Management and Treatment of Burn Wound

SURGERY CLINIC-Ⅲ
SURG-410
Department of Clinical Sciences, FVS, BZU.

Assigned to;
Roll no. 02,05,06,07,08

Presented to;
Dr. Abdul Asim Farooq.
Burn : Tissue changes due to excessive absorption of heat is known as burns.
Scald : A scald is a burn caused by moist heat.
The degree of injury depends on the temperature of the object and its duration of
contact with the body. A scald is likely to be more severe than a burn because the hot
liquid may penetrate deeper into the tissues.
Etiology; 
 Dry heat
 Actinic rays (sunburn)
 Irradiation 
 Moist heat 
 Electricity 
 Friction 
 Dry heat causes desiccation and charring. 
 Moist heat causes boiling or cooking of tissue resulting in coagulation.
Classification
1st degree: Epidermis alone is affected, erythema present. There is diffuse swelling
and sometimes vesicle formation. (A vesicle is a small circumscribed elevation of the
epidermis containing a serous liquid). The vesicles subside within about a week.
2nd degree: Along with erythema, coagulative necrosis of the epidermal cells takes
place. Bullae (blisters) are formed. by the exudation of plasma. The exudation may
continue for thirty six to forty eight hours. The blisters are very painful.
3rd degree: Destruction of epidermis, dermis and upto hypodermis or the
subcutaneous tissue.
4th degree: The changes are similar to the 3rd degree burn but extend to the
subcutaneous fascia and may upto deeper tissues(muscle and bone).
In 3rd and 4th degree burn the complete thickness of skin plus subcutaneous
fat/muscles/other deeper tissues are involved. The dead area of skin appears brownish
black and leathery. There may be a bad odour. The area surrounding a burn shows
oedema and hyperaemia. During healing the dead portions slough off. This sloughing
is a slow process taking eight to nine weeks. The sloughed tissues are replaced by scar
tissue which appears thin, shining and hairless, if hair roots are damaged.
The 1st and 2nd degree burn wounds are more painful than 3rd degree burn.

Fig; 4th degree burn wound in buffalo

Severity of Injury
1. Extent of body surface burnt :
Assessment of burned area in human beings can be estimated on the basis of rule of
nine of Wallace
Head and neck-9%
Body (dorsal)-2x9%
Body (ventral)-2x9%
Leg (each)-9% (4x9%)
Penile and pubic area-1%
Shock may result if more than 4% of the skin surface is affected by burns. Prognosis
is unfavourable if more than 50% of the skin surface is involved. In first degree burn,
healing may take place within 10 days and second and third degree burn may like
three to four weeks or more.
2. Depth of burn:
Depending on the depth of the skin destruction, the burn can be classified as:
i. Partial thickness: Partial thickness burns heals faster because of remnants of
epidermis in hair follicle and sweat glands spread over the wound surface.
ii. Full thickness: Healing is slow in full thickness burns and such type of burn is
rarely painful due to destruction of most of the nerve endings.
3. Associated injuries/illness: Concurrent diseases like renal, cardiovascular or
metabolic disorders increases mortality in burn cases.
Patho-Physiology
1. Immunosuppression  An Immunosuppressive agent is released from severely
burned patient which inhibits the migration of peripheral leucocytes and causes the
lyses of peripheral lymphocytes from burned patients.
2. Inhalation Injury/Respiratory Tract Burn 
 Oral or nasal burn develops stirdor, respiratory distress and laryngeal edema.
 Endotracheal intubation of such patients should be done before total obstruction.
Lower respiratory tract burns causes edema with bronchospasm.
 Treatment included bronchodilators like aminophylline along with steroids. In
severe cases mechanical ventilation is indicated. 
 Aldehyde (Acrolein) in smoke causes severe pulmonary edema & death.
3. Burn Shock 
Just after burn (first 8 hours), sudden and dramatic changes in circulatory dynamics
result in burn shock.  Causes are fluid loss and fluid shifts, electrolyte imbalances,
blood protein losses, myocardial depression, marked increase in peripheral vascular
resistance, increased blood viscosity etc.
Loss of circulatory volume (Hypovolemia) in the first 24 hour through water,
electrolyte and plasma protein loss in blister fluid, exudates, edema and by
evaporation.  This is due to vasodilation and increased capillary permeability of the
wound, probably mediated by the liberation of histamine, kinins, prostaglandins and
fibrin degradation products.
4. Burn Toxins
Lipoproteins etc.
Treatment 
 Immediate care includes application of cold, clean water to the affected part and
changes it after every 3 minutes. 
 Antitetanus toxoid should be given. 
 Partial thickness burns may be relieved by cold water compress and dressings.
Cold application retards pain. 
 Analgesic or sedative: morphine, ketamine or diazepam in dogs and xylazine or
triflupromazine in large animals. 
 Hypovolemic shock develops because of losses from burn wound and the
formation of inflammatory edema.
 The lost fluid should be replaced with colloid solution such as synthetic plasma
expander e.g. dextran 80. The amount of fluid needed in the first 4 hours =Body
wt in Kg x % burn / 2 
 Fluid requirement can also be monitored by estimating the hematocrit, central
venous pressure (CVP) and urine output. 
 Urine output should be kept above 1 ml/kg b.wt./h. 
 Fluid input will exceed urine output by approximately 3-4 times in the first 48 h.
(3-4 ml /kg b.wt/h). 
 Mild to moderate degree of acidosis is usually corrected by bicarbonate
precursors in electrolyte solutions (lactate, gluconate, acetate etc.). Up to 5
mEq /kg b.wt of Na2 CO3 can be administered over 30-60 minutes. 
 Serum protein should be kept between 3.5–6.5 gm/dl and red blood cells should
be given if hematocrit falls below 25%. 
 Treatment of inhalation injury: Aspiration of fluid from the trachea and bronchi
may be needed. Assisted respiration and oxygen is essential. Tracheotomy can be
done. Corticosteriods and administration of systemic antibiotics.
 Local wound therapy/ burn dressing: Ointments of mafenids and silver
sulphadiazine can be applied. 
 Oil based (tulles): Promotes drying of the wound but tend to adhere and cause
pain at dressing changes. The tulles contain Nitrofurazone or Chlorhexidine. 
 Water based cream : The water based cream should contain antibacterial agents
such as Sulphadiazine and 0.5% silver nitrate to reduce the emergence of gram
negative organisms in the wet wound environment.
 Local treatment consists of applying emollients.
 The blisters may be ruptured to drain the exudate. The dead portion of skin
covering the blister is not removed at this stage because by doing so the
underlying raw surface will be exposed.
 If the skin surface is eroded, the exposed areas are protected by astringent,
antiseptic and anodyne ointments.
 Local analgesics may be incorporated in these ointments to control pain.
Ointments commonly used are tannic acid ointment, iodoform ointment etc.
Antibiotics ointments like penicillin ointment are also advisable to control
bacterial infection.
 Antibiotics may also be given systemically to counteract septicemia.

