BURN

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Skin

Epidermis Dermis Subcutaneous

Vascular supply Subpapillary Dermal Subdermal

Skin Function

• Protection• Sensation• Thermoregulation• Control of evaporation• Storage and synthesis• Absorption• Water resistance

Burn

Definition

Burn is a tissue injury from thermal (heat or cold) application or absorption of physical energy of chemical contact

Type of Burn

• Thermal• Non-Thermal

• Electrical• Chemical• Radiation• Cold

Thermal burn injury

PATHOPHYSIOLOGY

Local change

thermal injury causes coagulative necrosis of the epidermis and underlying tissues

the depth of injury dependent on

the temperature

the specific heat of the causative agent

the duration of exposure.

Systemic change

Circulation Burns produce an inflammatory reaction This leads to vastly increased vascular

permeability Water, solutes and proteins move from the

intra- to the extravascular space The volume of fluid lost is directly

proportional to the area of the burn. Above 15 per cent of surface area, the loss

of fluid produces shock Peripheral circulation : Limb-threatening

ischemia

Hematology Acute hemolysis Coagulopathy

GI Microvascular damage and ischemia to the

gut mucosa Reduce gut motility Reduce food absorption Increase bacterial translocation Abdominal compartment syndrome

Immune system and infection Significant reduced Cell-mediated immunity Increase risk of bacterial and fungal

infection

Renal Destroy renal tubule Oliguria Acute renal failure Proteinuria

Injury to the airway and lungs

Inhaled hot gases

Inhaled steam

Inhaled smoke particles

Inhaled poisons Full-thickness

burns to the chest

supraglottic airway burns and laryngeal oedema

subglottic burns and loss of respiratory epithelium

chemical alveolitis and respiratory failure

metabolic poisoning

mechanical blockage to rib movement

Upper airway : Dangers of smoke, hot gas or steam inhalation

Injury to the airway and lungs

Rare injury

Heat exchange mechanism at supraglottic airway

Lower airway

Steam

Large latent heat of evaporation

Thermal damage to lower airway• RE rapidly swelling and detach• Cast• Obstruct main airway

MANGAEMENT

Immediate care of burn

Pre-hospital careEnsure rescuer safetyStop the burning processCheck for other injuriesCool the burn woundGive oxygenElevate

Immediate care of burn

Hospital care Assessment as trauma care

“ABCDEF” A - Airway control B - Breathing and resuscitation C - Circulation D - Disability - neurogenic status E - Exposure with environmental

control, Elevate burn limb F - Fluid resuscitation

Indication for admission<Burn center referral

criteria>

ABCDEF

Airways : Initial management of the burned airway• Early elective intubation is safest• Delay can make intubation very difficult because of

swelling• Be ready to perform an emergency cricothyroidotomy, if

intubation is delayed• Key : History + Early symptom

ABCDEF

Breathing: Inhalation injuries Thermal burn injury to the lower

airway Metabolic poisoning Mechanical block to breathing

Assessment of the burn wound

SizeDepth

Burn depth

First degree burn

Epidermis Redness Dry Painful Sensation Take 1 wk to healing

1st degree burn

Superficial second degree burns• No deeper than the papillary dermis

• Blistering and or loss of the epidermis

• Pink and moist

• Pinprick sensation is normal

• Heal without residual scarring

in 2-3 wk

Deep second degree burn

Deeper parts of the reticular dermis The exposed dermis is not moist Abundant fixed capillary staining Sensation is reduced Take 3 or more weeks to heal

without surgery and usually lead to hypertrophic scarring and scar contracture

2nd degree burn

Third degree burn The whole of the dermis is

destroyed in these burns Hard , leathery feel skin Charred , black skin no capillary

return Visible thrombosed vessels Anesthetised skin Treatment by skin graft

3rd degree burn

Fourth degree burn

Extends through skin, subcutaneous tissue and into underlying muscle and bone

Charred with eschar Painless, Hard and dry skin Amputation, significant functional

impairment

4th degree burn

Zone of injuries

Depth of burns

Fluid resuscitation

Intravenous fluid resuscitation In children with burns over 10 per

cent TBSA In adults with burns over 15 per cent

TBSA, consider the need for If oral fluids are to be used, salt must

be added

Parkland formulaTBAS X Weight X 4 = volume(mL) ½ give in 1st 8

hours½ give in 16

hours

Fluid resuscitation

Crystalloid resuscitation Ringer’s lactate is the most common used Children < 2yrs : add 5%dextros

