The document discusses the epidemiology, assessment, treatment and management of burns. It notes that the majority of burns in children are scalds, while flame burns are more common in adults. Assessment involves determining the percentage of total body surface area burned and burn depth. Treatment includes fluid resuscitation, wound care using dressings like silver sulfadiazine, and management of complications like inhalation injury and infection. Good outcomes depend on factors like percentage and depth of burns, and presence of an inhalation injury.

1. BURNS

2. Epidemiology Incidence varies between cultures Majority in children are scalds Adolescents experimenting

3. Epidemiology Flame burns in adults Most electrical & chemical burns in adults Mental diseases , epilepsy, alcohol & drug abuse

4. On arrival burn case treated as trauma ABC Soot ,charring around nose – think of inhalation injury

5. Assessment of burns area Wallace’s rule of nine Adult >20% ,child >10% needs IVF i/v access for analgesia

6. Prognosis Percentage body surface area burned Age & percentage add together to a score of 100 , considered fatal

7. Assessment of burn depth Temperature of burning agent Mode of transmission of heat Duration of contact

8. Skin anatomy Epidermis waterproof Replaced from the basal layer Dermis-thicker strength & integrity Contains the adnexal structures

9. Superficial burns Epidermal burns Heal by epithelialisation alone Red & painful Blisters not present

10. Superficial burns superficial dermal Blistered Painful Heal by epithelialisation in 14 days

11. Deep burns Adnexal structures lost Heal by second intention scarring

12. Deep burns Blistered Blotchy red appearance No capillary return on pressure Absent sensation to pin prick

13. Full thickness burns White/ charred appearance No sensation Charred layer consists of denatured contracted dermis - eschar

14. Pathophysiology Injuries to skin Injury to airway & lungs Inflammation & circulatory changes Other effects

15. Injuries to skin MC organ affected is skin Area affected Depth

16. Inhalational injury Hot gases cause injury to upper airway Stridor, hoarseness, cough, resp. obstruction CO causes chemical burn dr shabeel’s presentations

17. Injury to airway & lungs damage airway & lungs Airway injury suspected in face & neck burns Person trapped in burning vehicles,house , plane etc

18. Injury to airway Burns above larynx Below larynx Metabolic poisoning Inhalational injury Mechanical block on rib movement

19. Above larynx Hot gases burn nose , mouth, tongue , palate & larynx Linings start swelling May block the airway

20. Below larynx Rare as heat is absorbed in supra glotic area But steam has a large latent heat of evaporation Epithelium swells & detaches This cast block the airway dr shabeel’s presentations

21. Metabolic poisoning CO –product of incomplete combustion Affinity 240 times than Hb for O2 Blocks transport of O2 Carboxy Hb > 10% is dangerous Need pure O2 >24 hrs Death occurs with 60%

22. Another metabolic toxin is hydrogen cyanide Metabolic acidosis by blocking mitochondrial respiration

23. Inhalation Caused by minute particles within smoke Stick to moist lining alveoli Chemical pneumonitis

24. Intense edema Decreasing gaseous exchange Bacterial pneumonia

25. Mechanical block on rib movement Burned skin – thick & stiff Stop movement of ribs Common in large full thickness burn across the chest

26. Inflammation & circulatory changes Burned skin activate a web inflammatory cascades Pain - Release of neuro peptides & activation of compliments Hageman s factor – protease driven cascades

27. Inflammation & circulatory changes Compliments – degranulation of mast cells Coats the proteins burned Attracts neutrophils – degranulate – free radicals & proteases

28. Inflammation & circulatory changes Mast cells release primary cytokines – TNF alfa Secondary cytokines Alter the permeability of vessels

29. Inflammation & circulatory changes Large protien molecules escape Oncotic pressure again increases More flow of water into extra vascular space

30. Inflammation & circulatory changes Water ,solutes, proteins – ECF Occurs in first 36 hrs 10-15% burns – shock >25% loss occurs in remote vessels

31. Other effects Immune system & infection Changes in intestine Peripheral circulation

32. Immune system & infection Inflammatory changes affect immune system CMI reduced in large burns Bacterial & fungal infection

33. Changes in intestine Micro vascular damage & ischemia of gut mucosa Motility & absorption affected Failure to enteral feeding Translocation of gut bacteria

34. Septicemia Abdominal compartment syndrome- mucosal swelling, stasis, peritoneal edema Splinting of diaphragm

35. Peripheral circulation Full thickness burns- coagulation of collagen Elasticity of skin lost Circumferential burn of the limb act as tourniquet

36. Regional problems Circulation May affect the limb circulation Not by direct damage to main vessel edema - venous obstruction Muscle compartment syndrome

