Burn Management

Dr. Mahmoud AminConsultant Plastic Surgery

K.F.H.H.

Skin AnatomySkin AnatomyEpidermis

Dermis

Hypodermis

Skin AnatomySkin Anatomy

Epidermis

• Outermost layer of the skin• Protective barrier• Moistened by Sebum to make it waterproof and pliable

Skin AnatomySkin Anatomy

Dermis

• Contains blood vessels, glands and nerve endings• Temperature regulation• Sweat mechanism

Functions Of The Skin

• Skin is the largest organ of the body

• Essential for:

- Thermoregulation

- Prevention of fluid loss by evaporation

- Barrier against infection

- Protection against environment provided by sensory information

What is a Burn?What is a Burn?

• An injury to tissue from:

–Exposure to flames or hot liquids–Contact with hot objects–Exposure to caustic chemicals or radiation–Contact with an electrical current

Where do most burns occur?

• 0 - 4 years, from kitchen, bathroom.

• Teenagers, suicide (females).

• 5-74 years, outdoors, kitchen.

• > 75 years, kitchen, outdoors.

Types of burns

When do most burns occur? Seasonal variations

Major causes of burns in the home• Carelessness dealing with hot fluid specially

TEA ????????• Hot water from water heaters set at high

levels above 60° C• Carelessness with cigarettes!!• Cooking accidents• Space heaters• Gasoline• Chemicals

Types of Burn Injury• Thermal burns: Scald burns ( hot fluids ) ,flame,

flash, contact with hot objects.• Chemical burns: necrotizing substances (acids,

alkalis).

• Electrical burns: intense heat from an electrical current

• Smoke & inhalation injury: inhaling hot air or noxious chemicals

• Cold thermal injury: frostbite.

• No one is immune from thermal injury

Thermal flame Burns

Thermal scald Burns

chemical Burns

Chemical burns

Acids AlkalisOrganic

compounds

• Burning will continue as long as the chemical is on the skin• It is important to remove the person from the burning agent

or vice versa.• The latter is accomplished by lavaging the affected area with

copious amounts of water.

chemical Burns

chemical Burns

Factors That Determine Severity:

•Agent•Concentration•Volume •Duration of contact (delay in treatment)

Immediate coagulative necrosis creating an eschar though limiting the spread of burn injury

chemical Burns

acids

chemical Burns

Liquefactive necrosis with continued penetration into deeper tissue resulting in extensive injury

alkalis

chemical Burns

• Dry Chemicals ( Lime):Exothermic reaction with water

– brush away as much of the chemicals as possible– then wash off with large quantities of water

• Liquid Chemicals– wash off with copious amounts of fluid

• Flush for 20-30 minutes to remove all chemicals

chemical Burns

• Phenol– Not water soluble– If available, use alcohol before flushing except in

eyes– If unavailable, use copious amounts of water

Spcial chemical Burns

• Sodium/Potassium metals– Reacts violently on contact with H20

– Requires large amounts of water

• Sulfuric Acid– Generates heat on exposure to H2O (exothermic)

– Wash with soap to neutralize or use copious amounts H2O

• Tar Burns– Use cold packs– Do not pull off, can be dissolved later

Spcial chemical Burns

• Hydrofluric Acid– Most tissue reactive inorganic acid– Fluoride ion penetrates & binds tissue

• Ceases when it combines with Ca or Mg• Burns greater than 5%TBSA – can be life threatening

– Copious irrigation with H2O or Zephiran (benzalkonium chloride)

– Topical calcium gluconate gel or Epsom salts– If pain persists, inject 10% Ca gluconate into site

Spcial chemical Burns

electrical Burns

Occurs when electricity is converted to heat as it travels through tissue .

• The severity depends on:amount of voltage tissue resistancecurrent pathwayssurface area in contact with the current length of time the current flow.

• Divided into:– High voltage – greater than 1000 V– Low voltage – less than 1000 V

• Hands & wrists are common entrance wounds

• Feet are common exit wounds

electrical Burns

• Extremely difficult to evaluate clinically

• Greatest tissue damage occurs under and adjacent to contact points

• Superficial tissues cool more rapidly than the deeper tissue

electrical Burns

• Cutaneous Burn with no underlying tissue damage– No passage of current through patient

• Cutaneous Burn plus deep tissue damage– Involving fat, fascia, muscle and/or bone

• Muscle damage associated with myoglobin release– Urine may be light red to “port wine” colour– Risk of kidney damage

electrical Burns

Management of Electrical Management of Electrical Injury:Injury:

– Examine the urine for pigment – Maintain urine output 75-100 ml/hr until clear– Alkalization of urine– Mannitol 12.5 mg/liter to maintain urine output

Management of Electrical Management of Electrical Injury:Injury: Peripheral Circulation Peripheral Circulation• Remove all rings, watches and jewelry

• Hourly monitoring of skin color, sensation, capillary refill and peripheral pulses

• Surgical correction of vascular compromise

• Decompression by escharotomy or fasciotomy

Electrical Burns in the Pediatric Electrical Burns in the Pediatric PatientPatient

• Low voltage accidents is the most common– Generally household (faulty insulation, frayed

cords, insertion of metal object into wall socket)– Cutaneous injury, no muscle damage

Electrical injury can cause:• Fractures of long bones and vertebra

• Cardiac arrest or arrhythmias--can be delayed 24-48 hours after injury

• Severe metabolic acidosis--can develop in minutes

• Myoglobinuria--acute renal tubular necrosis.

