This document provides an overview of burn injuries, including epidemiology, classification, pathophysiology, management approaches, and specific considerations for certain burn types. Some key points: - Burn injuries represent a devastating physical and psychological trauma that remains a major problem globally. - Burn depth, extent, cause, and presence of inhalation injury or other comorbidities determine classification and treatment approach. - Goals of burn care include restoring form and function as well as facilitating psychological recovery. - Initial management focuses on rescue, resuscitation, and wound care with subsequent rehabilitation. - Surgical excision and skin grafting are often needed to promote healing.

1. Dr. Oladele Situ
Registrar in Surgery, Plastic
Surgery Unit, NHA. January 2015

2. • Introduction
• Epidemiology
• Pathophysiology and Types of Burns
• Relevant anatomy
• Pathophysiology and systemic effects
• Classification
• Aims and phases of burn care: rescue → review
• Burns in developing countries
• Prognosis and causes of mortality in burn patients
• Prevention
• Conclusion
• References

3. • Burn injuries are one of the most devastating conditions
encountered in medicine.
• The injury represents an assault on all aspects of the
patient, from the physical to the psychological
• Still a major problem in both developing and developed
countries
• Prevention is still the key in its management

4. • In the United Kingdom about 250 000 people are burnt
each year.
• Over two million burn injuries are thought to occur each
year in India
• Nepal has about 1700 burn deaths a year for a
population of 20 million
• Estimated 2 million burn injuries in USA, 75000 requiring
admission, 1/3 Pt > 2months

5. 0
10
20
30
40
50
60
Scald Fire Chemical & Eletrical

6. Category Age Common
Aetiology
percentage
Young
children
<4yrs Scald 20%
Older
children and
adolescence
5-14 yrs Fire,
Electrocution
10%
Working
group
15-64 yrs Fire 60%
Elderly >65yrs Scald,
contact burn,
flame
10%

7. • Alcoholism
• Psychiatric illness
• Epilepsy
• Medical illnesses e.g. paraplegia

8. • Illegal fuel storage
• Vandalism
• Poor fire service response
• Poor fire protocol and shortage of water
• extinguishers, exit doors, Illiteracy
• Faulty equipment and electrical wiring
• Cigarette smoking

9. • Largest body organ: 0.25m2 - 1.8m2
• Epidermis and Dermis
• Protection role
• Thermoregulatory role
• Vitamin D

11. • Coagulative necrosis of Skin & Denaturing of Cellular
proteins (Chromatin, BM)
• Jackson 1947: zones of coagulation/necrosis,
stasis/injury, hyperemia
• Possibility of wound conversion
• Inflammatory Mediators: Leukotriens, PGs, Bradykinins,
Histamine, Thromboxane, O. radicals, Vasoamines

13. Transient Vasoconstriction the
vasodilation
Increased capillary permeability
Increased interstitial pressure
Extravasation of fluids, proteins,
electrolytes

14. • Epidermis: damaged BM + progressive desiccation =
charring
• Dermis: vaso-occlusion then vasodilation, endothelial
damage, plasma exudation, bleb formation separating
epidermis
• HAEMOCONCENTRATION = risk of thrombosis
(Virchow’s triad)
• HYPOTHERMIA from loss of skin’s thermoregulatory role
• Increased risk of Infection
• Increased interstitial loss of fluid and increased fluid loss
from convection & radiation

15. • Thermal:
• Fire (flash or flame),
• contact,
• scald (Liquid {spill or immersion}, grease or steam)
• Chemical
• Irradiation
• Electrical (including lightening)
• Cold (frost nip, bite)

16. • Posterior Pituitary: ADH,
• Anterior Pituitary: ACTH, GH, TSH
• Adrenal cortex: Aldosteron, glucocorticoids
• Adrenal medulla: Epinephrine
• Sympathetic Nerves: Norepinephrine
• Pancrease: Insulin, Glucagon
• Kidney: Renin
• Cytokines: IL 1, 6, TNF

