Download Burn

Objectives
Describe epidemiology of burn injury
 Discuss causes of burn
 Classify burn injury
 Discuss Pathophysiology of burn
 Assessment of burn patient
 Describe treatment plans for burn
patient by using ATLS principles
 Discuss complications of burn

Wednesday, May 24, 2017
BURN
2
Introduction
Burn
Tissue injury
○ thermal ( heat, cold)
○ electrical
○ Radiation
○ chemical
 coagulative necrosis
Wednesday, May 24, 2017
BURN
3
Epidemiology

1% of the world population each year

USA ~ 2.4 million burn injuries/ yr & 10,000 death/yr




UK ~ 250,000 patients treated with burns & 700 deaths/yr.
In Kenya 5,000 deaths/yr
TZ(MNH) 10% of admission in pediatric surgical ward
??BMC
Wednesday, May 24, 2017
BURN
4
epid……
Age
Scald - < 5 year of age
flame, electrical & chemical burn - adult
Sex
domestic burn - females
occupational - males
Race
No race predilection exists in burn injuries
Wednesday, May 24, 2017
BURN
5
Risks factors
Diseases e.g. epilepsy, diabetes
 Children< 5years; Elderly > 75 years
 Cold weather
 Occupational – electricians/industrial
 Alcoholism
 ??Low socioeconomic status

Wednesday, May 24, 2017
BURN
6
High morbidity and mortality
emotional & psychological
Wednesday, May 24, 2017
BURN
7
Anatomy
Skin
The epidermis
 derived from ectoderm
 it can regenerate.
The dermis
 from mesoderm
 cannot re-generate,
Wednesday, May 24, 2017
BURN
8
AETIOLOGY
 Thermal injuries
 Scald
 Flame
 Flash
 Contact
 Chemical injuries
 Electrical injuries
 Radiation injuries
 Cold injuries
Wednesday, May 24, 2017
BURN
9
classification
type /cause
body site
degree
size/extent
severity
Wednesday, May 24, 2017
BURN
10
 Class.. - type
Thermal burn
○ Scald
○ Flame burn
○ Contact burn
○ Flash
Electrical burn
Chemical burn
Radiation burn
Cold burn
Wednesday, May 24, 2017
BURN
11
Class..
site
depth
 Facial burn
 Superficial burn
 Head & neck
○ Epidemal
 Trunk
○ Dermal
 Limbs
 Deep burn
 Perineal burn
○ Dermal
○ Full thickness
 Mixed burn
Wednesday, May 24, 2017
BURN
12
Class..
degree of tissue injury
 First degree burn
 Second degree burn
• 2nd Degree Superficial (superficial Dermal)
• 2nd Degree Deep (deep Dermal)
 Third degree burn
 Fourth degree burn
Wednesday, May 24, 2017
BURN
13
Class..
Size/Extent
Total body surface area (TBSA) burned
severity of burn
• Minor burn
• Moderate burn
• Major burn
Wednesday, May 24, 2017
BURN
14
PATHOPHYSIOLOGY
Burn injuries result in: local
response
 systemic
Wednesday, May 24, 2017
response
BURN
15
Pathophysiology……
LOCAL RESPONSE
 Inflammation

