BURN

Burns is defined as a wound caused by exogenous

agent leading to coagulative necrosis of the tissue.

Causes
• Thermal Burns
1. Dry heat
2. Contact burn
3. Flame burn
4. Moist heat – Scald burn
5. Smoke and inhalational injury

• Chemical Burns – Acids and Alkali

• Electrical Burns – High and low voltage
• Cold Burns – Frostbite
• Radiation Burn
• Sun Burns
Classification
1. Depending on the Percentage of Burns:
a) Mild:
 Partial thickness burn less than 15% in adult or less than
10% in children or full thickness less than 2%.
 Moderate:
Second degree 15-25% burns in adult or 10-20% in
children or third degree 2-10% burns.
 Major:
Second degree >25% burns in adult or >20% burns in
children or third degree >10% burns or burns involving
eyes, ears, feet, hand, perineum. All inhalational and
electrical burns.

2. Depending on Thickness of Skin Involved:

(a) First degree:
Injury localized to the epidermis.
(b) Second Degree:
i) Superficial second degree: injury to the epidermis and
superficial papillary dermis.
ii) Deep, second degree: injury through the epidermis and
deep upto reticular dermis.
(c) Third degree:
full-thickness injury through the epidermis and dermis into
subcutaneous fat.
(d) Fourth degree:
Injury through the skin and subcutaneous fat into
underlying muscle or bone.
Degree of Burns

First Degree
Burn

Second Degree
Burn

Epidermis

Dermis

Hypodermis
Clinical Features:
i) First degree burns:
• Reddened skin
• Pain at burn site
• Involves only epidermis
• Blanch to touch
• Have an in-tact epidermalbarrier
• Do not result in scarring
Examples : Sun-burn, minorscald from a kitchen
Accident

ii) Superficial 2nd Degree Burns :

• Intense pain
• White to red skin
• Blisters
• Involves epidermis & papillary layer of dermis
• Spares hair follicles, sweatglands etc.
• Erythematous & blanch to touch
• Very painful/sensitive
• No or minimal scarring.
• Spontaneously re-epithelialization from retained
epidermal structures in 7-14 days
.
Clinical Features
iii) Deep second degree burns:
• Injury to deeper layers of dermis, i.e, reticular dermis.
• Appears pale & mottled.
• Do not blanch to touch.
• Capillary return sluggish or absent.
• Less painful, remain painful to pinprick.
• Takes 14 to 35 days to heal by re-epithelialization from
hair follicles & sweat gland, keratinocytes often with
severe scarring.
• Contractures possible.

iv) Third Degree Burn:

• Dry, leathery skin (white, dark brown, or charred).
• Loss of sensation (little pain).
• All dermal layers/tissue maybe involved.

v) Fourth degree burn:

• Involves structures beneath the skin- muscle, bone.
 Third Degree
Burns

Fourth Degree
Burns
Assessment of Burns

1. Wallace Rule of Nine:

2. Lund and Browler chart: Each Part of body is

individually assessed for involvement of burns
Pathophysiology

i) Local Changes:
Thermal injury causes coagulative necrosis of
epidermis and underlying tissue, with depth of injury
dependent on temperature to which skin is exposed,
the specific heat of causative agent, duration of
exposure

 The area of cutaneous or superficial injury has been

divided into three zones:

(a) Zone of coagulation:

Necrotic area of burn where cells are disrupted.
(b) Zone of satsis:
Its area surrounding zone of coagulation where
vessel leakage & vessel damage present
(c)Zone of hyeremia
It is area where Vasodilation & inflammation is present.
2. Systemic changes
• Cardiac:
Decreased cardiac output.

• Pulmonary:
Respiratory insufficiency as a secondary process.
Can progress to respiratory failure.

• Gastrointestinal:
Decreased or absent GI motility.
Curling's ulcer formation.

• Metabolic:
Hypermetabolic state.
Increased oxygen and calorie requirements.
Increase in core body temperature.

• Immunologic:
Loss of protective barrier.
Increased risk of infection.
Suppression of humoral and cell-mediated immune
responses.
Systematic changes
MANAGEMENT
First Aid:
1. Stop the burning process.
2. Cool the area with tap water with continuous irrigation
for 20 minutes.

Indications Of Admission in Burns:

1. Moderate and severe burns.
2. Airway burns of any type.
3. Burns in extremes of age.
4. All electrical or deep chemical burns.

Definitive Treatment:
1. Maintain airway, breathing, circulation (ABC).
2. Sedation and analgesia.
3. Assessment of percentage, degree and type of burn
and accordingly fluid management.
4. Chemoprophylaxis: tetanus toxoid antibiotics and
local antiseptics.
5. Ryle's tube insertion initially for aspiration and later
for feeding.
Fluid Resuscitation
• Formulas to calculate fluid replacement:
1. Parkland Regimen:
 Total Fluid replacement in 24 hours = 4ml per % of
burn per kg body weight.
 Half of the volume is given in first 8 hours, rest is
given in next 16 hours.