17. • METABOLISM CHANGES
• Hypermetabolism and catabolism: Plateau response at
70% TBSA
• Protein loss: 1pound/day
• Evaporative water loss: 300ml/m2/hr
• Heat loss: 580Kcal/L in evaporation
• Immunologic depression

18. • CARDIAC CHANGES
• VASCULAR PROBLEMS
• RENAL CHANGES
• PULMINARY CHANGES
• GENITOURINARY
• GASTROINTESTINAL
• PSYCHIATRIC CHANGES
• AESTHETICS & MALIGNANCIES
• CEREBRAL FAILURE

19. • Burn depth
• Burn extent (TBSA)
• Causative agent
• Severity

20. • SUPERFICIAL BURN (1O): epidermis only, hyperemic,
intact sensation. 3-7days
• SUPERFICIAL PARTIAL (2O): papillary dermis, pink,
moist, blanches, blisters, painful, intact capillary refill,
intact hair follicles. 7-14 days
• DEEP PARTIAL/DERMAL: (2o)reticular dermis, absent
capillary refill, dry white or mottled pink. Decreased
sensation (sharp prick and deep pressure)

21. • FULL THICKNESS:
• Dermis and subcute
• Dense white, brown, or leathery
• Charred* appearance
• No sensation
• No capillary refill
• Destroyed follicle
• Destroyed sweat gland
• Perfusion only begining to be
established after 3 weeks

22. • Clinical- Best judgement of an experienced surgeon
• Fluorescein dyes
• USS
• Laser doppler
• MRI
• Thermography
• Indocyanine green video angiography

23. DEPTH ADULT CHILDREN OTHER
FACTORS
Major 2nd degree >25% >20% Inhalational,
eye, hand,
perineum,
feet,
electrical,
major
trauma,
3rd degree >10%
Moderate 2nd degree 15-25% 10-20%
3rd degree <10%
Minor 2nd degree <15% <10%
3rd degree <2%

24. ADULT % BODY PART CHILDREN %
9 HEAD & NECK 18
18 ANTERIOR &
POSTERIOR
TRUNK
18
9 EACH UPPER
LIMB
9
18 EACH LOWER
LIMB
14
1 EACH PALM 1
1 PERINEUM 1

26. Body part % TBSA
Face/anterior half scalp; Posterior half scalp 3.5; 3.5
Neck 1
Anterior trunk 13
Posterior trunk 13
Upper arm (anterior, posterior) 2; 2
Forearm (anterior, posterior) 1.5, 1.5
Hand (palm, dorsum) 1.25, 1.25
Perineum 1
Buttocks 2. 5 each
Anterior and posterior thigh 4.75
Anterior and posterior leg 3.5
Dorsum and planter surfaces of feet 1.75

27. • Restore form: restore the damaged area to as close as
possible to normal
• Restore function: Maximise patient’s ability to perform
pre-injury activities
• Restore feeling: Enable psychological and emotional
recovery

28. Rescue: get away from the source of the injury, first aid
Resuscitate: Immediate support for any failing organ
system.
Retrieve: transfer to a specialist burns unit for further
care
Resurface: simple dressings to aggressive surgical
debridement and skin grafting
Rehabilitate: return patients, as far as is possible, to
their pre-injury level of physical, emotional, and
psychological wellbeing.
Reconstruct: Scar reconstruction
Review: especially children, require regular review for

29. • Ambulance, Remove clothing, jewelleries
• Running water, chlorhexidine wash, debridement, rest
• ABCDE of resuscitation
• Temperature control (shivering starts @ <35.5 oC)
• Initial wound care
• Drugs: 5 ‘A’s
• Attention to other comorbid illness
• Initial Labs: FBC, EUCr, LFT & Prt, ABG, Xmatch
• Escharotomy (usually after >6hrs post-burn)
• NG-tube insertion (almost all Pt with 25% TBSA = ileus)
• Monitoring

