2. Definition.
• Injuries that result from direct contact or exposure to any
physical, thermal, chemical, electrical, or radiation
source are termed as Burns.
5. Thermal Injuries
• Most common.
• Types:
o Dry.
• Direct Contacts.
• Contact with hot object (i.e. pan or iron).
• Anything that sticks to skin (i.e. tar, grease or food).
• Contact with flame.
o Wet .
• Scalding.
• Most common in pediatrics
• Direct contact with hot liquids or vapors.
• Cooking, bathing.
6. Electrical Burns
• Usually follows accidental contact with exposed object
conducting electricity:
o Electrically powered devices.
o Electrical wiring.
o Power transmission lines.
• Can also result from Lightning
• Damage depends on intensity of current.
7. • Low-tension injuries(<1000 V)
o Low energy burns Minimal damage to subcutaneous tissue
o Entry & Exit points (usually fingers) small deep burns
o AC Tetany within muscles, cardiac arrest due to
interference with normal cardiac pacing.
o High-tension injuries(>1000V)
• Earthed high tension lines Arc over the patient Flash
burn
8. • Severity depends upon:
owhat tissue current passes through (Low voltage/ High
voltage)
owidth or extent of the current pathway
oAC or DC
oduration of current contact
11. Chemical Burns
• Usually associated with industrial exposure
• Accidental mishandling of household cleaners
Degree of tissue damage determined by:
- Chemical nature of the agent
- Concentration of the agent
- Duration of skin contact
Acids i.e.
Formic acid, sulphuric acid
Alkalis i.e.
Lime, potassium hydroxide
12. Radiation Exposure
• Waves or particles of energy that are emitted from radioactive sources
• Alpha radiation:
Large, travel a short distance, minimal penetrating ability
Can harm internal organs if inhaled, ingested or absorbed
• Beta radiation:
Small, more energy, more penetrating ability
Usually enter through damaged skin, ingestion or inhalation
INHALATION
Smoke and inhalation injury:
• carbon monoxide poisoning.
• inhalation injury above glottis.
• inhalation injury below glottis.
13. According Depth of burn
First Degree burn(Superficial Partial-Thickness).
• Cause:-
o Sunburn
o Low-intensity flash
• Skin involvement:-
o Epidermis
• Symptoms:-
o Reddened.
o Tingling.
o Pain that is soothed by cooling.
14. Second Degree (Deep Partial-Thickness)
Cause:
• Scalds
• Flash flame
• Contact burns
• Chemical
Skin involvement:-
o Epidermis, upper dermis, portion of deeper dermis.
Manifestations:-
o Blisters that are red, shiny.
o Severe pain caused by nerve injury ,mild to moderate edema.
o Recovery in 2 to 4 weeks, some scarring and depigmentation contractures
15. Third Degree (full thickness)
Cause:-
• Flame.
• Prolonged exposure to hot liquids.
• Electric current.
• Chemical.
Skin involvement:-
o Epidermis, entire dermis, and sometimes subcutaneous tissue; may involve connective tissue, muscle, and
bone
Manifestations:-
o Dry; pale white, Leathery, visible thrombosed blood vessels.
o Pain free, all skin elements and local nerve endings are destroyed.
o Surgical intervention required for healing.
17. Extent of Body Surface Area
Injured
• RULE OF NINES.
• LUND AND BROWDER METHOD.
• PALM METHOD.
18.
19. LUND AND BROWDER
METHOD
• A more precise method of estimating the extent of a burn is the
Lund and Browder method, which recognizes that the
percentage of TBSA of various anatomic parts
• By dividing the body into very small areas and providing an
estimate of the proportion of TBSA
20.
21. PALM METHOD
• In patients with scattered burns, a method to estimate the
percentage
• of burn is the palm method. The size of the patient’s palm is
approximately 1% of TBSA.
22. Location of burn
• Burns to face, neck ,chest and back may inhibit respiratory
function due to mechanical obstruction secondary to
edema, eschar formation.
• Burns to the ear, nose are susceptible to infection because
of poor blood supply.
• Burns to buttocks, genitalia are susceptible to infection
because of contamination.
• Burns on extremities cause circulatory compromise and
neurologic impairment.
24. Zones of burn injury
• The inner zone (known as the zone of coagulation, where
cellular death occurs) sustains the most damage
o Necrotic area with cellular disruption
o Irreversible tissue damage
• The middle area, or zone of stasis, has a compromised blood
supply, inflammation, and tissue injury, Can survive or go on to
coagulative necrosis depending on wound environment
• The outer zone—the zone of hyperemia—sustains the least
damage
29. PRE HOSPITAL MANAGEMENT
• Rescuer to avoid injuring himself
• Remove patient from source of injury
• Stop burn process
• Burning clothing; jewelry, watches, belts to be removed
• Pour ample water on burnt area (not ice/ ice packs – skin injury
& hypothermia)
30. Chemical burns:
Remove saturated clothing
Brush skin if agent is powder
Irrigation with copious amount water to be started and continued in
hospital
Electrical burns:
Turn off the current
Use non-conductor item to separate from source
31. • Small thermal burns (<10% TBSA ) may be covered with
a clean, tap water-damped towel for patient comfort and
protection until definite medical care instituted
• Cooling of injured area within 1 minute helps minimize
the depth of injury
• If the burn injury is large (>10% TBSA) it is not
advisable to immerse the body part in cool water since
doing so might lead to extensive heat loss
32. Do not break blisters.
Do not apply lotions, powders, grease, ghee, gentian
violet, calamine lotion, toothpastes, butter and other
sticky agents over the burn wound.
