Easy and quick review of burns,almost covering all types of burns and their management

1. BURNS
BY
DR IHTISHAMZARIN
PG TRAINEE SURGICAL B WARDSTHSWAT

2. BURN:
ACCORDING TO WHO
BURN IS AN INJURY TO THE SKIN OR OTHER ORGANIC TISSUE
PRIMARILY CAUSED BY HEAT OR DUE TO RADIATION,
RADIOACTIVITY, ELECTRICITY,FRICTION OR CONTACT WITH
CHEMICALS.IN ADDITION, RESPIRATORY DAMAGE RESULTING
FROM SMOKE INHALATION ARE ALSO CONSIDERED TO BE BURNS.

3. OVER 96% OF FATAL RELATED BURNS OCCURS IN LOW AND MIDDLE INCOME
COUNTRIES.IN ADDITION TO THOSE WHO DIE, MILLIONS MORE ARE LEFT WITH LIFE
LONG DISABILITIES AND DISFIGURMENTS.
HIGH INCOME COUNTRIES HAVE MADE CONSIDERABLE PROGRESS IN LOWERING
RATES OF BURNS DEATH,THROUGH COMBINATION OF PROVEN PREVENTATIVE
STRATAGIES AND THROUGH IMPROVMENTS IN THE CARE OF BURNS VICTIMS.MOST OF
THESE ADVANCES IN PREVENTION AND CARE HAVE BEEN INCOMPLETELY APPLIED IN
LOW AND MIDDLE INCOME COUNTRIES.
A STUDY WAS CONDUCTED IN BURN UNIT OF LRH IN 2000.IN THIS 1 YEAR STUDY 758
PATIENT WERE STUDIED.CONCLUSION OF THE STUDY WAS;
MAJORITY OF BURN ACCIDENTS OCCURS AT HOME AND ARE
PREVENTABLE.SCALDS INJURY IS THE MOST COMMOMN CAUSE OF BURN RESULTING
IN 2/3 OF THE TOTAL BURNS.MAJORITY OF THE PATIENTS ARE CHILDREN.

4. TYPES OF BURNS
THERMAL
CONTACT WITH HOT OBJECTSFLAME
HOT FLUIDS OR SCALDS
COLD

5. CHEMICAL
ALAKALIES
ACIDS
OTHER CHEMICALS
ELECTRICAL
LOW VOLTAGE
HIGH VOLTAGE
LIGHTENING
RADIATION
SUN BURNS
RADIOACTIVITIES e.g. X-Rays, Radiotherapies and nuclear explosions
etc.

6. PATHOPHYSICOLOGY:
LOCAL EFFECTS:
TISSUE DAMAGE:
HUMAN SKIN IS THE MOST COMMON ORGAN EFFECTED.IT CAN TOLERATE
TEMP UPTO 45C ABOVE THIS PERMANENT DAMGAGE OCCURS, RESULTS IN
DIRECT CELL DEATH AND NECROSIS.COLLAGEN IS DENATURED AND THE
CAPPILLERIES ARE EITHER THROMBOSED WHERE THE DAMAGE IS SEVER OR IN
LESS DAMAGED AREAS THERE IS INCREASED PERMEABILITY SUCH THAT THE
TISSUES BECOME EDEMATOUS.
INFLAMMATION:
THERE IS MARKED AND IMMEDIATE INFLAMATORY RESPONSE.THE PRECISE
CAUSE OF THE IMMEDIATE VASODILATION MAY REPRESENT A
NEUROVASCULAR RESPONSE SIMILAR TO LEWIS TRIPLE
RESPONSE,.MACHROPHAGES PRODUCES INFLAMATORY MEDIATORS LIKE TNF-
P ETC AND PHAGOCYTOSE NECROTIC CELLS.NEUTROPHILS AND LATTER
LYMPOCYTES PROVIDES PROTECTION AGAINST INFECTION,

7. OVERALL EFFECT:
ZONE 1: PRIMARY CELL INJURY
ZONE 2: THROMBOSED AREA
ZONE 3: HYPERMIA

8. REGIONAL PROBLEMS:
LIMB CIRCULATION MAY BE COMPROMISED.DIRECT DAMAGE TO
A MAIN LIMB VESSEL IS UNLIKELY,ALTHOUGH IT MAY OCCUR FROM
HIGH TENSION ELECTRICAL BURNS.IF THERE IS GROSS EDEMA IN A LIMB
FOLLOWING BURNING , THE SWELLING AND TISSUE TENSION MAY LEAD
TO VENOUS OBSTRUCTION, THIS IS PARTICULARLY LIKELY WHERE
THERE IS CIRCUMFRENTIAL BURN TISSUE (ESCHAR) WHICH IS
INCAPABLE OF DISTENDING,THERE IS ALSO POSSIBILITY OF MUSCLE
COMPARTMENT SYNDROME IN AFFECTING ANY COMPARTMENT OF THE
LIMB.

