Burn Management

Mekonen Eshete MD, FCS(ECSA)Plastic and Reconstructive Surgeon

Burn Management

• Coagulative Lesions involving the surface layers of the body

High- risk groups

• No one is immune to thermal injury but there are four high-risk groups that are the predominant victims of severe burn injuries

• The very young• The very old• The very unlucky (about 20% of burn victims

are innocent bystanders to a fire)• And the very careless (75% of burn injuries

result from the victim’s own action

Con….

• Burns are usually caused by heat

• Scalds are thermal injuries caused by wet heat, most usually boiling water or steam.

• Temperatures are relatively low and injury is usually superficial

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con• The skin is the largest organ of the human body

• It may seem as a simple outer covering, but is in fact complex and multifunctional

• It consists of a superficial layer (the epidermis) adhering closely to the deeper layer (the dermis) via a basement membrane (the basal cell layer)

• Loose connective tissue and fat underlie the dermis

• Deep to the skin lie the fascial layers and the muscles

Con…

• Skin provides– protection, barrier to infection,– temperature regulation, – sensation, – specific metabolic function and aesthetic containment .

Clinical Classification

• First degree• Partial thickness

burns:– Superficial dermal – Deep dermal

• Full thickness Burns •There is little erythema •Superficial dermal burns blister

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BURNSBURNS

SuperficialSuperficialDermalDermal

Partial thickness burnsPartial thickness burns

Con…

• In partial thickness burns part of the dermis survives allong with the epidermal appendages (hair follicles and sweat and sebaceous glands)

• In the superficial dermal burns only the superficial layers of the dermis are involved

Con…

• Deep dermal burns reach down into the deeper layers of the dermis

• But still, some of the epidermal appendages (mentioned before) survive

DeepDeepDermalDermal

Con..

Con…

• In deep dermal burns, spontaneous healing may be delayed for 3-4 weeks and is frequently followed by the development of hypertropic scars

con• In full thickness

burns there are no patent capillaries remaining in the bed and coagulation destroys the etrire dermis together with the epidermal cells

• This means that there is no spontaneous healing from the bed

Full Full ThicknessThickness

Full thickness Burn

Types of injury

• The Primary injury:– Is the immediate damage caused by the burn

• To limit the extent of injury– Remove the heat source – Rapid cooling– Copious irrigation

con

• The Secondary injury:– Sequellae resulting from the primary injury– Influenced by management

The burn wound • Three distinct areas within every burn wound:– Irreversibly damaged– May recover under the correct condition

– vasodilatation and increased blood flow reversible.

Burn management

Burn typeBurn type depthdepth blistersblisters SensationSensation HealingHealing

superficialsuperficial Epidermis onlyEpidermis only yesyes painfullpainfull ++

Superficial dermal (partial Superficial dermal (partial –thickness)–thickness)

Epidermis to Epidermis to papillary papillary dermisdermis

yesyes painfullpainfull UsuallyUsually

Deep dermal(partial Deep dermal(partial thikness)thikness)

Epidermis to Epidermis to reticular dermisreticular dermis

nono Reduced Reduced sensatiosensatio

n of n of painpain

--

Full-thicknessFull-thickness Whole thickness of Whole thickness of skin skin

nono insensateinsensate --

BURN Management

• Morbidity and mortality determined by:– the extent of injury, – the depth of injury, – the age of the patient, – associated injuries,– co-morbid conditions and– the adequacy of care at all stages, from rescue, triage,

resuscitation, wound care, rehabilitation and psychosocial recovery.

Burn Management• Lund and Browder chart

RESPIRATORY BURN INJURY

• Respiratory burn is a major factor in mortality and morbidity in burn injury.

• Increases the severity of a burn• Can increase resuscitation fluid requirements

Respiratory Burn Injury

• Suspected in – Fire in an enclosed space– Patient lying unconscious in a fire

• Symptoms– A hoarse or weak voice– stridor– cough– Restlessness

Respiratory Burn Injury

• Signs– Soot around the mouth and nose– Singed facial and nasal hair– A swollen upper airway– Hypoxia– Pulmonary edema– ARDS

Respiratory Burn Injury

• Consequence– Increased fluid requirement – Increased incidence of bronchopneumonia– Increased mortality

CON

• Diagnosis– Clinical– Bronchoscopy

• Treatment– Early recognition– Intubation and ventilation– Humudified oxygen– antibiotics

BURN CAREFIRST AID

• Remove the victim from the source of the injury• Remove clothing.• Rapid assessment of the injuries• Respiratory support• Intravenous fluid therapy• Management of associated injuries• Transport to nearest medical facility.• Tetanus immunization

Referral to burn unit

• Burn >10% TBSA in adults• Burn >5% TBSA in children• Full thickness burn >5% TBSA in adults• Significant burn to vital areas• Significant electrical and chemical burns• Extremes of age • Burns in patients with a significant pre-existing

illness

Burn Resuscitation

• Adults with burns covering more than 15% of TBSA

• Children with burns of 10% TBSA or more• Parkland formula of 4 mL/kg/%TBSA• Best guide to monitor resuscitation is hourly

urine output– >0.5 mL/kg/hr in adults– 1 mL/kg/hr in children

Burn Wound Infection

• Causes partial thickness burns to become full thickness burns

• Psuedomonas aeruginosa commonly isolated• Commonly used topical antimicrobials– Silver sulfadiazine– Mefenide acetate– Silver nitrate

BURN WOUND CARE

• Preserve the tissues that may survive.• Remove the tissues that are devitalized as

soon as possible.• Provide durable skin coverage as soon as

possible.• Prevent infection and if it is established, treat

it vigorously.• Protect recently healed tissues.

Timing of Surgery

• Early excision and grafting– Tangential excision– Fascial excision

• Late surgery– After three weeks

• Skin grafting– Split thickness skin grafting, sheet vs. meshed – Full thickness skin grafting

BURN CARE

WOUND CARE

Other modes of cover

• Amnion cover• Cadaveric skin cover• Xeno graft • Keratinocyte culture

Electrical Burns

• Two wound sites – inlet and outlet• Extensive deep muscle damage because of high bone

resistance• Fasciotomy instead of escharotomy• Myoglobinuria because of rhabdomyolysis leading to

ATN and ARF• Fluid requirement increased to have UO of

2mL/kg/hr• Sodium bicarbonate to alkalinize urine

Chemical Burns

• Causes– Alkalis– Acids

Chemical Burns

• Alkali Burns– Liquefactive necrosis hence deeper injury– Oven bleaches, fertilizers, cement– Lavage area with copious amount of water

• Acid Burns– Coagulative necrosis– Irrigate with water and sodium bicarbonate

BURN CARE

• Team approach to care and management.– Nursing.– Physical and occupational therapy– Nutrition.– Psychological & Spiritual support.– Family and social support.– Reentry into society.

BURN CAREREHABILITATION

BURN CARE

• THE BEST BURN CARE IS NOT A SUBSTITUTE FOR PREVENTION.

• 75% OF ALL INJURIES THAT WE SEE ARE PREVENTABLE.

Our responsibilities in burn care

• If we accept the care of a patient, we need to provide the standard of care that is appropriate for our region.

• We need to accept that we are taking care of a fellow human being who is in pain.

• Our goal is to restore function and appearance in the shortest period of time.

Summary

• Assessment & Decision (ABC)• Fluid Management• Pain Management• Wound Management & Topical Agents• Surgical Wound Management• Nutritional Management• Positioning, Splinting, Rehabilitation• Prevention of Complications • Prevention of Burn