2. Muir and Burclay Regimen:

 For colloid after 12-24 hours.
 1 Ration = % burns x body weight in kg/ 2.
 3 Rations given in 1st 12 hours.
 2 Rations given next 12 hours.
 1 Ration given in next 12 hours.

3. Galveston Regimen (Paediatric):

 5000ml/m2 burn area + 1500ml/m² total BSA.

• Fluids used:
 Ringer lactate is the fluid of choice.
 Blood is transfused after 48 hours.
 In 1st 24 hours only crystalloids should be given.
 After 24 hours colloids like plasma, gelatin, dextran,
hetastarch are used at the rate of 0.35-0.5 ml/kg/%
of burns.
 Urine output should be 30-50 ml/hr.
 Hourly TPR charting.
Local Management
1. Open Method:
Application of silver sulphadiazine without any dressings
commonly used in burns of face and neck.
Mefenide acetate & silver nitrate can be used.

2. Closed Method:
With dressings done to soothen and protect wound, to
reduce pain and as an absorbent.

3. Tangential Excision:
Skin grafting can be done within 48 hours with less than
25% burns.

Wound coverage
 In 3 weeks the area granulate well & split skin grafting is
done (SSG, Thiersch graft).
 For wider area Mesh split skin graft is used.
 In case of eschar, escharotomy is done to prevent
compression of vessels.
 Cultured skin graft.
HOMOEOPATHIC THERAPEUTICS

 ACONITE NAPELLUS- it helps to counteract the nervous

shock which is very difficult to be overcome by the patient.
First grade burns where skin is lost and ionic imbalance
takes place ; this remedy tries to compensate the same.
Violent and severe pains in affected parts

 CANTHARIS- Useful drug in superficial Or first degree

burns; which causes erypsipelatous vesicular type of
ulceration. The affected parts burn like fire with severe
pains and inflammation

 ARNICA- Burns with local inflammation of area of and

around the lesion. Cellular tissues are damaged which
causes extravasation of fluids thus the part becomes
oedematous
HOMOEOPATHIC THERAPEUTICS

 CALENDULA - This remedy is recognised as great

Homoepathic Antiseptic. It is observed and studied that the
drug has tremendous power in building the vitality in parts
which are damaged due to burns. Acts best when skin is lost
due to first and second degree burns

 ARSENIC ALBUM - It is useful remedy in first and second

degree burns. Vesicles are formed with blisters. Intense
burning of the parts. Area around burn is inflamed. Painful
and tender to touch

 CAUSTICUM - This is remedy of choice when the bad

effects of burns are observed. Skin is raw and sore due to
burns. Old burns that do not get well
Complications Of Burns

• Eschar: It is a charred, denatured, full thickness, deep

burns with contracted dermis.

Escharotomy:
• Incise along medial and/or lateral surfaces.
• Avoid bonyprominences.
• Avoid tendons, nerves, major vessels.

• Contracture:
Disorganised over formation of compact collagen (3
times than normal) causes hypertrophic scar finally
leading to contracture.

 Classification of Contracture in Neck ( BM Achauer)

1. Mild : Inability to see ceiling.
2. Moderate: Flexion possible but not extension.
3. Severe: Fully contracted in flexed position with pull on
lower lip.
4. Extensive: Mentosternal adhesions.
Complications of burns
 Complications of contracture:
1. Ectropion
2. Disfigurement of face.
3. Microstomia.
4. Hypertrophic scar and keloid formation.
5. Marjolin's ulcer.

 Treatment:
1. Z- Plasty
2. Random cutaneous flap, microvascular free flap,
faciocutaneous flap.
3. Physiotherapy
4. Pressure garments.
 Chemical Burns
 Acids
• Protein injury by hydrolysis.
• Thermal injury is made with skin contact.

 Alkali
• Saponification of fat.
• Hygroscopic effect- dehydrates cells.
• Dissolves proteins creation of alkaline proteinates
(hydroxide ions).

 Treatment:
Late neutralization with antidote done by 0.2% acetic acid in
alkali burns, sodium bicarbonate or calcium gluconate for
acid burns.
 Electrical Burns

• Greatest heat occurs at the points of resistance, i.e., at

entrance and exit wounds. Dry skin = Greater resistance &
Wet Skin = Less resistance
• Longer the contact, the greater the potential of injury
• Smaller the point of contact, the more concentrated the
energy, the greater the injury.

 Treatment:
• Assess Entrance & Exit wounds.
• Remove clothing, jewelry, and leather items.
• Treat any visible injuries.
 Radiation Burns

• Local burns causing ulceration need excision and

vascularised flap cover - usually with free flaps.
• Systemic overdose needs supportive treatment
• The damage is more difficult to define and slower to
develop than burns.
• Acute frost bite needs rapid rewarming, then observation.
• Delay surgery until demarcation is clear.
 Cold Burns
• The damage is more difficult to define and slower to
develop than burns.
• Acute frostbite needs rapid rewarming, then observation.
• Delay surgery until demarcation is clear.