Jackson zones (1947)
 coagulation /necrosis
 Stasis/ischaemia
 hyperemia
Wednesday, May 24, 2017
BURN
16
Pathophysiology……
SYSTEMIC RESPONSE:Significant burn  massive release of inflammatory
mediators, both in the wound and other sites.
Wednesday, May 24, 2017
BURN
17
Follow burn injury , neutrophils ,monocytes
& platelets migrate into burn wound
 Capillary permeability  locally & in
distinct organs.
↓ Plasma oncotic pressure
↑ Interstitial oncotic pressure due to
increased capillary permeability  protein
loss  edema in burned & un-burned
tissues
Wednesday, May 24, 2017
BURN
18
Biochemical …
↓ tissue perfusion tissue hypoxia
anaerobic resp
Pyruvate  ↑ lactic acid
metabolic acidosis
alter cellular enzymes activity
Wednesday, May 24, 2017
BURN
19
Biochemical…..
↓ATP↓ Na+Ka+-ATPase
↑↑Na+ intracellular & ↑↑K+ extracellular
cellular swelling
hyperkalemia
↓ ECF vol.
Cell death by necrosis or apoptosis
Wednesday, May 24, 2017
BURN
20
CVS
♥ ↓Myocardial contractility  TNF
♥ ↓ CO due to loss of intravascular vol, ↑ viscocity &
↓cardiac contractility.
These changes, coupled with fluid loss from the burn
wounds
systemic hypotension & end organ hypotension 
MOD  MOF
Wednesday, May 24, 2017
BURN
21
Respiratory
Inflammatory mediators →bronchoconstriction,
→ ARDS
Pulmonary dysfunction




Inhalation injury
Aspiration
Shock
Circumferential thoracic eschar
Wednesday, May 24, 2017
BURN
22
GIT



mucosal atrophy
changes in the digestive absorption
 intestinal permeability
Thromboxane A2  prominent mesenteric vasoconstriction 
↓gut blood flow compromise gut mucosal intergrity & ↓
immune fxn
 Stress (Curling’s) ulcer ( stomach & duodenum).
 Acute pseudo-obstruction of the colon (Adynamic
ileus)
 Acute dilatation of the stomach & colon.
 Acalculous cholecystitis
Wednesday, May 24, 2017
BURN
23
Renal Changes
 BV &↓ CO  RBF GFR
ATN
ARF
Wednesday, May 24, 2017
BURN
24
CNS Changes
CNS dysfunction in up to 14% of burn patients
 Delirium, disorientation
Hypoxia
 smoke inhalation,
 pulmonary edema,
 pneumonia
Wednesday, May 24, 2017
BURN
25
Haematological
 Haemoconcentration
 Anaemia
 Destruction of RBC
Continual loss of RBC for 1 wk
 Mild thrombocytopenia (sequestration) early,
followed by thrombocytosis (2-4x > normal) by end
of the 1st week
Persistant thrombocytopenia associated with poor prognosis
 suspect sepsis
 DIC with generalized bleeding can occur
shock, sepsis, hypoxia, reperfusion injury
Wednesday, May 24, 2017
BURN
26
Immunological
Innate immunity
Skin
Cellular Immune Function
lymphocyte function
Humoral Immune Function
IgG & IgA
Wednesday, May 24, 2017
BURN
27
Metabolic
 Ebb phase
 Flow phase
Catabolic phase
Anabolic [recovery phase]
Wednesday, May 24, 2017
BURN
28
Ebb phase
Occurs during the 1st 24 hours
 hypothermia
 CO &  O2 consumption
Wednesday, May 24, 2017
BURN
29
Catabolic Phase
Occurs after 24 hours of burn injury
 Mediated through release of catabolic hormones [
eg, catecholamines, glucocorticoids, glucagon ] and
other chemical mediators e.g. cytokines, lipid mediators.







↑ Cardiac output
↑ Oxygen consumption
↑ Heat production [hyperthermia]
↑ BMR
Hyperglycemia
Proteolysis
Peripheral lipolysis
Wednesday, May 24, 2017
BURN
30
BURNSTRE
SS
CORTISOL
Catecolamines
GLUCAGO
N
Gluconeogenes
is
Peripheral
Lipolysis
GLUCOSE
FREE FAT
ACIDS
Wednesday, May 24, 2017
BURN
Proteolysis
AMINO ACIDS
31
Anabolic / recovery phase
Characterized by:This phase continues for weeks to months after injury
Slow re-accumulation of protein and fat
Wednesday, May 24, 2017
BURN
32
ASSESSMENT OF BURN INJURY
Remember
 Establish cause.
 Associated injuries
 During escape from fire.
 Explosions throw patient a distance causing internal
injuries.
 Electrical muscular spasms can cause fractures.
Burns in enclosed space suggest inhalational injury.
 Pre-existing disease states, medication, allergies, lung
sensitivities.
 Establish tetanus immunization status.

