Definition
Injuries that results from direct contact with or exposure to any thermal, chemical,
electrical or radiation source are termed as burns.
Burn injuries occur when energy from a heat source is transferred to the tissue of the
body.
ETIOLOGY
Thermal Burns: are caused by exposure to or contact with flame, hot
liquids, steam hot objects.(e.g.) Residential fires, explosive automobile
accidents, cooking accidents or with ignition of poorly stored flammable
liquids.
Chemical Burns: are caused by contract with strong acids, alkalis or
organic compounds chemical burns can result from contact with certain
household cleaning agents and various chemicals used in industry &
agriculture.
Electrical Burns: are caused by heat that is generated from electric
energy as it passes through body. Electrical injuries can result from
contact with exposed or faulty electrical wiring or high voltage power
lines.
Radiation Burns: are caused by exposure to radio-active substances.
(e.g) ionizing radiation in industries therapeutic irradiation. Sun burn
prolonged exposure to U.V.rays.
Inhalation Injury: exposure to asphyixants (carbon monoxide) smoke
poisoning and direct thermal injury to lung tissue.
CLASSIFICATION
Burn injuries classified according to
1.Burn depth.
2. Extent of body surface area injures
Burn Depth : According to burn depth, burn injuries are categorized as:-
A. Superficial partial thickness burn.
B. Deep partial thickness burn.
C. Full thickness burn.
SUPERFICIAL PARTIAL THICKNESS BURN
The epidermis is destroyed and a position of dermis may be injured. The
damaged skin may be painful and appear red and dry as in run burn or it may
be blister.
Skin involvement:- Epidermis possibly a portion of dermis.
Symptoms:-tingling Hyperesthesia (supersentivity) Pain that is soothed
by cooling.
Wound appearance: Reddened, blanches with pressure, dry minimal or
no edema possible blisters.
Recuperative course: Complete recovery within a week, no scarring,
peeling.
DEEP PARTIAL THICKNESS BURN
Involves destruction of epidermis and upper layer of dermis and injury to
deeper portion of dermis. The wound in painful appears red and exudes fluid.
Capillary refill follows tissue blanching. Hair follicles remain intact. Deep partial
thickness burns take longer to heal or more likely to result in hypertrophic
scars.
Symptoms:- PaiWound appearance: Blistered moltled red base, broken
epidermis, weeping surface, edema.
Recuperative course: Recovery in 2 to 4 weeks some scarring and
deepigmentation contractures. Infection may correct it to full thickness.
n, hyperesthesia, sensitive to cold air.
FULL THICKNESS BURN
It involves total destruction of epidermis and dermis and in some cases,
underlying tissue as well. Wound color ranges widely from white to red, brown
or black. The burned area is painless because new fibres are destroyed.
Skin involvement: Epidermis entire dermis and sometimes
subcutaneous tissue may involve connective tissue, muscle and bone.
Symptoms: Pain free shock, hematuria and possibly hemolysis.
Wound appearance: Dry pale white leathery or classed. Broken skin
with fact exposed edema.
Recuperative cause: Eschar soughs grafting necessary scarring and loss
of countour and functions contractures, loss of digit or extremity
possible.
EXTENT OF BODY SURFACAE AREA INJURIES
Various methods are used to estimate the TBSA affected by burns among them
are
A. Rule of Nine.
B. Lund & Browder method.
C. Palm method.
Rule of NineIt is a quick way to calculate the extent of burns. The system
assigns percentage is multiples of nine to the major body surface.
Estimated percentage of TBSA in adults is arrived at by sectioning the
body surface into the area with numerical values related to nine.
Anterior surface 18%
Posterior surface 18%
Upper extremities 9% each.
Lower extremities 18% each
Head 9%
Perineal area 1%
Lund & Browder method
It is more precise method of estimating the extent of burn. It recognized the
percentage of TBSA of various anatomic parts specially the head and legs and
changes with growth.
Head 7%
Neck 2%
Anterior trunk 13%
Posterior trunk 13%
Right buttock 2 ½%
Left buttock 2 ½%
Gentialia 1%
Upper arm (Rt. & Left) 4% each.
Lower arm (Rt. & Left) 3% each
Hand (Rt. & Left) 2 ½%
Thigh (Rt. & Left) 9 ½%
Leg ( Rt. & Left) 7% each
Foot (Rt & Left) 3 ½%
PALM METHODS
In patients with scattered burn a method to estimate the percentage of
burn is palm method. The size of the patient’s palm is approximately 1%
of TBSA.
CLASSIFICATION OF BURN ACCORDING TO AMERICAN BURN ASSOCATION
Minor burn injury.
Moderate or uncomplicated burn injury.
Major burn injury
MINOR BURN INJURY
Second degree burn of less than 15% TBSA in adults or 10% - 20% in
children.
Third degree burns of 10% TBSA not involving special care areas.
Excludes electrical injury, inhalation injury, concurrent trauma, all poor
risk patients.
MODERATE UNCOMPLICATED BURN INJURY
Second degree burns of 15% - 25% TBSA in adults or 10% -
20% in children.
