Topic includes all aspects of burn management starting from its pathology

1. BURNS
Dr.P.Viswakumar, M.S
Assistant Professor of Surgery,
Dept of General Surgery,
PSGIMSR,
Coimbatore-4.

5. Key Facts
• An estimated 265 000 deaths every year are
caused by burns – the vast majority occur in
low- and middle-income countries.
• Non-fatal burn injuries are a leading cause of
morbidity.
• Burns occur mainly in the home and
workplace.
• Burns are preventable.

6. What is a Burn?
• A 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.

7. Burn Classification

8. Causes
• Flame—damage from superheated oxidized
air
• Scald—damage from contact with hot liquids
• Contact—damage from contact with hot or
cold solid materials
• Chemicals—contact with noxious chemicals
• Electricity—conduction of electrical current
through tissues

10. Depths
• First degree—injury localized to the epidermis
• Superficial second degree—injury to the
epidermis and superficial dermis
• Deep second degree—injury through the
epidermis and deep into the dermis
• Third degree—full-thickness injury through the
epidermis and dermis into subcutaneous fat
• Fourth degree—injury through the skin and
subcutaneous fat into underlying muscle or
bone

12. First Degree Second Degree
Third Degree Fourth Degree

13. Pathology Underlying Burns
• Skin is the largest organ on the human body,
provides a staunch barrier in the transfer of
energy to deeper tissues.
• Once the inciting focus is removed, however,
the response of local tissues can lead to injury
in the deeper layers.
• The area of cutaneous or superficial injury has
been divided into three zones—zone of
coagulation, zone of stasis, and zone of
hyperemia

15. • Fire/Flames,Contact with hot liquids,hot/cold
solid materials induce cellular damage via
transfer of energy directly leads to coagulation
necrosis.
• Chemical and electrical burns cause injury via
cell memberane damage in addition to
thermal injury.
• Depth of Injury depends on 3 factors
1) Temperature at which skin exposed
2) Casuative agents
3) Duration of Exposure.

16. Systemic Effects of Burns
• Severe burns covering more than 40% of the
TBSA are typically followed by a period of
stress, inflammation, and hypermetabolism .
• Characterized by a hyperdynamic circulatory
response with increased body temperature,
glycolysis, proteolysis, lipolysis, and futile
substrate cycling.
• Their severity, length, and magnitude are
unique for burn patients.

18. Post Burn Metabolic Phenomena
• Two Distinct phase of metabolic changes observed
in post burns.
• The first phase occurs within the first 48 hours of
injury and has been called the ebb phase.
• Characterized by decrease in cardiac output,
oxygen consumption, and metabolic rate, as well
as impaired glucose tolerance associated with its
hyperglycemic state.
• These metabolic variables gradually increase
within the first 5 days postinjury to a plateau
phase (the flow phase).

19. Time Post burn

21. Post Burn Squela
• Cardiac out put increases by 1.5 times
• Liver size increases by 225%
• Muscle protein is degraded much faster than it is
synthesized.
• The net protein loss causes loss of lean body mass
and severe muscle wasting.
10% loss – Immune Dysfunction
20% loss – Decrease wound healing
30% loss – Increased risk of Pneumonia &
Pressure sores
40% loss – Death

23. • Renal – Drecresed GFR and Renal blood flow
and can lead to ATN if left untreated
• The gastrointestinal response to burn is
highlighted by mucosal atrophy, changes in
digestive absorption, and increased intestinal
permeability.
• Burns cause a global depression in immune
function.
• Great risk for a number of infectious
complications, including bacterial wound
infection, pneumonia, and fungal and viral
infections.

25. Assessment & Management
of Burn patients

27. Assesment of Burn Size

28. Assesment of Depth and Degree

29. Basic Management
• Prehospital management

30. • Remove the person from source and burning
process must be stopped.
• Addressing Inhalation injury with 100%
oxygen
• Remove heated source like
rings,bracelet,Chain,Watches,etc.
• Pouring water with room temperature
advisable only upto 15 min beyond which it
can lead to hypothermia.

31. Initial Assessment
• By Primary and Secondary Survey.
• In Primary survey immediate life threatening
conditions are identified and treated
• In Secondary survey head to foot examination are
carried out.
• Exposure to heated gas and smoke leads to airway
injury which in turn manifest as airway
edema,hoarseness of voice.
• Airway injury must be suspected with facial burns,
singed nasal hairs, carbonaceous sputum, and
tachypnea

32. • BP monitoring in burn patient ?
Initial Wound Care :
• Aim is to protect wound from environmental
exposure by clean dry dressing.
• Avoid damp dressing
• Cover with blanket to prevent hypothermia
• The first step in diminishing pain is to cover
the wounds to prevent contact to exposed
nerve endings.

