BURNS

BY: CHAKA AMENU (MSC I)

 BURNS

• Learning objectives
• To assess area and depth of burns
• To understand methods for calculating the
rate and quantity of fluids to be given
• Techniques for treating burns and the patient
• The pathophysiology of electrical and
chemical burns
 Introduction
• The incidence of burn injuries varies year around
175,000 people visit accident and emergency
department suffering burn of whom about
13,000 need to be admitted.
• About 1000 have severe burns requiring fluid
resuscitation, and half of victims are under
16years of age.
• The majority of burns in children are scalds
caused by accidents with kettles,pans,hot drinks
and bath water.
The pathophysiology of burns injuries

• Burns cause damage in a number of different

ways ,but by far the most common organ
affected is skin.However,burns can also
damage the airways and lungs with life
threatening consequences.Airway injuries
occur when the face and neck are burned.
Respiratory system injuries usually occur if a
person is trapped in a burning vehicle, house ,
car , airplane and is forced to inhale that hot
and poisonous gases.
• Local response:
• Experimental work by Jackson has shown that
a burn wound
• consists of 3 zones
• zone of coagulation: cell death and immediate
coagulation
• of cellular proteins
• zone of stasis: damage in microcirculation
resulting in compromised circulation,
untreated it will lead to necrosis
• zone of hyperemia: damage causing
production of inflammatory mediators leading
to dilatation of blood vessels
 Physical burn injury to the air way
above the larynx
• The hot gases can physically burn the nose ,
mouth ,tongue,palate and larynx .
• Once burned linings of these structures will
start to swell. After a few hours , they may
start to interfere with the larynx and may
completely block the air way if action is not
taken to secure an air way.
 Dangers of smoke , hot gas or steam
inhalation
• Inhaled hot gases can cause supraglottic air way
burns and laryngeal edema.
• Inhaled steam can cause subglottic burns and
loss of respiratory epithelium.
• Inhaled smoke particles can cause chemical
alveolitis and respiratory failure.
• Inhaled poison , such as carbon monoxide , can
cause metabolic poisoning .
• Full thickness to the chest can cause mechanical
blockage to the rib movement.
 Physical burn injury to the air way
bellow the larynx
• Steam has a large latent heat of
evaporation and can cause thermal
damage to the lower air way. In such
Injuries the respiratory epithelium
rapidly swells and detaches from the
bronchial tree. This creates
Casts,which can block the main
upper airway.
 Metabolic poisoning
• The most common being carbon monoxide, a
product of incomplete combustion that is
produced by fire in enclosed space. Carbon
monoxide binds to haemoglobin with an
affinity 240 times greater than that of oxygen
and therefore blocks the transport of oxygen.
• Carboxyhaemoglobin concentration in blood
stream above 10 % are dangerous and need
treatment with pure oxygen for more than
24hrs.Death occurs with concentration around
60%.Another metabolic toxin produced in
house fire is hydrogen cyanide, which causes
a metabolic acidosis by interfering with
mitochondrial respiration.
 Inhalation Injury
• Is caused by the minute particles with in thick
smoke, because of their small size, are not
filtered by the upper airway, are carried down
to the lung parenchyma.
• They Cause intense reaction in the alveoli.
Chemical pneumonitis cause edema with in
the alveolar sack and decreasing gaseous
exchange over the ensuing 24hours often
gives rise to bacterial pneumonia.
Inflammation and circulatory changes
• Burns produce an inflammatory reactions.
• This leads to vastly increased vascular
permeability.
• Water, solutes and proteins move from the
intra to the extra vascular space.
• The volume of fluid lost is directly
proportional to the area of the burn.
• Above15% of surface area, the loss of fluid
produces shock.
 Other events with major burns
• 1. The immune system and infection
• Cell mediated immunity is significantly
reduced in large burns, leaving the victim
more susceptible to bacterial and fungal
infections. potential source of infection are
burn wound, lung if injured, venous lines
tracheostomies or urinary catheters.
• 2. changes to the intestine
• The inflammatory stimulus and shock can
cause microvascular damage and ischemia to
the gut mucosa. Gut mucosal swelling, gastric
stasis and peritoneal edema cause abdominal
compartment syndrome, which splints the
diaphragm and increases the airway pressure
need for respiration.
 3.Danger to peripheral circulation