30. • CRYSTALLOIDS:
• Parkland formula (4 X %TBSA X weight
• COLLOIDS (preferred after initial 24hr):
• Modified brook (2ml/ kg / %TBSA), then 0.3-0.5ml/kg/%TBSA in
the next 24 hours
• Evans formula (1ml/ Kg / %TBSA in 24hrs, then half this volume
in next 24 hrs)
• Muir and Barclay (½ x %TBSA x weight = 1 ration)
• Central line for those with >30% TBSA burns
• NB: insensate fluid loss is about 50ml/hr in humans

31. • Cooling with water at room temperature
• Topical anaesthetics e.g. Lidocaine
• Opiods preferred (I.V morphine@0.1mg/kg,
Pethidine@1mg/kg, methadone, Oxycodone for
“breakthrough pains”)
• Acetaminophine
• NSAIDS avoided due to risk od bleeding and worsen
curling ulcers
• Oral or Parenteral
• Diazepam (0.1mg/kg I.M + Ketamine 0.5mg/kg I.V) for
major dressing change
• I.V propofol in patients that are intubated

32. • Anti inflammatory
• Anti coagulant
• Neoangiogenic
• Epithelializing restoring effect
• Collagen restoring effect
• Relieves pain
• Enhances healing
• May allow for smaller volume of I.V.F for care

33. • 2nd & 3rd degree burns >10% TBSA in patients <10 or
>50yr
• Second and third degree burns >20% BSA in other
groups.
• Third degree burns >5% BSA in any age group.
• 2nd and 3rd degree burns that involve face, hands, feet,
genitalia, perineum, and major joints.
• Electrical burns, including lightening injury.
• Chemical burns with serious threat of impairment.
• Inhalation injury with burn injury.
• Circumferential burns with burn injury.
• Burn injury in patients with pre-existing medical

34. • Early wound cover/protection
• Open dressing or occlusive dressing
• Wound debridement, Eschar Excision and grafting
• Skin replacements
PROPERTIES OF THE IDEAL DERMAL-EPIDERMAL SUBSTITUTES
Presence of dermal and epidermal components
Easily availability, easy to prepare and easy to store
Suitable cost-effectiveness
Low antigenicity
Rheology comparable to skin
Hypoxia tolerant and resistant to infection
Resistance to shear

35. A. DURATION: temporary (alloderm, TransCyte) or
permanent (integra, Apligraft, Epicel)
B. SOURCE: autologous, Homologous (living or
cardaveric), Xenograft
C. TISSUE REPLACEMNT: epidermis (CEA) or dermis
(alloderm, integra, TransCyte)
D. SYNTHETIC (TransCte) or NATURAL (amnion)

37. • ↓ pain
• ↓ Fluid evaporation
• ↑ rate of re-epithelialization
• Prevents bacterial contamination
• Absorbs exudates
• Supports vessels and lymphatics
• Splints injured parts
• Eschars separates quikely

38. • Resumed within 24hrs
• R.E.E: 150-200% increase X stress factor
• Calorie: (Curreri formula)
<16yrs: 60KCal x weight + 35KCal x % TBSA
16-59yrs: 25KCal x weight + 40Kcal x % TBSA
>60yrs: 20Kcal x weight + 65KCal x %TBSA
NB: prevent weight loss of >10% premorbid body weight. Loss
of > 40% leads to imminent death
• Protein: 2-3kg/kg/day, Glycaemia control
• Mode: oral or parenteral
• Micronutrients: A 25,000 I.U, Bco (B1 thiamine=50mg,
B2 riboflavin 50mg), C 1.5g, E 400 U, Mg, Mn, Na, Fe, Zn
220mg, Selenium

39. • Galveston’s:
<1yr: 2100KCal/m2 + 1000KCal/m2 burn area
1-11: 1800KCal/m2 + 1300KCal/m2 burn area
>11 : 1500KCal/m2 + 1500KCal/m2 burn area
• Indirect calorimetry: patient on ventilator when FiO2 is <
50%

40. • Clinical
• C-reactive protein
• Pre-albumin
• Albumin
• Serum vitamin C
• 24hr total urea nitrogen

