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BURNS
Dr. Neil D’Souza
Overview
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Epidemiology
Definition
Assessment
Management
• Immediate
• Definite
• Complications
• Special considerations
Epidemiology
• More then 6 million people are burned in India every year
• Most are minor burns and treated in outpatient
• About 5% require hospitalization for appropriate treatment
• Death in burns is a typical bimodal distribution
• Immediately after injury
• Weeks later as a result of multi-organ failure
• 2/3rd of burns occur at home involving children less then 15yrs
or elderly more than 60yrs
Definition of a Burn
“Tissue injury caused by thermal, radiation,
chemical, or electrical contact resulting in
protein denaturation, burn wound edema, and
loss of intravascular fluid volume due to
increased vascular permeability.”
Approach to a Patient with Burns
• Cause of the burns
• Assessment of burn
• Depth
• Extent
• Immediate casualty treatment
• Definitive treatment
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Fluid resuscitation
Nutrition
Treatment of wound
Infection
Surgical intervention
• Prevention of complications and their treatment
Types of Burns
• Thermal burns
• Scald
• Flame
• Flash
• Contact
• Electrical burns
• Chemical burns
• Cold injury
• Radiation
• Effects of burns influenced by
• Intensity
• Duration of exposure
• Type of tissue
Classification of burns
• Depending on thickness of skin involved
• Depending on percentage of burns
• Depending on thickness of skin involved
Classification
• First degree
• Second degree
• Third degree
• Fourth degree
First-Degree Burns
• Does not go below basal
layer of the epidermis
• Dry and painful
• Appears red due to
increased blood flow
• Heals in a few days
Second-Degree Burns
• Extends below basal layer, but
not completely through
dermis
• Superficial
• Blister, very painful,
contains skin parts
(adnexa) which assist in
epithelialization
• Deep Partial-thickness
• Deeper in dermis, fewer
adnexa, longer healing
time, less painful
Third-Degree Burns
• Extends completely through
dermis
• Adnexa destroyed so can’t
heal by epithelialization
• Dermal plexus of nerves
destroyed-less painful
• Burns can be yellow, red,
black, brown
Fourth-degree burns
• Full-thickness destruction of skin/subcutaneous tissue
• Involves underlying fascia, muscle, bone or other structures
• Prolonged disability
• Depending on percentage of burns
• Mild
• Partial thickness < 15% in adult or <10% in children
• Full thickness < 2%
• Treated as outpatient
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Moderate
– Partial thickness 15-20%
– Full thickness 2-10%
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Severe
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Partial thickness > 25%
Full thickness > 10%
Involving eyes, ears, feet, hands, perineum
Burns with trauma
Zones of Burn Injury
• Zone of Coagulation
• Inner Zone
• Area of cellular death (necrosis)
• Zone of Stasis
• Area surrounding zone of coagulation
• Cellular injury: decreased blood flow & inflammation
• Potentially salvable; susceptible to additional injury
• Zone of Hyperemia
• Peripheral area of burn
• Area of least cellular injury & increased blood flow
• Complete recovery of this tissue likely.
ASSESSMENT OF BURNS
Rule of Nines
Burn Assessment Lund & Browder Chart
• Indications for admission
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Moderate or severe burns (2nd or 3rd degree)
Airway burns
Burns in extremes of age
Electrical or deep chemical burns
Burns with significant co-morbid conditions
Burns in pts who require special emotional, social intervention
Presentation
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H/o Burn
Pain
Anxious state
Blisters
Tachycardia
Tachypnea
In severe cases, shock
Pathophysiology
Fluid shift
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Vessels adjacent to burn injury dilate → ↑ capillary hydrostatic
pressure and ↑ capillary permeability
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Continuous leak of plasma from intravascular space into interstitial
space
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Associated imbalances of fluids, electrolytes and acid-base occur
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Hemoconcentration
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Lasts 24-36 hours
• After 36 hrs, fluid leak ceases
• Fluid shifts back into circulation
• Restores fluid balance and renal perfusion
• Inflammatory reaction is localised in small burns
• After 10-15% TBSA burns, inflammatory reaction (fluid loss)
can lead to shock
• Volume of fluid lost is directly proportional to area of the burn
Effects of burns
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Shock
Renal failure
Respiratory distress
Infections
Erosive gastritis
Electrolyte imbalance
Immunosuppression
Phases of Burn Care
• Emergency care (ABCs)
• Resuscitation (hours 0-48)
• Definitive care (day 3 until wounds are closed)
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Rehabilitation
First Aid
• Keep the patient away from the source
• Clothing to be removed
• Clean the part
• Cool the area with tap water
• Cover the part
ABCs of Emergency Burn Care
(Advanced Burn Life Support)
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A = Airway (with cervical spine assessment)
B = Breathing
C = Circulation
D = Disability
E = Exposure and Environmental Control
F = Fluid Resuscitation based on Burn Size and Weight
Measurement
• Secondary Survey
Definitive Treatment
• Fluid resuscitation
• Local management
Fluid Resuscitation
• 1 or 2 large bore IV lines
• Fluid replacement based on: size/depth of burn, age of pt.
