6. BURNS
• A form of tissue injury from hyperthermia high temperatures above 37OC when
it comes in contact with the skin,
• Very rarely, hypothermia can cause burn injuries
• or from absorption of physical energy or chemical contact
Predisposing factors
1. Epilepsy
2. Age extremes 8. Leprosy
3. Weather 9. Diabetes mellitus with
4. Blindness 10. peripheral neuropathy
5. Alcoholism 11. Psychiatric disturbance
6. Occupation 12. Drugs abuse
7. Metabolic conditions for example uremia
(unstable and confused)
13. Associated injuries like road traffic
accidents

7. CLASSIFICATION OF BURNS
Type of burn Tissue injury
Heat injury
Scalds (steam or hot fluids)
Fat burns
Flame burns
Electrical burns
Partial thickness / deep dermal skin loss
Usually full thickness skin loss
Patches of partial and full thickness
Full thickness with deep extension
Cold injury
Frost bites
Freezing injury
Ice formation tissue freezing
Direct damage and vasospasm
Friction burns Heat plus abrasion
Physical damage ionizing radiation- Sunburns,
Radiotherapy, Ultraviolet rays
Early tissue necrosis, later tissue dysplastic
changes
Chemical burn industrial chemical may be
inhaled. Acids or alkaline phenols e.g. Lysol
contact with skin
Inflammation, tissue necrosis and allergic
response

8. Type of burn
• C- Chemical injury
• H- Heat injury
• E- Electrical injury
• M- Mechanical (friction burns)
• I- ionizing radiation
• C- Cellular organisms (microbes)
• A- Antigen antibody reaction (allergy)
• L- Light Ultra violet

9. Heat Burn
• ABC management of burns
• A- Accident site
• B- Bring the burn patient to the hospital
• C- Casualty management-
• D = Dermal care –
• Discharge, admit to ward, death
• A- Accident site-Immediate resuscitation
• Burning bus, aero-plane, domestic (common) burning house
• Flames or boiling liquids
Airflow – stop the patient from running
Blanket
Cold water shower
• B- Bring the burn patient to the hospital
• Ambulance
• Water for drinking small volumes delay shock (ORS is better) water sugar
and salt is better

10. • C- Casualty management of burns
• Take history of mechanism of injury together with
resuscitation
• Assess to determine the severity of the burned surface
• Area-The extent of burn 100% or 50%
• Depth of the burn Superficial or deep burns
• Age- extremes of ages of the patients ()-14 years and above 50 years)
• Site- of burns (hands, feet, face or perineum)
• Temperature of the burning agent
• The mode of transmission (contact, radiated or flame)
• Duration of the contact

11. Determination of severity of burns
• Site- facial, perineum, joints, hands, feet, fingers are
severe burns.
• Agent- electric and acid burns are severe burns admit
no matter what the degree.
• Depth and extent
• Place of burns (medico legal)
• Age of the patient- very young below 5 years and
very old usual present with hypothermia and body
immunity is low.
• Associated injury- falling and burns in epilepsy,
associated disease example, malnutrition, diabetes
mellitus, renal failure, obesity, alcoholism.

12. ESTIMATE BURNS SURFACE AREA
• Morbidity and mortality rises with increasing burned surface area.
• Burns greater than 15 % in adults and greater than 10 % in a child or
• Even small burns occurring in the very young or elderly are considered
serious.
• Adults
• Wallace rule of 9% is mainly used to estimate the burned area in adults.
• The body is divided into anatomical regions that represent 9% of the
total body surface.
• Rule of the palm 1%
• The outstretched palm and fingers approximates to 1% of the body
surface area.
• If burned area is small assess how many times your hand covers the area.
• Infant below 1-year rule of 10 %