Prevent contamination: Wrap burn part in clean dry
sheet /cloth.
Assess for life threatening injuries.
33. EMERGENT/RESUSCITATIVE
PHASE
• This phase may last 24-48 hours after injury
Resuscitation phase characterized by:
Life-threatening airway problems
Cardiopulmonary instability
Hypovolemia.
Goal:
Maintain vital organ function and perfusion
34. • Assess A B C
• ET intubation + assisted ventilation with 100% O2 if:
o Overt signs and symptoms of airway obstruction
(Progressive hoarseness)
o Suspected inhalational injury (smoke/ carbon monoxide
intoxication)
o Unconscious patient/ rapidly deteriorating patient
o Acute respiratory distress
o Burns of face & neck
o Extensive Burns (> 40% TBSA)
35. • Large gauge I.V catheter
• Central line Insertion
• Venesection.
• Foleys catheter and NG tube placement
• Quick assessment of extent
• Tetanus prophylaxis (the only IM administered inj)
• Weigh the patient
36. • History
o Mechanism of injury
o Time of injury
o Surroundings (closed space/ chemicals)
• Physical examination
o Head to toe assessment
o Careful neurological examination (cerebral anoxia)
o Labs: CBC, electrolytes, BUN
o Pulmonary assessment: ABG, CXR, carboxyhemoglobin
37. • Pulse in extremities: manual/ doppler
• Loss of distal circulation
• Pallor/coolness/absent pulse/loss capillary refill/decreased
oxygen saturation
• Absent pulse: emergency escharotomy to release constrictive,
unyielding eschar
38. ESCHAROTOMY
• It is the surgical division of the nonviable skin and tissues , which
allows the cutaneous envelope to become more compliant
•Deep 2nd & 3rd degree circumferential burns
o Chest: To allow respiratory movement
o Limb: To restore circulation in limb with excess swelling under rigid
eschar.
• Not in SC tissue Exposes SC fat
41. Parkland Formula
Fluid of Choice
Lactated Ringer’s (RL)
NS can produce hyperchloremic acidosis
4 ml x % of burn x weight (Kg) in 24 hours
First ½ of total volume given in the first 8 hours
Remaining ½ of total volume given over following 16 hours
NEXT 24 HRS
Total volume ½ of first day
Colloids ( 0.5 ml / kg / % )
5 % glucose to make up the rest
42. Brooke formula( modified)
2 ml x % of burn x weight (Kg) in 24 hours
First ½ of total volume given in the first 8 hours
Remaining ½ of total volume given over following 16 hours
NEXT 24 HRS
Total volume ½ of first day
Colloids (0 .3-0.5 ml / kg / % )
43. Evan’s formula
Requirement for first 24 hrs
Colloids : 1ml/kg/% burn
Saline : 1ml/kg/% burn
D5 : 2000ml
Requirement for second 24 hrs
½ of first 24 hrs
44. Assessment of Adequacy of
Fluid Resuscitation
• Monitor
o Urinary Output
• Adult: > 1 ml/ kg/ hr
o Daily Weight
o Vital Signs
• Heart rate and blood pressure
• CVP
• Level of Consciousness
o Laboratory values
46. Wound care
• Wound care should be delayed until a patent airway,
adequate circulation and adequate fluid replacement
have been established.
2 types of wound treatment used to control infection
1. Open method.
2. Multiple dressing change method.
47. Closed method
AdvantagesLess:
o wound desiccation
o Decreased heat loss
o Decreased cross contamination
o Debriding effect
o More comfortable
Disadvantages:
o Time consuming
o Expensive
o Increase chances of infection if not changed frequently
48. Antimicrobial Agent
• Silvadene (silver sulfadiazine)1% cream.
• Most bactericidal agent.
• Minimal penetration of eschar
• Mafenide acetate 5% to 10% (Sulfamylon) hydrophilic-based
cream.
o Effective against gram-negative and gram-positive organisms
o Diffuses rapidly through eschar In 10% strength, it is the agent of choice for electrical burns because of its
ability to penetrate thick eschar.
• Silver nitrate 0.5% aqueous solution.
o Bacteriostatic and fungicidal.
o Does not penetrate eschar
50. ACUTE PHASE
o Begins 48 to 72 hours after the burn injury.
o In this phase the extracellular fluid start mobilize and start diuresis
o This phase is completes when wound is covered by skin grafts or the wounds
are healed
o This may take weeks or many months
o Eschar begins to separate fairly after injury
o Re epitheliazation begins at wound margin and appears as red/pink scar tissue
o Hyponatremia/hypernatremia.
o Hypokalemia/hyperkalemia.
o Decreased hematocrit.
