It was a small seminar on BURN.. tried to do something better.. thnx

1. Presented BY…….
Dr. Rezuan
Internee Doctor
Jahurul Islam Medical College & Hospital,
Bangladesh

2. Burn
It may be defined as injuries
resulting from the application of dry
heat or chemical substances to the
external surface of the body resulting
in more or less destruction of tissues.

3. INTRODUCTION….
 Throughout the country, an
estimated 1% of the population
suffers from different types of
burns each year.
OThe incidence of burn
injury varies greatly
between cultures.

4. Human skin can tolerate tempratures up
to 42 – 44* C But above these, the
higher the temperature the more severe
the tissue destruction
Exposure
10 seconds at 50ºC redness
10 seconds at 60ºC very superficial burn
10 seconds at 70ºC full thickness burn
1 second at > 70ºC partial thickness burn
1 minute at 55-65ºC partial thickness burn
5 minutes at 50ºC full thickness burn

5. SCALD
It is the injuries produced by
application by moist heat (like as hot water,
oil) to the body .

6. TRAITS BURN (Dry Heat) SCALD (Moist Heat)
Cause Flame , Hot Metal Boiling Water,milk,oil
etc
Site At or Above the site
of contact
At or Below the site
of contact
Singeing of hair Present Absent
Depth Often deep upto skin
or more
Usually depth is less
Healing Delayed Comperatively early
Scar Thick Thin
Contracture Common Not common

7. The common causes of burns in
Bangladesh are as follows:
A. Flame burn: 75% of
incidences occur due to flame injuries -
CAUSES OF BURN….

8. 1. Accidental:- this occurs
mainly in the home during
household work like cooking,
particularly from gas leakage or
burst stoves
2. Trapped in a burning house.
It includes..

9. 3. Using fire pots for warming in
the winter, especially old people
and children.
4. Warming the lower part of the
body after delivery specially
women in remote village areas.

10. B. Others: About 20% burns
are electric burns.
The cause of electric burn is
mainly accidental.
5. Homicidal and suicidal:
Pouring kerosene oil, diesel, gasoline
or other inflammable liquids onto a
human body

11.  Fluid Shift
 Period of inflammatory response
 Vessels adjacent to burn injury
dilate > increase capillary
hydrostatic pressure & increase
capillary permeability
Patho-phisiology…

12. The increase in permeability is such
that large protein molecules can also
now escape with ease.
The damaged collagen and these
extravesated proteins increase the
oncotic pressure within the burned
tissue, further increasing the flow of
water from the intravascular to the
extravascular space.

13.  Continuous leak of plasma from
intravascular space
 Associated imbalance of fluid,
electrolytes & acid-base occur
 Hemoconcentration
 Lasts 24 – 36 hours

14. SYSTEMIC CHANGES
Cardiac
 decreased cardiac output
Pulmonary
 Alveolar damage
 Gas exchange
 Can progress to
respiratory failure

15. Gastrointestinal
 Curling ulcer formation
 Blood flow to splancnic
circulation
 Metabolic
 Hypermetabolic state
 Immunologic
 Increased risk of infection

16. ■ Burns produce an inflammatory
reaction
■ This leads to vastly increased
vascular permeability
■ Water, solutes and proteins move
from the intra- to the extravascular
space
The shock reaction after burns :

17. ■ The volume of fluid lost is
directly proportional to the area
of the burn
■ Above 15% of surface area
the loss of fluid produces
shock
(Cont..)

18. Burn
Pathology of Burn
(Jackson’s Zone of Injury)
Zone of Hyperaemia
Zone of Stasis
Zone of Coagulation
Necrosis

19. Severity is determined by :
 Depth of burn
 Extend of Burn calculated in
percent of total body surface
 location of burn
 patient risk factor

20. Assessing the area of a burn :
■ The rule of nines is adequate for
a first approximation only
■ The patient’s whole hand is 1%
TBSA, and is a useful guide in
small burns
■ The Lund and Browder chart is
useful in larger burns

21. Burn size needs to be formally
assessed in a controlled
environment.
This allows the area to be
exposed and any soot or debris
washed off.

22. The best measurement is
to cut a piece of clean
paper as the size of the
patient’s whole hand
(digits and palm), which
represents 1% TBSA,
and match this to the
area.
In the case of smaller burns

23. which states that –
 each upper limb is
9% TBSA,
 each lower limb 18%,
 the torso 18% each
side
 the head & neck
9%,
 Perineum 1%
rule of nines

24. Before going to the Classification,
1st we take a look about the layers
of skin…..
The human skin is an intricate
organ. It has two layers-dermis and
epidermis.The outer most, known
as the epidermis, Below the
epidermis lies the dermis.
Classification Of Burn:

25. Layers Of Skin:
 Epidermis :
○ Stratum Corneum
○ Stratum Lucidum
○ Stratum Granulosum
○ Stratum Spinosum
○ Stratum Basale
 Dermis
○ Papillary Dermis
○ Reticular Dermis

