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05/02/2023 1
BURN
BY DR BADAL KHAN PGR1SURGICAL UNIT 3 BMCH
05/02/2023 2
INTRODUCTION
Majorty of burns in children are SCALDS caused by accidents with kettles,pans,hot drinks and bath waterIn young males burn caused by experimenting With mathes and inflamable liquides
Electrical and chemical injuries occur in adults with Associated conditions such as mental disease, Epilepsy Alcohal and drug abuse
05/02/2023 3
ETIOLOGY OF BURNSDRY HEAT
FLAME
ELECTRICT CONTACT
CHEMICAL
FROSTBITE
IONIZING RADIATION
05/02/2023 4
CLASSIFICATION OF BURNS
1.Depending on the percentage of burns MILDo Partial thickness burns <15% in adults and <10% In children oro Full thickness <2%
o Can be treated on outpatient department
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Classification (cont…….
MODERATEoSecond degree burn of 15-25% burns
oThird degree burn between 2-10% burns
oBurns which are not involving eyes,ears
Face,hand,feet and perineum
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CLASSIFICATION (CONT……)
SEVEREoSecond degree burns more then 25% in adults and More then 20% in childrenoAll third degree burns more then 10%oAll electrical burns and inhalation burnsoBurns with fractureoBurns involving eyes,ears,feet,hands and perineum
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Classification(cont…..)
2.Depending on thickness of skin involved First degree Second degree Third degree Fourth degree Partial thickness burns
I. SuperficialII. deep
Full thickness burns
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CLASSIFICATION(CONT…..)
a.First degree Epidermiss looks red and painfull No blisters formation Heals rapidly In 5-7 days by epithelialization Without scarring
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Classification(cont…..)
b.2nd degree burnsaffected area is red,mottled,painfullBlister formationHeals in 14-21 days by epithelialization With scaring
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CLASSIFICATION(CONT……)
C.3rd degree burnsAffected area is painless and insensetive with Thrombosis of superficial vesselsIt requires graftingD.4th degree burnsIt involves underlying Tissues Muscles bones
05/02/2023 11
Degrees of burns.Partial thickness and full thickness discuss in asessment of burn
05/02/2023 12
Pathophysiology of burn injuryMost common organ affected is the skinBurn can also damage airways and lungs with life Threatening consequensesRespiratory system injuries occure if person trapped In a burning vehicle,house,car and is forced to inhale The hot and poisonous gasesHot gases burn the lining of airway above the larynx And lining start to swell later on block the airwaySteam causes damage to the lower airways,respiratory Epithelium swells and detach from bronchial tree
05/02/2023 13
Pathophysiology(cont……)
Metabolic poisoningCarbon monoxide is a product of incomplete combustion That is often produced by fires in a closed space is one of Many poisonous gasesCo binds to hb with an affinity of 240> O2 so block Transport Of O2Level of carboxyhaemoglobin in blood can be measureConc >10% dangerous and need treatment with pure Oxygen for more then 24hoursHydrogen cynide causes metabolic acidosis by interefering With mitochondrial respiration
05/02/2023 14
Pathophysiology(cont……)
Inhalational injurycaused by mainute particles within thick smoke because Of their small size and are not filtered by the upper Airwayand are carried down to lung parenchymaStick to moist lining causes intense reaction in alveoliCauses chemical pneumonitis followed by oedema within Alveolar sac and dec gaseous exchangeBacterial pneumonia occures
05/02/2023 15
Pathophysiology(cont……)
Inflamtion and circulatory changesBurn skin release of neuropeptides activation of Complement are intiated by stimulation of pain fibers and Alteration of proteins by heat
Activation of hageman factor alter archidonic acid Thrombin and kallikrein pathways
05/02/2023 16
Pathophysiology(cont……)
At cellular levelComplement causes degranulation of mast cellsAttracts neutrophils which also degranulate and releases Large amount of free radicals and proteasesMast cells also releases TNF@ which act as chemotactic Agent to inflamatory cellsThese inflamatory factors alter permeability of bld vesselsLarge protein molecules can also escape with easeDamaged collagen and extravasated proteins oncotic Pressure further increase flow of water from intravascular To extravascular space
05/02/2023 17
PathophysiologyHeat causes coagulation necrosis of skin andsubcutaneous tissue.↓Release of vasoactive peptides↓Altered capillary permeability↓Loss of fluid → Severe hypovolaemia↓Decreased cardiac → Decreased myocardialoutput function↓Decreased renal blood → Oliguriaflow (Renal failure)↓Altered pulmonary resistance causing pulmonaryOedema infectionSystemic Inflammatory Response Syndrome (SIRS)↓Multi Organ Dysfunction Syndrome (MODS).
