overview of burn and management of patients

1. BURN
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2. BACKGROUND
Burn injuries are Skin and/or tissue damage due to exposure to or
contact with extreme temperature, electrical current, chemical agents
or radiations
Historically it carried a poor prognosis. Fortunately With advances:
1.In fluid resuscitation and
2.The advent of early excision of the burn wound.
50% decline in burn-related deaths and hospital admissions in the
United States over 20 years.
( Schwartz's principles of surgery 10th ed and Sabiston text book of surgery 17th ed ).
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3. Anatomy and Physiology of Skin
• Largest body organ.
• Protects underlying tissues from injury
• Temperature regulation
• Acts as water tight seal, keeping body
fluids in balance
• Sensory organ
• Injuries to skin which result in
loss, have problems with:
• Infection
• Inability to maintain normal
water balance
• Inability to maintain body
temperature

4. Skin
• Two layers
• Epidermis
• Dermis
• Epidermis ( outermost layer )
• Stratum basale, spinosum, granulosum, lucidum and corneum
and also contain pigment to protect against UV radiation
• Dermis ( papillary and reticular dermis )
• Consists of tough, elastic connective tissue which contains
specialized structures.

5. Skin
• Dermis - Specialized Structures
• Nerve endings
• Blood vessels
• Sweat glands
• sebaceous glands - keep skin waterproof, usually
discharges around hair shafts
• Hair follicles - produce hair from hair root or papilla
• Each follicle has a small muscle (arrectus pillorum) which can pull the
hair upright and cause goose flesh.

6. Cross-section of the Skin

7. Epidemiology
Burns are the 4th most common type of trauma worldwide, following
traffic accidents, falls, and interpersonal violence
Burn injuries vary across all age groups ( although high in children,
epileptic adults and elderly).
The incidence in low- and middle-income countries is 1.3 per 100,000
population compared with 0.14 per 100,000 population in high-
income countries.
Michael D peck “epidemiology of burn globally” up-to-date offline 2018
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8. Mechanism of Burn Injuries
Thermal ( flames, scald, contact burn,….)
Electrical
Chemical ( acids or alkalines)
Radiation
Cold Injuries
Inhalation
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9. RISK FACTORS TO BURN INJURY
Children under 5years.
Elderly .
Low socioeconomic status.
Cold weather.
Occupational – electricians/industrial
Alcoholism.
Diseases e.g. epilepsy, diabetes
Assaults with Chemicals e.g acid, alkalis, etc.

10. • “The most significant difference between burns and other injuries is
that the consequences of burn injury are directly linked to the extent of
the inflammatory response to the injury”.
• The larger and deeper the burn, the worse the inflammation ( thus
airway obstruction due to edema , ARDS due to capillary leak,..)
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11. Pathophysiology of burn
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12. Zones of Burn wounds
• Zone of Coagulation
• Inner Zone
• Area of cellular death (necrosis)
• Zone of Stasis
• Area surrounding zone of coagulation
• Cellular injury: decreased blood flow & inflammation
• Potentially salvable; susceptible to additional injury
• Zone of Hyperemia
• Peripheral area of burn
• Area of least cellular injury & increased blood flow
• Complete recovery of this tissue likely.

13. Classification of burn injuries
• Depending on surface of skin injuries using Wallace’s rule of nine or
palm. Thus , TBSA ( for fluid resuscitation )
• Depending on depth of injuries ( for surgical debridement
Superficial Burn
Partial Thickness Burn
Full Thickness Burn
Up-to-date 2019
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14. Total Body surface Area using rule of nine
12/8/2019 UR CMHS 14Adopted from ATLS Protocol 10th version 2019

15. • 1st degree :
• 2nd degree
• 3rd degree
• 4th degree
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• Rwanda, emergency protocol 2014

16. Superficial partial thickness
burn
• Superficial thickness burn
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17. Deep partial thickness burn
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18. Full-Thickness Burns
• Involves the entire epidermis and dermis
• Wound Appearance:
• Dry, leathery and rigid
• + Eschar (hard and in-elastic)
• Red, white, yellow, brown or black
• Severe edema
• Painless & insensitive to palpation
• Wound Healing:
• No spontaneous healing;
weeks to months with graft
• Wound Management:
• Surgical excision & skin grafting
• Eschalotomy
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19. Initial management
• Primary survey and Resuscitation of patients
with Burns
• Stop the Burning Process
• Establish Airway Control
• Ensure Adequate Ventilation
• Manage Circulation with Burn Shock Resuscitation
ATLS protol 2019
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20. At scene
• Remove the patient from the burning process ,
• Remove patient’s clothing to stop the burning ; however prevent
overexposure and hypothermia.
• If suspicion chemical or powders brush them the wound
decontaminate the burn areas by irrigating the wound with warm
running water or warm saline if possible for 20 min.
• Once the burning process has been stopped, cover
the patient with warm, clean, dry linens to prevent hypothermia.
ATLS protol 201912/8/2019 UR CMHS 20

