Burns

BURNS
-VIPIN PATIDAR
www.vipinpatidar.wordpress.com

DEFINITION:-
 Burns are the tissue injury caused by
the contact with flame, chemicals,
electricity, and radiation.
 A burn is an injury caused by an
exogenous agent that produces a
characteristic reaction to local tissues
which may vary from mild erythema to
full thickness destruction of the skin
and deeper tissues.

ETIOLOGY
 Thermal injury (Scald injury): From moist
heat. They are the commonest cause for
burn injury in children under 3 years of age.
E.g. Hot water, tea etc.
 Flame injury: Use of alternative heating
devices such as kerosene stove, chimney,
electrical wiring, smoking combination with
alcohol.
 Electrical injury: It is caused by high voltage
electric contacts e.g. infants chewing electric
cords, accidental contacts with high tension
wires www.vipinpatidar.wordpress.com

Continue…..
 Chemical and contact injury: it can
result from chemicals like acid, spirit,
petroleum products, etc in full thickness
burn.
 Radiation injury: childhood to
adolescents by U.V. rays medical
therapies.

Classification of Burns
1. Superficial burns (1st degree) 1) Thermal Burns:
2. Partial thickness burns (2nd degree) 2) Chemical Burns:
a) Superficial partial thickness: 3) Electrical Burns:
b) Deep partial thickness: 4) Radiation Burns:
3. Full thickness burns (3rd degree) 5) Inhalation injuries
4. Fourth degree burn: i) Smoke inhalation
ii) Carbon Monoxide
1) minor burn
2) moderate burn
3) major burn www.vipinpatidar.wordpress.com

1) Superficial burn (1st degree)
 Only the epidermis
 Red and tender.
 Painful
 Dry (no blisters)
 Mild discomfort some
good over the counter
(OTC) topical creams
used. Aloe vera,
Lidocaine

2) Superficial partial-thickness burn
(Superficial 2nd degree burn)
 Epidermis and part of the
dermis
 Blistered, red or White,
blanches with pressure
 Painful
 Blisters (wet)
 Often seen with scalding
injuries
 Sensitive to light touch or
pinprick
 Treated on outpatient basis, www.vipinpatidar.wordpress.com

3) Deep partial-thickness
 Epidermis and most of the
dermis
 Appears white or poor
vascularized, may not
blister
 Less sensitive to light touch
than superficial form
 Extensive time to heal (3-4
weeks)
 Often require excision of
the wound and skin graftingwww.vipinpatidar.wordpress.com

4) Full-thickness (3rd degree)
 Epidermis, dermis and into
subcutaneous tissue,
 Full-thickness extends to muscle
or bone
 Dry, leathery. Typically no
blistering
 Commonly seen when clothes
are caught on fire or skin is
directly exposed to flame
 Extensive healing time and need
for skin grafting www.vipinpatidar.wordpress.com

1. Minor Burns
 Partial thickness burns are no greater than
15% of the TBSA in the adult
 Full thickness burns are < 2% of the TBSA in
the adult
 Burn areas do not involve the eyes, ears,
hands, face, feet, or perineum
 There are no electrical burns or inhalation
injuries
 The client is an adult younger than 60
 The client has no pre-existing medical
condition at the time of the burn injury
 No other injury occurred with the burn

2. Moderate Burns
 Partial thickness burns are deep and are 15% to
25% of the TBSA in the adult
 Full thickness burns are 2% to 10% of the TBSA in
the adult
 Burn areas do not involve the eyes, ears, hands,
face, feet, or perineum
 There are no electrical burns or inhalation injuries
 The client is an adult younger than 60
 The client has no chronic cardiac, pulmonary, or
endocrine disorder at the time of the burn injury
 No other complicated injury occurred with the burn

3. Major Burns
 Partial thickness burns are > 25% of the TBSA in the
adult
 Full thickness burns are > 10% of the TBSA
 Burn areas involve the eyes, ears, hands, face, feet,
or perineum
 The burn injury was an electrical or inhalation injury
 The client is older than 60
 The client has a chronic cardiac, pulmonary, or
metabolic disorder at the time of the burn injury
 Burns are accompanied by other injuries

PATHOPHYSIOLOGY OF BURNS
BURN
↑ Vascular permeability
↓ Cardiac output
↑ Peripheral resistance
↑ Viscosity
↑ Hematocrit
↓ IV volume
Edema

ASSESSMENT OF
BURNS
Body Surface Area
 Rule of Nines
◦ Best used for large surface areas
◦ Tool to measure extent of burn
 Rule of Palms
◦ Irregular or splash burns
◦ Best used for burns <10% BSA
Lund and Brower chart

Burn Surface Area Estimation
1. Rule of Nines

2. Rule of Palms
A burn equivalent to the size of the
patient’s hand is equal to 1% body
surface area (BSA).

3 Lund and Brower chart

Burns management
phases of burn care
PHASE DURATION
Emergency/ resuscitative From onset of injury to
completion of fluid
resuscitation.
Acute/ intermediate From beginning of diuresis to
near completion of wound
care.
Rehabilitation From major wound closure to
return to individual’s optimal
level

Priorities…
 First aid.
 Prevention of shock
 Prevention of respiratory disorder
 Wound assessment and initial care
 Wound care and closure
 Prevention of complication
 Nutritional support
 Physical, occupational, vocational
rehabilitation.
 Cosmetic reconstruction
 Psychological counseling.