• Palmar Method
• Rule of Nines
• Lund-Browder Method
• Formula’s for replacement: Parkland formula and Brooke formula
Nutrition
• Burns patients need more calories
• Early enteral feeding in pts > 20 TBSA burns
Local management
• 1st degree burns
• Regular dressings is mainstay
• Topical ointments like neosporin , povidone iodine will suffice
2nd degree burns
• Regular dressings with antibiotic ointments
• Silver sulfadiazine
• Mafenide acetate
• Silver nitrate
• Or temporary coverage using biological/artifical synthetic
coverings
• If 2nd degree burns don’t heal within 2 weeks, skin
grafting is indicated
Biological/artifical coverings
• Biological
• Autograft
• Homograft
• Heterograft (xenograft)
• Isograft
• Amniotic membrane
• Cultured skin
• Artificial skin
• Two layered which creates an artificial dermis
• Synthetic dressing
• Solid silicone and plastic dressing
• Can see through to monitor wound status
Collagen dressing
• Indications
• Deep 2nd degree (non infected)
• 3rd degree burns as temporary covering after surgery
• Advantages
• Adheres to raw surfaces
• Peels off as wound heals and epithelisation occurs
• Promotes healthy granulation tissue in deep wounds
Artificial skin
• Complex of collagen and condroiton sulphuric acid with silicon
membrane
Systemic antibiotic therapy
• Usually not recomended in the first 48 hrs
• After 48 hrs, broad spectrum antibiotics started
• Re-evaluation with C&S should be done every 5 days
• Resistance and superinfection is common
Deep burns ( deep 2nd degree and
3rd degree)
• Early excision
• Tangential
• Sequential
• Followed by
• SSG
• Full thickness graft
EXCISION
• Done in any burns that does not heal within 3 weeks
• Specifically indicated in deep 2nd degree and 3rd degree burns
• Done in 2nd -5th post burn day
Tangential excision
• Done in deep dermal burns
• Dead dermis is removed layer by layer until fresh
bleeding occurs
• Later skin grafting is done
GRAFTING
• Split thickness graft (SSG)
• Done in 2nd and 3rd degree burns
• Meshed graft used for large surface area
• Thicker SSG more cosmetically accepted
• Full thickness grafts
• Used in small areas of cosmetic importance like face, hands
Eschar
• Eschar- charred, denatured, full thickness, deep burns with
contracted dermis
• Insensitive, with thrombosed superficial veins
• Can cause venous compression, arterial compression leading
to ischaemia and gangrene
Escharectomy
• Done usually in 2-5th post burn day or 3rd post burn week
• Non viable tissue removed with little pain
• Grafting done at a later date
Escharotomy
• Cut the burned skin to relieve the underlying pressure
• Cut along the inside or outside of the limb
• Knife or cautery is used
• Indications
• Circulation of the limb is in danger due to swelling
• Progressive loss of sensation/ motion
• Progressive loss of pulses by palpation or doppler
• In circumferential chest burns, patient might not be able to
expand the chest and thus might need escharotomy
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SPECIAL CONSIDERATIONS
ELECTRICAL BURNS