Wednesday, May 24, 2017
BURN
33
Clinical assessment
History
Physical examination
General
 Local
Systemic
Wednesday, May 24, 2017
BURN
34
history
Patient characteristics
age , occupation
History of injury
Time of burn
Place of burn
Nature of injury
○ Intentional
○ Unintentional
○ Undetermined
Wednesday, May 24, 2017
BURN
35
History….
 Type of burn





Thermal
Chemical
Electrical
Radiation
Cold
Mechanism of injury
Associated injuries
Associated inhalation injuries
Associated clothing ignition
Whether first aid measures was done at the site of
accident
Wednesday, May 24, 2017
BURN
36

ROS

PMHx
?? Epilepsy, DM, Psychosis

FSHx
??alcohol
Wednesday, May 24, 2017
BURN
37
General Exam
Body weight
Shock
Level of consciousness
Dyspnoea
In pain
Restless ± gasping
Anaemic
Dehydration
Wednesday, May 24, 2017
BURN
38
Physical examination
Local examination [assessment of burn wound]
 Examine
the wound
Body region burned
Extent of burn
Burn depth
Severity of burn
Systemic examination
Cardiovascular system
Respiratory system
PA
May
CNS
Wednesday,
24, 2017
BURN
39
Local exam
Body region
Head / neck
Upper limbs
Trunk
Lower limbs
Genitalia / Perineal areas
Wednesday, May 24, 2017
BURN
40
Extent of burn
Size of a Burn Injury
Total Body Surface Area (TBSA) Burned
Palmar Method
 A quick method to evaluate scattered or localized burns
 Client’s palm = 1 % TBSA
Rule of Nines (Wallace’s)
 A quick method to evaluate the extent of burns
 Major body surface areas divided into multiples of nine
 Modified version for children and infants (Rule of Sevens )
Lund-Browder Method
 Most Accurate; based on age (growth)
 Can be used for the adult, children & infants
Wednesday, May 24, 2017
BURN
41
Wednesday, May 24, 2017
BURN
42
Wednesday, May 24, 2017
BURN
43
Wednesday, May 24, 2017
BURN
44
Burn depth

Superficial (1st Degree)

Partial Thickness
Superficial (2nd Degree)
Deep ( 2nd Degree)

Full Thickness (3rd
Degree)

Deep-Full Thickness (4th
degree)
Wednesday, May 24, 2017
BURN
45
Superficial first degree burn
Epidermis
Wound Appearance:
 Red to pink (light skin)
 Mild edema
 Dry and no blistering
 Pain / hypersensitivity to
touch
○ i.e. Classic sunburn
 Desquamation occurs 2-3
days
Wound Healing
 Wound Healing
spontaneous
 Duration 3 to 5 days
 No scarring / other
complications
Wednesday, May 24, 2017
BURN
46
46
Superficial second degree burn
upper 1/3 of dermis
Wound Appearance
 Red to pink
 Wet and weeping wounds
 Thin-walled, fluid-filled
blisters
 Mild to moderate edema
 Extremely painful
Wound Healing
 In 2 weeks (spontaneous)
 Minimal scarring; minor
pigment discoloration may
occur
Wednesday, May 24, 2017
BURN
47
Deep second degree burn
deep dermis layer
Wound Appearance
 Mottled: Red, pink, to white
surface
 Moist
 Moderate edema
 Painful; usually less severe than
superficial 2nd Degree superficial.
 No blisters
Wound Healing
 May heal spontaneously 2-6
weeks
 If so Hypertrophic scarring /
formation of contractures
Wound Management:
 Treatment of choice surgical
excision & skin grafting
Wednesday, May 24, 2017
BURN
48
Full thickness third degree burn
entire epidermis and
dermisSubcutaneous fat
Wound Appearance
 Dry, leathery and rigid
 + Eschar (hard and in-elastic)
 Red, white, yellow, brown or
black
 Severe edema
 Painless & insensitive to
palpation
Wednesday, May 24, 2017
BURN
49

