BURNDR.NADIR MEHMOOD

ASST. PROFESSOR

SU.I. RMC.

Learning objectivesAt the end of this discussion, a student will be able to

• Define and enumerate types of burn and etiology

• Describe general pathology of burn and systemic

effects

• Calculate the surface area of a burn patient

• Enlist the priority in management of burn patient

• Calculate the fluid requirement of a burn patient

• Enumerate the local, regional and systemic

complications of burn

• Enlist the different options for dealing with common

complications of burn

Burn wounds occur when there is

contact between tissue and an

energy source, such as heat,

chemicals, electrical current, or

radiation.

The resulting effects of the

burn are influenced by the:

intensity of the energy

duration of exposure

type of tissue injured

• A form of trauma.

• 50% of major burns occur during the formative

& productive years of life.

• Destruction of skin by heat leads to local and

systemic physiological alterations, therefore

management requires not only diagnosis and

treatment of local injury but also of the

derangements that occur in the hemodynamic,

metabolic, nutritional, immunological &

psychological homeostatic mechanisms.

• After successful treatment victims require a

recovery period extending over months or years.

CLASSIFICATION OF BURNSACCORDING TO MECHANISM OF INJURY

THERMAL

1. Scalds

2. Fat burn

3. Flame burn

4. Cold thermal injury- frostbite

ELECTRICAL

CHEMICAL

RADIOTION

PHYSICAL Friction burn

ACCORDING TO DEPTH OF INJURY

1. Superficial burns

I degree (Epidermal)

II degree (Superficial dermal,

Partial thickness)

2. Deep burns

II degree (Deep partial thickness,

Deep dermal)

III degree (Full thickness)

IV degree (Subcutaneous tissue

injury)

ACCORDING TO SEVERITY

1. MINOR BURN

Partial thickness burn <15%

Full thickness burn <2%

2. MODERATE BURN

Partial thickness burn 15- 25%

Full thickness burn 2- 10%

3. MAJOR BURN

Partial thickness burn >25%

Full thickness burn >10%

Burn to primary areas (hands, feet, face, perineum, genitalia)

Inhalational injury

Any associated injury

Poor risk co-morbid factors

Burn Classifications

• First Degree Burn

(Superficial Burn)

Burn Classifications

• 2nd Degree

Burn

(Partial

Thickness

Burn)

Burn Classifications

• 3rd Degree Burn

(Full Thickness burn)

PATHOLOGY

• THERMAL DAMAGE TO THE SKIN

• DIRECT DAMAGE TO CUTANEOUS

VESSELS

• INCREASED CAPILLARY PERMEABILITY

• INFLAMMATORY HYPEREMIA

• ENORMOUS EXUDATION OF PROTIEN

RICH FLUID

• Contd:

PATHOPHYSIOLOGY OF

LOCAL BURN INJURY

• Human skin can tolerate temperatures upto

40°C for brief periods.

• Jackson’s three concentric zones of thermal

injury.

CoagZone

Of

hyperemia

Zone

Of

stasis

EFFECTS OF BURN INJURY

• LOCAL

1. Tissue damage ---Direct cell rupture

---Collagen denatured

---Damage to the peripheral microcirculation.

2. Inflammation

3. Infection --- local/ regional wound infection

--- bacteremia/ septicemia

• REGIONAL

1. Circulation (limbs especially)

- Direct damage

- Oedema/ Eschar

Escharotomy

• Circumferential full

thickness burns

– Chest

– Arms

– Legs

• Medial/Lateral incision

through burned skin

• SYSTEMIC

1. Fluid loss

2. Inhalational injury

3. Gastric/ duodenal ( Curling’s) ulcer.

4. Immunosuppression

5. Catabolic response to trauma

6. UTI

7. Deep venous thrombosis

8. Pulmonary embolism

9. Renal/Multiple organ failure

EVALUATION OF BURNS VICTIM

• ABC of trauma

• HISTORY --- mechanism of burning

possibility of associated injury

any co morbid factors

• EXAMINATION

specifically for inhalational injury

assessment of burn area--- in terms of %age

rule of nine for adults

assessment of depth--- Io = red, painful, no blisters

Superficial= erythema, blanching of

tissues, thin watery blisters

Deep= thick walled blisters, pale non

blanching wound bed, dry leathery

eschar, unreliable sensations.

CLINICAL APPROACH TO A

BURN PATIENT

• DETERMINATION OF SEVERITY OF BURN

• ANALGESIA

• TETANUS PROPHYLAXIS

• FLUID RESUSCITATION

• PREVETIVE MEASURES

– PREVENTION OF INFECTION

– PREVENTION OF DVT

– PREVENTION OF GASTRITIS

– PREVENTION OF LOCAL COMPLICATIONS

DETERMINATION OF

SEVERITY OF BURN

• SURFACE AREA: THE RULE OF NINE

• DEPTH: DEGREE OF BURNS

RULE OF NINE

Burn Assessment (cont.)

• Cannot use “adult” rule of 9’s for kids

• Head represents

– 19% BSA in a one year old,

– 13% in a six year old and

– 7% in an adult

• Thighs represent

– 11% BSA in a one year old

– 17% in a 12 year old

– 19 % in an adult

3 Phases of Burn Management

–emergent (resuscitative)

–acute

–rehabilitative

FLUID RESUSCITATION

• CRYSTALLOIDS

• COLLOIDS

• BLOOD TRANSFUSION

THE PARKLAND FORMULA

• RINGER’S SOLUTION

• FIRST 24 HOURS’ TOTAL

REQUIREMENT:

2-4cc/kg/percent of burn

• HALF OF IT IN FIRST 8 HOURS

• OTHER HALF IN THE NEXT 16 HOURS

MONITORING

• PULSE

• BP

• 1 Hrly URINE OUTPUT: TARGET

OUTPUT IS 0.5-1cc/kg/Hour

EARLY COMPLICATIONS

• CHEST COMPLICATIONS

• BURN WOUND INFECTION

• ACUTE RENAL FAILURE

• ACUTE EROSIVE GASTRITIS

• CURLING’S ULCER

• CATABOLISM AND NUTRITIONAL

DEFECIENCY

• DVT

LATE COMPLICATIONS

• SCAR PROBLEMS

– POST BURN CONTRACTURES

– HYPERAESTHETIC SCAR

– HYPERTROPHIC SCAR

– PRURITIC SCAR

– KELOIDS

– MARJOLIN’S ULCER

• CHRONIC CATABOLISM

• Contd:

LATE COMPLICATIONS

• COSMETIC DISFIGUREMENT

• FUNCTIONAL DISABILITY

PREVENTION OF LOCAL

COMPLICATIONS

• SPLINTAGE

• PHYSIOTHERAPY

• PRESSURE GARMENTS

• COMPRESSION BANDAGES

COSMETIC DISFIGUREMENT

POST BURN CONTRACTURE

Example of a pressure garment

KELOID