41. • Recommended in all burn wounds except the elderly or <1cm full
thickness
• Eliminates pains
• ↓ infection
• Allows early mobilisation
• Allows quick wound healing
• Useful and desirable in full thickness burns <10% or deep partial
thickness burns
• ↓ incidence of scarring, contracture in joints

42. • Post-burn day 3; 2-3 day interval
• Tangential Excision (Watson, Goulian Knife, Water Jet-
Powered Versa Jet)
• Fascial Excision (electrocutery)
• Excition done under torniquet control
• Extemities suspended from overhead
• Blood transfusion may be neede
• Ensure warmth in theatre

43. • Split thickness (thin, intermediate, thick)
• Full thickness
• Meshed or Unmeshed (sheet)
DONOR SITES SELECTION
FIXING SKIN GRAFTS
GRAFT DRESSING (open, moist, VAC, Unna boot)
DONR SITE CARE
acticoat
opsite
greasy guaze

45. • Chemical (Cement, HCL, etc)
• Inhalational injury
• Electrical
• Perineum
• Face
• Hand
• Joint

46. • Alkali or Acid
• Mechanism: Oxidation, reduction, vesicants, desiccants,
corrosive, protoplasmic poisons
• Adequate irrigation with pH testing after dry powder
brushing
• HF burns causes ↓Ca. 10% HF can be fatal (Ca
gluconate gel rapidly)

47. • Soot, CO, HCN → mucosa inflammation → PMN
migration + activation + edema
• Cytokines: IL 1, 6, TNF
• O. radicals and Proteases
• Damages ciliated epithelium with ciliary paraysis
• Separation of BM
• Mucosal inflammation and ulceration
• Bronchorrhoea, Mucus and fibrin cast
• SIRS, ARDS, reduce surfactant
• Bronchoconstriction
• Diagnosis and management

48. Material GASES
Wood, cotton CO, NO2, aldhydes
(acrolein)
PVC CO, HCL, Phosphagene
Rubber CO, SO2, H2S
Polystyrene CO, H20, Copious black
smoke
Polyerethrane, acrylonitrile,
Nitrogenous compounds
HCN
Fire Retardants Halogens (F, Cl, Br), NH4,
HCN, CO

49. • 0-10% Minimal (normal level in heavy smokers)
• 10-20% Nausea, headache
• 20-30% Drowsiness, lethargy
• 30-40% Confusion, agitation
• 40-50% Coma, respiratory depression
• > 50% Death

50. • Low volume ventilation
• Permissive hypercapnia
• High frequency percussive ventilation
• Nitric oxide
• Surfactant replacement
• Partial liquid ventilation (experimental)
• Extracorporeal membrane oxygenation (limited
application)

51. • Low (<1000V)or High Voltage (>1000V)
• Lightening = 100million volts, 200 thousand Amp
• “Splashe-on” pattern of skin burn
• Increased tissue resistance in skin, bone, fat
• Energy: current x Resistance2
• ECG for the first 24hr
• No fluid formula per se (more fluids)
• Early escharotomy, fasciotomy and compartment release
• Complications: cardiorespiratory arrest, thrombosis,
cataracts, fractures, SC injuries

52. • 2ce daily cleaning
• Traditional open dressing
• Nurse propped up
• Excision and grafting within 7-10days for full thickness or
else examine on day 10 for graft
• Sheet grafts, scalp as donor site
• Intra ocular wood lamp exam

53. • Hypothermia is corebody temperature <350C.
Heartbecomes irritable when temp <340C. Asystole when
temperature <280C
• Mech: Intracellular ice formation and microvascular
thrombosis
• Classification of Frost Bite: 1st, 2nd, 3rd, 4th degree
• Rewarming : Passive 0.2-20C hr (blankets) or Active
(External 10C Hr : warmed air, radiant warmer; Internal 1-
40C Hr: pre-warmed I.V.F, Oxygen, Bladder irrigation,
peritoneal and thoracostomy lavage. Extracoporeal
rewarming of blood can rewarm blood at 1-2 0C every
5min!
• Rewarming is painful. Water at 40-420C till perfusion