9. CIRCULATORY CHANGES:
FLUID LEAKAGE IN A SMALL BURN IS LOCALIZED BUT AS THE BURN SIZE
APPROCHES 10%-15% OF TBSA,THE LOSS OF INTRAVASCULAR FLUID CAN CAUSE
A LEVEL OF CIRCULATORY SHOCK.FURTHER MORE ONCE THE AREA INCREASES
TO 25% OF TBSA,THE INFLAMMATORY REACTION CAUSES FLUID LOSS IN VESSELS
REMOTE FROM THE BURN INJURY.
Cardiac output decreases due to:
Decreased preload induced by fluid shifts
Increased systemic vascular resistance caused by both hypovolemia and systemic
catecholamine release
A myocardial depressant factor has been described that impairs cardiac function
SYSTEMIC EFFECTS:

10. IMMUNE SYSTEM:
Mechanical barrier to infection is impaired because of skin destruction
The inflammatory changes caused by burns significantly reduces patient immune system, leaving
them more susceptible to bacterial and fungal infections.
Immunoglobulin levels decreased as part of general leak and leukocyte chemotaxis, phagocytosis,
and cytotoxic activity impaired
Potential sources apart from burn wound and lungs is, central and peripheral venous
lines,tracheostomies and urinary catheters.
CHANGES TO INTESTINES:
The inflammatory stimulus and shock can cause microvascular damage and ischemia to the gut mucosa
which reduces gut motility and can prevent the absorption of food.
Failure of enteral feeding in a patient with a large burn is a life threatening complication.
This process also increases the translocation of gut bacteria which can be the source of infection in large
burns.
Gut mucosal swelling, gastric stasis and peritoneal oedema can also cause abdominal compartment
syndrome,which splint the diaphragm and increases airways pressure needed for respiration.

11. Inhales hot gases can cause supraglottic airway burns and laryngeal oedema.
Inhaled steam due to a large latent heat can cause subglottic burns and loss of
respiratory epithelium.
Chemical alveolitis and respiratory failure due to smoke particles.
Mechanical blockage to ribs movements due to full thickness burns of the chest
SPECIAL CONSIDERATIONS
INJURIES TO AIR WAY AND LUNGS:
METABOLIC POISONING:
It is often produced by fires in enclosed area due to inhalation of CO and Hydrogen
cynide.
CO blocks transport of oxygen by Hg.Conc above 10 % is dangerous and needs 100%
oxygen for 24 hours.
Hydrogen cynide interfers with cellular respiration.

13. Typically, biphasic response
The initial period of hypo function manifests as: (a) Hypotension, (b) Low
cardiac output, (c) Metabolic acidosis, (d) Ileus, (e) Hypoventilation, (f)
Hyperglycemia, (g) Low oxygen consumption and (h) Inability to thermo
regulate
This ebb phase occurs usually in the first 24 hours and responds to fluid
resuscitation
The flow phase, resuscitation, follows and is characterized by gradual increases
in (a) Cardiac output, (b) Heart rate, (c) Oxygen consumption and (d)
Supernormal increases of temperature
This hyper metabolic hyperdynamic response peaks in 10-14 days after the
injury after which condition slowly recedes to normal as the burn wounds
heal naturally or surgically closed by applying skin grafting
PHYSIOLOGICAL RESPONSE TO BURN:

14. The major determinants of the outcome of a burn are
Extent of burn injury
Presence of injury to air ways or
inhalational injury
Age of the patient
Area of the body affected

15. DEPTH OF BURN
EXTENT OF BURN INJURY
TOTAL BURN SURFACE
AREA (TBSA)
FIRST DEGREE BURN
SECOND DEGREE BURN
THIRD DEGREE BURN
DEPTH OF BURN

16. First-degree Burns (mild):
Epidermis
Pain, erythema & slight swelling, no blisters
Tissue damage usually minimal, no scarring
Pain resolves in 48-72 hours
Superficial Second-degree Burns:
Entire epidermis & variable dermis
Vesicles and blisters characteristic
Extremely painful due to exposed nerve endings
Heal in 7-14 days if without infection
Deep Second-degree Burns:
Few dermal appendages left
There are some fluid & metabolic effects
Full-thickness or Third-Degree:
Entire epidermis and dermis, no residual epidermis
Painless, extensive fluid & metabolic deficits
Heal only by wound contraction, if small, or if big, by
skin grafting or coverage by a skin flap

