2. Burn can be defined as any injury that results
from the direct contact or exposure to any
thermal, chemical, electrical or radiation
source.
Or
A burn is a wound in which there is coagulative
necrosis of the tissue.
3. • There are different degrees of burns. Your
healthcare provider determines the
seriousness (degree) of a burn based on the
depth of the burn and the amount of affected
skin.
• Burns can be painful.
• Left untreated, a burn can lead to infection.
4. THE VARIOUS TYPES OF BUMS
• 1. ORDINARY BURNS
• 2. SCALDS
• 3. ELECTRIC BURNS
• 4. CHEMICAL BURN
• 5. RADIATION BURNS
• 6. COLD BURNS
5. ORDINARY BURNS
• ORDINARY BURNS are usually caused by dry
heat with fire, open flame, hot metal or
aeroplane crash in civil life and bomb injuries
in war time.
7. ELECTRIC BURNS
• Low-voltage electrical sources produce direct
injury at the point of contact.
• Skin and subcutaneous tissue are involved
most commonly, although muscle and bone
beneath the cutaneous bum may be damaged.
8. • High-voltage current not only causes direct
injury at the point of contact but also
damages tissues that conduct the electricity
through the body.
• Tissue damage associated with electrical
injury occurs when electrical energy is
converted to thermal energy.
• The resulting injury is a thermal bum.
9. • The skin gradually undergoes coagulation
necrosis.
• At high voltages, skin resistance is initially
overcome and the current flows through deep
tissues in the body unimpeded.
• Except bone, these internal tissues act as a
volume conductor offering little resistance to
electrical flow.
10. • Majority of electric bums are caused by high-
voltage electric current.
• The peculiarity of electrical burns is that it
causes minimal destruction of the skin.
• The skin is involved at 2 points —
• 1. At the point of contact with the electrical
source and
• 2. At the site of exit at which the patient is
grounded.
11. • The magnitude of injury of the tissues
between the point of entry and the point of
exit of the electric current is directly related to
the amount of electric current passing
through.
12. • The amount of damage also depends on the
resistance of the tissues.
• The muscle, the nerve and blood vessels offer
least resistance to the electric current and so
sustain maximum amount of tissue damage.
13. • But the skin offers considerable resistance and
that is why cutaneous injury may be
apparently small, although there may be
considerable deep tissue destruction involving
the upper and lower extremity musculatures.
14. • However it should be remembered that
electrical resistance of skin is markedly
reduced by moisture, so ulcers are more often
seen in the axilla and antecubital fossa in case
of electrical bum of the upper extremity.
15. • Electrical injury to the musculature is often
associated with release of haemochromogens
into the blood stream which are ultimately
excreted through urine.
• So 'port-wine' coloured urine is not unusual
following major electrical injury.
16. CHEMICAL BURN
• CHEMICAL BURN is caused by strong acid or base
which comes in contact with skin or any other
tissue.
• The severity of the damage is directly related to
the concentration of the chemical agent, the
amount of agent and the duration of contact.
• Such bum injury tends to be deeper than it is
assessed from outside.
• If the superficial slough is removed, the depth of
the injury can be assessed.
17. RADIATION BURNS
• RADIATION BURNS are usually caused by X-
rays or radium.
• This is in fact a type of inflammation of the
skin which can be regarded as bum.
• This only occurs when the tissue has been
irradiated beyond its tolerance limit.
18. Two types of radio dermatitis are usually seen:
1. ACUTE RADIODERMATITIS
2. CHRONIC RADIODERMATITIS
19. ACUTE RADIODERMATITIS
• which presents the usual changes of acute
inflammation with erythema, varying degrees
of oedema and exfoliation.
• These usually develop on or about the 5th
day.
• If the exposure dose is highly excessive, it may
cause necrosis in both epidermis and dermis.
• In such cases a slough is formed, which on
separation leaves a deep indolent ulcer.
20. CHRONIC RADIODERMATITIS
• May occur if small doses of irradiation are given
for too long a time or if acute radio dermatitis has
occurred a few years ago which may leave
chronic radiodermatitis as legacy.
• In this condition the skin shows irregular
pigmentation or depigmentation in certain areas,
telangieactases and small indolent ulcers.
• Microscopically there may be atrophy and
flattening of the epidermis, but the dermis
becomes dense and sclerotic.
21. • Skin appendages may disappear and the small
cutaneous vessels may become dilated.
• The most important feature of this chronic
radio-dermatitis is its liability to grow into
cancers.
