Medicine

1. KPEHE JIG MAIMIE INTERN

2.  Definition
 Pathophysiology
 Types of Burns
 Severity of Burn
 Estimation of the Extend of Burnt Surface
 General Admission Order
 Management of Burn
 Complications
 Causes of Death
 References

3.  Coagulative necrosis of the skin that may include deeper.
 Caused by:
Dry Heat Moist Heat
a) Electricity a) Hot Liquid
b) Chemical Caustic b) Flames
c) Irradiation c) Exploding gases
 Damage depends on : - The temperature of the heat Source
- The duration of the Tissue exposed to it
Burn in children often occur at home while adult at the work place or RTA.

4.  Initially, there systemic Vasoconstriction due to Catecholamine's
 Followed by released of Vasoactive Substance (Leukotrienes, Prostaglandin, Bradynin & Histamines
etc) ► vasodilation & ↑ Capillaries & Venules permeability ► Extravasation of Fluid, Electrolytes &
Plasma Protein (Albumin) to the Interstitium ► Edema in Interstitial Space & Distant tissue
 Edema ► ↓ blood flow to injured tissue ► Ischaemia & ↓ 02 to Tissue
 Destruction of Lymph Vessel prevents fluid drainage Plus ↑↑ interstitium Plasma Protein ► ↑↑ Osmotic
Pressure ► Hypovolemia ( If fluid therapy is not initiated) ► SHOCK
 Hypovolemia ► ↓↓ Renal Perfusion ► Hypoxia (Damage Renal Cell) ► Acute Tubular Necrosis &
Renal Failure

5. 1. Thermal – caused by contact w/ fire, steam, hot object or sun
exposure
2. Chemical – caused by exposure to extreme acid (battery acid, HCl)
or alkaline (Drano, fertilizers). Alkaline burn worse than acid burn!
3. Electrical - caused by Electrical shock or lightning strike. Deeper tissue damage
(Muscle); Complication – Electrical shock
4. Respiratory – Damage to the respiratory tract due to thermal (superheated air) and
chemical (smoke) Inhalation.
5. Circumferential Burns – ensuing edema may interrupt vascular supply to the distal
extremity. If on the chest wall, may interfere w/ breathing.

7. 1) First Degree Burn (Superficial)
o Burn restricted to epidermal layer
o Commonly due to sunburn.
o Tissue appears erythemic, very painful, blanches w/ pressure
o No Edema
2) Second Degree Burn (Partial thickness)
o Extends to the dermis
o Desquamation and / or blistering is present, tissue may feel moist
o Painful
o Healing occurs 7 – 10 days; Skin graft recommended.

8. 3) Third Degree Burn (Full – Thickness)
o Extends beyond the dermis to subcutaneous tissue
o Tissue is dry, leathery appearing and doesn’t blanch w/ pressure
o Less painful
o Eschar may be present
o Healing occurs > 21 days; Requires Skin Graft
2) Fourth Degree
o Burn that includes damage to deeper tissue such as muscle or
bone.

9. 20 Burn (Partial Thickness) 30 Burn (Full -Thickness)

10.  Wallace Rule of Nine
 Patient Palm = 1% BSA
 Lund & Browder Chest in Infant & Children

12.  Sup. Burns 15% BSA in adult or 10% BSA in children
 Deep Burns 7.5% or ↑ in adult or 5% in Children
 Significant burn to the face, Hands, Feet, External Genitalia and flexion creases
 Suspected airway or inhalational injury
 Electrical burns
 Circumferential burns: promptly remove jewelry or other articles (rings, bracelets,
watches) that may serve as tourniquets
 Very young or older pt (<5 or >55 yrs)
 Pts with co – morbid conditions (DM, HIV, Renal Failure, pulmonary or Vascular Dz)

13.  Principles - REVIVE, RESTORE, REPAIR & REHABILITATE
 Revival & Restoration – achieved through Intravenous Therapy to prevent or treat
Hypovolemia & Oliguria
 Repair - achieved through early slough removal & Immediate skin grafting
 Rehabilitation – physiotherapy to restore parts to normal

14. AIRWAY:
o Ensure airway is cleared in patient w/ facial & neck burns
o Use Fiberoptic bronchoscopy to further investigate if there’s
i) Inhalation of superheated air
ii) Greyish or blackish sputum
iii) Singed nasal hair
iv) Stridor, hoarsness, dyspnea, persistent hypoxia
v) Full – thickness, circumferential burn to the chest wall