13. Estimate depth of the burns
Depth of burn Characteristics Causes Healing
Superficial burns
First degree burn epidermis only
 Erythema, painful flushing skin,
no oedema.
 Skin is dry rarely blister forms
Sunburn Spontaneously
Increase or decrease in the
skin color.
Partial thickness
Second degree epidermis and
dermis
 Blister forms, oedema of the
underlying subcutaneous tissue,
 Burn site look red blistered, and
may be swollen and painful.
Contact with hot liquids Dermal damage result to
scaring
Full thickness/ deep burns
Third degree epidermis, dermis
and subcutaneous tissue
 The burn site may look leathery
dry, dead white
 Pain is absent.
 No skin sensation on pinprick due
to skin innervation
Fire, Electricity or lightning
Prolonged exposure to hot
liquids/ objects
Destroy all dermal element.
Fourth degree burns Fifth degree burns  Damage is extended
beyond muscle to involve
bones tendons
 Blackened and charred.
No feeling in the area since
the nerve endings are
destroyed.
Fifth degree burns  Damage is extended beyond muscle to
involve bones tendons
 Blackened and charred.

14. Superficial burns

15. Partial thickness

16. Full thickness/ deep burns

17. Fourth degree burns

18. Fifth degree burns

19. depth of the burns
• Is important for assessment of its severity and
to plan future wound care.
• The depth may change with time especially if
infection occurs.
• Any full thickness burn is considered serious.

20. Pathophysiology
• At temperatures greater than 44°C, cell and tissue damage
occurs which disrupts the skin's sensation, ability to
– prevent water loss through evaporation,
– ability to control body temperature,
– there is lose of potassium to the spaces outside the cell and up
take of water and sodium.
• In burns over 30% the inflammatory response results in
increased leakage of fluid from the capillaries and subsequent
tissue oedema.
• This causes overall blood volume loss, with the remaining
blood suffering significant plasma loss, making the blood
more concentrated.
• Poor blood flow to organs such as the kidneys and
gastrointestinal tract may result in renal failure and stomach
ulcers.

21. Difference between superficial and
deep burns
SUPERFICIAL BURNS DEEP BURNS
1 Very painful and red 1 Painless and white
2 Hair follicles present 2 Hair follicles absent
3 Exudate moist and wet wounds 3 Dry no exudate and firm
4 Healing from hair follicles and sweat
glands
4 Healing from edges that is from
granulation tissue
5 Usually blistered 5 No blisters
6 Pin prick test is positive 6 Pin prick test is negative

22. Healing of burns
• Healing depends on the depth of burns
• Partial thickness burns heal from epithelium to deeper part of
the skin.
• That is hair follicle to subcutaneous glands to the epithelium.
• Full thickness deep burns- all epithelium has been destroyed
and sloughs separates in 2- 3 weeks revealing a red granulation
tissue surface and this requires skin grafting 4 – 6 days post
burns or after de-sloughing of the burns.
• Characteristic of good granulation tissue
• Should be red
• No or minimal oozing
• Fine
• Just below the skin surface
• Edges should be bluish

23. Management of burns
• First aid treatment- Start at the site of burn.
• extinguish flames from burning clothes fire blanket, fire extinguishers used
on flames on the skin surface
• Treatment at pre-hospital : order of priorities in management is
resuscitation
• Airway adequate ventilation- tracheostomy head and neck burns.
• Control bleeding, secure an intravenous line, relieve pain by IV analgesia,
obtain blood sample for baseline biochemistry, Urea and electrolytes,
grouping and cross matching (GXM)
• Give analgesic, oral fluids and rush the patient to the hospital.
• Cover the patient with aluminum foil or polythene filling to prevent
hypothermia.
• Shock management
• Complete detailed case history and general examination and examine the
burned area.
• Contact a specialist burn unit for large burns and arrange for
transportation.