33. Resuscitation
• Adequate resuscitation of the burn patient
depends on the establishment and
maintenance of reliable IV access.
• Ringer lactate is always prefered solution of
resuscitation.
• Initial resuscitation volume is calculated with
body weight and TSBA
Eg., (80Kg x 40% TBSA)/8 = 400mL/hr

34. Resuscitation Formula’s
FORMULA CRYSTALLOID COLLOID FREE WATER
Parkland
4 mL/kg per %
TBSA burn
None None
Brooke
1.5 mL/kg/%
TBSA burn
0.5 mL/kg per
% TBSA burn
2.0 liters
Galveston
(pediatric)
5000 mL/m 2
burned area +
1500 mL/m 2
total area
None None

35. Escharotomies
• Deep 2nd and 3rd degree burn encompass
exterimities.
• Compromise vascular flow to the peripherals.
• Recognized by numbness and tingling in the
limb and increased pain in the digits.
• If tissue pressure >40 mm Hg requires
escharotomy.

37. Specific Treatment
Specific treatment part
Addresses
Inhalation injury
Local Wound care

38. Inhalation Injury
• Approximately 80% of fire-related deaths
result not from burns, but from inhalation of
the toxic products of combustion.
• Overall mortality rate was about 25-50% if
burn patient requires more than 1 wk
ventilatory support.
• Early diagnosis of bronchopulmonary injury is
therefore critical for survival.

39. Bronchoscopic findings
• Airway edema,
• Inflammation,
• Mucosal necrosis,
• Presence of soot and charring in the airway,
• Tissue sloughing,
• Carbonaceous material in the airway.
Early intubation is required if features of Airway
edema seen as it ll increase in first 24 hours.

41. Criteria for Intubation
CRITERIA VALUE
Pa o 2 (mm Hg) <60
Pa co 2 (mm Hg) >50 (acutely)
Pa o 2 /F io 2 ratio <200
Respiratory, ventilatory
failure
Impending
Upper airway edema Severe

42. Treatment of Inhalation Injury
TREATMENT TIME, DOSAGE, METHOD
Bronchodilator (e.g., Albuterol) q2h
Nebulized heparin
5000 to 10,000 U with 3 mL
normal saline q4h
Nebulized acetylcysteine 20%, 3 mL q4h
Hypertonic saline Induce effective coughing
Racemic epinephrine Reduce mucosal edema

43. Wound Care
• Treatment depends on the characteristics and size
of the wound.
• All treatments are aimed at rapid and painless
healing.
• Wound thoroughly cleaned and adequately
debrided.
• Clean dressing to address two functions of Skin
1) As Barrier from environmental infection
2) Prevention of thermal/water loss through
exposed wound.

44. Wound Care
• First and superfiscial second degree needs
topical oinment and pain killers.
• Deep 2nd and 3rd requires excision and
grafting.

45. DRESSINGS ADVANTAGES AND DISADVANTAGES
Antimicrobial Salves
Silver sulfadiazine (Silvadene)
Broad-spectrum antimicrobial; painless and
easy to use; does not penetrate eschar; may
leave black tattoos from silver ion; mild
inhibition of epithelialization
Mafenide acetate (Sulfamylon)
Broad-spectrum antimicrobial; penetrates
eschar; may cause pain in sensate skin; wide
application may cause metabolic acidosis;
mild inhibition of epithelialization
Bacitracin
Ease of application; painless; antimicrobial
spectrum not as wide as above agents
Neomycin
Ease of application; painless; antimicrobial
spectrum not as wide
Polymyxin B
Ease of application; painless; antimicrobial
spectrum not as wide
Nystatin (Mycostatin)
Effective in inhibiting most fungal growth;
cannot be used in combination with mafenide
acetate
Mupirocin (Bactroban)
More effective staphylococcal coverage; does
not inhibit epithelialization; expensive

46. Antimicrobial Soaks
Silver nitrate 0.5%
Effective against all microorganisms;
stains contacted areas; leaches
sodium from wounds; may cause
methemoglobinemia
Mafenide acetate 5%
Wide antibacterial coverage; no
fungal coverage; painful on
application to sensate wound; wide
application associated with
metabolic acidosis
Sodium hypochlorite 0.025% (Dakins
solution)
Effective against almost all microbes,
particularly gram-positive organisms;
mildly inhibits epithelialization
Acetic acid 0.25%
Effective against most organisms,
particularly gram-negative ones;
mildly inhibits epithelialization

