Burn refer to a wound that result from tissue damage by caused by Thermal Electrical Chemical Radiation

1. BURN
Department of Surgery
ELWA Hospital
Dr. J. Nutai Kolleh, Intern

2. Outline
• Overview
• Classification of Burns
• Burn Depth
• Prognosis
• Resuscitation
• Transfusion
• Inhalation Injury and Ventilator Management
• Treatment of the Burn Wound
• Nutrition
• Complications in Burn Care
• Rehabilitation
• Prevention
• Radiation Burns

3. Overview
Burn refer to a wound that result from tissue
damage by caused by
• Thermal
• Electrical
• Chemical
• Radiation.

4. 4
Skin Anatomy
• Skin Layers
• Epidermis
• Dermis
• Subcutaneous tissue
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5. 5
Skin Form & Function
• Largest body organ
• More than just a passive covering
• Functions:
• Sensation
• Protection
• Temperature regulation
• Fluid retention
• Metabolic (vit D synthesis and excretory function)
• Social( self-image, social image)
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6. Initial Evaluation
Initial evaluation of the burned patient
involves four crucial assessments:
•airway management
•evaluation of other injuries
•estimation of burn size
•and diagnosis of CO and cyanide
poisoning.

7. Initial Evaluation
• Perioral burns and singed nasal hairs necessitate
further evaluated for mucosal injury,
• Signs of impending respiratory compromise may
include a hoarse voice, wheezing, or stridor;
• subjective dyspnea is a particularly concerning
symptom and should trigger prompt elective
endotracheal intubation.

8. Initial Evaluation
• Burned patients should be first considered trauma
patients, especially when details of the injury are
unclear.
• Primary survey
• An early and comprehensive secondary survey must
be performed on all burn patients, but especially
those with a history of associated trauma such as
with a motor vehicle collision

9. Estimating Burn Size
• Superficial or first-degree burns should not be
included when calculating the %TBSA, and
thorough cleaning of soot and debris is mandatory
to avoid confusing
• Wallace rule of nine
• Laud Browder
• Rule of the Palm

11. Metabolic Poisoning
• Carbon Monoxide (CO) affinity for hemoglobin is
approximately 200 – 250 times more than oxygen
• Administration of 100% oxygen is the gold standard
for treatment of CO poisoning
• Hydrogen cyanide toxicity patients may have a
persistent lactic acidosis or ST elevation on
electrocardiogram (ECG).
• Treatment consists of sodium thiosulfate,
hydroxocobalamin, and 100% oxygen

12. Classification of Burn
• Burns are commonly classified as thermal,
electrical, or chemical burns, with thermal
burns consisting of flame, contact, or scald
burns.
• Flame burns are not only the most common
cause but also the highest cause of mortality

13. Electrical Burn
• Electrical burns are classified as low-voltage ( < 1000
volts) and high-voltage injuries (1000 volts and higher).
• There may be instant death from cardiac or respiratory
arrest or ventricular fibrillation from alteration of the
action potentials of nerves and muscles.
• Cardiac arrhythmia
• Compartment syndrome
• Rhabdomyolysis
• fasciotomies should be performed even in cases of
moderate clinical suspicion

14. Chemical Burn
• Chemical burns are less common but potentially severe
burns.
• Careful removal and irrigation for minimum of 30mins
• Lye powder should be swept away to avoid activating
the aluminum hydroxide with water
• Formic acid has been known to cause hemolysis and
hemoglobinuria, and hydrofluoric acid causes
hypocalcemia.
• Calcium-based therapies are the mainstay of treating
hydrofluoric acid burns

15. Burn Depth
• Superficial (First degree) – Involves only
epidermis, Red, Heal in ~7 days
• Partial Thickness (Second degree) – Extends into
the dermis, Salmon pink Heal in ~7 to 21 days
• Full Thickness (Third degree) Through epidermis,
dermis into underlying structures Thick, dry, Pearly
gray or charred black,
• Fourth degree burn – Involves underlying
structures , same finding as 3rd degree burn with
involved bone, muscle and tendon.