51. Management
GOALS
• Prevention of infection and Wound care
• Excision and grafting
• Pain management
• Nutritional therapy
• Physical, psychosocial and occupational therapy
52. Prevention of infection and
Wound care
• Burn wounds are frequently monitored for bacterial colonization
• Wound swab cultures and invasive biopsies
• Cleanse and debride the area of necrotic tissue that would
promote bacterial growth
53. Debridement of the wound
• May be completed at the bedside or as a surgical procedure.
Types of Debridement:
Natural
• Body & bacterial enzymes dissolve eschar; takes a long time
Mechanical
• Sharp (scissors), Wet-to-Dry Dressings or Enzymatic Agents
Surgical
54. Wound/Skin Grafting
• If wounds are deep (full-thickness) or extensive,
spontaneous re-epithelialization is not possible.
Therefore, coverage of the burn wound is necessary by
using patients own skin or other methods.
55. TYPES
1. Permanent Skin Grafts:
o Autografts.
o Cultured Epithelial Autografts (CEA).
2. Temporary:
o Biosynthetic.
• Homograft / allograft (cadaveric).
• heterograft / Xenograft (porcine).
o Artificial Skins (collagen based).
• Trancyte / Integra.
o Synthetic.
• Biobrane / Opsite.
56. Permanent skin graft
Autograft:
•Harvested from patent.
•Non-antigenic
•Less expensive
•Decreased risk of infection
•Can utilize meshing to cover large area
•Disadvantage : lack of sites and painful
57.
58.
59. Permanent skin graft
Cultured Epithelial Autografts (CEA)
o A small piece of pt’s skin is harvested and grown in a culture medium (PDGF
impregnated)
o Takes 3 weeks to grow enough for the first graft
o Very fragile; immobile for 10 days post grafting
o Useful for limited donor sites
Disadvantage:
o very expensive.
o poor long term cosmetic results and skin remains fragile for
years
60.
61. Temporary Skin Grafts
Biosynthetic
• Homograft/Allograft
• Live or cadaver human donors
• Fairly expensive/ all the function of skin
• Best infection control of all biologic coverings
• Disadvantage :
• Disease transmission (HBV & HIV)
• Antigenic: body rejects in 2 weeks
• Not always available
• Storage problems
62. Temporary Skin Grafts
BIOSYNTHETIC.
• Heterograft
o Xenograft
o Graft between 2 different species
o Porcine most common
o Fresh, frozen or freeze-dried (longer shelf life)
o Amenable to meshing & antimicrobial impregnation
o Antigenic: body rejects in 3-4 days
o Fairly inexpensive
o Disadvantage : Higher risk of infection
63.
64. Temporary skin graft
Artificial Skins:
• Transcyte:
oA collagen based dressing impregnated with newborn
fibroblasts.
• Integra:
oA collagen based product that helps to form a “neodermis”
ono anti-microbial property
Synthetic:
• Any non-biologic dressing that will help prevent fluid & heat loss
oBiobrane, Xeroform, OpSite or Beta Glucan collagen matrix
65.
66. Nutritional therapy
o High-protein & high-calorie diet
o Often requiring various supplements
• Routes:
o ORAL (BEST)
o Enteral
• Gut is the preferred alternative route
• G-tube or J-tube (Head injury/ surgery/ unconscious)
o Parenteral .
• TPN and PPN .
• Associated with an increased risk of infections
67. Physical and psychosocial care
• Active and passive ROM excercises should be performed all
joints
• Support and counselling
• Adjust with disabilities
68. Rehabilitation phase
• It starts when the patients burn wounds are healed and patient
is able to resume a level of self care activity
• This occur from weeks to months
• GOALS
• resuming a functional role in society and to accomplish
functional and cosmetic reconstructive surgery
69. • New skin starts to appear which is flat and pink
• Mature healing is reached in 6 months to 2 years
• Scarring can happen
discolouration
contour- skin is no longer flat or slightly elevate but become
elevated and enlarged above original burned area.
• Apply water moisturisers and emolients to prevent dryness and
itching
• Protect from direct sunlight for 6 to 9 months
70. Complications
1. EMERGENT PHASE
o CVS:- Dysrhythmias and hypovolemic shock.
o Resp:- Upper RT injury, pulmonary edema, ARDS, pneumonia.
o urinary:-Acute Tubular necrosis, ARF.
2. ACUTE PHASE
o Infection:- Sepsis, septicemia ( pseudomonas).
o G.I :- Paralytic ileus, curling ulcer.
3. REHABILITATION PHASE
o Contracture:- abnormal condition of a joint characterised by flexion and fixation.
o Curling's ulcer:- is an acute gastric erosion resulting as a complication from severe burns when
reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa.