24. Treatment of shock
• Mechanism of shock in burns
• There is loss of circulating fluids (haemorrage blister because of overwhelming sudden
intensity of pain.
• Estimate percentage of burns using Wallace rule of 9%
• Get weight of the patient
• If the patient has burns beyond 50% management needs circulation of fluids even if he
has burns 100%.
• If fluids is used beyond 50% may overload the heart.
• Use plasma expenders like Darrow's, Hartman's, dextran with adult more than 15% and
children with more than 10% burns
• Calculation of volume of fluids required
1. Parkland formula commonest used
– Adult percentage of burn surface area times body weight times constant 3ml.
– If it is 100% calculate with 50% x70x3ml- 10500ml
– In children percentage burns times body weight times 3ml.
1. Barklay’s formula
– Calculate the total surface area amount required
– = % burn times body weight times 1 divide by 2.
2. Evans formula

25. Treatment of shock Ctd’
Give - half of the total fluids in the first 6- 8 hours
•Half of the total fluids in the next 16 hours
•Half of total fluids electrolytes plus full maintenance in the next 24 hours.
•Monitor progress and control fluids requirement depending on clinical states
of the patient
•Pulse raised, blood pressure rise, respiratory rate , nausea and vomiting
•Monitor urine out put to in put catheterize the patient
•Analgesic; pethidine, morphine not in children to avoid systemic depression)
•Daily urinalysis
•Pass an NG tube to assist in passing oral fluids
•Blood transfusion incase of deep burns the red blood cells are destroyed in
deep burns and also surface area between 10- 25 % burns
•Post burns anemia is common cause of bleeding ulcers or due to
escharatomy

26. Local treatment of burns
2 ways of treatment
•Exposure
•Closed
Exposure method of the dressing
– Use non adhesive dressing such as paraffin and apply
antibacterial ointment (silver sulphadiazine)
– Place a thick gauze padding change dressing after 48 hours. If
fluid loss is severe change dressing daily.
– maintain good hygiene, maintain the bed cradle
Infection
– Antibiotics especially to children to limit metastatic infection
(streptococcus aureus and pseudeominas pyocyaneus)
– Swab culture, blood culture incase of any rise in temperature

27. Local treatment of burns Ctn’
Advantage of exposure method
• Minimal blood loss during dressing
• Cheap method
• Reduce chances of infection because it is well
aerated
• Easy to inspect the wound and see the progress.
Disadvantages
• Patient have a lot of pain
• Increased chance of heat loss

28. Local treatment of burns Ctd’
• Dressing closed wounds
• Dress in 3 bandages. Use sofratulle (soframicine
gauze) or use gauze impregnated with liquid
paraffin
• Bed cradle
• Advantages – less painful and less heat loss
• Disadvantages- increased blood loss during
dressing, difficult and time consuming, increased
chances of infection, very hard to monitor the
progress

29. General treatment of burns
• Take care of airway by suction Intubate endotracheal tube
• Give oxygen
• Anti tetanus Toxoid 0.5ml
• Burns are sterile therefore
• clean with mild disinfectant
• Dress wounds using cream silver nitrate meshed gauze (sufra tulle
paraffin gauze) and gauze and bandage
• Elevate area of burn e.g. legs
• Follow up give antibiotic if infected
• Put the patient on high protein diet- regain plasma protein
• Vitamins
• Hematinic- inferno iron when necessary
• Parenteral antibiotics: Xpen + Genta + Flaggyl
• Blood transfusion to avoid anemia if Hb is below 8g/dl

30. Surgical management
• Await spontaneous de-sloughing and apply Skin grafting at
3 weeks
• Early excision of burn and skin grafting
• Skin grafting
• For deep burns only there are 2types
• Free skin graft- can be splint thin or full thickness
• Pedicles graft- is borrowed from site e.g. thigh, arms,
buttocks and implanted somewhere it grows to be bigger
tissue
• N/B when skin grafting no antiseptic is used at the site.
• This usually encourage non effects
• Physiotherapy- Early mobilization to avoid joint
contractures y- burns involving joint to prevent stiffness.