21. Primary survey
• ABCDE approach
• Airway control ( airway obstructions are not always immediately )
• Anticipate in :Inhalation , facial, mouth burns and TBSA > 40%
• Enclose smoke injury
• Signs of airway obstruction vs inhalation injury (hoarseness, stridor,
accessory respiratory muscle use, sternal retraction, difficult in swallowing)
( later signs)
ATLS protol 2019
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22. Airways and breathings
• Administer supplemental oxygen with or without intubation.
• Early intubation with appropriate ETT ( Rapid sequence )
• Escharotomy for chest circumferential burns
• Don’t rely on SPO2 of 98% when burn occurred in enclose space ( CO) do ABG
above 10% is dangerous,
Signs include:
headache and nausea (20%–30%)
confusion (30%–40%)
coma (40%–60%)
 death
ATLS protol 2019
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23. Circulatory management
• Goal : maintain end organ perfusion.
• Candidates :
odeep partial, full-thickness ( 2nd and 3rd , 4th degree )
oburns larger than 15% for adults , 10% for children
• Take 2 large bore IV line (warm crystalloid; RL )
• 2 ml of lactated Ringer’s x patient’s body for 24 hours
weight in kg x % TBSA . ( half in 8 hrs then other half in following 16 hrs)
• Insert Foley catheter to assess perfusion
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24. Modified parkland formula
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25. • Pain : morphine 0.1mg/kg iv/im 4-6hrs as needed
• Vaccination : antitetanus vaccine + serum immunoglobulin
• Check blood sugar especially for children
• N.B: parkland is used for the 1st 24hours , treat shock with boluses
then substract form the total fluid , after 24hours consider to keep
maintainance fluids.
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26. Disability and Exposure
D:Compartment syndrome :
Pain out of proportion, Tense swelling of the affected compartment
Do fasciotomy to release the pressure
Distal loss of peripheral pulse is a later signs
Early sign include loss of sensation of deep perineal nerve big toe web
Exposure: percentage area of burn and other injuries.
Logroll for posterior aspect , remove rings avoid
circumferential ties
Do remember to prevent hypothermia
Keep wound sterile as much as possible
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WHO Surgical Care at the District Hospital 2003

27. Paraclinical investigations ( adjuncts )
Labs: FBC, Urea & creat, electrolytes, coagulation profile, ABG, Cardiac
enzymes(CK, Myoglobin, troponin)
Imaging: CXR,ECG
To appreciate burn related end organ damage
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28. ADMISSION
• Criteria
inhalational burns
Circumferential burns
Perineal burns
TBSA Greater than 10%in children and 15% in adult
Any burn in a patient at the extremes of age
Any burn with associated potentially serious sequelae(high-tension electrical burns
and concentrated hydrofluoric acid burns)

29. Wound Management
• Remove clothing and debris
• Clean with cool water
• Debridement of devitalized tissue with sterile saline soaked gauze
• Large, painful blisters and those likely to rupture should be removed
• Early wound coverage ( dressing )
• N.B prevent anything which can lead to hypothermia

30. Surgical procedures
Escharotomy vs fasciotomy
Surgical debridement
Direct wound closure
Skin grafting or skin substitutes
Tissue transfer – Local flaps, pedicle flaps
 release of contractures : after full scar maturation, in order to preserve
function.
The aims is to cover the burn wounds, promoting healing and recover function
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31. Debridement
• Early burn wound excision is essential to eliminate the bullae,
necrotic and potentially infected tissue, as soon as possible after the
burn injury, whenever possible.
• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre)
chlorhexidine solution, 0.1%
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WHO Surgical Care at the District Hospital 2003