54. • Delayed presentation
• Inconsistent history
• Lack of guilt about the incidence or concern for the
prognosis
• Doughnut sign
• Sparing of flexure creases
• No splash burns in scald injury
• Isolated Burns to the face, perineum, palms or soles of
feet
• Cigarette, iron, lighter marks
• Restraints injuries to upper limbs
• Symmetrical burns of uniform depth

55. • FACTORS AFFECTING RISK OF INFECTION
• Prolonged ICU stay
• Prolonged period of intubation
• Potential colonization of eschar
• Indwelling central lines
• SITE OF INFECTION
• Lungs, blood, burn wound, urine, pancreatitis, meningitis,
endocarditis, suppurative chondritis in the ear
• TIME OF BURN WOUND INFECTION AND ORGANISM
• Gram +ve (1st week of burns)*
• Gram –Ve (2nd week of burns)*
• Anaerobes (3rd week of burns)
• Fungi (usually after 3rd week)

56. GROUP EXAMPLES CLINICAL
CHARATERISTICS
Bacteria
ß-hemolytic strep Step pyogenes Cellulitis
Staphylococci MRSA Sub-eschar pus
Gram Negative Pseudomobas,
klebsiella, proteus,
acinetobacter
baumanii
Subeschar pus usually
Following antibiotic
use
Fungi
Filaments fungi Aspergillus, fusarium Aggressive invaders
candida Low potential for
invasion, surface
colonisers

57. • Fever
• Hypotension
• Dysglycaemia
• Depressed mental status changes
• Intolerance to tube feeding
• Raised WBC
• Delayed healing and graft failure

58. Routine use of “prophylactic” antibiotics in burns is
discouraged
• Significant wound contamination
• Inhalational wounds
• Associated co-injuries e.g Fractures
• Associated immunodeficiency states
• Associated co-morbid illnesses e.g DM

59. ANTIBIOTIC ADVANTAGE PROBLEMS
Silver sulphadiazine Grm +ve,-ve, Psuedomonas Pseudo eschar, not
effective in penetrating
eschar well, selflimiting
Leukopaenia (3-5%), allergy
Non-toxic, non-painful, non-
staining, easy to apply,
penetrates tx well, does not
cause argyria
Siver nitrate (0.5%) Good tx penetration, covers
Psuedomonas
Time consuming (qid),
messy, stains, Na, Cl & K
leaching, daily EUCr, pain
on application,
methemoglobinaemia
Mefanide (5% solution,
cream)
Readily penetrates eschar,
broad spectrum (Grm+/-),
protects against suppurative
chondritis e.g nose
Metabolic acidosis
(carbonic anhydrase
inhibitor)
Painful on application
Bacitacin Good gram +ve coverage Ay cause pain on
application, rash

60. ANTIBIOTIC ADVANTAGE PROBLEMS
Neomycin Some Corticosteroid
potency, Staph, E.Coli,
H.Influenza,Pseudomonas,
Klebsiella,
enterobacteriacae
Burning, itching, dryness,
hypertricosis, striae, skin
atrophy, etc
Gentamycin Good gram negative
coverage
Allergic dermatitis, pruritus,
erythema
Mupirocin Covers MRSA Burning, itching, dryness,
erythema, secondary
wound infection
Polymyxin B Relatively Safe in
pregnancy
hypersensitivity
Combination Treatments

62. moist exposed burn therapy 3-4times daily
• Phytosterol similar to cholesterol and hydrophobic in nature.
• Widely distributed in plant kingdom (avocados, cashew, soybeans,
etc)
• Cholesterol lowering, immunomodulation, anti-cancer effects
• Other uses: BPH, hyperlipidaemia, imune boost, SLE,
malignancies, pain, sexual performance, arthritis, HIV/AIDS,
headaches, etc
• Mech: moisture, anti-inflammatory, protect exposed nerve
endings, antifungal and antibacterial environment, liquefy necrotic
tissues, reduced fluid loss, local nutrition for wound bed cells,
absorbing residual heat.
• USE: burn wounds, donor graft sites, ulcers, surgical wounds,
cracked nipples
• Contraindicated in sitosterolaemia