17. Assessment of burn size
Properly expose the patient in a controlled
environment to assess the area of burns.
Take care not to cause hypothermia.
In the case of smaller burns or patches take a piece
of clean paper of the size of patient whole hand
which represents 1% of TBSA and measure the area.
In larger burns Lund and Browder chart is useful.
The rule of nine is a rough guide to TBSA

18. RULE OF NINE:

19. Extinguish flames by rolling in the ground, cover child with blanket,
coat or carpet
After determining airway is patent, remove smoldering clothes and
constricting accessories during edema phase in the 1st 24-72 hours
after
Brush off remaining chemical if powdered or solid then wash or
irrigate abundantly with water
Cover burn wounds with clean, dry sheet and apply cold (not iced)
wet compresses to small injuries; significant burns (>15-20% BSA)
decreases body temperature which contraindicates use of cold
compress dressings
If burn caused by hot tar, mineral oil to remove it
MANAGMENT
PRE-HOSPITAL OR IMMEDIATE CARE

20. APPROACH TO BURN PATIENT
ATLS approach
Brief HISTORY & EXAMINATION
.
FLUID RESUSCITATION - IVI
PAIN MANAGEMENT
Baseline Investigations:
FBC Chest Xray
U& C Blood Gases
Carboxyhaemaglobin Toxicology
Calculate the burn depth

21. Suspected airway or inhalational injury
Any burn likely to require fluid resuscitation i.e 2nd degree
burn of more than 15% in adults and more than 10% in
children.
Full thicknrss skin burn of more than 5%
Any burn likely to require surgery.
Burns of any significance to the hands,face,feet or
perineum.
Any burn in a patient at the extreme of age
Any burn with associated potentially serious sequelae
including high-tension electrical burns and chemical burns.
Any suspicion of non accidental injury
Patients whose psychiatric or social background makes it
inadvisable to send them home.
CRITERIA FOR ADMISSION:

22. HISTORY
Fire in an ENCLOSED SPACE
e.g. House fire
Car fire
Toxic fumes (Industrial)
EXAMINATION
Confusion / Altered Consciousness
Burns to Face / Oropharynx
Hoarseness / Stridor / Exp rhonchi
Soot in nostrils or Sputum
Dysphagia / Drooling

23. The burned airway creates symptoms by swelling and if not
managed proactively can occlude the airway.
The treatment is to secure the airway with an endotracheal
tube until the swelling subside usually after 48 hrs.
The symptoms of laryngeal edema such as change in
voice,stridor,anxiety and respiratory difficulty are very late
symptoms and intubation is difficult or impossible at this
time due to swelling so early elective intubation of suspected
airway burn is the treatment of choice.
Any mechanical block to breathing from Escher of a
significant full thickness burn on the chest wall if present
should be treated with eschratomy to allow the chest to
expand.
Emergency Tracheostomy
SUSPECTED INJURY TO THE AIR WAYS

24. Maintain patent airway by early ET intubation,
adequate ventilation and oxygenation
INVESTIGATIONS
Blood Gases
Carboxyhaemaglobin
Chest X-ray shows consolidations
Nebulizers - Saline Salbutamol / Terbutaline
Chest physiotherapy
Three syndromes:
Early CO poisoning, airway obstruction &
pulmonary edema major concerns
ARDS usually at 24-48 hrs or much later
Pneumonia as late complications (days to weeks)
Inhalation Injury

25. In children with burns over 10% and adults over 15% ,consider I.V fluids
resuscitation.
Crystalloids are as effective as colloids.
Colloids if indicated should be stared after 12 hrs.
Parkland formula is commonly used for calculating the crystalloids fluids required
in first 24 hrs.
wt in kg x % burn x 4cc = fluids in ml
Half = first 8 hrs. after injury
Half = next 16 hrs.
Muir and Barclay formula is commonly used for colloids.
0.5 x % area burned x wt = one portion
Periods of 4/4/4 ,6/6 and 12 hrs. respectively
One portion in each period
Fluids resuscitation
In children maintance fluid should also be given
100ml/kg for 24 hrs for the 1st 10kg
50ml/kg for next 10kg and
20ml/kg for each kg over20kg body weight

26. The key to monitoring is urine output ,so catheterize
the patient.
Urine output should be between 0.5 and 1.0 ml per
kg per hr.
If urine output is less than 0.5 increase infusion rate
by 50%.
Do not over resuscitate , if urine output more than 2
ml/kg/hr decrease the rate of infusion
Monitoring of fluids resuscitation

