Burns are one of the most serious injuries that can damage the skin and lead to complications. They are classified based on the percentage of total body surface area affected and depth of tissue damage. Common causes include scalds, flames, electricity, and chemicals. Proper management involves fluid resuscitation, wound care to prevent infection, and skin grafting for deep burns. Complications can be local, such as infection, contractures and scarring, or systemic like shock, organ failure and sepsis. Special consideration is needed for electrical or chemical burns.

1. Burns
By
Dr. Ahmed A. Balfakeeh

2.  Is one of the most serious injuries to the body.
 They cause dramatic damage of the
physiological functions of the skin which lead
to serious local or systemic complications.
 By size and weight the skin is the second
largest organ in the body next only to the
muscles.

3. Aetiology
1. Scalds caused by boiled liquids.
2. Flame burns
3. Electric burns
4. Chemical burns are due to either acids or
alkalis.
5. Inhalation burns due to exposure to hot
gases and may affect the upper and lower
airway.

4. Classification
A. Classification according to the
percentage surface area involved:
 This follow the rule of 9.
 In children he rule of 9 needs some modification
due to the large size of the head in comparison to
the rest of the body.

6.  Burns are classified into:
1 Major burn Involves more than 30% of the body surface
area.
2 Intermediate
burn
Involves 15-30% in adults & Between 10-30% in
child.
3 Minor burn than 15% in adult & 10% in children.

7. B. Classification according to the depth of
the burnt tissues:
1. First degree burns:
 as in sunburns
 Only the epidermis is damaged causing
erythema of the skin.
 They heal rapidly.

8. 2. Second degree burns:
 The epidermis & portion of dermis are damaged
 If no infection occurs epithelial regeneration can
occur from the remnants of hair follicles and sweat
glands in dermis and the burn will heal in 3 weeks.
 If infection occurs these epithelial elements are
destroyed and the case will be changed to a full
thickness burn.

9.  This degree if further subdivided into:
a) Superficial partial thickness burn: only
epidermis is damaged causing erythema
of the skin and heal rapidly.
b) Deep partial thickness burns: the
epidermis and portion of the dermis are
damaged.

12. 3. Full thickness burn:
 These is complete destruction of epidermis and
dermis.
 After separation of the eschar by the 3rd week, the
patient should be prepared for skin grafting.
 The differentiation of partial thickness from full
thickness burn sometimes difficult and even in the
same area.

13.  Both pattern may intermingle together, how ever
the following may help to differentiate:
Partial thickness burn Full thickness burn
1. Mottled red White or black eschar
2. Moist due to exudation of
plasma
Dry
3. Show blisters surrounded by
erythema
Possible visible thrombosed
subcutaneous vessels.
4.Very painful & sensitive to air
(pin pick test)
Painless due to loss of the terminal
nerve ending.
5. Heal within 3 weeks Granulation tissue formation and
eschar separation starts to occur
after 3 weeks.

17.  Epilation test:
Useful test is to pull on a hair, if the hair pulls
easily & painlessly the burn is deep one.

26. Pathophysiology
1. Increased capillary permeability lead to the
loss of enormous amount of fluids & protein
in the damaged area. It maximum in the first
8 hrs. and continue for 48 hrs.
2. Excessive loss of water by evaporation with
loss of calories.
3. The burnt area will be colonized by bacteria.

27. Complication
A. Systemic complication:
1. Inhalation injury:
 Asphyxia may occur immediately from
inhalation oh heat or gases.
 Atelectasis, pneumonia, emphysema and
pulmonary oedema may follow.
 Finally respiratory failure may occur with
systemic sepsis.

28. 2. Neurogenic & hypovolemic shock
3. Renal failure: acute renal failure can occur
after prolonged uncorrected hypovolemia.
4. Gastro intestinal complications:
a. Acute peptic ulcer (Curling’s ulcer).
b. Ileus usually occurs during the early post burn
period.
c. Acute ulcerations of the colon.
d. Multiple organ failure (MOF) often follow sepsis
(the outcome is poor).

