BURN

Heat, Chemical, Electrical Burns

Presented by: Prof. NAZIM JAT

FRCS
LEARNING OBJECTIVES

• The area and depth of burns.

• Methods for calculating the rate and quantity
of fluids to be given.
• Techniques for treating burns and the patient.
• The pathophysiology of electrical and
chemical burns.
 INTRODUCTION
• A burn is a type of injury to flesh or skin caused by
heat, chemical, electricity, light, radiation or friction.
• Most burns affect only the skin Rarely, deeper
tissues, such as muscle, bone, and blood vessels can
also be injured.
• Burns may be treated with first aid, in an out-of-
hospital setting, or may require more specialized
treatment such as those available at specialized burn
centers.
PREVENTION OF BURNS

 Implementing good health and safety

regulations, workplace, factories, automobile
accidents.
 Educating the public.
 Introducing of effective legislation to
employee safety measures.
 CLASSIFICATION
 Erythema ( Superficial burn)
 Superficial partial thickness
 Deep Partial Thickness
 Full thickness
 Layers Time to Complication
Names involved Appearance Texture Sensation healing s Example
Increased risk
Redness ( to develop
First degree Epidermis erythema) Dry Painful 1wk or less skin cancer
 later in life
Second Extends into Red with clear
degree superficial blister. Local
(superficial Moist Painful 2-3wks infection/
partial (papillary)  Blanches with cellulitis
dermis pressure
thickness)
Second Extends into Red-and- Scarring,
degree (deep deep white with Weeks - may contractures
bloody Moist Painful progress to (may require
partial (reticular) blisters. Less third degree excision and 
thickness) dermis
blanching. skin grafting)
Third degree Extends Stiff and Requires Scarring,
(full through white/brown Dry, leathery Painless excision contractures,
thickness) entire dermis amputation
Amputation,
Extends
through skin, significant
subcutaneous Black; functional
Fourth tissue charred with  Dry Painless Requires impairment,
degree  and into excision possible 
eschar gangrene,
underlying
muscle and and in some
bone cases death.
The Pathophysiology

Warning signs of burns to the respiratory

system
 Burns around the face and neck
 A history of being trapped in a burning room
 Change in voice
 Stridor
Injury to Airway & Lungs
 Physical burn injury to the airway above the larynx:

The hot gases can physically burn the nose, mouth ,tongue,
palate & larynx. Once burned, the linings of these structures
will start to swell. After few hours, they may start to interfere
with the larynx and may completely block the airway if
action is not taken to secure an airway.
Injury to Airway & Lungs

 Physical burn injury to the airway below the larynx:

This is a rare injury as the heat exchange mechanisms in the

supraglottic airway are usually able safely to absorb the heat
from hot air. However, steam has a large latent heat of
evaporation & can cause thermal damage to the lower
airway. In such injuries, the respiratory epithelium rapidly
swells & detaches from the bronchial tree. This creates
casts, which can block the main upper airway.
 Injury to Airway & Lungs
 Metabolic Poisoning:
There are many poisonous gases that can be given off in a fire, the
most common being carbon monoxide, a product of incomplete
combustion that is often produced by fires in enclosed
spaces.Carbon monoxide binds to haemoglobin with an affinity 240
times greater than that of oxygen & therefore blocks the transport
of oxygen. Levels of carboxyhaemoglobin in the bloodstream can be
measured.Concentrations above 10% are dangerous & need
treatment with pure oxygen for more than 24 hours. Death occurs
with concentrations around 60%.

Another metabolic toxin produced in house fires is hydrogen cyanide,

which causes a metabolic acidosis by interfering with mitochondrial
respiration.
Injury to Airway & Lungs

Inhalational injury:
Inhalational injury is caused by the minute
particles within thick smoke, which, because of
their small size, are not filtered by the upper
airway , but are carried down to the lung
parechyma. They stick to the moist lining,
causing an intense reaction in the alveoli.
This chemical pneumonitis causes oedema within
the alveolar sacs and decreasing gaseous
exchange over the ensuing 24 hours, and often
gives rise to a bacterial pneumonia. Its
presence or absence has a very significant
effect on the mortality of any burn patient.
Injury to Airway & Lungs

Mechanical block on rib movement:

Burned skin is very thick and stiff, and this can physically stop the ribs
moving if there is a large full thickness burn across the chest.
Injury to Airway & Lungs

 Inhaled hot gases can cause supraglottic airway

burns & laryngeal oedema
 Inhaled steam can cause subglottic burns & loss of
respiratory epithelium
 Inhaled smoke particles can cause chemical
alveolitis and respiratory failure
 Inhaled poisons such as carbon monoxide, can
cause metabolic poisoning
 Full thickness burns to the chest can cause
mechanical blockage to rib movement
Inflammation & Circulatory Changes

 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 % of surface area, the loss of fluid
produces shock
 Other Life – Threatening Events with
Major Burns