32. Wound Dressing
• Topical antibiotic covered with nonadherent dressing, or wet to dry dressing for 48hr
• Do not use alcohol-based solutions.
• Apply a thin layer of antibiotic cream (silver sulfadiazine).
• After 48 hrs, Dressings change should be on other day based ( clinical judgement)
• Dress vaseline gauze and dry gauze thick enough to prevent seepage to the outer
layers
WHO/EHT/CPR 2004 reformatted. 2007 WHO Surgical Care at the District Hospital 2003

33. Daily care
• Change the dressing daily (twice daily if possible) (to prevent seepage
through the dressing).
• On each dressing change, remove any loose tissue. •
• Inspect the wounds for discoloration or haemorrhage, purulent
(green exudate indicate developing P. aeruginosa infection ).
• Fever is not a useful sign as it may persist until the burn wound is
closed.
• Do Blood culture , swab analysis and antibiogram , urinalysis
• Cellulitis in the surrounding tissue is a better indicator of infection.
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WHO/EHT/CPR 2004 reformatted. 2007 WHO Surgical Care at the District Hospital 2003

34. Skin grafting
This surgery removes dead skin surface and replaces it with healthy skin from
another part of the body.
Usually applied to the face or hands for wound healing and better cosmetic
effect.
Split thickness sin graft:
Sheet graft : the whole piece of skin without the holes in it. better cosmetic
appearance but requires much more skin to cover a specific area.
Meshed skin
Full thickness graft
Tissue flap .

35. ESCHAROTOMY INCISIONS
• Cut through the eschar
along parallel lines
• Incisions only through eschar
(not through fascia)
• Done at bedside
• Use electrocautery

36. ESCHAROTOMY
google images

37. Hands burns
Treat burned hands with special care to preserve function.
Cover the hands with silver sulfadiazine and place them in loose polythene gloves or bags
secured at the wrist with a crepe bandage;
Elevate the hands for the first 48 hours, and then start hand exercises;
At least once a day, remove the gloves, dress the hands, inspect the burn and then reapply
silver sulfadiazine and the gloves;
− If skin grafting is necessary, consider to refer to a specialist after healthy granulation tissue
appears.
WHO/EHT/CPR 2004 reformatted. 2007

38. Electrical burns
• By direct exposure to an electrical current.
• Severity depends upon:
• What tissue current passes through
• Width or extent of the current pathway
• Duration of current contact
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39. Electrical Burns
• Skin burns where current enters and leaves can be almost trivial
looking :
 At entry point,
 At exit point
• Everything between can be cooked
• There is no way to tell how bad the burn is on the inside by the way it
looks on the outside.
• Though, higher voltage may result in more obvious external burns

40. Electrical Burns
They can be :
Electricity
Lighting

41. Effect of electrical Burns on different organs
• External tissue Burns
• Internal Burn
• Musculoskeletal injury
• Cardiovascular injury
• Respiratory injury
• Neurologic injury
• Rhabdomyolysis and
• Renal injury

42. Electrical Burn Management
• Make sure current is off
• Lightning hazards
• Do not go near patient until current is off
• ABC’s
• Maintain airways open, Ventilate and perform CPR as needed
• Oxygen
• Iv fluid based on ATLS protocol ( please ) : AKI ????
• ECG monitoring
• Treat dysrhythmias

43. Chemical Burn Management
• Exposure to acids, alkalies, and petroleum products.
• Acidic cause a coagulation necrosis of the surrounding tissue, which
impedes the penetration of the acid to some extent.
• Alkali burns penetrates more deeply by liquefaction necrosis of the tissues.
• Rapid brush off the chemicals immediately,
• Immediately flush away the chemical with large amounts of warmed
water, for at least 20 to 30 minutes longer for alkali and Eye contact
ATLS protocol 10th ed 2019

44. • Airway obstruction and Hypoxia ( inhalational injury )
• Burn Shock
• Infections
• Kidney injury
• Cardiac Arrhythmias
• Curling’s ulcer in large burns over 30% usually after 9th day
• Psychological trauma
• Contractures
• Cancer called Marjolin’s ulcer.
Dr. Mohamed Amin Plastic surgery department-burn unity ‘”PATHOPHYSIOLOGY & COMPLICATIONS OF BURN” slideshare.com
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Complications

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46. Preventive measures
• Educating the community for proper use of gases at home
• Prevent kids from reaching out scalds , flames and electricity ports
• Extinguishers in big institutions
• Early consultation and early with proper resiscutation of burn patients
• Training the health persons on burn
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Wish you to live Life free of Burns