Wound Healing
 No spontaneous healing;
 No epidermal or dermal
appendages remain, thus
must heal by reepithelialization from the
wound edges.
Wound Management:
Surgical excision & skin
grafting
Cx severe
scarring/contracture
Wednesday, May 24, 2017
BURN
50
Deep full thicknesss burn
Extends beyond the skin to include
muscle, tendons & possibly
bone.
Wound Appearance:
 Black (dry, dull and
charred)
 Eschar tissue: hard, inelastic
 No edema
 Painless & insensitive to
palpation
Wednesday, May 24, 2017
BURN
51
Deep full thickness……
Wound Healing
No spontaneous healing
Wound Management:
Surgical excision & skin grafting
Frequently requires amputation if extremity
involved
Wednesday, May 24, 2017
BURN
52
Severity classified as follows:-
Minor
Moderate
Major
Wednesday, May 24, 2017
BURN
53
Severity of burn is determined by
Type of burn
Depth of burn injury
Total body surface (TBSA) burned
Location of burn( face, hands, feet and perineum are
considered severe !! )
Patient’s Age
Presences of other preexisting medical conditions
Presence of associated injuries
Complications ( Inhalation , Hypothermia , Shock )
Wednesday, May 24, 2017
BURN
54
Minor burn
Characterized by: <10% in adult
 < 5% <10 yrs or >50 yrs
 < 2% full thickness
No associated injuries, no complications, no pre-
morbid illness, no circumferential burns, not
involving the hands, face, perineum
Minor burns needs outpatient Mnx.
Wednesday, May 24, 2017
BURN
55
Moderate burn





10 - 20 % in adult
5 - 10 % <10 yrs >50 yrs
High voltage, suspected inhalation,
circumferential or susceptibility to infection
Admit
Wednesday, May 24, 2017
BURN
56
Major burn
2nd & 3rd Degree burns >10% (BSA) in patients <10 or > 50 yrs
of age
2nd & 3rd Degree burns >20% BSA in pts btn 10 and 50 yrs of
age
2nd & 3rd Degree burns with serious threat to functional and
cosmetic impairment that involve the face, hands, feet,
genitalia, perineum, and other major joints
3rd Degree burns >5% BSA
Specialized injuries such as electrical burns, including
lightning and chemical burns, with serious threat of
functional or cosmetic impairment
Wednesday, May 24, 2017
BURN
57
Major burn…
Significant inhalation injuries
Circumferential burns of the extremities or the
chest
Pre-existing medical disorders that complicate
management, prolong recovery, or affect
mortality
Concomitant trauma in which the burn injury
poses the greatest risk of mortality
Wednesday, May 24, 2017
BURN
58
Management
aim
 prevent fluid and electrolyte imbalance
 rapid and painless healing
 prevent complications
 rehabilitation
Wednesday, May 24, 2017
BURN
59
Burn team
 Surgeons –reconstructive (plastic), General or









Wednesday, May 24, 2017
trauma surgeon, Paediatric surgeon
Nurses
Anesthetist
ICU team
Physiotherapist
Occupational therapist
Social workers
Psychologists
Psychiatrist
Dietitians
BURN
60
Criteria for admission
 Type
of burn
Electrical
Chemical
Lightining
 %TSBA
>15% in adult
>10% in children
 Body
site affected: face, hands, perineum,
genitalia
 Complications- inhalation burn
 Pre-existing illness – renal diseases, Diabetes
mellitus, respiratory diseases
 Circumferential burns of the limbs or chest
Wednesday, May 24, 2017
BURN
61
Phases of management
ATLS (Advanced Trauma Life Support)
 Phase I:
Primary survey phase
 Phase II: Resuscitation phase
 Phase III :Secondary survey phase
 Phase IV: Supportive care phase
 Phase V: Definitive treatment phase
Wednesday, May 24, 2017
BURN
62
Fluid Resuscitation
maintain tissue perfusion to the zone of stasis
and so prevent the burn from deepening
Indication= ped 10%, adult 15%
Fluid resuscitation formula
 not ideal
 guidelines
success relies on adjusting the amount of
resuscitation fluid ↔ against monitored
physiological parameters
hypoperfusion VS oedema
Wednesday, May 24, 2017
BURN
63
Resuscitation cont…..