31. Failure of grafting intake
• Poor management of tissue
• Poor oxygenation
• Non immobilized
• Accumulation of fluids at the site of graft
• Kept for too long
• Extra problems poor hygiene and other disease
like poor nutrition
• Tissue poor management

32. Complications.
Immediate complications
•Fluid loss, hypovolemic and shock.
•renal failure ,
•adrenal failure ,
•Respiratory distress from smoke inhalation or a severe chest burn.
•death.
Early complications (AEIOU)
•Anemia
•Electrolyte imbalance
•Infections example, osteomyelitis
•Organ failure- Renal, hepatic or heart failure
•Uremia secondary to reduced glomerular filtration rate
Anemia
•Red blood cell destruction at the site of burns
•Bleeding stress ulcers (circling ulcers)
•Bleeding during dressing
•Secondary to mal absorption
•Infection leading to hemolysis at site of burns or in the renal system
•Due to bone marrow depression
•Respiratory failure inhalation of any foreign matter or heat due to embolism, edema of the airway

33. Late complications
• Keloid formation around the neck shoulders ears lobes sternum
• Contractures
• Squamous cell carcinoma especially on the scalp or upper limbs may occur
5- 20 years after burns
• Protein losing enteropathy
• Hypopigmentation
• Tropical sores
• Gangrene due to sever tissue destruction
• Chronic renal failure
• Tracheal stenosis
• Esophageal stenosis
• Marjolins ulcers proceeds occurrence of squamous cell
• Disfigurement
• Syndectomy (fuse fingers after burns)
• Scarring and possible psychological consequences. Hypertrophic scarring is
more common following deeper burns treated by surgery and skin grafting
than with superficial burns.

34. Antibiotic therapy given
• Those patients with fever raised white blood cell
counts.
• All patients with inhalation and respiratory burns
• Give patients with concurrent infection
antibiotics
• Patients with facial burns
• Organism associated with burn
• Pseudomonas, klebsiella, proteus mirabilis,
ecoli,haemalytic strep,
• Staph aures,

35. Prevention
• There are many important aspects of prevention
of burns, including:
• Safety in the workplace.
• Safety in the home, including regularly checking
smoke alarms.
• Good parenting to protect children.
• Care of the frail elderly and the socially isolated.
• Prevention of sunburn: appropriate duration and
timing of sunbathing, sun protection creams and
regulation of tanning booths.

36. Emotional support
• Physical treatment from burns, as well as
handle their emotional needs.
–Patients may require:
–surgery
–physical therapy
–rehabilitation
–lifelong assisted care

37. Prognosis
• Will depend on depth of burn and the body surface area affected.
• Superficial burns usually heal within two weeks without surgery.
• Risk factors for death include age over 60 years, more than 40% of body
surface area affected and inhalation injury.
• Death may result from severe extensive burns or electric shock.
• The patient has the same priorities as all other trauma patients
• Assess-Airway
• Breathing- beware of inhalation and rapid airway compromise
• Circulation- fluids replacement
• Disability- compartment syndrome
• Exposure- percentage area of burns
• The source of burns is important like fire, hot water, paraffin, kerosene.
Electrical burns are often more serious than they appear.
• N/B: damaged skin and muscle can result to acute renal failure.

38. Prognosis
• The outcome is poor in severe burns.
Children burns greater than or equal to 10%
 Adults burns greater than or equal to 15 – 20%
Extent mortality
< 10% <1%
10- 30 % 0-20%
30- 50 % 30-50%
50- 70 % 60-80%
>70% >90%

39. Essential management points
• Stop burning
• ABCDE
• Determine the percentage area of burn (rule of 9%)
• Good IV access and early replacement
•
• The severity of the burn is determined by
• Burned surface area
• Depth of burn
• Other considerations
•
• Serious burns requiring hospitalization
• Greater than 15% burn in adults
• Greater than 10 % burns in a child
• Any burns in the very young, the elderly or the sick
• Any full thickness burns
• Burns of special regions, face, hands, feet, perineum
• Circumferential burns
• Inhalation injury
• Associated trauma or significant pre- burn illness e.g. diabetes
• NB patient with trauma of the face and neck are at risk of airway obstruction.

40. • End