BURNSKhaing Zay Aung

26. 3. 2015

Types of burnsdepending on insulting agent

• Thermal burns• Electrical burns• Chemical burns• Radiation burns• Cold injures

Non thermal burn injuries

Degree of damage

• Type of insulting agent• Temperature of agent• Mode of contact• Duration of contact

Degree of burns – 4 degrees

• 1st degree burn• 2nd degree burn• 3rd degree burn• 4th degree burn

• 1st degree burn – superficial partial thickness burn• 2nd degree burn - deep partial thickness burn • 3rd & 4th degree burns – full thickness burns

Anatomy of the skin

• Two main layers – the epidermis &

dermis• Subcuteneous fat• Structures under the subcutaneous

tissue

Superficial partial thickness burns

• Not deeper than papillary dermis• Blistering and/or loss of epidermis• Underlying dermis is pink and moist• Capillary return is clearly visible when blanched• Little or no fixed capillary staining • Pinprick sensation is normal• Heal without scarring within 2 weeks

Deep partial-thickness burns

• Deeper parts of the reticular dermis• Epidermis is usually lost• Not as moist as in superficial burns• Abundant fixed capillary staining• Color is not blenched with pressure• Sensation may be reduced• Takes 3 or more wks to heal without surgery• May heal with hypertrophic scarring

Full thickness burns

• Whole dermis is destroyed• Skin is hard and leathery feel• No capillary return• Thrombosed vessels can be seen under the skin• Completely anaesthesized• Healing takes longer• Needs surgery• Scarring (+)

• 4th degree burns – involvement of underlying structures s/a muscle, tendon , fascia or bone

Immediate care of a burn patient

• Prehospital care• Hospital care• Airway • Breathing • Fluid resuscitation

Prehospital care

• Ensure the rescuer safety• Stop the burning process• Check for the other injuries• Cool the burn wound• Provides analgesia and delays the microvascular damage• Minimum of 10 mins which is effective up to 1 hr• More important in scalds

• Elevate• Give Oxygen

Hospital care

• Check whether airway , breathing and status of circulations• Note the percentage of TBSA• Check for additional injuries• The depth of burns• Check for the airway burns

Airway

• Can completely occlude the upper airway by swelling• Secure the airway until the swelling has subsided• Symptoms of laryngeal oedema – late symptoms• Check for clues of airway burns ( by history & signs)• Time frame of burn to airway occlusion is usually 4 to 24 hrs, but may

be up to 5 days

Breathing 1) Inhalational injury

Trapped in fire > 2 minsSoot in nose or oropharynxProgress increase in resp effort & rateAnxious and confuse b/c of reduced O2 concentration

Secure the airwayPhysiotherapy Nebulisers Warm humidified oxygenContinuous or intermittent PPVMay need ICU management

2) Thermal burn injury to lower airway• More occur with steam

3) Metabolic poisoning • Fire in enclosed space• ABGA• High flow 100% oxygen for > 24 hrs

4) Mechanical block to breathing • Full thickness burn in chest if circumferential

Criteria for admission to burn unit

• Suspected airway or inhalational injury• Likely to require fluid resuscitation• Likely to require surgery• Include critical areas• Social or psychological background • Extremes of age• Suspect of non accidental injury• Associated with serious sequle

Assessment of burn wound

I. SIZE

II. DEPTH

Size of burn – 3 ways

• In infants or children – patient one hand is equal to 1% of TBSA• Rule of nine is used for rough assessment• Lund & Browder chart to get more accurate one

Assessing the depth of burns

• By history taking• Inspection • Capillary refill• Sensation

Inflammatory and circulatory changes in burns• Burnt skin activate a web of inflammatory cascade• Stimulation of pain fibers & alteration of proteins by heat• Neuropeptide release & activation of complement system• Activation of Hageman factor – activation of protein driven cascades

At the cellular level,

• Activation of complement• Degranulation of mast cells & coats the proteins altered by heat• Attracts the neutrophils & release of primary cytokines s/a TNF

• These inflammatory factors alter the permeability of blood vessels• Damaged collagen & these escaped proteins can create the oncotic

pressure in the burned tissue• Further increase in flow of water

• The overall effect is to produce the net flow of water, solutes and proteins from intravascular to extravascular compartment• 10 – 15% burn can cause shock• 25% of TBSA – the inflammatory reaction can cause the fluid loss in

vessels remote from the area of burn

Why important to measure the % of TBSA• Dictates the extent and impact of inflammatory reaction