16. Burn Depth
• Zone of coagulation – of necrosis in the center is
irreversibly damaged.
• ischemia or stasis where vascular spasms and
intravascular micro-thrombi result in compromised
perfusion with potential to progressive conversion
to tissue death.
• Zone of hyperemia, heal with minimal or no
scarring and is most like a superficial or first-degree
burn.

17. Prognosis
• The Baux score (mortality risk equals age plus
%TBSA) was used for many years to predict
mortality in burns.
• Analysis of multiple risk factors for burn mortality
has validated age and %TBSA as the strongest
predictors of mortality.
• However, age and burn size, as well as inhalation
injury, continue to be the most robust indicators for
burn mortality

18. Resuscitation
Google Images

19. Resuscitation
• For pediatrics, the simplest approach is to deliver a
weight-based maintenance IV fluid with glucose
supplementation in addition to the calculated
resuscitation fluid with lactated Ringer’s.
• The burn (and/or inhalation injury) drives an
inflammatory response that leads to capillary leak.
• Continuation of fluid volumes should depend on the
time since injury, urine output, and mean arterial
pressure (MAP).

20. Resuscitation
Other adjuncts
• High-dose ascorbic acid (vitamin C) may decrease
fluid volume requirements and ameliorate
respiratory embarrassment during resuscitation.
• Plasmapheresis may also decrease fluid
requirements in patients who require higher
volumes than predicted to maintain adequate urine
output and MAP

21. Transfusion
• A large multicenter study of blood
transfusions in burn patients found that
increased numbers of transfusions were
associated with increased infections and
higher mortality in burn patients, even when
correcting for burn severity.

22. Inhalation Injury and
Ventilator Management
• Inhalation injury decreases lung compliance and
increases airway resistance work of breathing
• Treatment of inhalation injury consists primarily of
supportive care.
• Aggressive pulmonary toilet and routine use of
nebulized bronchodilators such as albuterol are
recommended
• Inhaled nitric oxide may also be useful as a last
effort in burn patients with severe lung injury who
are failing other means of ventilatory support.

23. A classic study by Navar et al :
• burned patients with inhalation injury
required an average of 5.76 mL/kg/% burn,
vs. 3.98 mL/kg/% burn for patients without
inhalation injury, and this has been
corroborated by subsequent studies

24. Treatment of Burn Wound
Exposure method
• Allow daily inspection and any cracks in the eschar are
dressed with Vaseline gauzeor or sofra tulle
• In full thickness burns, exposure end as soon as the
eschar is broken
Dressing
• Occlusive dressing prevents bacterial contamination,
reduces pain and evaporative fluid loss and increases
the rate of re-epitheliazation.
• Providone-iodine: effective against gram positive
organisms and fungi. It is painful and causes excessive
drying of eschar.
• Honey: Honey prevent bacterial contamination and
promote healing

25. Google Images

26. Treatment of Burn Wound
• Early excision and skin grafting - Classically between
3-7 days
• Larger burn – meshed autografted skin
• Areas of cosmetic importance – use nonmeshed sheet
grafts ensure optimal results
• For excision of burns in areas such as the face, eyelids,
or hands, a pressurized water dissector may offer more
precision but is time consuming.
• Xenograft and cadaveric graft function as well as
allograft for temporary wound coverage.
• Amniotic Membrane

28. Burn in Specific Areas
Face
• Adequate cleaning of the face, exposure dressing with
antibacterial lotions/ creams.
Neck:
• Exposure treatment is ideal
• Flexion contracture – keep the neck extended by placing
a pillow under the shoulders.
• soft and hard neck collars and fabricated splints can be
use later
• Circumferential burn can form a tourniquet effect as the
edema progresses.
• Escharotomies are rarely needed within the first 8 hours
following injury and should not be performed unless
indicated

31. Burn in Specific Areas
• Axillae:
• Keep the arm in abduction.
• bulky axillary dressings are useful.
• Negative pressure wound therapy (NPWT), may benefit
patient requiring excision and grafting.
• Crucifix splint may be used in children
The Hands:
• dressed the fingers and the web spaces separately with
Vaseline gauze.
• Splint wrist in extension, Metacarpophalangeal joint and
90 degree flexion, interphalangeal joint in extension

32. Burn in Specific Areas
Perinerum
• Treated by exposure
• In children gallows splint ensures adequate
immobilization and exposure.
• Adults are nursed in supine position with the hip
joints in abduction.
The legs and feet: These must be elevated to
encourage venous drainage.