05/02/2023 18
ASSESSMENT OF BURNS
1.ASSESSING SIZEBurn size should be assessed in a controlled environmentTo avoid hypothermiaIn smaller burns just cut a piece a clean paper the size of patient ,s whole hand (digit and palm)which present 1% TBSAAnd match this to the areaAnother accurate way of measuring the size of burns is to drawThe burn on a LUND AND BROWDER CHART
Age in yrs
0 1 5 10 15 adult
A head 9 8 6 5 4 3
B thigh 2 3 4 4 4 4
C leg 2 2 3 3 3 3
05/02/2023 19
ASSESSMENT(CONT…..)RULE OF 9 (wallace,s rule of 9Each upper limb is 9% TBSAEach lower limb is 18% TBSATorso 18% each sideHead and neck 9%Perineum 1%In children head and neck is 18% andLower limb is 13.5% each=13.5*2=27%
05/02/2023 20
Rule of 9
05/02/2023 21
ASSESSMENT(CONT…..)2.Assessing depth from the historyBurning of human skin is temperature and time dependentIt takes 6 hours for skin maintained at 44c* for irreversible changesA surface teperature of 70c* for 1 second produce epidermaldestruction
Example of Exposure to hot water at 65c*45 second exposure produce full thickness burn15 second exposure produce deep partial thickness burn7 second exposure produce superficial partial thikness burn
05/02/2023 22
ASSESSMENT(CONT…..)a) Superficial partial thickness burns No deeper then papillary dermis Blister formation Loss of epidermis Capillary return visible When blanched Dermis is pink and moist Pin prick sensation normal Heal without scarring In 2 weeks Treatment is non surgical
05/02/2023 23
Superficial partial thickness burns
After 24 hours after burn After 2 weeks
05/02/2023 24
Superficial partial thickness burn after 3 monthsPigment returning
05/02/2023 25
ASSESSMENT(CONT…..)
b)Deep partial thickness burnDamage to deeper parts of dermisEpidermis is usually lostFixed capillary stainingColour does not blanch with pressureSensation is reducedPt is unable to distinguish sharp from blunt pressureTakes 3 or more weeks to heal without surgeryLeads to hypertrophic scarring
05/02/2023 26
ASSESSMENT(CONT…..)
