General surgery Burns

1. Burns. Frostbite.
Electrical injury.
Lecturer: Idrisova K.F.
Kazan, 2023
Kazan Federal University Institute of Fundamental Medicine
and Biology Department of Surgery, Obstetrics and
Gynecology

2. Burns
A burn is a type of injury to skin, or other tissues, caused by heat, cold,
electricity, chemicals, friction, or radiation. Most burns are due to heat from
hot liquids, solids, or fire.

3. Classification of burns
• Thermal
• Electrical
• Radiation
• Industrial
• Household
• Wartime
Burns are classified by depth (superficial and deep partial-
thickness, and full-thickness) and percentage of total body
surface area (TBSA) involved.

4. According to damage degree
• I degree - redness of the skin, erythema
• II degree - the formation of bubbles
• III degree:
A - partial necrosis of the skin
B - necrosis of the entire skin
• IV degree - necrosis of the skin and deep tissue.

5. Burn depth
• First-degree (also sometimes called
superficial) burns are limited to the
epidermis.
• Partial-thickness (also called 2nd-degree)
burns involve part of the dermis and can be
superficial or deep.

6. Burn depth
• Superficial partial-thickness burns involve the papillary
(more superficial) dermis.
• These burns heal within 1 to 2 weeks, and scarring is
usually minimal. Healing occurs from epidermal cells
lining sweat gland ducts and hair follicles; these cells
grow to the surface, then migrate across the surface to
meet cells from neighboring glands and follicles.
• Deep partial-thickness burns involve the deeper
dermis and take ≥ 2 weeks to heal. Healing occurs only
from hair follicles, and scarring is common and may be
severe.

7. Burn depth
• Full-thickness (3rd-degree) burns extend through
the entire dermis and into the underlying fat.
Healing occurs only from the periphery; these
burns, unless small, require excision and skin
grafting.

8. https://www.grepmed.com/images/1205/classification-superficial-epidermal-diagnosis-clinical

9. Degree of skin burns

10. Pathophysiology
• Heat from burns causes protein denaturation and thus
coagulative necrosis. Around the coagulated tissue,
platelets aggregate, vessels constrict, and marginally
perfused tissue (known as the zone of stasis) can
extend around the injury.
• In the zone of stasis, tissue is hyperemic and inflamed.
• Damage to the normal epidermal barrier allows
• Bacterial invasion
• External fluid loss
• Impaired thermoregulation

12. Pathophysiology
• Damaged tissues often become edematous,
further enhancing intravascular volume loss.
Heat loss can be significant because
thermoregulation of the damaged dermis is
absent, particularly in wounds that are
exposed.

13. Pathogenesis of a burn

14. The burn disease
Burn shock Burn toxemia Burn septicotoxemia Period of convalescence
Light shock
Up to 20% and
10% of deep
burns
Severe shock
> 20% of the
body surface.
Extremely
severe shock
> 60%
Temperature 38-39 * С
Excitation
Delirium
Insomnia
Convulsions
Apathy
Toxic myocarditis
Hypotension
Cyanosis of the mucous
membranes
Pneumonia
Icterus of the skin
Purulent-
resorptive fever
Weight loss
Burning
exhaustion
Disturbance of
microcirculation
and tissue
respiration
Complete healing
of the burn
Restoring ability to
move and self-
service

15. Factors affecting the prognosis
• Degree of burn
• Area of damage
• Burn Localization
• Damage factor
• State of the body
• Age
• Infectious complications
• Accompanying illnesses

16. Systemic burn complications
• The greater the percentage of total body surface
area (TBSA) involved, the greater the risk of
developing systemic complications. Risk factors
for severe systemic complications and mortality
include all of the following:
• Second- and third-degree burns of ≥ 40% of TBSA
• Age > 60 years or < 2 years
• Presence of simultaneous major trauma or smoke
inhalation
• The most common systemic complications are
hypovolemia and infection.

17. Hypovolemia
Hypovolemia, causing hypoperfusion of burned
tissue and sometimes shock, can result from fluid
losses due to burns that are deep or that involve
large parts of the body surface; whole-body edema
from escape of intravascular volume into the
interstitium and cells also develops.
Also, insensible fluid losses can be significant.
Hypoperfusion of burned tissue also may result
from direct damage to blood vessels or from
vasoconstriction secondary to hypovolemia.

