BURN INJURIES

Margaret Tandoh,MD

Assistant Professor of Surgery

University of Vermont

OBJECTIVES

• TYPES OF BURNS

• HOW DEEP IS IT

• HOW MUCH IS BURNED

• HOW DO YOU CARE FOR THE BURN

SCOPE OF THE PROBLEM

• Burn injuries receiving medical treatment: ~450,000

• Hospitalizations: 45,000 (10%)-- ~25,000 at burn centers

• Fire/Burn deaths/year: 3,500– 3,000 residential, 500 other(MVC, aircraft, etc)

• 75% of deaths at scene or initial transport

SCOPE OF THE PROBLEM

• GENDER: 70% males, 30% females

• ETHNICITY: 60% Caucasian, 19% African-American, 15% Hispanic, 6% Other

CAUSES:

– Flame 44% – Scald 33% – Contact 9% – Electrical 4% – Chemical 3% – Other 7%

SCOPE OF THE PROBLEM

• In severe burns:

– 37% flame

– 24% scalds

– Structural fires: 50% of death due to CO, not burns

ANATOMY

• Largest organ

• Protective barrier

• Regulates temperature

ANATOMY

TYPES/CLASSES OF BURNS

– THERMAL

• FLAME

• SCALD

• FLASH

• CONTACT

TYPES/CLASSES OF BURNS

– NON-THERMAL

• CHEMICAL

• ELECTRICAL

• RADIATION

• COLD

PAHOPHYSIOLOGY OF THE BURN WOUND

• Burn injury-coagulation necrosis-increased capillary permeability-fluid moves from intravascular space toward burn

• Ebb phase

– Initial decrease in CO, metabolic rate

• Flow phase(after resuscitation)

– Increase CO, resting energy expenditure

PATHOPHYSIOLOGY cont’d

• 3 zones of tissue injury:

– Coagulation: dead or dying cells, most intimate contact with heat source

– Stasis: vasoconstriction and ischemia, may convert to coagulation

– Hyperemia: vasodilation, viable cells

SCALDS

• Most common cause of burns

• Water at 140F causes full-thickness burns in 3secs, at 156F in 1sec.

• Cup of coffee, 180F

• Grease clings to skin

• Thicker soups and sauces remain in contact longer

FLAME

• Most common in severe burns

• 67% in Caucasian population

• 66% involve a flammable liquid

• 63%, gasoline is liquid of choice

• 26% association with EtOH

CONTACT

• Can be 4th degree

• Unconscious patients resting on hot surface

• Toddlers falling on to wood stoves

• Industrial accidents: contact and crush

ELECTRICAL INJURIES

~ 20, 000 ED visits/yr

~ 500-1000 deaths/yr

> 50% of deaths occur at workplace

• 2-3% of burns in children

ELECTRICAL BURNS

• 3-5% of all admitted burns

• Visible burned areas represent only a small portion of destroyed tissue

• Electrical currentheat tissue with lowest resistance(nerves, vessels muscles)

• Low-voltage: similar to thermal burns, only local damage, 110-220 V

• High-voltage:1000 V or more, CPR, full trauma evaluation, EKG monitoring

• Multiple complications: cataracts(up to 30%), neurologic

CHEMICAL BURNS

• Most are from household cleaners

• Industrial exposures

• Injury caused by protein destruction

• Speed is essential in management

• Copious lavage with water

• Alkalis: lime, KOH, bleach, cement(calcium oxide), NaOHusually deep

• Acids:protein breakdown by hydrolysishard escharnot as deep as alkalis

ASSESSMENT OF THE BURN WOUND

• Outcome dependent on depth and extent of injury

• Extent of injury

– Rule of nines

– Lund Browder chart

– Palm size(of patient) including digits

DEPTH OF BURN

• 1st degree

– Epidermis only, painful, dry, heals in ~ 7days, no scars

• 2nd degree

– Superficial: various portions of superficial dermis, painful, moist(dermal vessels present), blisters, minimal scarring, heals in ~ 14 days

DEPTH OF BURN

• 2nd degree – Deep: usually insensate, no blisters, treat like 3rd

degree

• 3rd degree – Full-thickness necrosis, painless, dry, can be any

color, will scar, needs excision

• 4th degree – Underlying structures(muscle, bone) involved

FOURTH DEGREE

• Extends into muscle, bone, etc

SIZE OF THE BURN WOUND

INITIAL MANAGEMENT

• Airway

• Breathing

• Circulation

• Disability

• Exposure/environment

INITIAL MANAGEMENT

• Cover with clean dry sheet

• Irrigate copiously chemical burns)

• No antibiotics

• No ice

• Leave blisters

• Tetanus prophylaxis

INITIAL TREATMENT

• Stop burning process

• Primary and secondary survey

• Resuscitation: Parkland(4ml/kg/% TBSA) and Brooke(1.5ml/kg/%TBSA + 0.5/kg/%TBSA)

• Escharotomies: edema impedes venous outflow and then arterial inflow. Look for numbness and tingling in limbs, increased pain in digits

• Tetanus

WOUND CARE

• Early excision and grafting deep 2nd and 3rd degree wounds

• Full-thickness skin grafts:decreased contracture, but limited and can only be used once. Not commonly used in burn wounds.

• Split-thickness skin grafts: commonly used

FROSTBITE

• 1805: first modern report published

• 1814: Dominique Larrey(Surgeon General of Napoleon’s forces) described frostbite in the forces during the campaign in1812-1813

• His treatment held for over 150 years!

• Friction massage with snow or ice, rather than thawing rapidly

PATHOPHYSIOLOGY

• Direct cellular damage and death

– Caused by extracellular ice crystals

– Rapid coolingintracellular ice crystals, more severe cell damage

Progressive tissue ischemia

Wet/moist skin more susceptible

Alcohol use very common

CLASSIFICATION

• Based on acute physical findings and imaging after rewarming:

• Frostnip: no ice crystals, no tissue loss, not frostbite, but may precede it

• 1st degree: numbness, erythema, mild edema

• 2nd degree: clear or milky blister, erythema, edema

• 3rd degree: hemorrhagic blisters

• 4th degree: extends into muscle or bone

SIGNS AND SYMPTOMS

• 90% is acral

• Ears, nose, cheek, penis also involved

• Numbness prior to rewarming, then severe pain, usually throbbing

• Tingling can occur

• Initial appearance can be deceptive

TREATMENT

• Rapid rewarming

• Temperature should be 40-42C for 15 – 30 mins or until complete

• Tetanus

• Drain clear blisters, leave bloody blisters

• NSAIDS

REMINDERS/PRACTICALS

• Smoke alarms save lives

• Set water temperature to 125F

• Avoid ice to burns

• Dry socks in the winter

• Take oxygen off when smoking

• Smother oil fire, no water

REFERENCES

• Some pictures from Google Images

• Total Burn Care, 3rd edition

• McIntosh, S et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite, Wilderness & Environmental Medicine. 22, 156-166(2011)

• ABA Fact Sheet 2011