c) Full thickness burnsWhole of the dermis destroyedHard and leathery feelNo capillary returnOften thrombosed vessels can be seen under The skinThese are completely anesthetisedNo pain and no bleeding
05/02/2023 27
Causes of death in burns
a. Hypovolaemia and shock
b. Renal failure
c. Pulmonary oedema and ARDS
d. Septicaemia
e. Multiorgan failure
05/02/2023 28
Full thickness burnWraped in cling film
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Deep partial thickness burntangential shaving to remove dead dermisDermis remove layer by layer untill bleeding
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Hypertrophic scarring following a deep dermal burn.After 3 or more weeks
05/02/2023 31
Management of burns
Management of burns is consist of prehospital care & hospital care
05/02/2023 32
Management of burnsPrehospital careStop the burning processStop,drop and roll is a good method of extinguishingFireCool the burn woundThis provide analgesia and slow the delayed micro--vascular damage which occure after a burn injuryCooling should be for minimum 10 mintues and up toOne hour to avoid hypothermiaGive oxygenGive oxygen especialy if there is altered level concious_-ness level
05/02/2023 33
Management of burnsElevateSitting a patient up with a burned airway may prove lifeSavingElevation of burned limbs reduce swelling and discomfortCheck for other injuriesA standard ABC check followed by a secondary surveyPatients burned in explosions may have head and spine injuriesAnd other life threatening problems
05/02/2023 34
Management of burns
Indications for admission in burnsSusected airway or inhalational injuryAny burn require fluide resusciationAny burn in extreme of agesAll electrical and chemical burnsAny burn which require surgeryBurn of any significance to hands,face,feet or perineumSuspicious of non accidental injury
05/02/2023 35
Management of burns
Hospital careAdmit the patientAirway controlBreathing and ventilationCirculationDisabilityExposure with environment controlFluid resuscitationAssess the %age,degree and type of burnKeep the patient in clean environmentSedation and proper analgesia
05/02/2023 36
Management of burnsA.AIRWAY CONTROL
Burned airway creates problems by swelling and can completely Occlude the airwaySecure airway with an endotracheal tube until swelling subsided which is Usually 48 hoursDelayed diagnosis of airway burn make difficult to intubate the Patient in presence of lyrangeal oedema so cricothyroidectomy Should be doneEarly intubation of suspected airway burn is the treatment of Choice in such patients
05/02/2023 37
Management of burnsB.BREATHINGA progressive increase in respiratory rate and effort ,anxietyRising pulse and confusion with decreasing o2 saturationThese symptoms take 24 hours to 5 days to appearTreatment starts as soon as possible includingPhysiotherapyNebulisersWarm humidified oxygen
05/02/2023 38
Management of burns
Fluide resuscitationIv volume must be maintained following a burn in order to provide sufficient circulation to perfuse not only the organs but also the peripheral tissues,especially damaged skinIv resuscitation is appropriate for any child with a burn greaterThen 10% and 15%for TBSA for adultsIf oral resuscitation is to be commenced then water is givenShould not be salt freeIt is appropriate to give oral rehydration with a solution such asDIORALYTE*Most common fluid used is ringer lactate
05/02/2023 39
Management of burnsFluid volume is relatively constant in proportion to the areaOf body burned therefore there are formulate that calculateThe approximate volume of fluid needed for the pt of a givenBody weight with a given %age of the body burnedFormulas to calculate the fluid replacement1.parkland regime (commonly used)4ML/%burn/kg body weight/24 hours4*50*60=12000ml in 24 hoursHalf this volume is given in the frist 8 hoursSecond half is given in the subsequent 16 hoursOthers1. Evan,s formula2. Muir and barclay3. Modified brook formula
05/02/2023 40
Management (cont…)
Fluids usedCrystalloid resuscitationRinger lactate is the most commonly used crystalloid These are as effective as colloids for maintaining intra--vascular volumeLess expensiveIn childrenDextrose saline given for maintanaince100ml/kg for 24 hours for frist 10kg50ml/kg for 24 hours for next 10kg20ml/kg for 24 hours for each kg above 20kg body weight
05/02/2023 41
Management (cont…)hypertonic saline it produces hyperosmolarity and hypernatremia
Reduces shift of intracellular water to extracellular space
AdvantagesInclude less tissue oedema and a resultant decrease inEscharotomies and intubations
05/02/2023 42