15.  All burn pts must be placed on supplemental oxygen
 Nasal cannula is sufficient in most cases. However, pt with suspected
Respiratory burns should be on 100% Oxygen via facial mask
 Pulse oximetry should be monitored
Note: pts w/ respiratory burn may have a falsely elevated O2
(due to CO).
 Promptly get the Carboxyhemoglobin level & minus the measured
O2 Sat to get the true O2 Sat

16.  CBC, BMP, type & Cross match
 Electrical burns – EKG, cardiac enzymes, urine myoglobin,
CT head if there’s loss of consciousness
 Respiratory Burn: Carboxyhemoglobn, CXR, ABGx, Cardiac
enzymes, EKG
 For ensuing renal damage due to myoglobinemia, order Serial BMPs

17.  V = (% of body area burned) x (kg wt) x (4ml /kg) / (6ml/kg in peds)
 Ringer’s Lactate preferred
 Administer ½ over the first 8 hours, ½ over the next 16 hrs and ½
over the subsequent 24 hours
 This is in addition to maintenance fluid (D5W)
Insert Foley Catheter
 To monitor Urinary Output
 Adequate OU = 0.5 to 1ml /kg/hr; ml/kg/hr in peds patient
 Burn to the genital, a Suprapublic Catheter may be placed
 IIeus may develop during the early stage of management
 Place pt on NPO and NG tube suction to reduce ileux sx.

18. First Aid
 Remove burnt patient from source
 Drench the burn thoroughly with cool water (30 minutes) to ↓↓ Pain, Oedema &
Minimize Tissue further damage
 Remove all burned clothing.
 Apply clean wraps (if burn area is large after cooling) to prevent systemic hypothermia
Initial Treatment
 Administer Tetanus Prophylaxis
 Debride all bullae & Excise adherent necrotic (dead) tissue initially
 After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine
solution, 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic.
Do not use alcohol-based solutions
 Apply a thin layer of antibiotic cream (silver sulfadiazine).
 Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to the
outer layers

19.  Change dressing daily ( Twice daily if possible)
 Administer topical antibiotic chemotherapy daily.
i) Silver nitrate (0.5% aqueous) - is the cheapest, is applied with occlusive dressings
It does not penetrate eschar. It depletes electrolytes and stains the local environment.
ii) Silver Sulfadiazine (1% miscible ointment) with a single layer dressing.
It has limited eschar penetration and may cause neutropenia
Indicated for general management of burns w/ no eschar present.
iii) Triple Antibiotic Ointment (Bacitracin, neomycin, polymyxin B) is indicated for
general management of burns on the face
iv) Mafenide acetate (11% in a miscible ointment) is used without dressings. It penetrates
eschar but causes acidosis is indicated for deeper burns w/ eschar present.se sparing

20.  Nutritional Support Formula (daily energy requirement)
= 100j/kg body wt plus 160j % surface burn for an adult and 240j/kg body wt plus 140j%
surface burn for children < 8)
- 60kg man with 50% burns need 14000j (3500 cals) of energy and 120 to 150g of protein
- Enteral feeding is preferred to TPN (depresses the immune system)

21.  IV opiates (Morphine, Pentazoine, Tramadol) are indicated for severe
burn later transitioned to Oral opiates & to NSAID
 Pts w/ first or second degree burns who are managed on an outpatient
setting may be discharged w/ NSAID
 “ Disinfection, Dressing & Pain Control” are the basis of Outpatient but Management .
- First Degree – apply non – adherent dressing and NSAID for pain management
- Second Degree – treated by deroofing any open blisters and applying Silver
Sulfadiazine. Pain can be managed w/ NSAID
Pts be advised to return if there’s Fever or Erythema/pain worse
Rx : PO antistaph Penicillin ( Dicloxacillin0 or 10 Cephalosporin (Cephalexin)

22.  Hypovolemic Shock
 Infection - Strept., Staph, Pseudomonas, E. Coli, Proteus, C. tetani
GI Respiratory
 Paralytic Ileus Pneumonia
 Curling Ulcers - PPI instituted Atelectasis
Genitourinary
 Renal Failure
 Vascular
 DVT
 Deformity and Contractures
 Keloid and Hypertrophic Scars

23.  Hypovolemic Shock ( first 48hrs)
 Renal Failure
 Sepsis
Pulmonary Problem – Laryngeal edema, Pneumonia, Pulmonary Edema
 Curling Ulcers – leading to GI bleeding & Perforation

24. 1. Norman S. Williams et al, Bailey & Love Short Practice of Surgery, 25th Edition
2. Principles & Practices of Surgery in the Tropics “ Archampong 2010 Edition.
3. F. Charles Brunicardi et al, Schwartz Principles of Surgery, 2014 Edition
4. WHO Surgical Manual at District Hospital
5. UMSLE