Parkland formula
 4mls x KgBwt x %TBSA1st 24hrs
 crystalloid formula
 For burn >50% TBSA, use 50% for calculation
(to prevent fluid overload)
 ½ given in 1st 8 hrs & ½ next 16hrs.
 In children add the maintenance fluid
Wednesday, May 24, 2017
BURN
64
Resuscitation cont….
After 1st 24 hrs, colloid infusion is started at
a rate of:0.5 ml× (%TBSA)×(Bwt in kg) and
Maintenance crystalloid (usually DNS) is
continued at a rate of
1.5mlsx%TBSAxBwt
End point to aim is a urine output of:0.5-1.0 ml/kg/hr in adults
1.0-1.5 ml/kg/hr in children
Wednesday, May 24, 2017
BURN
65
Resuscitation cont…..
Colloid use is controversial:
○ some units start colloid after 8 hrs( as the
capillary leak begins to shut down)
○ whereas others wait until 24 hrs
FFP is often used in children,
albumin or synthetic high molecular weight in
adults.
Wednesday, May 24, 2017
BURN
66
Resuscitation cont…
The Modified Brooke formula
RL: 2 mls x % BSA x Bwt (kg)

Replacement reassessed on an hourly basis.
Urine output< 0.7ml/kg/hr.
If urine output is inadequate, increase infusion by 200ml
next hour
2nd. 24 hours
Colloid (Albumin, Dextran 70)
(0.3-0.5ml/kg/%BSA)
Dextrose to maintain urinary output
Wednesday, May 24, 2017
BURN
67
Phase III :Secondary survey phase
 History
 Physical examination
 Investigations
Wednesday, May 24, 2017
BURN
68
Secondary survey cont…
Baseline investigation for major burn.
 Blood
○ Hb
○ Grp & x-match
○ CoHb
○ Serum glucose
○ Electrolytes
○ Arterial blood gases
 X-rays
Wednesday, May 24, 2017
BURN
69
Phase IV: Supportive care phase











Analgesics
Haematenics
PPI
Systemic antibiotics against ß- hemolytic
streptococcus
Tetanus toxoid
NGT for pts with > 20%TBSA
Urethral catheterization
Monitor
 vital signs
 Input /output
Maintain body Temp
Nutrition support
Elevate limbs
Wednesday, May 24, 2017
BURN
70
Phase V: Definitive treatment
phase (Wound care)








Wednesday, May 24, 2017
Escharotomy
Fasciotomy
skin grafting
Dressing
Debridement
Application of autograft
Splinting
Contractures Mnx.
BURN
71
Complications
Can be classified as: Early Complications
 Late Complications
Wednesday, May 24, 2017
BURN
72
a. Early Complications
Fluid / Electrolyte imbalance
Hypovolaemic shock
Thermoregulation dysfunction
Acute renal failure
Inhalation injury
Infections
Wednesday, May 24, 2017
BURN
73
b. Late Complications
Contractures
Keloids
Hypertrophic scars
Marjolin’s ulcer
Wednesday, May 24, 2017
BURN
74
‘‘Once you start studying medicine,
you never get through with it’’
Charles H. Mayo (1865-1939)
Wednesday, May 24, 2017
BURN
75
Wednesday, May 24, 2017
BURN
76