• Extent of injury depends upon
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Type of current
Amount of current
Path of current
Duration of current
• Injury from electrical burns
results from coagulation
necrosis that is caused by
intense heat generated from
an electric current
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
• Massive muscle damage --- myoglobinuria --- mechanical block to
renal tubules --- acute renal tubular necrosis
• Cardiac arrhythmias are the
most serious immediate injury
that occurs with electrical
contact
• V-Fib
• V-Tach
ELECTRICAL BURNS
Treatment of electrical burns
• Fluids- RL or other fluids
• Osmotic diuretic (Mannitol)
• To maintain urine output
• Local management
CHEMICAL BURNS
• Acids - can be neutralized
• Alkalis - adhere to tissue, causing protein hydrolysis and
liquefaction
• Inorganic compounds
• Organic compounds
• Acids
• Immediate coagulation necrosis creating an eschar though self-limiting
injury
• Coagulation of protein results in necrosis
• Affected tissues are converted into a dry, dull, homogeneous
eosinophilic mass without nuclei
• Bases (Alkali)
• Liquefactive necrosis with continued penetration into deeper
tissue resulting in extensive injury
• Characterized by dull, opaque, partly or completely fluid remains
of tissue
CHEMICAL BURN
COURTESY ROY ALSON,
M.D.
• Injure the skin
• May be absorbed into the body and damage internal organs
• May be inhaled into the lungs and cause lung tissue damage
• May have minimal skin injury and yet cause severe systemic
injury
FACTORS CAUSING TISSUE
DAMAGE IN CHEMICAL BURNS
• Type of chemical
• Concentration of
chemical
• Amount of chemical
• Duration of contact
• Manner of contact
• Mechanism of action
ACID BURN
TREATMENT OF CHEMICAL EXPOSURE
• Remove all contaminated clothing
• Brush off dry chemical
• Flush with copious amounts of water or any drinkable
liquid
• Wipe or scrape any retained chemical and irrigate
again
INHALATION INJURIES
• Carbon monoxide poisoning
• Toxic gas inhalation
• Smoke inhalation
• Heat inhalation
• Steam inhalation
• Asphyxiation
Inhalation injuries
• Carbon monoxide poisoning
• CO poisoning and asphyxiation account for majority of deaths
• Treatment
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Ventilator support for several weeks
Hyperbaric oxygen
Antibiotics
Bronchoscopy, at regular intervals to remove bronchial casts
Tracheostomy whenever required
• Inhalation injury above the glottis
• Caused by inhaling hot air, steam, or smoke - thermally produced
• Mechanical obstruction can occur quickly
• Watch for facial burns, signed nasal hair, hoarseness, painful
swallowing, and darkened oral or nasal membranes
• Inhalation injury below glottis
• Below glottis-it is usually chemically produced.
• Amount of damage is related to length of exposure to smoke or
toxic fumes
• Can appear 12-24 hours after burn
Features of upper airway burns
• Burns of the face
• Singed eyebrows or nasal hairs
• Burns in the mouth
• Sooty sputum
• History of being burned while
confined to an enclosed space
COURTESY ROY ALSON, M.D.