Chemical burns
Injuries caused by chemicals like strong acids and alkalies are referred to as chemical
burns. The chemical produces localized necrosis of skin and deeper tissues with
which it comes in contact. The degree of tissue destruction depends on the strength of
the chemical and the duration of contact. The degree of necrosis is severe if the
corrosive chemical is not promptly removed. A line of demarcation is seen between
the dead and healthy tissues. The devitalized tissues may get infected. After sloughing
of necrosed area an ulcer is produced which heals gradually.
Treatment
If detected immediately, the chemical may be neutralized by a suitable acid or
alkaline solution. Alkalies like sodium bicarbonate and soap solution are used in the
case of burns due to acids; acidic solutions like vinegar are used in the case of burns
due to alkalies. If suitable acid or alkaline solutions are not available, washing with
plenty of plain water may be resorted to. The ulcer produced by the sloughing of
necrosed areas is treated on general principles.
Electric shock
Electric current passing through the animal body may cause coma and death, if the
current is sufficiently strong. It may also cause burns locally. Treatment consists of
administering artificial respiration, parenteral administration of respiratory and
cardiac stimulants, etc., in addition to the treatment of burns.
Lightning stroke
Animals struck by lightning may die immediately or within a few hours. Rarely they
do remain in an unconscious or semiconscious state for sometime and then recover.
Some of the recovered animals may show unsteady gait, partial paralysis, etc., due to
nervous lesions, while others may be apparently normal. The cause of sudden death is
believed to be ventricular fibrillation.
Lesions: The nerve tissue of animals seriously affected with lightning stroke shows
on microscopical examination small haemorrhages and degenerative changes. On
unpigmented skin the so called lightning figures may be seen in the form of dark
branching lines.
Treatment is symptomatic like administration of cardiac and respiratory stimulants,
artificial respiration, etc.
Sun stroke, Heat stroke, etc.
These are conditions caused by disturbances in the heat regulating mechanisms of the
body. Etiology High environmental temperature, high humidity and inadequate
ventilation.
Sun stroke is caused by direct exposure to sun rays. Excessive physical strain and
obesity are predisposing causes.
Heat stroke is more commonly seen in dogs and horses. The chief symptoms are
deep accelerated breathing and collapse. The symptoms occur suddenly. The rectal
temperature may be raised up to 110°F. There is a staring expression in the eyes.
Vomiting may also be noticed.
The treatment should be prompt as otherwise the condition is likely to be fatal. Cold
water should be applied to the body. Small animals like dogs may be immersed in
water, if possible. Ice packs are applied to the head. Cold water enemas are also
indicated. The rectal temperature should be taken every five minutes and treatment
should be modified according to the response shown.
Largactyl may be given to lower the body temperature. Large animals should be given
a dose of 10 to 15 cc of a 5% solution IM per 1000 lb. body weight. Small animals
should be given 1.25 cc of 2.5% solution IM per 25 lb body weight.
Heat cramps are common in animals doing work in a hot environment and result
from deranged electrolyte balance due to excessive electrolyte loss, especially through
sweat (acute salt loss). Draft horses are commonly affected. The chief symptoms are
severe muscular spasm and sudden cessation of sweating. Vomiting may be present.
The condition is treated by administering cold water through stomach tube. If
vomiting is present, physiological saline is given intravenously instead of
administration by stomach tube.