Presentation on :Burns: Assessment & Management

Swornim GyawaliIntern GMC2010 batch

Outline• Objective• Introduction• Type of Burn injury• Classification of Burns• Pathophysiology of Burns• Assessment of the Burn wound• Management of Burns– Primary– Secondary

• Complications of Burn Injuries

Objectives• At end of this presentation we be

able to know1. definition and causes of Burn injuries2. Types and classification of burns3. pathophysiology of burns 4. Management of a patient who sustained burn injury5.Complications of burns

IntroductionDefinition• A burn is a coagulative destruction of the

surface layers of the body.• It occur when some or all of the cells in the

skin or other tissues are destroyed by heat cold electricity Radiation Lightening caustic chemicals

Types of Burn Injury• Thermal

Flame : fire injuryScald : moist heat/steamFlash : explosion Contact : to hot surfaces

• Cold exposure (frostbite)Usually occurs in distal parts of the body

Common sites: Fingers, Toes, Nose and EarsSevere Vasoconstriction & Decreased Blood

flow Ischemia

• Chemical burns Cause progressive damage Acid produces tissue coagulative Necrosis. Alkaline burns generate colliquation Necrosis. Systemic absorption of some chemicals is life

threatening

• Electrical mechanisms of injury :

i. Electrical current injuryii. Electrothermal burns from arcing

currentiii. Flame burn caused by ignition of

clothes Deep destruction of muscles

rhabdomyolysis myoglobinuria ATN ARF

• Inhalation Hot smoke

• Radiation sunburn

Pathophysiology of BurnLocal Changes1. Burn causes coagulative necrosis of the

epidermis and underlying tissues2. depth of injury: temperature & duration of

exposurearea of cutaneous injury

Systemic changes

Assessment of The Burn Wound• Burn Depth Cutaneous burns are classified

according to the depth of tissue injury:

1. superficial or epidermal (first-degree), 2. partial-thickness (second degree), or 3. full thickness (third degree). 4. Burns extending beneath the

subcutaneous tissues and involving fascia, muscle and/or bone are considered fourth degree

First degree (Superficial)

• Red, erythematous • Very sensitive to touch • Very painful • Usually moist • No blisters

Second degree (partial-thickness)

• Erythematous or whitish with a fibrinous exudate

• Wound base is sensitive to touch and Painful

• Commonly have blisters • Surface may blanch to pressure

Third degree (Full thickness)

• Surface may be: White, Black, leathery, Pale or Bright red

• Generally anesthetic or hypoesthetic • Subdermal vessels do not blanch • No blisters • Hair easily pulled from its follicle

Fourth degree • Involves deep tissues including fascia, muscle, bone, and tendons

Assessment of The Burn Wound (cont’d)

• Total percentage of body surface area (TBSA)

1. Lund-Browder chart

• Rule of Nines

Management; Primary Survey

Initial Intervention Airway maintenance with cervical

spine control Breathing and Ventilation Circulation with Haemorrhage

Control Disability: Neurological Status Exposure with Environmental

Control

Diagnostic tests and monitoring • Arterial blood gas• Chest x-ray• Serial peak expiratory flow rates

(PEFR)• Pulse oximetry• Capnography• fiberoptic laryngoscopy and

bronchoscopy

Treatment• Supplemental oxygen and airway

protection• Close monitoring of fluid

resuscitation• Mechanical ventilation• Inhaled nitric oxide• aerosolized heparin and N-

acetylcysteine (NAC)

Fluid resuscitation American Burn Association's practice guidelines, patient with greater than 15 percent total body surface area (TBSA) non-superficial burns should receive formal fluid resuscitation.

Fluid selection Formulae1. Parkland : 4ml x wt (Kg) x % TBSA burn -Ringer’s lactate or Hartman solution2. Evans :1ml x wt x %TBSA3. Brooke :1.5ml x wt x %TBSA4. Modified Brook:2ml x wt x % TBSA 

Management; secondary Survey (cont’d)

• History • Thorough physical examination• Lab studies and monitoring CBCElectrolytes RFTGlucoseVenous blood gasCaboxyhemoglobinArterial blood gasChest x-ray ECG

Management; Secondary Survey (cont’d)

ChemoprophylaxisTetanus immunizationAntibioticWound management Wound dressing and care Escharotomy

Chest - at the anterior axillary line Extremity - can be done at a bedside

without local anesthesia

Nutrition• Hypermetabolism develops as a

response to injury• If TBSA >40%, lean body weight ↓ by

25% over the first 3 weeks • Patient with major burn needs high

calorie in the form of: CHO (50%), protein (20%) , fat (30%) and some vitamins & minerals

Nutritional Requirement Calculations

Curreri formula• Age 16–59 years: (25)W + (40)TBSA• Age 60+ years: (20)W + (65)TBSASutherland formula• Children: 60 kcal /kg + 35 kcal%TBSA• Adults: 20 kcal /kg + 70 kcal%TBSAProtein needs• Greatest nitrogen losses between days 5 and

10• 20% of kilocalories should be provided by

proteins

Burn Complications 1. INFECTION2. Curling ulcer- stress ulcers3. Contracture 4. Marjolin’s ulcer, Hypertrophic scar, keloidPschological aspect• PTSD• Flash backs• Avoidance behavior• Sleep disturbance

Minimizing complications1. Hand washing before & after

touching each patient.2. Aseptic techniques for dressing &

procedures3. Early nutritional support4. Early excision of deep burns5. Use of topical antimicrobials 6. Early excision and grafting

Thank you !!!

• Queries ????

Refrences 1. SCHWARTZ :Principles of

surgery ,9th edi.20082. BAILEY & LOVE : Short practice of

surgery ,25th edi,20083. American Burn Association's practice guidelines, 20124. Internet (pictures)5. Medscape.com