47. Synthetic Coverings
OpSite
Provides a moisture barrier;
inexpensive; decreased wound pain;
use complicated by accumulation of
transudate and exudate, requiring
removal; no antimicrobial properties
Biobrane
Provides a wound barrier; associated
with decreased pain; use
complicated by accumulation of
exudate, risking invasive wound
infection; no antimicrobial properties
Transcyte
Provides a wound barrier; decreased
pain; accelerated wound healing; use
complicated by accumulation of
exudate; no antimicrobial properties
Integra
Provides complete wound closure
and leaves a dermal equivalent;
sporadic take rates; no antimicrobial

48. Burn Wound Coverage
Biologic Coverings
Xenograft (pig skin)
Completely closes the wound;
provides some immunologic
benefits; must be removed or
allowed to slough
Allograft (homograft, cadaver
skin)
Provides all the normal
functions of skin; can leave a
dermal equivalent; epithelium
must be removed or allowed to
slough

49. Burn wound Excision

50. Tangential Excision:
Requires repeated shavings for deep,partial
and full thickness burns.
0.005 – 0.010 inch excision carried.
Full thickness Excision :
0.015 to 0.030 inch thickness.
Fascial Excision :
Reserved for burns extending down through
the fat into muscle, where the patient presents
late with large infected wounds and life-
threatening invasive fungal infections.

51. Multiorgan Failure and Death

52. Nutritional Support
MAINTENANCE BURN WOUND
AGE GROUP NEEDS NEEDS
Infants (0-12 mo) 2100 kcal/% TBSA 1000 kcal/% TBSA
burned/24 hr burned/24 hr
Children (1-12 yr) 1800 kcal/% TBSA 1300 kcal/% TBSA
burned/24 hr burned/24 hr
Adolescents (12-
18 yr)
1500 kcal/% TBSA 1500 kcal/% TBSA
burned/24 hr burned/24 hr

53. Pharmacologic Support
• Recombinant Human Growth Hormone.
• Insulin-Like Growth Factor
• Oxandrolone
• Propranolol
• Insulin
• Metformin

54. Electrical Burn
• Of all burn patients admitted, 3% to 5% are
injured from electrical contact.
• Electrical current enters a part of the body, such
as the fingers or hand, and proceeds through
tissues with the lowest resistance to current,
generally the nerves, blood vessels, and muscles.
• The skin has a relatively high resistance to
electrical current and is therefore mostly spared.
• Heat generated by the transfer of electrical
current and passage of the current itself then
injures the tissues.

55. • The muscle is the major tissue through which the
current flows, and thus it sustains the most
damage.
• Injuries are divided into high- and low-voltage
injuries.
• Low-voltage injury is similar to thermal burns
without transmission to the deeper tissues.
• The syndrome of high-voltage injury consists of
varying degrees of cutaneous burn at the entry and
exit sites, combined with hidden destruction of
deep tissue .
• Address Cardiac derangement.
• The key to managing patients with an electrical
injury lies in the treatment of the wound.

58. Chemical Burns

59. Burns Referral
• Patients with the following criteria should be referred
to a designated burn center:
• 1. Partial-thickness burns more than 10% of the TBSA
• 2. Burns involving the face, hands, feet, genitalia,
perineum, and/or major joints
• 3. Any full-thickness burn
• 4. Electrical burns, including lightning injury
• 5. Chemical burns
• 6. Inhalation injury
• 7. Burns in patients with preexisting medical
disorders that could complicate management,
prolong recovery, or affect outcome

60. • 8. Any patient with burns and concomitant trauma
(e.g., fractures) in which the burn injury poses the
greater immediate risk of morbidity and mortality. In
these cases, if the trauma poses the greater
immediate risk, the patient may be initially stabilized
in a trauma center before being transferred to a burn
unit. Physician judgment is necessary in these cases
and should be in conjunction with the regional
medical control plan and triage protocols.
• 9. Burned children in hospitals without qualified
personnel or equipment to care for children
• 10. Burns in patients who will require special social,
emotional, or long-term rehabilitative intervention.

61. Take Home message

62. • The treatment of burns is complex.
• Minor injuries can be treated in the
community by knowledgeable physicians.
• Moderate and severe injuries, however,
require treatment in dedicated facilities.
• Burn injury treatment depends on the depth
and total body surface area affected.
• Early systemic response would be dampening
of all responses and followed
hypermetabolism.

63. • Early fluid resuscitation with adequate fluids
and addressing inhalation injury saves lots of
life.
• Addressing wound comes second after initial
resuscitation with adequate covering of wound.
• Main aim of wound care to protect body from
infection and hypothermia.
• Early wound excision and grafting prevents
wound contracture.
• Electrical burns- High voltage burns addressed
in multidimentional way.
• Chemical burns – Alkali and Acids treated
differently.

64. Thank you