Management of Acute Burn

BYPROF GOUDA ELLABBAN

Introduction Burn: Coagulative destruction of the skin and/or

its contents by thermal energy or absorption of physical energy.

Thermal damage occurs above 48 ºC.

Caused by

Heat

Chemical Electrical

Irradiation

magnitude of Damage

The magnitude of injury depend on:1. Duration of exposure2. Temp. of the conductor3. The mode of transmission. (wither by contact,

radiated heat, or flame)

- age- extent (percentage)- depth- location- Associated factors

Factors to evaluate the patient:

Estimation of Burn size

1- Estimation of Burn Size Using Palm.

2- The Lund and Browder chart

Estimation of Burn Size:3- Rule of Nines: Estimation of Burn Surface Area (BSA)

Classification of Burn severity:

1)minor burns:-in children :< 10% provided that it is superfacial & not

involving critical area-in adult: < 15%- no need for admission

Classification of Burn severity:

2) moderate burns: -children:10-20 % -adult:15-25%

3)major: -children >20 % -adult>25 % -or involving critical area or deep or associated with

other problems

Classification of Burn Depth

1. Partial skin thickness (superficial) or 1st degree: Burns extend through the epidermis and as far as the

most superficial dermis only. They are characterized by reactive processes in the

residual dermis (erythema, blistering) Heal spontaneously without scarring in two weeks. The treatment is non-surgical.

1st degree Burn:

Continue..

2- Deep dermal burns or 2nd degree: extend more deeply in to the dermis, but with

preservation of enough skin adnexal structures in the remaining dermis to allow spontaneous healing from these in three or more weeks.

Usually lead to hypertrophic scarring.

2nd degree Burn:

Continue..

3- Full thickness (deep) or 3rd degree: Deep burns destroy all dermal elements. There is therefore no reactive erythema, the skin is

often white in colour but may be charred where damage is extreme.

There is no skin sensation on pinprick due to skin innervation.

3rd degree Burn:

Causes of Burn Injuries and their likely depth

Type of burn Tissue injury

scalds Partial-thickness/ deep dermal skin loss

Fat burn Usually full-thickness skin loss

Flame burn Patches of partial and full thickness

Electrical burns Full thickness with deep extensions

Cold injury Ice formation, tissue freezing, vasospasm

Friction burn Heat + abrasion

Ionising radiation Early tissue necrosis, later tissue dysplastic changes

Chemical burn Inflammation, tissue necrosis, systemic effects

The effects of burn The effects of the burn upon the patient can be

considered as: * local: direct cellular damage, Inflammation &

Infection. * regional

* systemic

Local effect:1)Direct cellular damage: direct cell rupture or cell necrosis. denaturation of the connective tissue matrix. The capillaries are either thrombosed where the

damage is severe or in less damaged areas there is increased capillary permeability such that the tissues become oedematous and there is external leakage of serous fluid.

2)Inflammation:

marked and immediate inflammatory response. More severely damaged tissue may develop a more

prolonged inflammatory response. Macrophages produce inflammatory mediators and

phagocytose necrotic cells.

3)Infection: The damaged tissue represents a nidus for infection. Burn wounds will almost inevitably be colonised by micro-

organisms within 24-48 hours and this may remain as a local wound or regional infection.

There may in addition be a bacteraemia or septicaemia and metastatic infections may develop at other sites.

Bacteraemia is a common cause of fatality in a severe burn and may occur at any time from the first day until the point when all the wounds have entirely healed.

Beta-haemolytic streptococci and pseudomonads produce protease enzymes that prevent skin graft adhesion.

Regional : Limb circulation may be compromised (swelling and

tissue tension may lead to venous obstruction) muscle compartment syndrome ischaemic fibrosis and contractures

Systemic effects: Fluid loss & dehydration Multiple organ failure. Inhalation injury systemic complications Nonspecific complications

Fluid loss: may be lost from damaged capillaries either by

visible external loss or internally into the tissues from oedema in the region of the burn.

It is likely that this is mediated by cytokines acting on the microcirculation.

Multiple organ failure:

There may be progressive failure of renal or hepatic function or heart failure.

cerebral toxaemia, particularly in children, which has been attributed to electrolyte imbalance but other factors almost certainly apply.

Inhalalion injury: is not primarily thermal in origin but more of an

allergic response to inhaled irritants.

Pulmonary damage and failure can also be caused by circulating cellular debris and toxins from the burn wound; this is the pulmonary manifestation of multiple organ failure.

Systemic complications:

There are well-documented systemic complications in association with burns such as Curling's (gastric or duodenal) ulcer which may result in acute haematemesis.

