burn injury typess classification causes assesment and managment

Dr Syed Kashif Hussain

Benazir Bhutto Hospital

Rawalpindi

BURNS: ASSESSMENT & MANAGEMENT

1

Introduction Assessment Treatment

•Definition

•Types

•Causes

•Classification

•Accidental burn ?

•Total Surface Area

TSAB

•Burn Thickness

•ATLS Approach

•Skin Tx

•Special site

•Supportive Tx

2

BURNS: INTRODUCTION

DEFINITION. TYPES, CAUSES, CLASSIFICATION

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BURN:

Tissue Injury caused by application of thermal

energy in any form to the body surface is termed as

Burn.

Coagulative necrosis of tissue occur with depth of

coagulation corresponding to temperature and

duration of exposure.

4

CAUSES:

Flames

Fumes

Electricity

Chemical

Radiation

Friction

5

THERMAL INJURY

Flames:

Majority in Adults

Suicidal / Homicidal / Accidental

Fumes:

Hot fluids and gases

result in scalds

Contact:

too hot object

too long contact6

ELECTRIC BURNS:

Domestic Current: 220V -240V

Arrhythmias

High tension Injuries: >1000 V

Severe burn at entry & exit points

Flash injuries:

No direct current through the body but

heat nearby by can cause superficial burns.7

CHEMICAL BURNS:

Alkali’s burn more than Acids

Until the corrosive agent is completely removed

burn tends to be deep.

Never treat an Acid burn with Alkali

Vice versa!

8

RADIATION BURNS:

UV – Radiations damage the DNA and results in

Temporary Damage

Benign Changes

Malignancies

Dark Skin Protects

Not for long

Later Malignancy occurs often aggressive

9

IONIZING RADIATIONS:

Detaches electrons and damages the DNA of cell

Mostly superficial in nature

If pregnant are exposed to excessive Diagnostic or

Therapeutic Radiation

Offspring can Develop Cancer later in life

Born with Birth defects

10

ACUTE RADIATION SYNDROME / RADIATION POISONING:Symptoms develop in first 24 hours

Nausea

Vomiting

Bleeding tendencies

Falling blood count

Neurological defects

Rapid death

If above symptoms develop treat aggressively eg. Antibiotic

, Blood transfusion, marrow transplant etc. 11

ASSESSMENT OF BURN INJURY

HX TAKING, TBSAB, BURN THICKNESS,

12

CONSIDER NON ACCIDENTAL INJURIES:

Indicators:

No splash marks in a scald injury

Symmetrical burns of uniform depth

Burn of Face, genital, buttocks, sole , palms

Only upper limbs

On investigation:

Inconsistent story

Lack of guilt / concern13

Do it early and quick

Exact timing

Exact injury

Exact mechanism

Look for previous injuries

Rule out non accidental injury

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TOTAL BODY SURFACE AREA BURNED

There are three methods to estimate TBSAB:

i. Hand surface Area

ii. Wallace Chart: Rule of Nine

iii. Lund and Browder Chart

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TBSAB: HAND SURFACE AREA

Surface hand palm and finger is 0.8%

It is used to calculate

<15% TBSAB

>85% TBSAB

It is not 100% accurate but quick and

convenient for initial management

It may differ

Bit smaller in obese patients.16

WALLACE CHART: RULE OF 09

Adapted version for children

( Less accurate )

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Best solution in children

Given more percent to face/head and less area to

lower limbs, gradually decreasing the percentage

as the child ages.

It is more extensive but accurate

Separate anterior and posterior %age

Difficult to remember..!

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TBSAB: LUND & BROWDER’S CHART

TBSAB: LUND & BROWDER’S CHART

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HISTOLOGY OF SKIN:

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FIRST DEGREE BURNS:

SUPERFICIAL EPIDERMAL

Superficial

Painful

Red base

Brisk bleeding on prick

Blanch on pressure

Quick return of color

No scars

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SECOND DEGREE BURNS:

SUPERFICIAL DERMAL

Painful

Red base

Bleed on prick

Blanch on pressure

Slow return of color

Sometimes scar

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SECOND DEGREE BURNS:

DEEP DERMAL

Delayed bleeding on prick

Dull sensation

Dry wound

Whitish color

No blanching

No scar

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THIRD DEGREE:

FULL THICKNESS BURNS

No sensation

No bleeding on prick

Leathery white

no blanching

Severe scar

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FORTH DEGREE:

Full thickness burn

Bones and tendon exposed

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26

DeathIncreasing Age

InfectionInhalation

Trauma

Increasing

Burn Size

MANAGEMENT OF BURN INJURY

LABS, ATLS, FIRST AID, PROPER TREATMENT

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INVESTIGATIONS:

Full blood count

Urea

Electrolyte

12 lead ECG

ABGs

Cardiac enzymes

CXR

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ATLS APPROACH:

AIR WAY

Inhalation of hot gases:Look for inhalation trauma

Edema

Indication for intubation:•Orophryngeal swelling

•Stridor

•Tachypnea

•dyspnea

•Hoarseness of voice29

BREATHING:

Mechanical restriction due to chest Escher

CO inhalation and carboxy hemoglobin

Smoke a direct irritant

100% humidified o2 inhalation

30

CIRCULATION:

Too much fluid results in edema

Too little results in poor perfusion and hypoxia

The goal is to achieve a proper organ perfusion

PARKLAND Formula for Resuscitation:

04ml (crystalloids )x (TBSAB %) x Weight (kg)

50 % in first 08 hours

50% in remaining 16 hours

Also add daily maintenance fluid31

PAIN CONTROL:

Use combine analgesics to reduce Narcotic doses

Never give IM drugs if TBSA >10%

Lorazepam : it decrease pain by decreasing

acute anxiety

32

FIRST AID TO BURN SKIN:

Remove clothing

Cooling with tap water for 20 minutes

Avoid very cold water / Hypothermia

It cause vasoconstriction and worsen ischemia

Dressing: eg

water soak gauze, paraffin gauze,

Vaseline gauze, silver sulfadiazine gauze

Augment healing

Maintain hygiene

Alleviate pain

33

Epidermal burns:

Analgesia is required at most

Superficial dermal burns:

Analgesia + limb elevation

Keep the wound moist

Healing occurs in 02 weeks

Deep dermal burns:

Reassess after 48 hours

Slow healing with keloids and contractures

Excise to a viable depth

Non adhesive dressing and elevation34

Full thickness burns:

Excise the necrotic tissue

if impossible than grafts or transposition flaps

New developments:

Vacuum assisted closure

Skin traction technique

35

SPECIAL SITES:

FACIAL SKIN BURNS

Clean face with chlorhexadine BD

Liquid paraffin x01 hourly

Men shave daily

Use pillow to minimize edema

For eye use Chloromphenicol eye drops/cream

Avoid application of steroids and gauze to cornea

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BURN HANDS:

Refer burned tendon, cartilage, bone and joints

Expose joints usually require arthrodesis /

amputation

Thick burn to fingers need escharotomy

Excising and grafting of hand / foot injury must be

preferred

Raise hands to minimize edema

Dressing with moist plastic bags

Physiotherapy and splinting to prevent stiffening

and contracture.

37

SUPPORTIVE TREATMENT:

Special burn centre care

Systemic antibiotic prophylaxis

Topical antimicrobials

Maintain a good nutrition to prevent catabolic state

Burn injuries cause 03x BMR with hyperpyrexia

Splanic hypo perfusion and decrease absorption

38

Daily dressing

Pressure garments

Special contact media i.e. silicon gel

Moisturizing creams

Sun protection

Early mobilization

Physiotherapy

Psychological support

Monitoring

Brief Counseling39

SUPPORTIVE TREATMENT:

MANAGE HYPER METABILIC STATE:

Reduce heat lose

Treat infection

Early entral feeding

Early wound closure

40

SYSTEMIC COMPLICATIONS

When the burn reaches >30% TBSA

Bronchoconstriction / RDS

Shock and electrolyte disturbance

3x BMR

Down regulation of immune responses

Inability of local vasoconstriction

41

OTHER COMPLICATIONS:

Keloids

Hypertrophic scars

Contractures

Amputation

Cosmetic effects

Pruritis

Pain / agony

Acute anxiety

Depression

Social deprivation42

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CARE IS BETTER THAN CURE