MODERN

MANAGEMENT

MODERN

MANAGEMENT

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Dr.B.SELVARAJ,MS;Mch;FICS; Dr.B.SELVARAJ,MS;Mch;FICS;

Pediatric Surgeon

Associate Professor

Melaka Manipal Medical College

Melaka; Malaysia

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OBJECTIVES You should be able to

• Identify types of Burns and their

causes

• Understand the pathophysiology of

Burn injury

• Describe the principles of managing

a patient with Burns

• Explain proper wound management

techniques for treating Burns and

Burn scars

Definition

“ It is the response the of skin,

mucous membrane and

subcutaneous tissues to the

thermal and few nonthermal

injuries”

Types and Causes • Thermal injury

- Scalds� Spillage of hot liquids

- Flame burns

- Flash burns due to hot gases and

combustible liquids

- Contact burns�contact with hot metals

• Electrical injury

• Chemical injury� acid & alkali

• Cold injury� frostbite

• Ionising radiation

•

Pathophysiology

l . Zone of coagulation:

necrotic area where tissue

will not recover

2. Zone of stasis: surrounds

the zone of coagulation. The

tissue can become

necrotic or recover. There is

decreased tissue perfusion

3. Zone of hyperemia :

Healing process begins from

this viable tissue .

History

• Find out the exact mechanism, including

temperature of flame or water,duration of

contact, concentration of chemical, voltage etc

• Record factors suggesting inhalation injury,

e.g. burns in a confined space,flash burns.

• Enquire about other injuries.

• Document first aid given so far.

• Document timings of injury, first aid, and

resuscitation

Estimating depth of burn: • Epidermal: Erythema only.

• Superficial dermal: Pink, wet or blistered,

sensate, blanches and refills.

• Deep dermal: Blotchy red, wet or blistered, no

blanching, insensate.

• Full thickness: White or charred, leathery, no

blanching, insensate

Estimating depth of burn:

Burns- Degrees 1st degree 2nd degree

3rd degree

Physical Examination

Estimate area of burn(TBSAB) Do not include areas of unblistered erythema.

• Rule of nines

• Rule of palm� Patient’s hand is

approximately 1% total body surface area

(TBSA).

• Lund and Browder chart is the most accurate

method� Fillup the chart

Estimate area of burn(TBSAB)

Signs of inhalation injury • Singed nasal hair.

• Burns to face or oropharynx. Look for

blistered palate.

• Sooty sputum.

• Drowsiness or confusion due to carbon

monoxide inhalation.

• Respiratory effort, breathlessness, stridor,

or hoarseness are signs of impending

airway obstruction and require immediate

intubation

Burns- Initial management

Immediate first aid • Stop the burning process (do not

endanger yourself ).

• Cool the wound. Douse with running

water at 2–15*C for 20min (beware risk of

hypothermia in infants, young children,

and adults with >25% TBSA).

Resuscitation • A. Airway maintenance with C-spine control.

Intubate if suspected

inhalation injury; airway edema can be rapidly

fatal.

• B. Breathing and ventilation.

• C. Circulation with haemorrhage control.

• D. Disability and neurological status.

• E. Exposure and environmental control.

• F. Fluid resuscitation: child, >10% TBSA;

adult, >15% TBSA burned.

• Two large peripheral IV lines, preferably through

unburned skin.

• Send blood for FBC, U&E, clotting, amylase,

carboxyhaemoglobin.

• Give 3–4mL Hartmann’s solution/kg/% TBSA burned.

Half of this is given over the first 8h following injury, half

over the next 16h.

• Children need maintenance fl uid in addition.

• Monitor resuscitation with urinary catheter (aim for

urine output0.5–1mL/kg/h in adults and 1–1.5mL/kg/h in

children).

• Consider ECG, pulse, BP, respiratory rate, pulse

oximetry, ABGs.

Burns- Fluid resuscitation

Management of burns wound

• Superfi cial dermal burns will heal without

scarring within 2 weeks as long as infection does

not deepen the burn.

• For small burns, outpatient treatment with

simple, non-adherent dressings and twice weekly

wound inspection is sufficient.

• Wash burns with normal saline or chlorhexidine.

• Debride large blisters. Elevate limbs to reduce

pain and swelling.

• Dress hands in plastic bags to allow mobilization

• Topical silver sulphadizine is used on deep burns to reduce risk of infection.

• Escharotomy Performed for circumferential full thickness burns to the chest that limit ventilation or

to the limbs that limit circulation. Patients may also

need fasciotomies.

• Excision and skin grafting Performed for deep dermal or full thickness burns that are too large to

heal rapidly by secondary intention.

Criteria for referral to a burns unit

• >15% TBSA burn in adult; >10% TBSA in child.

• Burns to face, hands, feet, perineum, genitalia,

major joints.

• Full thickness burns >5% TBSA.

• Electrical or chemical burns.

• Associated inhalation injury—always intubate

before transfer.

• Circumferential burns of limbs or chest.

• Burns in very young or old, pregnant women, and

patients with significant comorbidities.

• Any burn associated with major trauma.

Burns- Video podcast