26. Nowthe Classification of Burn……….
 A. According to Depth Of burn:
 Superficial Partial Thickness Burn:
Involve epidermis + Papillary Dermis
 Deep Partial Thickness Burn:
Involve epidermis + Upto Reticular Dermis
 Full thickness Burn:
Involve the whole dermis

27. B. Traditionally :
 1St Degree Burn : Only Epidermis
 2nd Degree Burn: Epidermis and part
of Dermis
 3rd Degree Burn: Full thickness Skin

28. Superficial partial thickness burn
Clinical features-
-blistering and or loss of epithelium
-underlying dermis is pink and moist
-the capillary return is clearly visible when
blanched
-pin prick sensation is normal

29. Deep partial thickness burn
Clinical features-
1. the epidermis is usually lost.
2. the exposed dermis is not as moist as that in a superficial
burn.
3. the colour does not blanch with pressure.
4. sensation is reduced.
5. unable to distinguish sharp from blunt pressure.

30. Full thickness burn
Clinical features-
1. The whole of the dermis is destroyed in this burn .
2. They have a hard ,leathery feel.
3. There is no capillary return.
4. Often thrombosed vessels can be seen under the skin.
5. These burns are completely anaesthetised.

31. Difference Between Superficial
and Deep Burn
Trait Superficial Burn Deep Burn
Involvement Only Epidermis Epidermis, Dermis and
Appendages
Pain Intense pain Less or no pain
Blister Present Absent
Fluid Loss Less Fluid More Fluid
Need Of Skin Grafting No need Needed
Healing Heals completely Heals with ugly scar
Complication No Heals with formation of
Hypertrophied scar or
keloid

32. Causes of burn withprobable depth..
Causes of burn Probable depth of burn
1.Scald 1.Superficial but with deep
dermal patches in the absence
of good first aid.
2.Fat burn 2.Deep dermal
3.Flame burn 3.Mixed deep dermal and full
thickness.
4.Alkali burn including cement 4.Often deep dermal or full
thickness.
5.Acid burns 5.Weak concentrations -
superficial, strong
concentrations -deep dermal.
6.Electrical contract burn 6.Full thickness.

33. MANAGEMENT
 Pre- Hospital Care
 The principles of pre-
hospital care are:
-Ensure rescuer safety
-Stop the burning
process
-Check for other injuries
-Cool the burn wound

34.  Give oxygen-
If anyone
involved in a fire
in an enclosed
space or if there
is an altered
consciousness
level.

35.  Elevate-
sitting a patient up with
a burned airway may
life saving in the event
of a delay in transfer to
hospital care. Elevation
of burned limbs will
reduce swelling and
discomfort.

36. Criteria for Hospitalization:
Children with > 10%TBSA Burn
Adult with > 15%TBSA Burn
Burn around mouth, nostrils, eyes,
ears, genitalia, anus, breasts,
hands,Face.
Burn with inhalation injury
Deep burn of any percentage
Acid and other chemical burn
Electric burn
Extreme of ages

37. Hospital care
 The principles of managing an acute
burn injury are the same as in any
acute trauma case that is according
to ATLS .
 Assessment and resuscitation
should be carried out
simultaneously-

38.  A - Airway control
 B - Breathing and Ventilation
 C – Circulation
 D – Disability
- neurological status
 E – Exposure with environmental
control.
 F – Fluid resuscitation
1.. ATLS

39. 2.. Analgesic
3.. Broad spectrum antibiotic
4.. Tetanus prophylaxis
5.. Blood transfusion (if
anaemia)
6.. IV nutrition

40.  Airway
 Rapid primary survey
and check airway-
Burn injury to the
airway above the larynx
by hot gases or to the
lower airway by inhaled
steam cause the
respiratory epithelium to
swell rapidly and that
may completely block the
airway.

41.  Breathing
Inhalational injury:
Difficulty in breathing due to
chemical pneumonitis is
caused by the minute particles
that stick to the moist lining
cause intense reaction to the
alveoli.

42. 1.Treatment-
-nebulizers and warm
humidified oxygen,
-physiotherapy,
- sometimes continuous
or intermittent positive pressure
ventilation in an intensive care
unit may be needed.

43. Warning signs of burns
to the respiratory
system:
■ Burns around the
face and neck
■ A history of being
trapped in a burning
room
■ Change in voice
■ Stridor

44.  Circulation :
1. Intravenous fluid therapy
 Primary Requirements:
-Intravenous drip
Wide bore canula.
CVP catheter.
- Blood sample
Hb%, Haematocrit, S.Electrolyte,
S. Creatinine, Blood Urea, Blood
grouping & Cross matching.
- Urinary Catheterization.