22. 6. COLD BURNS
• Are caused by exposure to cold which include
freezing injuries (frostbite) or non-freezing cold
injuries e.g. chilblain (localized painful erythema
in the fingers, toes or ears produced by cold
damp weather), trench foot (seen in soldiers due
to prolonged exposure to extreme cold water
combined with circulatory disturbances
predisposed by tight clothing, garters or ill-fitting
shoes) and immersion foot (a condition
resembling trench foot occurring in shipwrecked
persons who have spent protracted periods in
waterlogged boats).
23. • It is usually a concern in military populations,
though it is being encountered increasingly in
the civilian population with the rise in
popularity of winter sports.
• Cold burns also cause coagulative necrosis of
the tissue.
24. FROSTBITE
• FROSTBITE results in actual freezing of tissues
with the formation of ice crystals.
• Mostly the skin and subcutaneous tissue of the
hands, feet, ears and nose are affected.
• When these parts are exposed to low
temperatures for prolonged period of time such
injury may occur.
• Tissue necrosis following frostbite is related
primarily to the mechanical effects of ice crystals,
cellular dehydration and microvascular occlusion.
25. • Crystals of ice appear both intra cellularly and
extra cellularly in any tissue.
• As freezing progresses intracellular water
shifts to the extracellular space and leads to
intracellular dehydration with increase in
intracellular concentrations of electrolytes,
proteins and sugar.
• The resulting hyperosmolarity leads to
denaturation of intracellular proteins.
• The skin is relatively resistant to these
damaging effects, though other tissues like
nerves, muscles and blood vessels are quite
sensitive.
26. Clinical features of frostbite are
described by various degrees:
• First-degree frostbite is hyperaemia and oedema of the
skin without necrosis.
• Second-degree frostbite causes hyperaemia, vesicle
formation and partial thickness necrosis of the skin.
• Third-degree frostbite causes necrosis of the entire skin
thickness and may extend to a variable degree into the
underlying subcutaneous tissue.
• Fourth-degree frostbite means necrosis of full thickness
of the skin including subcutaneous tissue and all
underlying structures including muscle and bone.
• This leads to gangrene of the affected part.
27. PATHOLOGY OF BUMS
• For advantage of description, pathological
changes of bums are divided into 2 heads —
• I. Local changes and
• II. Systemic changes.
28. I. LOCAL CHANGES
• These can be described under 4 heads —
1. Severity of bum,
2. The extent of bum,
3. Vascular changes and
4. Infection.
29. • 1. SEVERITY OF BURN.
• Bums are classified into 3 grades or degrees
according to the depth of necrosis.
• In first-degree bum there is simply hyperaemia of
the skin with slight oedema of the epidermis.
• There is only microscopic destruction of the
superficial layers of the epidermis, which are
desquamated within a few days.
• It is of little clinical significance as the superficial
layers of epithelium are soon replaced from the
basal layers, so that there is no scarring.
30. • First-degree burns rapidly heal if the patient
avoids further exposure to source of heat.
• First-degree burns are not considered while
estimating the magnitude of bum for
purposes of planning intravenous fluid
replacement.
31. • In second-degree burns the entire thickness of
the epidermis is destroyed.
• Blebs or vesicles are formed between the
separating epidermis anddermis.
• Vesiculation is the hall mark of the second-
degree burn.
• Second-degree bum is further subdivided into
• (a) Mild and
• (b) Severe varieties.
32. • In mild cases enough epithelium is left in the
hair follicles and dermal glands to provide new
cells for resurfacing the burned area.
• In severe cases, there is not enough
epithelium left, so that resurfacing of the
burned area is not possible and skin grafting
becomes necessary.
33. • In third-degree burn there is complete
destruction of the epidermis and dermis with
irreversible destruction of dermal appendages
and epithelial elements including the sensory
nerves.
• Skin grafting becomes obligatory to cover the
area.
34. ANOTHER TYPE OF CLASSIFICATION
• Another type of classification is in vogue to
describe severity of bum. In this classification
two degrees are considered —
• (a) partial thickness bum and
• (b) full thickness bum.
35. (a) Partial thickness burn
• Partial thickness burn is that type of bum in which
the superficial layers of the skin e.g. the whole of
epidermis and sometimes the superficial part of
the dermis become destroyed.
• But there are enough epithelial cells surrounding
the hair follicles or sweat glands from which
regeneration may take place.
• So in partial-thickness bum, spontaneous
regeneration of epithelium is expected and skin
grafting is not necessary.
36. (b) Full thickness burn
• Full thickness burn: In this condition the whole
thickness of the skin including the epidermis and
the total depth of the dermis is destroyed.
• Spontaneous regeneration of epithelium is not
possible, so development of scar tissue and
contractures are inevitable unless skin grafting is
performed in right time.
