This document provides an overview of burns, including definitions, epidemiology, classification, pathophysiology, evaluation, treatment and management. It begins with defining burns as destruction of skin layers through coagulative necrosis. Globally, an estimated 180,000 deaths occur annually from burns, most in low and middle income countries. Burns are classified based on depth and degree of injury. Initial management focuses on ABCs, estimating burn size, preventing infection, and providing wound care and nutrition. Complications can include shock, infection, pulmonary, gastrointestinal and renal issues.

1. Burn: Classification,
Pathophysiology and
Management
Prepared by: Loza Getachew and
Yared Nekeatibeb

2. Outline
Definition
Epidemiology
Etiology
Classification
Measurement of Extent of Burn
Evaluation and Treatment

3. Definition
A burn injury is destruction of the surface
layers of the body by way of coagulative
necrosis.
Human skin can tolerate temperatures up
to 44⁰c.

4. Epidemiology
• In Ethiopia a community based study showed ;
annual incidence was 1.2% according to
Ethiopian journal of health development 2002
with highest incidence in children less than
five years old
Scald burn (59%)
Flame (34%)

5. Cont’d
• Globally an estimated 180 000 deaths occur
every year due to burn injuries according to
WHO.
• The vast majority occur in low and middle
income countries like Africa and south-east
Asia.
• Burn injuries usually occur in home or
workplace areas.

6. Etiology
Thermal injury
 Scald burns
 Flame burns
 Contact burns
Chemical injury
Electrical injury
Radiation injury
Cold injury
Sun burns

7. Cont’d
I. Scald burns
• Scalds from hot water are very common
causes of burn
• Depth of the burn is proportional to the
temperature of the water, duration of contact
and thickness of skin.

8. Cont’d
II. Flame burns
• Caused by house fires, automobile accidents
or falling into an open fire

9. Cont’d
III. Contact burns
• Results from contact with hot metals, plastic,
glass or hot coals.
• Can be limited in extent but very deep.

10. Cont’d
 Chemical burns
• Caused either by strong acid or alkaline
substances.
• Chemical burns should be considered deep
dermal or full thickness until proven
otherwise.

11. Cont’d
 Electrical burns
• Caused by intense heat generated by an
electric current.
• Severity depends up on amount of voltage,
tissue resistance, current pathways, surface
area of contact and length of time of the flow.

12. Cont’d
 Cold injury (frost bites)
• Resulting from prolonged exposure to freezing
or sub-freezing temperatures
• Usually affects fingers, toes, nose and ears.

13. Cont’d
 Sun burn
• Skin injury from spending a prolonged amount
of time in the sun.

14. Classification
Burn injury is classified based on:
1. Depth
– Superficial
– Superficial partial thickness
– Deep partial thickness
– Full thickness
2. Degree

16. Classification based on degree

17. Pathophysiology
Heat causes coagulative necrosis of skin and subcutaneous tissue
↓
Release of vasoactive peptides
↓
Altered capillary permeability
↓
Loss of fluid→ severe hypovolemia
↓
Decreased cardiac output function
↓
Decreased renal blood flow→ oliguria
↓
Altered pulmonary resistance causing pulmonary Edema→ infection
↓
Multi organ dysfunction syndrome(MODS)

18. Measurements of extent of burns
• Wallace’s Rule of 9
Provides a quick estimate of percent of burn
It is in accurate in children and hence should only
be used for adults
It divides the total body surface area into
multiples of 9

19. Wallace’s rule of nine

20. Cont’d
• Lund and Browder measurement:
More accurate assessment tool
 Different percentages are used because the ratio
of the combined surface area of the head and
neck to the surface area of the limbs is typically
larger in children than that of an adult.

21. Lund and Browder measurement

22. Cont’d
• Rule of palms
 Basically we consider the palm of the patient to
be 1% of the total body surface area and use the
palm for measurement
 Good for estimating small patches of burn wound

23. Evaluation and Treatment

24. Initial Assessment
• Initial approach to a patient with a major burn
is similar to that for any other patient
experiencing major trauma
• Assessment begins with a primary survey
including evaluation of the A, B, C of
resuscitation
• Later, a complete secondary survey should be
conducted

25. Pre-hospital Care
• Stop the burning process
• Cool the burn wound.
• Elevate
• Check for other injuries

26. Primary Survey
• ABC of life
• Mucosal edema evolves in those with extensive body
burns or inhalation injury, obstruction of the upper airway
can develop rapidly
– Provide an adequate Airway with C-spine
immobilization
– Provide sufficient Breathing including intubation if
necessary
• Evaluate Circulation considering clinical signs and
symptoms of shock and tamponade
– Assess peripheral circulation adequacy
• Clothing, rings, watches, and other jewellery should be
removed from any injured limbs