33. Nutrition
• Nutritional support may be more important in
patients with large burns than in any other patient
population
• Adjuncts such as metoclopramide promote
gastrointestinal motility.
• if other measures for gastric feeding are
unsuccessful, advancing the tube into the small
bowel with nasojejunal feeding can be attempted.

34. Nutrition
• Harris-Benedict equation, is a commonly used
formula in nonburned population.
• The Harris-Benedict equation may be inaccurate in
burns of less than 40% TBSA, and in these patients,
the Curreri formula may be more appropriate.
• This formula estimates caloric needs to be 25
kcal/kg/d plus 40 kcal/%TBSA/d.

35. Nutrition
• β-Blocker use in pediatric patients decreases heart rate
and resting energy expenditure
• There may be benefits to β-blockade in adult patients.
• Insulin may have a metabolic benefit in burn patients
• Oral hypoglycemic and prevent hyperglycemia and
prevent muscle catabolism.
• A recent double-blind, randomized study of
oxandrolone showed decreased length of stay, improved
hepatic protein synthesis, and no adverse effects on
endocrine function,

36. Causes of death in burn patients
• Hypovolaemic shock in the
first 48 hours.
Renal failure
• (i) Pre-renal from
hypovolaemia .
• (ii) Acute tubular necrosis from
myogtobinuria or
hemoglobinuria
• Sepsis may be a local infection
or septicemia often with
endotoxic shock.
• Tetanus may also occur.
Respiratory tract infection
accounts for 50 % of bum
sepsis and 50% of deaths.
• Pulmonary problems: Laryngo-
tracheo-bronchitis, laryngeal
oedema, pulmonary oedema,
pneumonia
• Some studies have reported an
incidence of over 50% of multi-
Organ failure in deaths after bum
injury.

37. Complications
• Early complications and
include;
1. HypovolaemicShock
Infections
• 3. Gastrointestinal problems
• Acute gastric dilatation,
Paralytic ileus, Curling's
ulcers, Liver damage
• 4. Cardio-respiration problems
• Respiratory obstruction
• Tracheo-bronchitis
• Pneumonia, atelectasis
• 5. Genito-urinary problems
• Renal failure
• Cystitis, pyelonephritis,
Calculi
• 6. Vascularproblems
• Thrombophlebitis,
• Deep venous thrombosis
• Pulmonary embolism
• 7. Anemia
• Disseminated intravascular
coagulation (DIC)

38. Complications
• Late complications of burns are usually related to
consequences of poor healing of the burn wound and
include
• Unstable scars and chronic burn wounds.
• Burn scar hypertrophy and Keloids
• Burn scar contractures and deformities
• Dyschromic scars (hypo-, hyper-, & de-pigmentation)
• Bum Scar metaplasia and Marjolin's ulcers
• Loss of body parts.
• Psychiatric problems including PTSD

39. Rehabilitation
• Patients should be taught exercises they can do
themselves to maintain full range of motion.
• Psychological rehabilitation is equally important in
the burn patient.
• Depression, posttraumatic stress disorder, concerns
about image, and anxiety are essential.

40. Radiation
• Radioactive material results in both acute injury from
immediate exposure and more prolonged injury from
delayed exposure to radioactive fallout or
contamination.
• The explosion results in a direct pressure wave and an
indirect wind drag
• After initial evaluation and decontamination by
removing clothing, a useful way to estimate exposure is
by determining the time to emesis.
• Patients who do not experience emesis within 4 hours of
exposure are unlikely to have severe clinical effects.

41. • Irrigation fluid should be collected to prevent
radiation spread into the water supply.

42. Prevention
•Burns is preventable, the common
denominator in most instances being
ignorance, carelessness and poverty
•Smoke alarms are known to decrease
mortality from structural fires.

43. References
• Schwartz's Principle of Surgery, 10th edition
• Baja’s Principles and Practice of Surgery, 5th
edition