Radiation Burns

Radiation Burns causes

•Ionizing radiation enters a cell and changes it•Unshielded radiation from a radioactive source•Dust debris containing small active particles

Radiation Types

• Alpha radiation -Weak source blocked by paper, skin clothes etc.

• Beta radiation -Greater strength than alpha can penetrate skin and clothes

• Gamma radiation -Very powerful penetrates the entire body blocked by lead shielding

• Neutron radiation is very dangerous not easily blocked by anything

Smoke and Inhalation Injury• Can damage the respiratory

mucosa of the respiratory tract• soot around nares, or signed nasal

hair

Cold Thermal Injury (Frostbite)

Classification of Burn Injury

Severity is determined by:– (WHAT) depth of burn– (WHAT) extend of burn calculated in percent of

total body surface (TBSA)– (WHAT) location of burn– (IS IT ANY) patient risk factors

BURN DEPTH• 11stst Degree Degree - Painful, - erythematous, - blanch to touch - No scarring• 22ndnd Degree Degree * Painful *Superficial Partial Thickness (SPTL) *Deep Dermal(DD)

• 33rdrd Degree Degree i.e. FULL THICKNESS Painless

Erythema

Super.

Dermal

Deep

Dermal

Full

Thickness

1st Degree

Superficial Partial Thickness

Deep dermal

Full thickness

Pathophysiology Local response

Zone of coagulation: irreversible tissue loss due to coagulative necrosis

Zone of stasis: decreased tissue perfusion. Tissue is viable but can deteriorate to necrosis if not adequate resuscitation.

Zone hyperaemia: outermost zone with increased tissue perfusion. Tissue usually recovers in absence of severe infection or severe tissue hypo perfusion

Pathophysiology Systemic response

Pathophysiology Systemic response

Extend of Burns Rule of Nines

Referral Criteria• 2nd or 3rd Degree Burns >10% TBSA• Burns to precious areas :Face,

neck ,Chest ,Perineum ,Hand and Joint regions• circumferential burns• Electrical Burns • Chemical Burns• Inhalation Injury

Pre-hospital Care• Remove from affected area! Stop the

burn!• If thermal burn is large--FOCUS on the

ABC’s

A=airway-check for patency, soot around nares, or signed nasal hair

B=breathing- check for adequacy of ventilation

C=circulation-check for presence and regularity of pulses

Other precautions...

• Burn too large--don’t immerse in water due to extensive heat loss

• Never pack in ice

• Pt. should be wrapped in dry clean material to decrease contamination of wound and increase warmth

Pertinent History– How long ago?– What care has been given?– What is the cause?– Burned in closed space?

• Products of combustion present?• How long exposed?• Loss of consciousness?

– Past medical history?

Care of B U R N SB -B - breathing

UU - urine output

RR - rule of nines

resuscitation of fluid

N -N - nutrition

S S - shock

Management in the emergent phase is...

• Airway management-early nasotracheal or endotracheal intubation before airway is actually compromised (usually 1-2 hours after burn)

• ventilator? ABGs? Escharotomies?

Circulatory Status

– Burns do not cause rapid onset of hypovolemic shock

– If shock is present, look for other injuries– Circumferential burns may cause decreased

perfusion to extremity

Fluid Therapy• 1 or 2 large bore IV lines• Consider Fluid Therapy for

– >10% BSA 30

– >15% BSA 20

– >30-50% BSA 10 with accompanying 20

• LR using Parkland Burn Formula– 4 (2-4) cc/kg/% burn– 1/2 in first 8 hours– 1/2 over 2nd 16 hours

Assessment of adequacy of fluid replacement• Urine output is most commonly used

parameter

• Urine osmolarity is the most accurate parameter

• UOP= 30-50 ml/hr in an adult

Wound Care• Staff should wear disposable hats, gowns,

gloves, masks when wounds are exposed

• keep room warm

• careful hand washing

• any bathing areas disinfected before and after bathing

Wound care continued...

• Treat Burn Wound – Low priority - After ABC’s and initiation of

IV’s– Do not rupture blisters– Cover with sterile dressings

Wound care continued...

• Escharotomy / Fasciotomy

Wound care continued...Excision and Application of skin graft

Drug Therapy• Analgesics and Sedatives

• Antacids

• Tetanus immunization• Antimicrobial agents: Silver sulfadiazine

Nutritional Therapy• Burn patients need more calories & failure

to provide will lead to delayed wound healing and malnutrition.

Clinical Manifestations• Burn wound either heals by primary

intention or by grafting.• Scars may form & contractures.• Mature healing is reached in 6

months to 2 years • Avoid direct sunlight for 1 year on

burn • new skin sensitive to trauma

Scar Management

• Massage

• Compression

• Silicone gel sheeting

• Steroid injection

• Surgery (await scar maturity)