29. B. Local complication:
a) Early local complication:
1. Infection:
 Is the primary cause of death
 May lead to development of septicaemia and septic shock
 It usually occurs between 4-7 days post burn.
 Treatment: by prevention through proper local burn wound
care and systemic antibiotic therapy.
2. Constricting eschars: may form in deep circumferential
burns of the limbs and chest and should be treated by urgent
escharotomy (release).
3. Oedema: in burn of the face & neck, may lead to suffocation
and urgent tracheostomy may be needed.

30. B. Delayed complications:
1. Contracture across joint
2. Scar formation (hypertrophic or keloid)
3. Malignant transformation ( Marjolin ulcer)

31. Management of burns
A. First aid management:
1. Patent airway should be assured.
2. Strong analgesic as 50 mg Pethidine I.V
3. Tetanus prophylaxis
4. Saline or tap water at room temperature
for 15 minutes to decrease oedema and
relieve the pain.

32. B. Minor burns:
 Can treated as outpatient & treatment as
1. Dressing using proper local chemotherapeutic
2. Analgesia
C. All majors and most moderate burns (except very
superficial ones) should be admitted to the burn unit:
1. A wide bore I.V. cannula is inserted
2. Foley’s catheter to check the urine output
3. Treatment essentially consist of :

33. I. Resuscitative fluid therapy:
 The amount & rate of fluid replacement:
 Depend on the patient’s weight and the % of total body
surface area injured.
 Must be given for the first 48 hrs. and after that
 The amount infused during the first 24 hrs. is 2 ml/ percent
surface area burn / kg body weight. Half the amount
calculated is given over the first 8 hrs. and other half over
next 16 hrs. Also half the calculated is given over the
second day.

34.  The types:
1. Evan’s formula:
 1st day: 1 ml/kg/ % burn normal saline + 1 ml /kg/ %burn colloid
(dextran) + 200 ml glucose.
 2nd day: ½ ml /kg/ %burn normal saline + 0.5ml/ kg / %burn
colloid + 200 ml glucose.
1. Parkland’s formula:
 4 ml / kg / %burn RL / day
 ½ the amount is given in the first 8 hrs. , ¼ in the second 8hrs. ,
and ¼ in the third 8 hrs.
3. Modified Brook’s formula:
 1st day: 2-3 ml/kg/ %burn LR + 2000 ml glucose.
 2nd day: 1 ml/kg/ %burn RL + 0.5 ml/kg/ %burn colloid +2000ml
glucose.

35. N.B:
 In all formulae, the maximum percentage of
burn calculated is 50% , otherwise serious over
infusion may occur.
 Administration of blood can be started after
48hrs. guided by haematocrit value.
 Oral intake is avoided during the first 48hrs. to
avoid gastrointestinal complication then started
gradually after that.

36. II. Local burn wound care: (after
resuscitation):
 Constricting eschars (in the limbs and chest) have to
be released immediately. Urgent fasciotomy in
deeper burns may be limb saving.
 The aim of the local wound care is to avoid infection.
 After cleansing & conservative debridement, topical
antibiotics should be applied.

37. The wound is managed by either:
A. The exposure method
B. Bulky occlusive dressing (the occlusive
method)

38. Open method Closed method
Indication
1. Burns of face, neck,
perineum.
2. Burns involving one side
of trunk.
1. Circumferential
burns.
2. Limbs (to prevent
stiffness &
adhesions.
Advantages
1. More comfortable to
patients.
2. Avoid repeated
dressing.
3. Decrease anaerobic
bacterial growth.
1. Decrease cross
infection.
2. Decrease fluid loss
by evaporation.
3. Decrease pain by
covering exposed
nerves
4. Decrease oedema of
tissue by
compression.

39. Special types of burns
A. Electrical burns:
 Severity of the burn is divided into high and low tension
injuries according to the voltage.
 Tissue damage is due to the passage of the electric current
through blood and bones.
B. Chemical burns:
 Severity of burn is determined by the strength of the agent,
amount, duration of skin contact and its mechanism of
action.
 Management:
a. Systemic control >> by antidote
b. Locally the agent should be thoroughly cleaned.