27. Cont’d
• Fluid resuscitation
– For any adult 15% TBSA or any child with 10%
TBSA

28. Cont’d
• Place urinary catheters and nasogastric tube
• Ordering proper radiological and laboratory
investigations
– CBC
– Renal function test
– Chest X-ray
– RBS
– Serum Electrolytes
– ABG analysis

29. Secondary Survey
• Complete history taking
Time of injury
Place of injury (open/closed)
Unconsciousness during incidence
Mechanism of burn injury/agent
Duration of exposure to agent
Pre-existing illnesses such as diabetes,
hypertension, and cardiac or renal disease
Last Tetanus shot

30. Cont’d
• Physical Examination
– Assess the respiratory system by inspecting the
mouth, nose, pharynx
– Burns of the lips, face, ears, neck, eyelids, eyebrows,
and eyelashes are strong indicators that an inhalation
injury maybe present
– Change in respiratory pattern
– Audible wheezes and stridor
– Measure central and peripheral pulses, blood
pressure, capillary refill and pulse oximetry
– Assess bowel sounds

31. Cont’d
• Burn Size Estimation
– Lund-Browder chart
– Rule of nines
– Palmar method
• Determination of Burn Depth
– Superficial
– Superficial partial-thickness
– Deep partial-thickness
– Full-thickness

32. Initial Therapy

33. Emergent Phase
• Maintaining proper oxygenation and tissues
perfusion
• Maintaining fluid and electrolyte balance
• Relieving pain
– Morphine may be used, but not for full-thickness
burns
– IV > IM
• Preventing infection
• Relieving anxiety and providing psychological
support

34. Acute Phase- Medical Managements
• Prevent Infection
– Prophylactic antibiotics
– Immunization- most recent toxoid booster injection
more than 1 year before injury should receive booster
and if never immunized, human antitetanus globulin
and an immunizing dose of toxoid.
• Provide metabolic support
– Curreri formula is the most popular-
Adult: 25 kcal. X weight (kg) + 40 kcal. X %TBSA
– Enteral nutrition > parenteral nutrition
– Gastric feeds > small bowel feeding

35. Cont’d
• BMD (butter milk diet)
– 1L of milk
– 4 eggs
– 3 banana
– 50gm sugar
• 1mL of BMD provides 1 Calorie and 0.047gm protein
• 5 mg/kg per minute glucose and protein at 2.5 g/kg
per day + intravenous fat emulsions if parenteral
routes are preferred

36. Cont’d
• Provide wound care
– Wound cleaning and debridement
– Topical antimicrobial treatment
• Wound dressing
– Full thickness & deep dermal burns need
antimicrobial dressing
– Superficial burns need simple dressing
1. Open (exposure) method- in warm climate
2. Closed (occlusive dressing) method- in cold climate
• Electrolyte abnormality

37. Acute Phase- Surgical Managements
1. Escharotomies
– 2-6 hrs after burn injury
– Neurovascular checks are indicated for any partial-
thickness or full-thickness near-circumferential
burn of the extremities

38. Cont’d
2. Fasciotomy
– Usually not necessary, except in patients with very
deep burns in the extremities and burns from
electrical injuries
– Confining tissue is the deep fascia and not the
eschar

39. Cont’d
3. Wound grafting
– Biologic graft types
– Biosynthetic and synthetic graft types

40. Rehabiliation Phase
• Minimizing functional loss
– Exercise
– Positioning
• Provide psychological support
– Self image issues
– Physical limitations
– Reintegration into society

41. Complications of Burn
• Burn Shock
• Wound Infection
• Pulmonary
 Pneumonia
 ARDS
 Pulmonary edema
• Gastrointestinal
 Curling’s Ulces
 Paralytic Ileus
 Acalculous Cholecystitis
• Renal
 AKI
 Pigment Nephropathy

42. Cont’d
• Cardiovascular
– Arrhythmia
• Neurologic
– Burn Encephalopathy
• Integumentary
– Marjolin’s Ulcer
– Contracture
– Keloid
– Hypertrophic Scar
• Thrombophlebits
• UTI

43. Cont’d

44. References
1. Oxford Textbook of Surgery , Morris & Wood
2. Bailey & Love Short Practice of Surgery , Sir
Norman Williams
3. Grabb & Smith’s Plastic Surgery, Kevin Chung
4. UpTo Date 2018

45. Thank You