18. Infection
Infection, even in small burns, is a common
cause of sepsis and mortality, as well as local
complications. Impaired host defenses and
devitalized tissue enhance bacterial invasion and
growth.
The most common pathogens are streptococci
and staphylococci during the first few days and
gram-negative bacteria after 5 to 7 days;
however, flora are almost always mixed.

19. Metabolic abnormalities
• Metabolic abnormalities may include hypoalbuminemia
that is partly due to hemodilution (secondary to
replacement fluids) and partly due to protein loss into the
extravascular space through damaged capillaries. Dilutional
electrolyte deficiencies can develop; they
include hypomagnesemia, hypophosphatemia,
and hypokalemia.
• Metabolic acidosis may result from
shock. Rhabdomyolysis or hemolysis can result from deep
thermal or electrical burns of muscle or from muscle
ischemia due to constricting eschars. Rhabdomyolysis
causing myoglobinuria or hemolysis causing
hemoglobinuria can lead to acute tubular
necrosis and acute kidney injury.

20. Hypothermia
• Hypothermia may result from large volumes of
cool IV fluids and extensive exposure of body
surfaces to a cool emergency department
environment, particularly in patients with
extensive burns.
• Ileus is common after extensive burns. Ileus is the
medical term for this lack of movement
somewhere in the intestines that leads to a
buildup and potential blockage of food material

21. Local burn complications
• Eschar is stiff, dead tissue caused by deep burns.
• A circumferential eschar, which completely encircles a limb
(or sometimes the neck or torso), is potentially constricting.

22. Scarring and contractures
Scarring and contractures result from healing of
deep burns. Depending on the extent of the
scar, contracture deformities can appear at the
joints. If the burn is located near joints
(particularly in the hands), in the feet, or in the
perineum, function can be severely impaired.
Infection can increase scarring. Keloids form in
some patients with burns, especially in patients
with darker skin.

24. Symptoms and Signs
NB! Wound symptoms and signs depend on burn depth

25. First-degree burns:
• These burns are red, blanch markedly and widely
with light pressure, and are painful and tender.
Vesicles or bullae do not develop.

26. Second-Degree Hand Burn with
Swelling

27. Deep Second-Degree Burn

28. Third-Degree Burn on Foot

29. Superficial partial-thickness burns:
• These burns blanch with pressure and are painful and tender. Vesicles or
bullae develop within 24 hours. The bases of vesicles and bullae are pink
and subsequently develop a fibrinous exudate.

30. Deep partial-thickness burns:
• These burns may be white, red, or mottled red
and white. They do not blanch and are less
painful and tender than more superficial
burns. A pinprick is often interpreted as
pressure rather than sharp. Vesicles or bullae
may develop; these burns are usually dry.

31. Full-thickness burns:
• These burns may be white and pliable, black and
charred, brown and leathery, or bright red
because of fixed hemoglobin in the subdermal
region. Pale full-thickness burns may simulate
normal skin except the skin does not blanch to
pressure. Full-thickness burns are usually
anesthetic or hypoesthetic. Hairs can be pulled
easily from their follicles. Vesicles and bullae
usually do not develop. Sometimes features that
differentiate full thickness from deep partial
thickness burns take 24 to 48 hours to develop.

32. Determination of a burn area
The measurement of the
surface area is important. The
"rule of nines" is commonly
used for this purpose.
However, the proportional
contribution of the various
major body segments to the
total body surface area
changes with obesity. Similarly
infants have very large heads,
altering the total contribution
of other body segments to the
total body surface area.

33. The rule of nines provides
reasonable estimates of the body
area for patients ranging from 10
to 80 kg.
For obese patients weighing
more than 80 kg a rule of fives is
proposed: 5% body surface area
for each arm, 5 x 4 or 20% for
each leg, 10 x 5 or 50% for the
trunk, and 2% for the head .
For infants weighing less than 10
kg a rule of eights applies: 8% for
each arm, 8 x 2 or 16% for each
leg, 8 x 4 or 32% for the trunk,
and 20% for the head.