27. Analgesia is a vital part of burns management
Small burns respond well to oral analgesics
,paracetamol ,Nsaids
Large burns need intravenous opiates in the form of
continuous infusion.
Powerful, short acting analgesics should be given
before dressing changes.
Intramuscular injection should not be given in acute
burns over 10% of TBSA as absorption is
unpredictable and dangerous.
Analgesia

28. Early irrigation and debridement using normal
saline and sterile instrument to remove loose skin
layers, followed by application of topical
antimicrobial agents and sterile dressing.
Daily dressing change.
assess the depth
Full thickness and deep partial thickness burns need
antibacterial dressing to delay colonization prior to
surgery.
Superficial burns need simple dressing.
Dress limb in position of function and elevate it.
Treatment of the burned wound

29. There is some controversy to remove or
leave the blisters intact.
In the pre-hospital setting, there is no
hurry to remove blisters.
Leaving the blister intact initially is less
painful and requires fewer dressing
changes.
The blister will either break on its own,
or the fluid will be resorbed.
If the blisters are already ruptured then it is
necessary to remove them.
Blisters

30. 1% silver sulphadiazine
0.5% silver nitrate
Mafenide acetate cream
Cerium nitrate and silver nitrate.
Polymyxin B sulphate
Acticoat
Option for topical treatment
Silver sulphadiazine
Commonly used, broad spectrum, effective against
pseudomonas and MRSA
Poor eschar penetration and anaerobic coverage
Can cause staining, transient leukopenia.
Contraindicated in G6PD deficient patient.
Silver nitrate can be used in patient allergic to sulpha drugs but
causes black staining and have poor gram negative coverage.
Mafenide acetate has good eschar penetration and gram negative
and anaerobic coverage but is painful and can cause
hyperchloremic acidosis by inhibiting carbonic anhydrase.
Polymyxin B good for facial burns because it does not disclor skin
but have poor eschar penetration and gram negative coverage.
Acticoat available as easy- to- apply sheet ,has good antimicrobial
activity and can be left for three days but is costly.

31. Burn wound is a focus for sepsis
Burn stimulates inflammatory mediators
Deep burns cannot heal without grafts
Possible effect on future scar quality
but
Non full-thickness burns may heal spontaneously
Superficial burns heal with acceptable scars
Excised burn wound must be closed
Why excise the burn

32. High-tension electrical injury
Urgent surgery
May be necessary in full thickness circumferential burns of
the neck, torso or extremities when peripheral circulation
is impaired or chest involvement restrict breathing.
Full thickness incisions through the insensate burn eschar
provide immediate relief.
Longitudinal escharatomy performed on medial or lateral
aspect of the extremities and the anterior axillary lines of
the chest.
COMPLICATIONS
Bleeding: might require ligation of superficial veins
Injury to other structures: arteries, nerves, tendons
NOT every circumferential burn requires escharotomy.
In fact, most DO NOT need escharotomy.
Repeatedly assess neuro-vascular status of the limb.
Those that lose circulation and sensation need escharotomy.

34. One of the important aspect in burns management is nutrition as
burn injuries are catabolic and burns patients need extra feeding
A N/G tube should be passed in all patient with burns over 15%.
And feeding started within 6 hrs
Commonly used curreri formula for feeding
Age 16 -59 yrs : (25)wt + (40)TBSA in Kcal
Age 60+ yrs : (20) + (65)TBSA in Kcal
20% of calories should be provided by protein
Nutrition

35. Burns patient are immunocompromised and susceptible to infection
Sterile precaution must be rigorous.
Swabs should be taken regularly.
Systemic antibiotic should be reserved for infection treatment not prophylaxis as they
cause resistant organism to multiply.
Tetanus immunization.
A rise in leucocytes count ,thrombocytosis and increased catabolism are warning signs.
Remember that in large burns the core temperature is reset by hypothalamus above 37C
and significant temperature are those above 38.5C.
Infection control

36. All burns cause swelling especially the limbs.
Elevation,splintage and exercise reduce swelling,
prevent burn contractures and improve the final
outcome.
Physiotherapy should be started on day 1.
Physiotherapy

37. Any deep partial thickness and full thickness burns more than 4 cm2 need surgery.
Deep dermal burns need tangential shaving and split skin grafting
In these burns the top layer of dead dermis is shaved until punctate bleeding is
observed.
Full thickness burns require full thickness excision of the skin and a skin graft
wherever possible.
Surgery for the acute burn
With very large burns the synthetic dermis or homografts provides temporary stable
covering which can be replaced with a meshed autograft.
Postoperative management requires evaluation of fluid balance, hemoglobin and
regular change of dressing.