• Proportionate to the amount of fluid needed to control shock

Fluid Resuscitation• The principle of fluid resuscitation is that the intravascular volume

must be maintained to provide sufficient circulation to perfuse not only the vital organs but also to the peripheral tissues especially the burned skin

• Intravenous resuscitation is needed in …• Oral resuscitation – fluid should not be salt free• The volume of fluid resuscitation is constant proportional to the area

of body burned• The fluid loss is maximum in the first 8 hrs

Types of resuscitation fluid

• Crystalloid • Ringer’s latate• Dextrose saline ( in children)

• Hypertonic saline • Less t/s oedema

• Colloid • Human albumin solution • Inward oncotic pressure• Proteins should be given after the first 12 hrs of burns

The Formulae

• In children • Parkland formula • %TBSA x BW (kg) x 4 = volume of fluid in ml• ½ within 1st 8 hr & another ½ in next 16 hr

• Muir and Barclay formula• For colloid• 0.5 x %TBSA x BW (kg) = one portion • 4/4/4, 6/6 & 12 hr

Monitoring of Resuscitation

• Urine output is the best and easiest • 0.5 – 1 ml / hr• If not – increase the infusion rate• IV 10 ml / kg bolus is needed when• If > 2 ml / kg

• Hct• Transoesophageal USG• Central catheters

Treating the Burn Wound

I. Deep burn of small area • Excision of the burn skin f/b immediate skin graft

II. Escherotomy • Circumferential full thickness burns• They can exert tourniquet effect• Incising the whole length of full thickness burns• Can cause significant amt of blood loss

III. Exposure therapy or open dressing technique• Cleaning of wound• Excised the necrotic tissue• Puncture the blisters• No covering or dressing• The advantage is that the scab is formed in 24 hrs

IV. Closed dressing technique or 3 layers dressing• Antibiotic cream• Thin layer gauze • Thick layer absorbant cotton • Bandage or plaster • Drawbacks are

V. semi-open dressing technique •Apply silver sulfadiazine cream to wound •Thin layer of gauze•Continue repeated until the wd heal

VI. Deep burns of large area•Skin cover is necessary•Temporary • Allograft, xenograft, amnion or synthetic cover

•Permanent • Autograft, autograft of meshed skin, autograft of keratinocyte

• The dressing should be• Easy to apply• Non adherent• Reduce pain• Simple to manage • Locally available

• Choice of dressing can determine • Surgery or no surgery• Scar or no scar

• Heavily contaminated wd• Debridment under GA• More chronic contamination…

• Permeable wd dressings• Allows to dry• Prevent adherent to clothes or sheets• Vaseline impregnated gauze• Hydrocolloids • Biological dressings

• Early debridment and grafting is the key to effective Rx in deep partial thickness burns and full thickness burns

Additional aspects of treating the burn patient

1. Analgesia (acute & subacute)

2. Energery balance & nutrition

3. Monitoring & control of infection

4. Nursing care

5. Physiotherapy

6. Psychological

Surgery in acute burn wound:

• Any full thickness burn & deep partial thickness burns except ..• Any depth – reassess after 48 hr• The essence of burn surgery is “control”• To reduce bld loss….• Skin graft should be apply whatever possible• Post op care (Hb%,elevation, splint)

Delayed Reconstruction & Scar Management• Eyelids must be grafted before exposure keratitis occur• Single band – Z plasty• Wider ones – transposition flap• Tissue expansion – burn alopecia• Larger ones – graft or flaps• Itch – pharmacological Rx• Hypertrophic scars or keloid scars - …

Non thermal burn injuries

• Electrical burns• Low tension • High tension• Mostly deep burns• May induce cardiac arrhythmias or sudden cardiac arrest• Look for and treat myoglobiuria

• Chemical burn• Damage by corrosion or poisoning• Corpious larvage with water • Identify the chemical and assess the risk of absorption

• Radiation burn• If ulcerate needs excision• Deep burns

• Cold injuries• Industrial • Frosbite

Complications

• Immediate • Psychological • Pain • Suffocation • Associated injuries

• Early • Hypovolaemic shock• Renal failure• Septic shock • Tetanus • overload

• Late complications• Burns scar contracture• Disability • Psychological • Complications of scar• Cosmetic • Complication of involvement of special areas

• Other complications• Stress hyperglycaemia• Stress ulcer