• As sensory nerves are also destroyed in full
thickness bum, sensation is lost in full thickness
burn and pin prick test (by firmly pressing a
needle over the burned area) will be negative.
37. • To the contrary sensation of the skin remains
and pin prick test will be positive in partial
thickness burn.
• It must be remembered that since skin varies
in thickness in different parts of the body,
application of the same intensity of heat for a
given period of time will result in a burn which
will vary in depth depending on the thickness
of the skin in the local area and on the degree
of development of the dermal appendages
(sweat glands and hair follicles) and dermal
papillae.
38. 2.EXTENT OF BURN
• EXTENT OF BURN.— The length and width of
the bum wound is expressed as a percentage
of the total surface area displaying either
second or third-degree bum.
• The extent of burn is most commonly
estimated by the 'rule of nines'.
39. 'Rule of nines' for estimating percentage of body
surface involved in bums are as follows:—
Anatomic area Percentage of body surface
• Head, face and neck 9%
• Right upper extremity 9%
• Left upper extremity 9%
• Right lower extremity (thigh - 9%, leg and foot - 9%)
18%
• Left lower extremity 18%
• Anterior trunk ( chest - 9%, abdomen - 9% ) 18%
• Posterior trunk ( upper half - 9%, lower half - 9% ) 18%
• External genitalia 1%.
Above-mentioned 'rule of
nines' is applicable only to
the adults.
40. INFANTS AND CHILDREN
• The surface area of the head and neck of
children is significantly larger than 9%.
• For example in one year old child the surface
area associated with head is about 19% as
compared to only 7% in adults.
• In contrast, each lower extremity represents
only 13% of the total body surface area in
these patients.
41.
42. 3. VASCULAR CHANGES
It is of great importance in the burnt area. Two
main changes are noticed —
• There is dilatation of small vessels due to
direct injury to the vessel walls and to local
liberation of histamine.
• This increases blood flow to the injured part
as seen in case of inflammation.
• This increased blood flow is not followed by
stasis as happens in inflammation.
43. • Capillary permeability is greatly increased.
• Due to this, plasma rich in protein pours out
continuously in large amount.
• This exudate collects in blisters or begins to
dry to form a dry brown crust which protects
the wound.
• This crust separates in one or two weeks in
case of superficial bums, but it takes longer
times in case of deep bums.
44. 4. INFECTION
• Skin is sterilized.
• In case of first-degree bums the intact epidermis
will act as barrier against infection.
• But in case of deep burns, if the crust which
protects the raw wound is broken virulent
organisms may enter the bum wound to cause
severe infection.
• Moreover general malnutrition, loss of plasma
and blood volume and anemia in extensive bums
severely handicap the defense mechanism
against infection.
45. • Bacteriaemia and bacteriaemic shock are the
second commonest cause of death in bum
following oligaemic shock.
• This usually occurs between the second and
third weeks.
46. SYSTEMIC CHANGES
• These can be conveniently described under
four heads —
• 1. Shock.
• 2. Biochemical changes.
• 3. Changes in blood.
• 4. Systemic lesions.
47. 1. SHOCK
• This is the most important effect of bums.
• Various types of shock are come across in
burns, but by far it is the oligaemic shock
which is the most important and claims
majority of lives following burns.
• (a) Oligaemic shock.
• (b) Neurogenic shock.
• (c) Cardiogenic shock.
• (d) Bacteriaemic shock
48. 2. BIOCHEMICAL CHANGES
• (i) Electrolyte imbalance.
• (ii) Hypoproteinaemia.
• (iii) Hyperglycemia.
• (iv) There will be rise in blood urea, N.P.N. and
creatinine levels due to kidney damage in
extensive bums.
49. 3. CHANGES IN BLOOD
• (i) Haemoconcentration.
• ii) Apparent increase in the number of red cell
is also due to outpouring of plasma.
• (iii) Sludging of blood may occur due to
intravascular agglutination of R.B.Cs.
• (iv) An abrupt fall in the eosinophil count
during the first 12 hours is very characteristic
of bums.
• (v) Aggregation of red cells, white cells and
platelets is a common finding in burns. This
increases blood viscosity.
50. • In the course of 24 hours the count should
begin to rise.
• Eosinophil count may give an indication to the
prognosis of the case.
• A persistent eosinopenia, failure in the early
rise after the initial drop and lack of late rise in
the eosinophil count indicate bad prognosis.
51. • (vi) Anaemia.
• (vii) A biphasic alteration of the coagulation
system is also seen in burns.
52. 4. SYSTEMIC LESIONS
• (i) The liver may show numerous areas of focal
necrosis.