In full thickness burns, the collagen fiber are

coagulated. The elasticity of the skin is lost. A
circumferential full-thickness burn to limb acts
as tourniquet as the limb swells. If untreated
this will progress to ischemia
 Immediate care of the patient
Pre hospital care
• 1 Ensure rescuer safety- this is particularly
important as in the case of electrical injury.
• 2 Stop the burning process.
• 3 Check for other.
• 4 Cool the burn wound.
• 5 Give oxygen.
• 6 Elevate
 Hospital Care
• A Air way control
• B Breathing and ventilation
• C Circulation
• D Disability
• E Exposure
• F Fluid resuscitation
 Criteria for admission
• Suspected airway or inhalation injury
• Burn that require fluid resuscitation
• Burn that require surgery
• Significant burns to hands, face, feet or
perineum
• Burns with high tension electrical and
concentrated hydrofluoric acid
• Any burn in the extremes of age
 Assessment of the burn wound
• 1 Assessing size
• In the case of smaller burn or patches of burn,
the best measurement is to cut apiece of
clean paper the size of the patient’s hand(digit
& palm),which reprents1%TBSA,and this to
the area.
 The rule of nine for adults:
• Each upper limb is 9%TBSA
• Each lower limb is 18%TBSA
• Each side of torso is18%TBSA
• Head and neck is 9%TBSA
• Genital organ is 1%TBSA
Relative percentage of body surface
area affected by growth
• For each year older than 1 year subtract 1%
from the total percentage of the head and add
0.5% for each leg.
• Note that by the time a child has reached the
age of 10 years it has the proportions of an
adult.
 Assessing depth

The burning of human skin is temperature

and time dependent. It takes 6 hrs for skin
maintained at 44 degree centigrade to suffer
irreversible change, but a surface temperature
of 70 degree centigrade for 1 second is
needed to produce epidermal destruction.
 SUPERFICIAL PARTIAL THICKNESS BURN

• The damage goes no deeper than papillary

dermis
• Blistering and/or loss of epidermis
• The underlying dermis is pink & moist
• Capillary is visible when blanched
• Pin prick sensation is normal
• Heals with out residual scarring
 DEEP PARTIAL THICKNEESS BURN
• Damage to the deeper parts of the reticular
dermis
• Epidermis is usually is lost
• The color does not blanch with pressure
• Sensation is reduced(unable to distinguish
sharp from blunt).
 FULL THICKNESS BURNS

The whole dermis is destroyed

They have a hard leathery feel
There is no capillary return
Are completely anaesthetised
 FLUID RESUSCITATION
• In children with burns over 10%TBSA and
adults over 15%.
• If oral fluids are to be used salt must be
added.
• The key is to monitor urine out put.
• There are three types of fluid used. The most
common is Ringer’s lactate. Some centers use
human albumin solution, fresh frozen plasma
or hypertonic saline.
• The simplest and most widely used formula is
the parkland formula.
%TBSA X Wt (KG) X 4=VOLUME(ml)
Half this volume is given in the
first 8 hrs, and the second half in
the subsequent 16 hrs.
• In children maintenance fluid must be given.
Burn resuscitation formula =deficit+maintenance
• This is normally dextrose-saline given as
follows:
• 100ml/Kg/24hrs for the first 10kg
• 50ml/Kg/24hrs for the next 10Kg
• 20ml/Kg for each Kg over 20 Kg body weight.
• Use sodium chloride 0.9% and Dextrose water
5-10%
• Up to 10 kg 4 cc/kg/hr or 100 cc/kg/24 hrs
• From 11- 20 kg 2 cc/kg/hr or 50 cc/kg/24 hrs
• From 21- 30 kg 1 cc/kg/hr or 20 cc/kg/24 hrs
 Another formula used is:
2 x weight in kg + 10 = cc/hr
• When there is no scale available calculate the
weight in children < 12 years using this
formula: 2 x (age in years + 4) = … kg
 TREATING THE BURN WOUND
• Circumferential full thickness burns to the
limbs require escharotomy.
• Topical treatment of deep burns with:
• 1%silver sulphadiazine cream
• 0.5% silver nitrate
• Mafenide acetate cream
 ADDITIONAL ASPECTS
Analgesia (paracetamol, NSAIDS),IV opiates for
large burns.
IM should not be given in acute burns
over10% of TBSA ,as absorption is
unpredictable and dangerous.
Energy balance and nutrition, As there is
greatest nitrogen losses between day 5&10
20% of Kcal should be provided.
Physiotherapy &Psychology.
 SURGICAL CONSIDERATION
• Any deep partial thickness and full thickness
burns except that are less than about 4cm
square need surgery.
NON THERMAL INJURY BURNS
• Electrical injuries are divided in to low & high
voltage injuries the threshold being 1000V.
Low voltage injuries cause small, localized,
and deep burns.
• They cause cardiac arrest through pacing
interruption.
• High voltage injuries damage by flash
(external burn) &conduction(internal burn).
• Myocardium may be damaged without pacing
interruption
• Limbs may need fasciotomies or amputation
 CHEMICAL BURNS
There are two aspects of chemical injury. The
first is the physical destruction of the skin, and
the second is poisoning caused by systemic
absorption. common injuries are caused by either
acids or alkalis. Alkalis are more destructive.
The initial management of any injury is copious
lavage with water . But water is not help for
phosphorous and elemental sodium , which
occasionally in laboratory explosions.
• This substances need to be removed physically
with forceps. Hydrofluoric acid burns affecting
fingers and caused by dilute acid are initially
managed with calcium gluconate gel topically.
If the patient has been burnt with
concentration greater than50%, the treatment
of hypocalcaemia & arrhythmia becomes high
and early excision needed.
 REFERENCES
• Bailey &Love’s 25 edition 2008
• Surgical Care at the District
Hospital(WHO)2003
• BURNS MANUAL 2nd edition 2008 (MALAWI)