38. Tangential burn excision
and split skin grafting

39. Excision to fascia

40. Superior outcomes where suitably equipped
mortality
length of hospital stay
morbidity during acute burn
scar quality
Early burn surgery

41. Scar management
Pre-emptive measures
prompt surgery
splintage & physiotherapy
Pressure garments and conformers
Silicone gel and contact media
Medical and surgical treatment

42. Splintage
Almost universally used
Apparently effective
Many published observations
Pressure garments

43. Conformers and splints
Mechanism not fully known - not press
Silicone gel

44. Burn Shock
Pulmonary complications due to inhalation injury
Acute Renal Failure
Infections and Sepsis
Curling’s ulcer in large burns over 30% usually after
9th day
Extensive and disabling scarring
Psychological trauma
Cancer called Marjolin’s ulcer
Complications of Burns

45. Face
Mouth
Neck
Hands and feet
Burns of special areas of the body
Be VERY concerned for the airway!!
Eyelids, lips and ears often swell
alarmingly.
In fact, they look even worse the next day.
But they will start to improve daily after
that.
Cleanse eyes with warm water or saline.
Apply antibiotic ointment or liquid tears
until lids are no longer swollen shut.
Bacitracin cream/ointment will serve
FACE

46. Dressings should not impede circulation.
Leave tips of fingers exposed.
Keep limb elevated.
Hands and feet

47. Usually associated with industrial exposure
First Consideration:
Does the patient need decontamination before treatment?
Burning will continue as long as the chemical is on the skin
Poisoning due to absorption
Chemical burns
Acids
Immediate coagulation-type necrosis creating an eschar
coagulation of protein results in necrosis in which affected
cells or tissue are converted into a dry, dull, homogeneous
eosinophilic mass without nuclei
Bases (Alkali)
Liquefactive necrosis with continued penetration
into deeper tissue resulting in extensive injury
characterized by dull, opaque, partly or completely
fluid remains of tissue
Dry Chemicals
Exothermic reaction with water

49. Definitive treatment is to get the chemical off!
Begin washing immediately - removal the patient’s
clothing as you wash
Watch for the socks and shoes, they trap chemicals
Chemical burns management
Liquid Chemicals
wash off with copious amounts of fluid
Dry Chemicals
brush away as much of the chemicals as possible
then wash off with large quantities of water
Flush for 20-30 minutes to remove all chemicals
Do not attempt neutralization
can cause additional chemical or thermal burns from the heat
of neutralization
Assess and Deliver secondary care as with other thermal and
inhalation burns

50. Flood the eye with copious amounts of water only
Never place chemical antidote in eyes
Flush using NS/H2O from medial to lateral for at
least 15 minutes
Remove contact lenses
May trap irritants
Chemical burns to the eyes

51. Specific chemical consideration
Dry lime
Brush off
Dry lime is water activated
Then flush with copious amounts of water
Phenol
Not water soluble
If available, use alcohol before flushing except
in eyes
If unavailable, use copious amounts of water
Sodium/Potassium metals
Reacts violently on contact with H20
Requires large amounts of water
Sulfuric Acid
Generates heat on exposure to H2O (exothermic)
Wash with soap to neutralize or use copious
amounts H2O
Tar Burns
Use cold packs
Do not pull off, can be dissolved later

52. May be low voltage or high voltage
Threshold being 1000 volts
Potentially dangerous
Always admit patient
Electrical injury
Caused by domestic appliances
Usually cause small, localized, deep burns at the
entry and exit points usually at fingers without
significant damage in between.
Can cause cardiac arrest through pacing
interruption without significant direct myocardial
damage .
Low voltage injuries

54. Can cause damage by flash (external),and the
current conduction(internal) itself.
The flash can ignite the patient clothes and so can
cause normal flame burn.
If the current passed through patient it cause not
only damage to the entry and exit points but huge
amount of subcutaneous tissue are also damaged.
High voltage injuries
The damage to the muscles in affected limb can
cause rapid onset compartment syndrome
The release of myoglobin can cause myoglobinuria
and subsequent renal dysfunction.
Causes direct myocardial muscle damage with
significant ECG changes and raised cardiac enzyme

55. During resuscitation maintain high urine
output upto 2ml/kg/hr.
Severe acidosis need bicarbonate
Severe injury through a limb may need
primary amputation.

56. May be generalized or localized.
Localized radiation causing ulceration need excision
and covering with vascularised flap over it.
Whole body radiation can cause a number of
symptom depending on dose.
Lethal dose causes acute desquamation of the skin
treated supportively.
Non lethal dose can cause damage to gut mucosa
and immune dysfunction.
Usually conservatively treated
Radiation injuries

57. THANKS