• (ii) Kidney is often involved due to low blood perfusion.
• (iii) Adrenals become slightly enlarged and deeply
congested.
• (iv)Gastric and duodenal mucosal changes indicative of
focal ischaemia can be observed as early as 3 to 5
hours after bums.
• (v) Alterations of pulmonary function.
• (vi) A change in the endocrine pattern.
• (vii) Neurogenic changes are not commonly seen in
burn injuries.
• (viii) Immunologic impairment
53. TREATMENT
• This is conveniently described under three
headings —
• I. Treatment of shock,
• II. General treatment and
• III. Local treatment of bum wound.
54. I. TREATMENT OF SHOCK
• 1. Sedation
• 2. Fluid resuscitation
• 3. Maintenance of airway
55. II. GENERAL TREATMENT
• 1. Escharotomy and fasciotomy.
• 2. Tetanus prophylaxis
• 3. Antibiotics.
• 4. Nutritional support.
• 5. Gastric decompression.
• 6. Treatment of G. I. complications.
56. III. LOCAL TREATMENT
• 1. First-aid measures
• The patient should be immediately removed
from source of heat.
• Cold clean water should be applied to the
burned area immediately and is continued
every 5 minutes.
57. • 2. Burn wound care
• After proper resuscitation, attention should be
directed to the burn wound.
• It should be cleansed with a surgical detergent
and all loose nonviable skin should be trimmed
away.
• The second-degree bums or partial thickness
bums usually present as vesicular lesions.
• The overlying blister should be punctured and the
upper nonviable skin is removed.
• Such debridement should usually be performed
without anesthesia, but with tremendous aseptic
care
58. • At the time of wound cleansing, the entire wound
should be inspected.
• Silver nitrate must be used soon after injury,
before bacteria have proliferated on the wound.
• Majority of the topical antimicrobial agents
appear to be equally effective in controlling burn
wound infection when applied early before heavy
colonization has occurred.
• The nonviable skin of the third-degree or whole
thickness bum injury is known as the eschar.
• Usually the eschar remains tightly adherent to
the underlying subcutaneous tissue and its
removal may cause significant pain and severe
haemorrage. 72
59. MANAGEMENT OF BURNS
First Aid
• Stop the burning process and keep the patient
away from the burning area.
• Cool the area with tap water by continuous
irrigation for 20 minutes (not cold water as it
can cause hypothermia).
60. Indications for admission in burns
• Any moderate and severe burns
• Airway burns of any type
• Burns in extremes of age
• All electrical/deep chemical burns
62. Primary Remedies
• Apis mellifica
• This remedy relieves pink, swollen skin with itching,
burning pain improved by applying cold compresses.
• Cantharis
• This remedy relieves blisters from burns or friction.
• Urtica urens
• When a burn is mild and the primary symptoms are
redness and stinging pain, this remedy often brings
relief. It is often useful for sunburn when the pain is
prickly and stinging.
63. Other Remedies
• Arnica
• This is a valuable first-aid remedy to help reduce pain and
swelling and prevent the onset of shock after any injury.
Another remedy that is more specific to the burn should be
considered after Arnica.
• Belladonna
• This relieves red, hot and painful skin from burns or
sunburn.
• Calendula Ointment
• This remedy has a slight antiseptic action, speeds up the
healing of damaged skin, and keeps the skin moisturized.
• Causticum
• If a burn is intensely painful and blisters seem to be
forming, this remedy may help to bring relief. The person
often feels more sad than restless from the pain. Rawness
and soreness may develop in the injured area. Causticum is
also helpful when pain remains in older burns, or when
burns have not completely healed.
64. Other Remedies
• Hepar sulphuris calcareum
• This remedy is helpful for treating very sensitive and painful
burns in people who are prone to infection. The person
may feel extremely vulnerable and irritable, and may have
chills or be very sensitive to cold.
• Hypericum
• This remedy is often helpful when the pain of a burn is
intense and the nerves are extremely sensitive. Along with
the usual discomfort of a burn, stabbing or shooting pains
may be felt in the injured area.
• Phosphorus
• This remedy may be useful for the pain of electrical burns,
on the way to medical care. (When electrical burns occur,
the damaged area may look small on the surface, but be
more extensive underneath; they should always be
examined by a doctor.)
65. Other Remedies
• Calendula and Hypericum tinctures
• These tinctures (used topically in
unpotentized herbal form) often is helpful in
soothing burns and promoting tissue healing.
• Ten drops of
either Calendula or Hypericum tincture, or
both, may be mixed in an ounce of water and
applied to the area several times per day.