Management (cont…)Colloid resuscitationPlasma proteins are responsible for the inward oncoticPressure that counteracts the outward capillary hydrostaticPressure.Without proteins there will be oedemaProteins should be given after frist 12 hours of burn beforeThis time proteins will leak out of cellsGiven through muir and barclay formula0.5*%age bsa burn*weight=one portionPeriods of 4/4/4, 6/6, 12 hours respectivelyOne portion to b given in each period
05/02/2023 43
Management (cont…)
Monitoring of resuscitationThe key to monitoring of resuscitation is urinary outputOutput should be between 0.5ml and 1.0ml/kg/hourIf urine output is below this infusion rate should increaseBy 50%If still output is inadequate then a bolus of 10ml/kg given2ml/kg/hr urinary output signals decrease in the rate ofPerfusionHaematocrit measurement is a usefull tool in confirmingSuspected under or overhydration
05/02/2023 44
Management (cont…)Treating the burn woundDressingsParaffine guazeHydrocolloids (duoderm)Biological dressings synthetic (biobrane) natural (amniotic membrane)Full-thickness and deep dermal burns need antibacterialdressings to delay colonisation prior to surgeryOpen methodSilver sulfadiazine application without dressings commonly Used in burns of face,head and neck.Closed methodDressing done to soothen and to protect the woundTo reduce the painAs an absorbent
05/02/2023 45
Management (cont…)Treating the burn wound (cont……Tangential excisionCan be done within 48 hours with skin grafting in patients with less Then 25% burnUsually done in deep dermal burnsDead dermis is removed layer by layer Untill fresh bleeding occursLater skin grafting done
05/02/2023 46
Treating the burn wound (cont……Treating the burn wound (cont…… escharotomyCircumferential full-thickness burns to the limbs require emergencySurgeryThe tourniquet effect of this injuryis easily treated by incising the whole length of full-thicknessburns.This should be done in the mid-axial line, avoiding majorNervesThe burn needs to be cleaned and the size and depth need to be Full thickness burns and deep partial-thickness burns that will requireoperative treatment will need to be dressed with an antibacterialdressing to delay the onset of colonisation of the wound
05/02/2023 47
A full-thickness burn to the upper limb with a mid-axialescharotomy.The soot and debris have been washed off.
05/02/2023 48
Topical agent advantages problems
Silver sulfadiazine 1 %
-Antiseptic (G +ve and G –ve-Soothening, good penetration- Hydration and softening of eschar occurs
-Neutropenia, pseudoeschar-- Causes wound maceration
Sulfamylon – 5% -(Mafenide acetate)
Antipseudomonal, anticlostridial- Penetrates very well in to tissues
Very irritant,painfulCauses acidosis
Silver nitrate – 0.5% - Antiseptic Stains burn area
Povidone iodine (5%) - Used on
granulation tissue - after eschar separation
IrritantPainfullNot used in partialburns
Silver sulphadiazine and cerium nitrate
- Boosts cell mediated immunityand forms sterile eschar
05/02/2023 49
Additional aspects of treating burn patientAnalgesiaOral form of paracetamol and nsaids in superficial burnsIv opiates for large burnsIm should not be given in over 10% of TBSA as absorption is UnpredictableShort acting analgesia given before dressingEnergy balanceFeeding should start within 6 hrs of injury to reduce gut mucosal damage.Burns patients need extra feedingA nasogastric tube should be used in all patients with burns over 15%of TBSA and 10% in case of children Burn injuries are catabolic in the acute episode.Removing the burn and achieving healing stops the catabolic drive
05/02/2023 50
Additional aspects of treating burn patient
control of infectionPatients with major burns are immunocompromised,pathogenic and opportunistic bacteria and fungi enter via the burn wound,cathetars and iv linesThey have compromised local defences in the lungs and gut due to oedemaSterile precautions must be rigorous Swabs should be taken regularly A rise in white blood cell count, thrombocytosis and increased catabolism are warnings of infectionNursing carePhysiotherapyPsychological support
05/02/2023 51
SURGERY FOR THE ACUTE BURNAny deep partial-thickness and full-thickness burns exceptthose that are less than about 4 cm2, need surgeryA topical solution of 1:500 000 adrenaline also helps to reducebleeding,deep dermal burns, the top layer of dead dermis is shavedoff until punctate bleeding is observed and the dermis can beseen to be free of any small thrombosed vesselsFull-thickness burns require full-thickness excision of theSkinPostoperative management of these patients obviouslyrequires careful evaluation of fluid balance and levels of haemoglobin.