63. • Manuka honey
• Used by Greek Physician Dioscorides in 50A.D
• Medical grade (irradiated) honey licenced in 1999
• Therapeutic Properties:
• Antimicrobial (bacteria and fungi) but against botulism
• Antioxidant: phenolic content
• Debriding: plasminogen → plasmin, acids denatures proteases,
H202
• Anti-imflammatory
• Deodorising
• Osmotic

64. • Doctor
• Nurse
• Physiotherapist
• Occupational therapist
• Psychologist
• Speech therapist
• beauticians

65. • AIM: function, appearance, comfort
• TIME: 1 year
• Urgent Procedures
• Essential
• Desirable

66. • Strong patient-surgeon relationship
• Psychological support
• Clarify expectations
• Explain priorities
• Note all available donor sites
• Start with easy quick procedures
• Preschool age surgeries
• Offer Multiple simultaneous procedures

67. • WITHPUT DEFICIENCY OF TISSUE
• Excision and primary closure
• Incision and transposition of flaps (Z-plasty)
• WITH DEFICIENCT OF TISSUE
• Simple skin graft
• Simple reconstruction
• Dermal templates and skin grafts
• Flap reconstruction of underlying tissues

68. • Pressure garments: collagen re-orientation
• Acrylic face masks
• Massage: restrictive band release
• Moisturising creams: skin pliability
• Contact media: silicon gel, hydrocolloids
• USS: low dose, rapidly progressing inflammation

69. • Pain: background, procedural
• Anxiety: acute stress disorder, PTSD
• Depression
• Sleep disturbance
• Apparent premorbid psychologic state
• grief

70. • PHYSICAL
• Itching, limited endurance, decreased function
• SOCIAL
• Changing roles, returning to work, body image, sexual issues
• PSYCHOLOGIC
• Anxiety and depression

71. • Epidemiology
• Problem statements
• Strategies for burn management
• Cost effective burn treatments
• Characteristics of burn disaster
• Role of hospital in burn disaster

72. • Age (Baux Formula, Zawacki’s index)
• Size and depth
• Inhalational
• Co-morbid illness, other trauma
• Evidence suggests that a patient aged over 60 with a
burn covering more than 40% of body surface area and
an inhalational injury has a >90% chance of dying.

73. 1st 24 hours:
• Burn shock: Hypvolemic and distributive shock
• Airway obstruction
• ARF
• Co-injuries and Hypothermia
>24hours
• Burn wound sepsis
• Burn shock
• Electrolyte imbalance and Renal failure
• MOD and Respiratory complications
• Sever malnutrition

74. • 90% burns are preventable
• The basis for all prevention is good epidemiological data
to reveal specific causes of burns and at risk populations,
both of which can be targeted
• UK government @Fire Kills” Campaign, 2002
• Education is “active”, a change in an behaviour.
Legislation is “passive”

75. • Grabb and Smith’s Plastic Surgery, Charles H. Thorne, 6th Ed,
Lippincott Williams and Wilkins; 2007
• Principles and practice of Surgery (Including Surgery in the
Tropics) by Badoe, Achampong,
• The Washington Manual of Surgery, 5th Edition, Lippincott
Williams and Wilkins, 2008
• ABC of Burns Series, BMJ
• Current Diagnosis and treatment in Surgery by Gerald M.
Doherty, Lange Publications 13th Ed, 2010
• Comprehensive approach to Long cases in Surgery by Emeka
Kesieme, N-Trinity Press, 2013
• Review of Medical Physiology by W.F. Ganong, 21Ed. Lange
Publications
• Mustoe.T.A; Evolution of silicon therapy and mechanism of
action in scar managemnt, Springer Science+business media,
LLC 2007

76. • Mebo ointment for burn wound and management.
www.medicinep.com/mebo-ointment-for-burn-wound-
and-management-1756.html
Acknowledgements:
• Management of Burns by CPT Allen Proulx, MPAS, PA-C
• Google images