Hypertonic saline Colloid resuscitation

Protein : after 12 hours

Monitoring of resuscitationdepend on time, Urine output and MAP

Time : leak close MAP : 60 mmHg Urine output

Adult : 0.5-1 ml/kg/hrChildren : 1-1.5 ml/kg/hr

• If urine output is below this , increase infusion rate 50%• Sign of hypoperfusion , 10ml/kg iv bolus• If urine output >2 ml/kg/hr , decrease rate iv

Treating of burn wound

Escharotomy Circumferential

full-thickness burns to the limbs

Emergency surgery

Incising the whole leghth of the full thickness burn

Treating of burn wound Early burn wound care

Wound dressing by NSS

Scrubbing

Debriment

First-degree wounds : no dressing and are treated with topical salves to decrease pain and keep the skin moist.

Second-degree wounds : daily dressing changes with topical antibiotics, cotton gauze, and elastic wraps. Alternatively, the wounds can be treated with a temporary biologic or synthetic covering to close the wound.

Deep second- and third-degree wound : excision and grafting for sizable burns

Treating of burn wound

Topical antimicrobial agent1% silver sulphadiazine cream0.5% silver nitrate solutionMafenide acetate creamSerum nitrate, silver sulphadiazine

and cerium nitrate

Surgery for acute burn wound

Escharectomy Tangential excision Fascial excision

Surgery for acute burn wound

For Deep partial-thickness and full-thickness burns, except those that are less than about 4 cm2,

the anesthetist needs good control of the patient. subcutaneous injection of a dilute solution of

adrenaline and tourniquet control Deep dermal burns need tangential shaving and

split-skin grafting Full-thickness burns require full-thickness excision

of the skin. the burn excision is down to viable fat. Wherever possible, a skin graft should be applied immediately.

Surgery for acute burn wound

Postoperative management Requires careful evaluation of fluid

balance and levels of haemoglobin. Physiotherapy and splints are

important in maintaining range of movement and reducing joint contracture.

Analgesia

AcuteSmall burn : paracetamol ,

NSAIDs, Topical coolingLarge burn : Intravenous opioids

SubacuteLarge burn : continuous analgesiaShort acting analgesia before

dressing changes

Energy balance and nutrition

Adult with burn > 15 % TBSA Children with burn >10 % TBSA All patient with burn 20 % TBSA Removing the burn and achieving healing

stops the catabolic drive

Nutritional requireme

ntNG tube

Complication of burn Burn wound infection Pneumonia Sepsis Fungal infection Urinary tract infection Curling’s ulcer Scar contracture Hypertrophic scar Deformity Loss joint function

Physical therapy and Rehabilitation

Physical therapy program Prevent prolong immobilization Splinting and Positioning Prevent hypertrophic scar

Delayed reconstruction and scar management

Delayed reconstruction of burns Common for large full-thickness burn Eyelids must be treated before exposure

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 Pharmacological treatment of itch is

important

Non thermal burn injury

Electrical Low-voltage injuries :

cause small, localized, deep burns. They can cause cardiac arrest through pacing

interruption without significant direct myocardial damage

High-voltage injuries : damage by flash (external burn) and

conduction (internal burn). Myocardium may be directly damaged

without pacing interruption

Limbs may need fasciotomy or amputation Look for and treat acidosis and

myoglobinuria

Low-voltage injury

High-voltage injury

Chemical injury

More than 70000 different chemicals can cause burn injury

Damage is from corrosion and poisoning Copious lavage with water helps in most cases Then identify the chemical and assess the risks

of absorption Acids VS Alkalis

Radiation injury

Local Ulceration Tx: excision and vascularised flap

cover, usually with free flaps Systemic

Lethal : particular slow unpleasant death

Non-lethal : systemic effects related to gut mucosa and immune dysfuction

Tx: Supportive treatment

Reference

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