05/02/2023 52
Delayed reconstruction and scarmanagement
is common for large Full thickness burnsEyelids must be treated before exposure keratitis arises Transposition flaps and Z-plasties with or without tissueexpansion are useful Full-thickness grafts and free flaps may be needed for largeor difficult areas Hypertrophy is treated with pressure garments to be wornfor 6-18 monthsSmaller areas of hypertrophy, silicone patches will speedscar maturation,as will intralesional injection of steroid. Pharmacological treatment of itch is important
05/02/2023 53
Effects of burn Shock due to hypovolaemia Renal failure(toxins from burn&myoglobin) Pulmonary oedema,resp infections,ARDS,resp failureInfection by staph aureus,pseudomonas,klebsella leads toSepticemia Fungal and viral infections of dangerous type can occureGIT: Hypovolaemia, ischaemia of mucosa, erosivegastritis—Curling’s ulcer (seen in burns > 35%). Fluid and electrolyte imbalance.immunosuppression predisposes to severe opportunistic infection.Eschar formation and its problems like defectivecirculation, ischaemia when it is circumferential.Electrical injuries often cause fractures, majorinternal organ injury, convulsions.
05/02/2023 54
Effects of burn(cont…..)Inhalation burn causes pulmonary oedema,respiratory arrest, ARDS.Chemical injury causes severe GIT disturbances likeerosions, perforation, stricture oesophagus (alkali),pyloric stenosis (acid), mediastinal injury.Other problemsDVT, pulmonary embolismbed-sores,severe malnutrition with catabolic status, Toxic shock syndrome: It is a life-threatening exotoxin mediated disease caused byStaphylococcusaureus. It is common in children, presents withrashes, myalgia, diarrhoea, vomiting, and multiorganfailure with high mortality.
05/02/2023 55
Effects of burn(cont…..)
Development of contracture is a late problem. Itleads to ectropion, microstomia, disability ofdifferent joints, defective hand functions, growthretardation causing shortening
COMPLICATIONS OF BURNS CONTRACTUREEctropion of eyelid causing keratitis and cornealulcer.Disfigurement in face.Narrowing of mouth microstomia.Contracture in the neck causing restricted neck movements.Disability and nonfunctioning of joints due to contractureHypertrophic scar and keloid formation.
05/02/2023 56
COMPLICATIONS OF BURNS CONTRACTUREMarjolin’s ulcer
It is a very well-differentiated squamous cell carcinoma occurring in a scar ulcer due to repeated breakdown (unstable scar of long duration).• It is locally malignant.• As there are no lymphatics in the scar, so thereis no spread to lymph nodes.• As there are no nerves in the scar it is painless.• It has raised and everted edge with induration.• Biopsy confirms the diagnosis.TreatmentRadiotherapy is not given for Marjolin’s ulcer.Treatment is either wide excision or amputation. It is curable.Once it spreads out of the scar tissue it behaves likeany other squamous cell carcinoma and so can spread to regional lymph nodes
05/02/2023 57
Marjolin’s ulcer developed over burns contracture
05/02/2023 58
Contracture at different parts of body chest and neck
05/02/2023 59
Contracture at different parts of bodySevere contracture at knee joint causing deformity Contracture at face
05/02/2023 60
Complication of contracture
Hypertrophic scar Keloid formation
05/02/2023 61
Treatment of burn contracture
• Release of contracture surgically and use of skin graft or “Z” plasty or different flaps.
• Proper physiotherapy and rehabilitation is essential.
• Pressure garments to prevent hypertrophic scars.
• Management of itching in the scar using aloe vera, antihistamines and moisturizing creams.