Burns management
1. Emergency first aid:-
 Stopping the burning process
 Cool the burn
 Remove restrictive objects.
 Cover the wound.
 Use of blanket
 ABCs of trauma care
 Transport the patients to hospital
 Switch off electrical supply.
 Wash the parts incase of chemical burns
(irrigate chemical burn)

Continue..
2. General protective measures:-
 First aid
 Ice packs and cold water application
 Loose the tightened clothing
 Provide patent airway
 Use aseptic procedures
 Don’t break or peal off blisters

Continue..
3. Supportive management:-
 Analgesics and sedatives
 Fluid replacement therapy
 Transportation to hospital under
medical supervision.

Continue..
4. Hospital management:-
a) General supportive measures:
 Assess airway
 Manage breathing
 ECG
 Provide feeding by nasogastric tube
b) Fluid therapy:
Establish central line for fluid
replacement

FLUID THERAPY
Parkland formula
a. Initial 24 hours: Ringer’s lactated (RL) solution 4 ml x
body weight (kg) x % burn for adults.
 This formula recommends no colloid in the initial 24 hours.
 The calculated half fluid should be given in first 8 hours
and remaining fluid should be given in next 16 hours.
b. Next 24 hours:
 Colloids given as 20–60% of calculated plasma volume. No
crystalloids.
 Glucose in water is added in amounts required to maintain
a urinary output of 0.5–1 ml/hour in adults.

Continue..
Brooke army formula
 Initial 24 hours: RL solution 1.5 ml x body weight
(kg) x % burn
+
 colloids 0.5 ml x body weight (kg) x % burn
+
 2000 ml glucose in water
 Next 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25
ml/kg/% burn and the same amount of glucose in
water as in the first 24 hours

Continue..
Consensus formula
 RL solution 2-4 ml x body weight (kg) x % burn
Evans formula
 RL solution 1ml x body weight (kg) x % burn
+
 colloids 1ml x body weight (kg) x % burn
+
 2000 ml glucose in water

Continue..
 Assess for B.P., vitals, Hct. plasma,
blood volume etc regularly
 Adequacy of fluid therapy is to be
assessed by urinary output (1-
2ml/kg/hr)
 Central venous pressure should be
maintained 7-15 cm of H20.
 Prophylaxis : T.T.
 Hyper immune tetanus globulin with
T.T. will be given 6 weeks and 6
months interval www.vipinpatidar.wordpress.com

Continue..
Chemotherapy:
 Crystalline penicillin for 5 days
 Wound swab culture for culture and
sensitivity
 Antibiotics
 Aseptic and barrier nursing
Sedation:
 Pethadine- 1to 2 mg/kg intravenously.

Continue..
e) Nutrition:
 Diet rich in calories and proteins
because of negative nitrogen
balance.
 Calories= 60kcal/kg + 35kcal/1% burn
 Protein= 3 gm/kg body wt + 1
gm/1%of burn
 N.G. feeding
 Vitamin A, Zn, Cu is important

Wound care and treatment
Dressing: Hydrotherapy
 Daily cleansing and debridement are
necessary to promote skin integrity
 May use tubs or shower carts, mobile
stretchers.
Wound debridement
 To remove tissue contaminated by bacteria
and foreign bodies
 To remove dead tissue and promote wound
healing.
 Three types- natural, mechanical,
surgical www.vipinpatidar.wordpress.com

Contd..
 The choice of method depend upon
injury and environment of patient.
 Closed method: closed wound, sealed
off completely by dressing, prevent
complications, and cross infection
 Exposed method: exposed wound,
apply topical agents.

Contd…
Topical antibiotics: decrease both risk of
infection, fluid loss from burn.
 Silver sulfadiazine: painless, poor eschar
penetration, broad antibacterial spectrum, no
metabolic side effects
 Mafenide: Penetrates tissue well, broad spectrum
antibiotics, painful on application.
 Bacitracin: often used for burns of face, painless,
no pigment bleaching (can be seen with silver
sulfadiazine)
 Aqueous silver nitrate 0.5%: painless
application, poor eschar formation. www.vipinpatidar.wordpress.com

Surgical treatment
1. Escharotomy: a surgical incision into
necrotic tissue resulting from a severe burn
to lessen the pressure on neurovascular
structures. Incision of burnt tissue down
into fat.
Indications: Circumferential full thickness
or 3rd degree burns
burns to limbs (longitudinal),
chest (anterior axillary line,
lateral cuts joined by transverse cuts &
costal margin) or neck.

Surgical treatment
2. Fasciotomy: It is a surgical procedure
that cuts away the fascia to relieve tension
or pressure.
Indications: skeletal trauma, crush injury,
high-voltage electrical injury or if involving
tissue beneath the investing fascia.
3. Grafting: it is a transplantation of tissue
from one body part to an other.
Indications: Full thickness, Cosmetic
review

CONTRACTURE
S

Complications
 Shock
 Septicemia
 Low cardiac output
 Acute tubular necrosis
 Pulmonary edema
 Throbophebitis
 Bronchopneumonia
 Marjolin’s ulcer (burn scar carcinoma)
 Septic arthritis
 Curling’s ulcer (gastroduodenal
hemorrhage)

Prevention
 Proper storage of inflammable articles
 Use of platform when cooking, heaters
 Fire alarms
 Closure of electric sockets
 Need for high protein and high calorie
diet
 Care of burn wound

Burns

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