34. First aid for burns
• Remove victim from the fire
zone
• Remove the smoldering
remnants of clothing
• Don’t use lotion and
washing!
• Put a dry aseptic bandage
• Send to a specialized
hospital
Thermal Burns Treatment: https://www.webmd.com/first-aid/thermal-heat-or-fire-burns-treatment

35. Principles of treatment of burns
• Fighting burn shock
• Primary treatment of burn surface: closed and
open methods
• Restores hypovolemia
• Correction of water-electrolytic exchange
• Antibiotic therapy
• Detoxification therapy

36. Initial treatment
Treatment begins in the prehospital setting.
The first priorities are the same as for any injured patient: ABC
(airway, breathing, and circulation). An airway is provided,
ventilation is supported, and possible associated smoke
inhalation is treated with 100% oxygen. Ongoing burning is
extinguished, and smoldering and hot material is removed.
All clothing is removed. Chemicals, except powders, are
flushed with water; powders should be brushed off before
wetting. Burns caused by acids, alkalis, or organic compounds
(eg, phenols, cresols, petrochemicals) are flushed with
copious amounts of water continuing for at least 20 min after
nothing of the original solution seems to remain.

37. Intravenous fluids
IV fluids are given to patients in shock or with
burns > 10% TBSA. A 14- to 16-gauge venous
cannula is placed in 1 or 2 peripheral veins
through unburned skin if possible. Venous
cutdown, which has a high risk of infection, is
avoided.

38. The Parkland formula
The Parkland formula (4 mL/kg) × % TBSA burned
(second-degree and third-degree burns) is used to
estimate fluid volume needs in the first 24 hours after the
burn (not after presentation to the hospital) and
determines the rate of IV fluid administration.
Half the calculated amount is given over the first 8 hours;
the remainder is given over the next 16 hours. Fluid is
given as lactated Ringer's solution because large amounts
of normal saline could result in hyperchloremic acidosis.
Ringer's solution is a solution of several salts dissolved in water for the purpose of creating
an isotonic solution relative to the body fluids of an animal. Ringer's solution typically
contains sodium chloride, potassium chloride, calcium chloride and sodium bicarbonate,
with the last used to balance the pH.

39. The Parkland formula
For example, in a 100-kg man with a 50% TBSA
burn, fluid volume by the Parkland formula would
be.
CLINICAL CALCULATOR: HTTPS://WWW.MSDMANUALS.COM/PROFESSIONAL/INJURIES-POISONING/BURNS/BURNS#V1112906

40. Features of chemical burns
• Sluggish flow
• Slow development of cleansing of wounds
• Slow regeneration
• Shock and toxemia almost never happen
• Acids cause coagulation of proteins to form a
dense scab

41. Topical treatment may be with:
• Antimicrobial salves (eg, 1% silver
sulfadiazine, mafenide acetate)
• Commercial dressings incorporating silver (eg,
sustained-release nanocrystalline silver
dressings)
• Biosynthetic wound dressings (also called
artificial skin products)

43. Treatment of chemical burns
• Immediately wash off
chemicals
• Neutralization of the
chemical reagent:
acids - 2% solution of
bicarbonate soda,
alkali - 2% solution of
acetic acid
• Open wound
management - using
coagulating agents

44. Surgery
Surgery is indicated for burns that are not
expected to heal within 2 weeks, including most
deep partial-thickness burns and all full-
thickness burns.
Eschars are removed as soon as possible, ideally
within 3 days to prevent sepsis and facilitate
early wound grafting, which shortens
hospitalization and improves the functional
result.

45. Surgery
• If burns are extensive and life threatening, the
largest eschars are removed first to close as much
burn area as early as possible.
• An escharotomy is an emergency surgical
procedure involving incising through areas of
burnt skin to release the eschar and its
constrictive effects, restore distal circulation, and
allow adequate ventilation.
• Escharotomy for 3rd Degree:
https://www.youtube.com/watch?v=E1kddnVS0iA

46. Surgery
• After excision, grafting proceeds ideally using partial-
thickness autografts (the patient’s skin), which are
permanent.

47. Surgery
• Autografts can be transplanted as sheets (solid
pieces of skin) or meshed grafts (sheets of
donor skin that are stretched to cover a larger
area by making multiple, regularly spaced,
small incisions). Meshed grafts are used in
areas where appearance is less of a concern
when burns are > 20% TBSA and donor skin is
scarce. Meshed grafts heal with an uneven
gridlike appearance, sometimes with excessive
hypertrophic scarring.