 The immune system and infection

 Changes to the intestine
 Danger to peripheral circulation
Other complication of burns
 Infection from the burn site, lungs, gut, lines and catheters
 Malabsorption from the gut
 Circumferential burns may Compromise Circulation to a
limb
Immediate Care of the Burn Patient

 Pre-Hospital Care:
 Ensure Rescuer Safety:
 Stop the burning Process
 Check for other Injuries
 Cool the burn wound
 Give Oxygen
 Elevate
 Hospital Care
 A Airway Control
 B Breathing & Ventilation
 C Circulation
 D Disability – Neurological Status
 E Exposure with environmental Control
 F Fluid resuscitation
Major Determinants of the outcome of a burn

 Percentage surface area involved

 Depth of burns
 Presence of an inhalational injury
The Criteria of Acute admission to a burn
unit

 Suspected airway or inhalational injury

 Any burn likely to require fluid resuscitation
 Any burn likely to require surgery
 Patients with burns of any significance to hands, face,
feet or perineum
 Patients whose psychiatric or social background makes it
inadvisable to send them home
 Any suspicion of non-accidental injury
 Any burn with associated potentially serious sequelae
including high-tension electrical burns and concentrated
hydrofluorine acid burns.
 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.
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.
Assessment of the Burn Wound

Assessing the area of a burn

 The patient’s Whole hand is 1% TBSA(Total
body surface area), and is a useful guide in
small burns
 The Browder chart is useful in larger burns
 The rule of nines is adequate for a first
approximation only
Age in Years 0 1 5 10 15 Adult
A Head 9 8 6 5 4 3
B Thigh 2 3 4 4 4 4
C leg 2 2 3 3 3 3
Causes of burns & their likely depth

Causes of burn Probable depth of burn

Scald ( burn by hot fluid) Superficial, but with deep dermal
patches in the absence of good
first aid. Will be deep in a young
infant
Fat burns Deep dermal
Flame burns Mixed deep dermal and full
thickness
Alkali burns including cement Often deep dermal or full
thickness
Acid burns Weak concentration superficial,
strong concentrations deep
dermal
Electrical contact burn Full thickness
Assessing the depth of a
burn
 The history is important – temperature, time
and burning material
 Superficial burns have capillary filling
 Deep partial – thickness burns do not blanch
but have some sensation
 Full thickness burns feel leathery and have no
sensation
 Fluid Resuscitation
 Crystalloid Resuscitation
 Ringer’s lactate is the most commonly used crystalloid
 Effective as colloids
 Significantly less expensive
 Hypertonic Saline
 Human albumin solution (HAS) is commonly used
colloid
 Produces hyperosmolarity & hypernatraemia
 Colloid Resuscitation
Fluid Resuscitation

 In children with burns over 10 % TBSA and

adults with burns over 15% TBSA, consider
the need for intravenous fluid resuscitation
 If oral fluids are to be used, salt must be must
be added
 Fluids needed can be calculated from a
standard formula
 The key is to monitor urine output
Options for treatment of deep burns

 1% silver sulphadiazine cream

 0.5% silver nitrate solution
 Mafenide acetate cream
 Serum nitrate, silver sulphadizine and cerium nitrate
Dressing with nanocrystalline silver:
• Silver sulphadiazine cream (1%)
• Silver nitrate solution ( 0.5%)
• Mafenide acetate cream
• Silver sulphadiazine and cerium nitrate
 Principles of Dressing for burns

 Full thickness & deep dermal burns need antibacterial dressing to

delay colonisation prior to surgery
 Superficial burns will heal & need simple dressing
 An optimal healing environment can make a difference to outcome in
borderline depth burns
Additional Aspects of Treating The burned
patient
• Analgesia
i. Acute
ii. Subracute
• Energy balance & Nutrition care
i. Burns patients need extra feeding
ii. A nasogastric tube should be used in all patients with burns over 15% of
TBSA
iii. Removing the burn and achieving healing stops the catabolic drive
INFECTION CONTROL IN BURNS PATIENTS

 Burns patient are immunocompromised

 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
Acute burn wound

Surgical treatment of deep burns

 Deep dermal burns need tangential shaving and split-
skin grafting
 All but the smallest full – thickness burns need surgery
 The anaesthist 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 reduce burn load
Delayed reconstruction of burns

 Eyelids must be treated before exposure

keralitis 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
ELECTRICAL INJURIES

 low voltage injuries cause small, localised, deep burns

 They can cause cardiac arrest through pacing
interruption without significant direct myocardial
damage
 High voltage injuries damage by flash ( external burn) &
conduction ( internal burn)
 Myocardium may be directly damaged without pacing
interruption
 Limbs may need fasciotomies or amputation
 Look for and treat acidosis and myoglobinuria
CHEMICAL BURNS

 Damage is from corrosion and poisoning

 Copious lavage with water helps in most
cases
 Then identify the chemical and assess the
risks of absorption
Radiation burns

 Local burns causing ulceration need excision

and vascularised flap cover – usually with free
flaps
 Systemic overdose needs supportive
treatment.
Cold Injuries

 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.