37. Effects of burn injury Local Regional Systemic

38. Local effects Tissue damage Inflammation Infection

39. Tissue damage Heating -> cell rupture / necrosis Cells of periphery injured Denaturation of collagen

40. Tissue damage Capillaries thrombosed in severe cases Increased damage in less severe case Tissues become edematous

41. Inflammation Marked response Erythema in least burned areas Neurovascular response like Lewis triple response

42. Severe – cytokines Phagocytose necrotic cells Damaged tissues separate by de sloughing in 3 wks

43. Infection Damaged tissue – nidus of infection Colonization in 24 – 48 hrs Bacteremia is a common cause of fatality

44. Systemic effects Fluid loss Multiple organ failure Inhalational injury Systemic complications

45. Fluid loss External loss Internal loss as edema Mediated by cytokines

46. Management Immediate care Assessment of burn wound Fluid resuscitation Treatment of burn wound

47. Immediate care Pre hospital Hospital care

48. Pre hospital Ensure rescuer safety – house fire , chemical , electrical Stop the burning process – stop, drop & roll Check for other injuries Cool the burn wound

49. Pre hospital Cool the burn wound – minimum 10mts to an hour Oxygen elevate

50. Hospital care Airway Breathing Circulation Disability Exposure with environmental control Fluid resuscitation

51. Major determinants of outcome Percentage area Depth Inhalational injury

52. Criteria for admission Inhalational injury Fluid resuscitation Needing surgery Suspicion of non accidental cause Extremes of age Associated potential sequelae

53. Airway Burned airway causes obstruction Endo tracheal tube for 48 hours Symptoms of laryngeal edema appear late

54. Airway Intubation will be difficult after symptoms appear Crico thyroidotomy needed in late diagnosis Recognition of potentially burned airway

55. Breathing Inhalational injury Thermal burns to lower airway Metabolic poisoning Mechanical block to rib movement

56. Inhalational injury Observe anyone trapped in a fire Presence of soot in nose & oro pharynx Chest x-ray - patchy consolidation

57. Clinical features Progressive increase in resp effort & rate Rising pulse , anxiety , confusion Decreasing oxygen saturation

58. Treatment Secure the airway Physiotherapy, nebulisation, warm humidified oxygen Monitor the progress IPPV for severe cases

59. Burns of lower airway Steam injury Supportive management Like inhalational injury

60. Metabolic poisoning Fire within a closed space Altered consciousness ABG

61. Metabolic acidosis High inspired O2 for 24 hrs if >10% Displacement from Hb

62. Mechanical block to rib movement Eschar on the chest CO2 retention & high inspiratory pressure if ventilated escharotomy

63. Assessment of burn wound Size depth

64. Size Formally assessed in a controlled environment Allows areas to be exposed & any soot / debris to be washed off Do not cause hypothermia

65. Patients whole hand – 1% of TBSA Lund & Browder chart Wallace rule of nine - approximate

66. Depth Superficial partial thickness Deep partial thickness Full thickness

67. Fluid resuscitation Maintain the intravascular volume Needed in a child with > 10% 15% in adults

68. If oral water should not be salt free Stress hormones – anti diuresis Hypo natremia & water intoxication

69. Resuscitation volume – area burned Maximum loss in 8hrs Lasts 24 – 36 hrs

70. Fluids Ringer lactate / Hartmans Human albumin solution / FFP Hypertonic saline

71. Parkland formula % burns x body wt x 4 Half in first 8hrs Half over next 16 hrs

72. Maintanance fluid given for children as DNS 100ml/kg for 24 hrs for 10Kg 50ml/kg for next 10 kg 20ml/kg for each Kg over 20Kg

73. Monitoring Key is urine output 0.5 -1 ml /kg body wt / hr If output low increase the infusion rate by 50% Should not be over resuscitated

74. Monitoring Acid base balance Hematocrit measurement CVP monitoring

75. Treatment of burn wound Eshcarotomy Full thickness Superficial partial

76. Eshcarotomy Circumferential full thickness burns of limbs Incised in mid axial line to avoid nerves Management of burn wound same

77. Full thickness 1% silver sulphadiazine Silver nitrate solution 0.5% Mefenide acetate Serum nitrate

78. 1% silver sulphadiazine Broad spectrum prophylaxis Pseudomona MRSA

79. Silver nitrate solution 0.5% Highly effective – pseudomonas Poor against some gram negative aerobes Needs change every 2 -4 hr Black staining

80. Mefenide acetate Popular in USA Painful 5% solution Metabolic acidosis

81. Serum nitrate Hard effect on the burned skin Especially in elderly Reduces the CMI suppression

82. Superficial burns Honey Boiled potato peel Synthetic biological dressings