LIP BURNS & SOOT IN
MOUTH
Management
• Airway, Oxygenation and Ventilation
• Assess for airway edema early and often
• Early intubation
• When in doubt, oxygenate and ventilate
• High flow oxygen
• Bronchodilators may be considered if bronchospasm present
• Circulation
• Treat shock
• IV Access
• Large bore, multiple IV cannulas
• RL/NS
• Titrate fluids to maintain systolic BP and perfusion
CHRONIC PROBLEMS
• Post- burns contracture
• Wound shortening
• Can be intrinsic by loss of tissue or extrinsic by pull during healing
phase
• Hypertrophic scar
• Seen in 2nd and 3rd degree burns allowed to heal by primary
intention or delayed excision
• Initial pressure therapy followed excision and grafting
• Marjolins ulcer
• Chronic ulceration of old burns scar
• Associated with SCC
• Wide excision with potential amputation
Post- burns contracture
• Prevention
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Head and neck- extended with no piillow
Eyelids- ointments 3 times daily
Lips- moisturizing agents
Axilla- abducted
Hand- elevation and apply splint in functional position
Knee- extended
Foot - dorsiflexed with support
• THE POSITION OF COMFORT IS THE POSITION OF CONTRACTURE
• Joint exercise in full range during recovery
• Pressure garments
• Topical silicone sheeting
• Saline expanders for scars
Treatment of contractures
• Non surgical
• Constant pressure dressings with splints (difficult and time
consuming)
• Surgical techniques
• Contracture release
• Z plasty with pressure dressings, splinting and exercise
SKIN GRAFTING
• Transfer of skin from one area (donor area) to the required
defective area (recipient area)
• It is an autograft
Types
• Partial thickness graft (split-thickness skin graft—SSG)
• Full thickness graft
PARTIAL THICKNESS GRAFT
• Also called as Thiersch graft
• Is removal of full epidermis + part of the dermis from the
donor area
• It may be
• Thin SSG
• Intermediate SSG,
• Thick SSG
• Depends on the amount of thickness of dermis taken
Prerequisite
• Healthy granulation area
• β-haemolytic streptococci load less than 10 to the power
of 5 per gram of tissue, otherwise graft failure will occur
Indications
• Well granulated ulcer
• Clean wound or defect which can not be apposed
• After surgery to cover and close the defect created
• For example:
• After wide excision in malignancy
• After mastectomy
Contraindications
• SSG can not be done over
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Bone,
Tendon,
Cartilage,
Joint
Technique
• Donor sites: Thigh, arm, leg, forearm
• Blade is Eschmann blade, Down’s blade
• Using Humby’s knife graft is harvested
• Punctate bleeding is observed which says that proper graft has
been obtained
• Donor area is dressed and dressing is opened after 10 days
• Window cuts in the graft are made to prevent the
development of seroma
• Recipient area is scraped well and the graft is placed & fixed
• On 5th day, dressing is opened and observed for graft take up
• Mercurochrome is applied over the recipient margin to
promote epithelialisation
Stages of Graft Intake
• 1. Stage of plasmatic imbibition: Thin, uniform, layer of
plasma forms between recipient bed and graft.
• 2. Stage of inoculation: Linking of host and graft which is
temporary
• 3. Stage of neovascularisation: New capillaries
proliferate into the graft from the recipient bed which
attains circulation
Advantages
• Technically easier
• Wide area of recipient can be covered
• To cover large area like burns wound, graft size is increased by
passing the graft through a Mesher which gives multiple openings
to the graft, which can be stretched on the wider area like a net.
It can cause expansion upto 6 times
• Graft take up is better
• Donor area heals on its own
Disadvantages of SSG
• Contracture of graft. Two types:
• A. Primary contracture means SSG contracts significantly once
graft is taken from donor area (20-30%). Thicker the graft more
the primary contracture
• B. Secondary contracture occurs after graft has taken upto
recipient bed during healing period, due to fibrosis. Thinner the
graft more the secondary contracture
• Seroma and haematoma formation will prevent graft take up
• Infection
• Loss of hair growth, blunting of sensation
• Dry, scaling of skin due to nonfunctioning of sebaceous
• glands. So after healing, oil (coconut oil) should be applied
over the area
• Graft failure
FULL THICKNESS GRAFT
• Wolfe Graft
• It includes both epidermis + full dermis.
• It is used over the face, eyelid, hands, fingers and over the
joints
Technique
• It is removed using scalpel blade
• Underlying fat should be cleared off properly
• Deeper raw donor area is closed by primary suturing
• If large area of graft is taken, then that donor area has to be
covered with SSG
• Common sites of donor area
• Post-auricular area
• Supraclavicular area
• Groin crease area
Advantages
• Colour match is good, especially for face
• No contracture (unlike in SSG)
• Sensation, functions of sebaceous glands, hair follicles
are retained better compared to SSG
• Functional and cosmetic results are better
Disadvantages
• It can be used only for small areas
• Wider donor area has to be covered with SSG to close
the defect
• Can not be used to cover ulcers
THANK YOU