05/02/2023 62
Prevention of development of contracture
• Joint exercise in full range during recovery period ofburns
• Pressure garments for a long period
• Topical silicon sheeting
• Saline expanders for scars
05/02/2023 63
NON THERMAL INJURIESElectrical burnsChemical burnCold injuriesIonising radiation
05/02/2023 64
Non thermal(cont……)
Electrical burns 1000vLow tension injuriesLow tension injuries do not have enough energy to cause Significant destructionEntry and exit points normally in the fingers suffers small Deep burns may damage underlying nerves and vesselsAc creates a tetany within muscles so patient unable to Release the device untill the power was turned offMay interfere with normal cardiac pacing and can cause Cardiac arrest
05/02/2023 65
Electrical burns(cont…..)
high tension injuries3 sources of damage
1) The flash2) The flame3) The current
When a high tension line is earthed it can arc over the ptAnd causes a flash burnExtremely rapid heating of the air causes an explosionThat propel the victim backwardIt is always a major burnThere is a wound of entry and wound of exitMajor internal organ injuries occuresConvulsions can develope
05/02/2023 66
Electrical burns(cont…..)
ManagementDepending on injury it is managed accordinglyPatient should always be admitted and should be assessed by
i. ECGii. u/s abdomeniii. Chest x-ray iv. Ct scan head sometimesv. Cardiac enzyme analysis
Acidosis is common so bicarbonate infusion neededFractures and dislocations common so managed accordinglyRelease of myoglobin can cause renal tubular damage and renal Failure so manitol is used to prevent myoglobin induced renal failure (compartment syndrome)
05/02/2023 67
Wound of entry in an electric burn.Electric burn
05/02/2023 68
Electrical burns(cont…..)
An exit wound of a high-tension injury,Amputation and cover with the lateral portion of the second toe.
05/02/2023 69
Chemical burnsThere are 70000 different chemicals in regular use within industryOccasionally these cause burnsThere are two aspects to a chemical injury
1. Physical destruction to the skin2. Systemic absorption
The initial management of any chemical injury is copious lavageWith water but some need to be remove physically eg.phosphorusA component of millitary devicesThe more common injuries are caused by either
1. Alkalis2. acids
05/02/2023 70
Chemical burns(cont…)
After copious lavage, the next step in themanagement of any chemical injury is to identify the chemicaland its concentration and to elucidate whether there is anyunderlying threat to the patient’s life if absorbed systemically
Alkali burns occur in oral cavity and oesophaguswhich leads to multiple oesophageal strictures.
Alkalisalkalis are more destructive and especially when come in contactWith eyesCommonly used alkalis are sodium hydroxide,lime,bleachThey cause fat sponification,fluide loss,release of alkali proteinase
05/02/2023 71
Chemical burns(cont…)
AcidsAcid burn occurs in skin, soft tissues and GIT. In GIT,Burns affecting the fingers and caused by dilute acid are relatively common.The initial management is with calcium gluconate gel topically severe burns or burns to large areas of the hand can be subsequently treated with Bier’s blocks containing calcium gluconate 10 per cent gelit is common in stomach either due to nitric acid or sulphuric acid which may lead to severe gastritis or pyloric stenosis.Other acids are formic acid, hydrofluoric acid.They cause metabolic acidosis, renal failure, ARDS, haemolysis.Acidaemia should be corrected by IV sodium bicarbonate.
05/02/2023 72
Cold injuries
Cold injuries are principally divided into two types1. Acute cold injuries from industries2. Frost bite
inflammatory reaction is not as marked.The tissue is more resistant to cold injury than to heat injuryThe assessment of depth of injury is more difficult,Frostbiteinjuries affect the peripheries in cold climatescold injury produces delayed microvascular damage similar to that of cardiac reperfusion injury.The initial treatment is with rapid rewarming in a bath at 42°C.The level of damage is difficult to assesssurgery usually does not play a role in its management
05/02/2023 73
Ionising radiationThese injuries can be divided into
1. Localised 2. Whole body exposure
The management of localised radiation damage is usually Conservative until the true extent of the tissue injury is apparent.If damage have caused an ulcer, then excision and coverage with vascularised tissue is required.A patient who has suffered whole-body irradiation and is sufferingFrom acute desquamation of the skin has received a lethal dose ofRadiation which can cause a particularly slow and unpleasant deathDose may be lethal and may not be lethalGiving iodine tablets, the management of these injuries is supportive
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THANKS