48. Surgery
• When burns are > 40% TBSA and the supply of
autograft material appears insufficient, an
artificial dermal regeneration template can be
used as temporary coverage.
• Allografts (viable skin usually from cadaver
donors) or xenografts (eg, pig skin) can also be
used temporarily; they are rejected, sometimes
within 10 to 14 days. Both types of temporary
coverage must ultimately be replaced with
autografts.

49. Surgery
• Fasciotomy is done when edema within a
muscle compartment elevates compartment
pressure > 30 mm Hg.

50. Supportive measures
• Hypothermia is treated, and pain is relieved. Opioids
(eg, morphine) should always be given IV, and large
doses may be needed for adequate pain control.
Treatment of electrolyte deficits may require
supplemental calcium (Ca), magnesium (Mg),
potassium (K), or phosphate (PO4).
• Nutritional support is indicated for patients with
burns > 20% TBSA or preexisting undernutrition.
Support with a feeding tube begins as soon as possible
if oral nutrition is not feasible or adequate. Parenteral
support is rarely necessary.

51. Electrical Injuries
• Electrical injuries are a complex form of trauma that is
often associated with high morbidity and mortality.
The severity of the injuries depends upon the type of
current, the voltage, and the resistance.

53. Features of electric shock
• Development of violations across the path of the electrical current in the body.
• Defeat at a distance.
• The appearance in the body of general changes, burn, mechanical damage,
electrolysis in tissues.
• Damage primarily due to the effect of current on the central and autonomic
nervous system.

54. Pathophysiology
Traditional teaching is that the severity of electrical
injury depends on Kouwenhoven’s factors:
• Type of current (direct [DC] or alternating [AC])
• Voltage and amperage (measures of current
strength)
• Duration of exposure (longer exposure increases
injury severity)
• Body resistance
• Pathway of current (which determines the
specific tissue damaged)

55. Pathology
• Application of low electrical field strength
causes an immediate, unpleasant feeling
(being “shocked”) but seldom results in
serious or permanent injury. Application of
high electrical field strength causes thermal or
electrochemical damage to internal tissues.

56. Damage may include:
• Hemolysis
• Protein coagulation
• Coagulation necrosis of muscle and other
tissues
• Thrombosis
• Dehydration
• Muscle and tendon avulsion

57. Pathology
• High electrical field strength injuries may
result in massive edema, which, as blood in
veins coagulates and muscles swell, results
in compartment syndrome. Massive edema
may also cause hypovolemia and hypotension.
• Muscle destruction can result
in rhabdomyolysis and myoglobinuria, and
electrolyte disturbances.

58. Pathology
• Myoglobinuria, hypovolemia, and hypotension
increase risk of acute kidney injury.
• The consequences of organ dysfunction do
not always correlate with the amount of tissue
destroyed (eg, ventricular fibrillation may
occur with relatively little tissue destruction).

60. Symptoms and Signs
1. Severe involuntary muscular contractions,
seizures, ventricular fibrillation, or
respiratory arrest due to central nervous
system (CNS) damage or muscle paralysis
may occur.
2. Brain, spinal cord, and peripheral nerve
damage may result in various neurologic
deficits.
3. Cardiac arrest.

61. Symptoms and Signs
• An electrical shock can cause powerful muscle
contractions or falls, resulting in dislocations
(electrical shock is one of the few causes of
posterior shoulder dislocation), vertebral or other
fractures, injuries to internal organs, and other
blunt force injuries.
• Subtle defined neurologic, psychologic, and
physical sequelae can develop 1 to 5 years after
the injury and result in significant morbidity.

62. Diagnosis
• Head-to-toe examination.
• ECG.
• Complete blood count (CBC), measurement of
cardiac enzymes, and urinalysis (to check for
myoglobin) should be considered.
• Patients with impaired consciousness may
require CT or MRI.

63. Treatment
• Shutting off current
• Resuscitation
• Analgesia
• Sometimes cardiac monitoring for 6 to 12
hours
• Wound care

64. Prehospital care!!!
• The first priority is to break contact between
the patient and the current source by shutting
off the current (eg, by throwing a circuit
breaker or switch, by disconnecting the device
from its electrical outlet).