Third degree burns of 10% TBSA not involving special care
areas.
Excludes electrical injury, inhalation injury, concurrent
trauma, all poor risk patients.
MAJOR BURN INJURY
Second degree burns exceeding 25% TBSA in adults or 20% in
children.
All third degree burns exceeding 10% TBSA.
All burns involving eyes, ears, face hands fee perineum, joints.
All inhalation injury electrical injury concurrent trauma all poor
risk patients.
PATHOPHYSIOLOGY
The pathophysiology changes that occur after burn are categorized
as:-
Cutaneous burn.
Inhalation burn.
CUTANEOUS BURNS
Pathophysiology changes that occurs depends upon the extent and size
of burn
After burn injury
Vasoactive substances are released from injured site.
Increase in capillary permeability is seen.
Plasma from capillaries come out in surrounding tissues.
Further Na+ entres and k+ exists from cell.
Increase in intracellular pressure along with interstial fluid edema
Decreased intravascular volume
The fluid losses through the burnt wound
If the condition continuous the patient may go into hypovolemic shock
or death may occur.
INHALATILON BURN
Expose to asphyxiants (CO)
Oxygen molecule displaced
CO binds to hemoglobin (COHb)
Tissue hypoxia occurs.
CLINICAL MANIFESTATION
INHALATION BURN
Facial burn
Erythema,
Hoarse voice.
Cough with sputum
Swelling of oropharynx and nasopharynx.
Anxiety tachypnoea.
Nasal flaring
Stridor.
Wheezing
Dyspnoea.
CUTANEOUS BURNS:
Tingling hyperthesia.
Pain.
Sensitivity to coild air.
Broken epidermis.
Leaking blisters.
Hematuria in severe burns
Edema
It may include muscles and deep tissue of skin.
Diagnosis
To diagnose burns:-
1 Physical assessment and history taking.
2.Rule of nine.
3.Plam method.
Medical Management
Management of burn injury divided into four phases:
Emergent Phase
Resuscitative Phase
Acute Phase
Rehabilitative Phase
1. Emergent Phase: Description
The emergent phase begins at the time of injury with the restoration of
normal capillary permeability (fluid resuscitation) usually at 48 to 72
hours following injury, this phase include prehospital and emergency
room care.
Primary goal is to prevent hypovolemic shockand preserve vital organs
functioning.
Prehospital care
Prehospital care include at the scene of accidents are-
Remove the victim from the source of burn.
When clothing catch fire, the victim fall on the floor or ground and rolls,
anything available to smother the flames, such as a blanket, rug or coat
may be used.
Soaking the burn area intermittently in cool water or applying cool
towels gives immediate & striking relief from pain & restricts local tissue
edema & damage.
If possible, remove clothing immediately adherent clothing may be left
in place once cooled.
Clothing & all jewellery should be removed to allow for assessment and
to prevent constriction secondary to rapidly developing edema.
Burn should be covered with sterile or clean clothes.
Assess ABC’s – airway, breathing & circulation.
Assess the need for intravenous fluids
Transport.
Emergency room care is a continuous of care administered at the scene
of the injury.
Major Burns
Evaluate the degree & extent of the burn and threat life-threatning
conditions
Ensure a patent airway & administer 100% oxygen as prescribed if the
burn occurred in an enclosed area.
Monitor for respiratory distress & assess the need for intubation.
Assess oropharynx for blister or erythema.
Monitor arterial blood gases and carboxyhemoglobin levels.
For an inhalation injury, administer 100% O2 via tight fitting re-breather
face mask as prescribed until the carboxyhemoglobin levels fall below
15%.
Initiate intravenous access to non-burned skin proximal to any extremity
burn or prepare for the insertion of a central venous lines as prescribed.
Assess for hypovolemia & prepare to administer fluids intravenously to
maintain fluid balance.
Monitor vital signs closely
Insert a foley catheter as prescribed & maintain urine output as 30-
50ml/hr
Maintain NPO status
Insert a nasogastric tube as prescribed to remove gastric secretions &
prevent aspirations.
Administer tetanus prophylaxsis as prescribed.
Administer pain medications as prescribed by the IV route.
Prepare the client for an escharotomy or fasciotomy as prescribed.
Minor Burns
Administer pain medication with small doses of morphine sulphate or
meperidine (Demerol) as prescribed.
Instruct client in the use of oral analgesic as prescribed.
Administer tetanus prophylaxsis.
Administer wound care which may include cleansing, debriding loose
tissue & removing any damaging agents, followed by the application of
topical antimicrobial cream & a sterile dressing.
Resuscitative Phase
Description: It begins with the initiation of fluids and ends when
capillary integrity return to near normal levels & the large fluids shifts
have decreased.
The amount of fluid administered is based on client’s & extent of injury.
Most fluid replacement formulas are calculated from the time of injury
& not from the time of arrival at the hospital
The goal is to prevent shock by maintaining adequate circulatory blood
volume & maintaining vital organ perfusion.