Later there is a catabolic response to trauma with severe weight loss.

Nonspecific complications:

urinary tract infection from catheterisation deep vein thrombosis pulmonary embolism.

Management..

1- prehospital care :

The principles of prehospital care are as follows: Ensure rescuer safety Stop the burning process Check for other injuries Cool the burn wound Give oxygen Elevate

2- Hospital care :

The principles of managing an acute burn injury are the same as any acute trauma case

The priorities in the management of a major

burn: Airway

BreathingCirculationDisabilityExposure

Fluid resuscitation

Airway

Early intubation of suspected airway burn is the treatment of choice

The burned airway creates symptoms by swelling and if not managed can occlude the upper airway completely

Delay can make intubation very difficult due to swelling

Be ready to perform an emergency cricothyroidotomy if intubation is delayed

Recognition of the potentially burned airway :

A history of being trapped in the presence of smoke or hot gases

Burns on the palate or nasal mucosa, or loss of all the hairs in the nose

Deep burns around the mouth and neck

Breathing

Inhalational injury :

Time is a factor Anyone trapped in a fire for more than a couple of

minutes must be observed for smoke inhalation Soot in the nose, oropharynx and a chest radiograph

showing patchy consolidation are important signs

Clinical features of inhalational injury :

Increase in respiratory effort and rate Rising pulse Anxiety Confusion Decreased oxygen saturation

These symptoms may not be apparent immediately and can take 24h to 5 days to develop

Treatment of inhalational injury :

Physiotherapy Nebulizers Warm humidified oxygen

The patient’s progress should be monitored using respiratory rate and blood gas measurements

Fluid resuscitation

The principle is that the intravascular volume must be maintained following a burn in order to provide sufficient circulation to perfuse to essential visceral organs and peripheral tissues

In children with burns over 10% TBSA and adults with burns over 15% consider the need for intravenous fluid resuscitation

If oral fluids are to be used salt must be added

Fluids needed can be calculated from a standard formula and the most used one is parkland formula

Total percentage body surface area*

Weight in kilograms*4=

Volume in ml

Half of this volume is given in the first 8 hours and the second half is given in the subsequent 16 hours

There are 3 types of fluids used1. Ringer’s lactate2. Hartman’s solution3. Human albumin sloution or fresh frozen plasma

Key of monitoring resuscitation is urine output

Treating the brun wound

Escharotomy : Circumferential full-thickness burns to the limbs require

emergency surgery The tourniquet effect of this injury is easily treated by

incising the whole length of full-thickness burn. This should be done in the mid-axial line avoiding major

nerves Thereafter the management of the burn wound remains

the same irrespective of the size of the injury

Full thickness burns and obvious deep dermal wounds : The 4 most common dressings are :-

1% sulphardiazine cream 0.5% silver nitrate solution Mafenide acetate cream Serum nitrate

Superficial partial thickness wounds :-

Will heal almost irrespective of the dressing Thus the key lies with dressings that are easy to

apply ,non painful ,simple and locally available The simplest method of treatment is by exposure The initial exudate needs to be managed by frequent

changes in clean linen around the patient

Additional aspects of treating the burned

patient

Analgesia :1. Acute: Superficial small burns

respond well to simple oral analgesia

Topical cooling is specially soothing

Large burns require intravenous opiates

2. Subacute: patients with large

burns need continuous analgesia

Beginning with infusion and continuing with

oral tablets

Energy balance and nutrition :

Burns patients need extra feeding A nasogastric tube should be used in all

patients with burns over 20% TBSA Burn injuries are catabolic in acute episode. The catabolic drive continues while the wound

remains unhealed. Removing the burn and achieving healing

stops the catabolic drive.

Infection control in burn patients :

Burn patients are immunocomprimised They are susceptible to infection from many

routes Sterile precautions must be rigorous Swabs should be taken regularly A rise in white blood cell count,

thrombocytosis, and increased catabolism are warnings of infection

Others :

Nursing care Physiotherapy Psychological

Surgery for the acute burn wound :

Deep dermal burns need tangential shaving and split-skin grafting

All but the smallest full-thickness burns need surgery and excision

The anesthetist needs to be ready for significant blood loss

Topical adrenaline reduces bleeding All burnt tissue needs to be excised Stable cover, permanent or temporary, should be applied

at once to reduce burn load

Delayed reconstruction of burns :

Eyelids must be treated before exposures keratitis arises Transposition flaps and Z-plasties with or without tissue

expansion are useful Full thickness grafts and free flaps may be needed for

large or difficult areas Hypertrophy is treated with pressure garments Pharamalogical treatment of itch is important

THANK YOU !!