65. Resuscitation
• Patients are resuscitated while being assessed.
Shock, which may result from trauma or
massive burns, is treated.
• Fluids are titrated to maintain adequate urine
output (about 100 mL/h in adults and 1.5
mL/kg/h in children).

66. Resuscitation
• For myoglobinuria, maintaining adequate
urine output is particularly important, while
alkalinizing the urine may help decrease the
risk of renal failure.
• Surgical debridement of large amounts of
muscle tissue may also help to decrease
myoglobinuric renal failure. Debridement will
promote reepithelialization.

67. Resuscitation
• Severe pain due to an electrical burn is treated
by the judicious titration of IV opioids.

68. Treatment
Cardiac monitoring for 6 to 12 hours is indicated for
patients with the following conditions:
• Arrhythmias
• Chest pain
• Any suggestion of cardiac damage
• Pregnancy (possibly)
• Known heart disorders (possibly)
• Appropriate tetanus prophylaxis and topical burn
wound care are required.
• Pain is treated with nonsteroidal anti-inflammatory
drugs or other analgesics.

69. Frostbite
• Frostbite of tissue – it is damage caused by the
action of low temperature.
• Development is facilitated by:
- old age
- fatigue
- exhaustion
- circulatory disorders
- intoxication
- high humidity
- the wind

70. Classification of frostbite

71. Classification of frostbite

72. Symptoms and Signs
• The affected area is cold, hard, white, and
numb. When warmed, the area becomes
blotchy red, swollen, and painful.
• Blisters form within 4 to 6 hours, but the full
extent of injury may not be apparent for
several days.

74. Symptoms and Signs
• Blisters filled with clear serum indicate superficial
damage; superficial damage heals without
residual tissue loss.
• Blood-filled, proximal blisters indicate deep
damage and likely tissue loss.
• Freezing of deep tissue causes dry gangrene with
a hard black carapace over healthy tissue. Wet
gangrene, which is gray, edematous, and soft, is
less common.
• Wet gangrene is characterized by infection, but
dry gangrene is less likely to become infected.

75. Symptoms and Signs
All degrees of frostbite may cause faulty nail
growth and long-term neuropathic symptoms:
• sensitivity to cold,
• excessive sweating,
• numbness (symptoms resembling those
of complex regional pain syndrome).

76. Diagnosis
• Clinical evaluation
• X-ray
• Bone scan
• MRI

77. Risk factors
• Medical conditions that affect your ability to feel or
respond to cold, such as dehydration, excessive
sweating, exhaustion, diabetes and poor blood flow in
your limbs
• Alcohol or drug abuse
• Smoking
• Fear, panic or mental illness, if it inhibits good
judgment or hampers your ability to respond to cold
• Previous frostbite or cold injury
• Being an infant or older adult, both of whom may have
a harder time producing and retaining body heat
• Being at high altitude, which reduces the oxygen
supply to your skin

78. Complications of frostbite
• Gangrene of the extremities
• Tetanus
• Phlegmon
• Sepsis
• Skin atrophy
• Changes in or loss of nails
• Trophic ulcers
• Joint stiffness (frostbite arthritis)

79. Treatment of frostbite
-Put to heat
-Washing with 5%
solution of boric
alcohol
-UV-therapy
-Bandage with
ointments
Bubbles are opened
-Epidermis is removed
-Training with alcohol,
5-10 days.
-Physiotherapy
-Antibiotics
-Bandage with
hypertonic solution
(0.9% normal saline
solution)
-Open wounds
management
-Stimulation of
epithelialization
-Necrectomy
-Amputation
1 degree 2 degree 3 degree 4 degree

80. Ongoing care
• Adequate nutrition is important to sustain
metabolic heat production.
• Using Doppler ultrasonography to assess
pulses and tissue appearance.
• Other imaging tests include radionuclide
scanning, microwave thermography, and laser-
Doppler flowmetry to help assess circulation,
determine tissue viability, and thus guide
treatment.

81. Ongoing care
• Usually, surgery is delayed as long as possible because
the black carapace is often shed, leaving viable tissue.
• Patients with severe frostbite are warned that many
weeks of observation may be required before
demarcation and the extent of tissue loss become
apparent.

82. Ongoing care
• Whirlpool baths at 37°C 3 times a day followed by gentle
drying, rest, and time are the best long-term management.

83. Thank you for your attention!