45. Fig: 62% burn patient with Subclavian central venous catheter
C.V.P.
cathete
r

47.  Different fluids used in
resuscitation
 Crystalloid:
- Ringer’s lactate
.Widely & safely use all
over the World.
- 0.9% Sodium chloride solution
- Hypertonic saline solution
- 5% DNS
- Hartman’s solution
- 5% DA
 Colloid:
- Plasma
- Plasma substitute
e.g. Dextran, Gelatin

48. Parkland Formula
In 1st 24 hrs:
Total fluid – 4ml x bodyWeight in kg x
% burn. = ml Ringer’s lactate
In 1st 8 hrs – ½ of total fluid
In 2nd 8 hrs – ¼ of total fluid
In 3rd 8 hrs – ¼ of total fluid
 In children, maintenance fluid must also be given. This
is normally dextrose–saline given as follows:
• 100 ml kg–1 for 24 hours for the first 10 kg;
• 50 ml kg–1 for the next 10 kg;
• 20 ml kg–1 for 24 hours for each kilogram over 20 kg
body weight.

49.  Colloid resuscitation
Plasma proteins are responsible for
the inward oncotic pressure.
Without proteins, plasma volumes
would not be maintained as there
would be edema.
Proteins should be given after the first
12 hours of burn,
because before this time, the massive
fluid shifts cause proteins to leak out of
the cells.

50. The commonest is the Muir and
Barclay formula:
• 0.5 x percentage body surface
area burnt x weight = one portion;
• periods of 4/4/4, 6/6 and 12
hours respectively;
• one portion to be given in each
period.
FOR COLLOID

51. Nutrition of Burn Patient
■ Burns patients need
extra feeding
■ A nasogastric tube
should be used in all
patients with burns over
15% of TBSA
■ Removing the burn and
achieving healing stops
the catabolic drive

52. Monitoring
 Clinical
 Bio Chemical & Haematological
 Invasive

53. Clinical Monitoring
-Pulse rate : <120beats/min.
-Blood pressure
-Urine output : Reliable guide
0.5 –1.5 ml / kg / hrs in
adult,
10-20 ml / hrs. in child
-Core & shell temperature
-Thirst
-Sensorium

54. Biochemical & Haematological
Monitoring
- Hb % & Haematocrit
- Urine osmolality
- Serum electrolyte
- Serum creatinin & blood urea
Invasive Monitoring
- CentralVenous pressure:
-should maintain 2-8 cm of
water
- Arterial blood pressure

55. Management of Burn Wound
- Conservative
- Surgical

56. Management of burn wound has
undergone remarkable changes
since middle of the 1960’s,
when burn physician has multiple
agents to choose in controlling
bacterial growth.
 1% silver sulfadiazine
(silcream, silverzin)
 0.5% silver nitrate.
 Gentamycin cream
 Povidone iodine.
Common topical agents

57. Principles of dressings for burns
■Full-thickness and deep dermal
burns need antibacterial dressings
to delay colonisation prior to
surgery
■ Superficial burns will heal and
need simple dressings
■ An optimal healing environment
can make a difference to outcome
in borderline depth burns

58. • Dressing procedure should be
performed in operation
theatre.
• All instruments and dressing
materials used, should be
sterile and of medical grade.

59. Surgical treatment of deep burns
 Deep dermal burns need tangential shaving
and split-skin grafting
 All but the smallest full-thickness burns
need surgery
 All burnt tissue needs to be excised
 Stable cover, permanent or temporary,
should be applied at once to reduce burn
load

60. q Type of Burn suitable for excision :
- Deep partial thickness burn.
- Deep burn.
q Excision can be done by :
- Tangential excision
- Total burn excision
Burn Excision

61. Complications of BURN
 Immediate Complication:
 Shock : Hypovolumic and Neurogenic
 Renal Failure
 Acute respiratory Distress Syndrome (ARDS)
 Pneumonia
 Respiratory Failure
 Laryngeal Edema
 Acute GIT ulcer: Curling’s ulcer
 Hypothermia
 Multiple organ system failure (MOSF)

62.  Delayed Complication:
 Wound Infection
 Septicaemia
 Protein lossing enteropathy
 Cerebral damage
 Late Complication:
 Hypertrophic Scar
 Keloid
 Post burn Contracture
 Marjolin’s ulcer.

63. Complication
Figure: Hypertrophic scarring
following a deep dermal burn.
Figure: Keloid

64. Complication
Fig: Post Burn Contracture Fig: Marjolin Ulcer

65. Measures to Prevent
Complication Of Burn.
 I/V fluid for volume replacement.
 Adequate Dressing
 Antibiotic to prevent infection.
 Anti ulcerants to prevent Curling
ulcer.
 Escheratomy in case of deep burn

66. (Cont..)
 High protein diet
 Physiotherapy to prevent
contracture
 Vitamin C supplementaion
 Diuretics to prevent renal
failure
 Early skin grafting.

67. THANK YOU……..