Burns

Dr Janai A. M. Ondieki
For Clinical Medicine Diploma Class
yr 2
 Definitions
• Burns are caused by transfer of energy from a heat
source to the body. Heat may be transferred
through conduction or electromagnetic radiation.

• Burns are defined as a wound caused by exogenous

agent leading to coagulative necrosis of tissue

• Tissue destruction results from coagulation, protein

denaturation, or ionization of cellular contents.
 Aetiology
• Thermal Burns
– Dry Heat
• Contact Burn
• Flame Burn
– Moist Heat-Scald Burn
– Smoke and Inhalation
• Chemical Burns Acids and Alkali
• Electrical Burns -High & Low Voltage
• Cold Burns - Frost bIte
• Radiation
 Thermal Burns

– Heat changes the molecular structure of tissue causing

denaturing of proteins

– The extent of burn damage depends on

• Temperature
• Amount of heat
• Duration of contact

For example, in the case of scald burns in adults, 1 second of contact with hot
tap water at 68.9°C (156°F) may result in a burn that destroys both the
epidermis and the dermis, causing a fullthickness (third-degree) injury.
Fifteen seconds of exposure to hot water at 56.1°C (133°F) results in a similar
full-thickness injury.
• The effects of thermal burns are influenced by

– Intensity of the energy

– the duration of exposure
– the type of tissue injured
 Pathophysiology of burns

•Burns that do not exceed 25% TBSA produce a primarily local

response.

•Burns that exceed 25% TBSA may produce both a local and a
systemic response and are considered major burn injuries.

•The incidence, magnitude, and duration of pathophysiologic

changes in burns are proportional to the extent of burn injury,
with a maximal response seen in burns covering 60% or more
TBSA

•These systemic responses are due to the release of cytokines

and other mediators into the systemic circulation
• Fluid shift
– period of inflammatory response
– Vessels adjacent to burn injury dilate, increased
capillary hydrostatic pressure and permeability
– Continous leak of plasma from intravascular space
into interstitial space
– associated imbalences in fluids, electrolytes and
acid-base occur
– Haemoconcentration
– Lasts 24-36 hours
• Fluid mobilization

– capillary leak ceases and fluid shifts back into the circulation

– Restores fluid balance and renal perfusion

• increased urine formation and diuresis

– continued electrolyte imbalances

• hypokalaemia
• Hyponatremia

– Haemodilution
• Systemic Changes

• Cardiac
– decreased cardiac output

• Pulmonary
– Respiratory insufficiency as a secondary process
– can lead to respiratory failure

• Gastrointestinal
– Decreased or absent motility
– Stress Ulcer formation ( Curlings Ulcer)
• Metabollic

– Hypermetabolic state
– increased oxygen and calorie requirements
– increased in core body temperature

• Immunological

– loss of protective barrier

– increased risk of infection
– suppression of humoral and cell-mediated immune responses
 Acute Phase

• Clinical issues

• External loss of Plasma

• Loss ofd circulating red cells

• Burn oedema
 Sub Aute Phase

• Diuresis
• Clinical Anaemia
• Accelerated metabolic rate
• Nitrogen Disequilibrium
• Bone and joint changes
• Endocrine disturbances
• Electrolyte and chemical imbalance
• circulatiry derangements
• loss of function of skin as an organ
 Body's response to Burns

• Emergent Phase (stage 1)

– Pain response
– Catecholamine release
– tachycardia, tachypnoea, mild Hypertension, mild anxiety
• Fluid Shift Phase (stage 2)
– Length 8-24 hours
– Begins after emergent phase
• reaches peak in 6-8 hours
– damaged cells initiate inflammatory response
• increased blood flow to cells
• Shift of fluid from intravascular to extra vascular space
– MASSIVE OEDEMA
• Hypermetabolic Phase (stage 3)
– Lasts for days to weeks
– Large increase in the body's need for nutrients as
it repairs itself

• Resolution phase(stage 4)
– scar formation
– general rehabilitation and progression to normal
function
 Jackson's theory of Thermal Burns

• Zone of coagulation
– Area nearest to the heat source
that suffers the most damage as
evidenced by clotted blood and
thrombosed blood vessels

• Zone of Stasis
– Area surrounding zone of
coagulation characterized by
decreased blood flow

• Zone of Hyperemia
– Peripheral area around burn
that has increased blood flow
• Severity of burns is determined by

– depth of the burn

– Extent of the burn/total Burn Surface A (TBSA)
– Location of the burn
– Patient risk factors
 Grading of burn according to depth

• First Degree - Injury to the

Epidermis

• Superficial Second Degree - injury

to epidermis and Superficial
Papillary dermis

• Deep secondary Degree - Injury

from epidemis to reticular dermis

• Third degree -full thickness burn

through epidermis and all layers
of dermis

• Fourth degree - injury trhough

skin, subcutaneous fat into
• Burn Depth
• Burn depth determines whether epithelialization will occur.
• Determining burn depth can be difficult even for the
experienced burn care provider.
• The following factors are considered in determining the depth
of the burn:
– How the injury occurred
– Causative agent, such as flame or scalding liquid
– Temperature of the burning agent
– Duration of contact with the agent
– Thickness of the skin
1st Degree Burn

• Involves only the epidermis

• Reddening/Darkening of
the skin
• Pain at burn site
• Blanch to touch
• Have an intact epidermal
barrier
• Do not result in scarring
• Examples: Sun Burn, Minor
Scald from Kitchen accident
• Treatment aimed at
comfort
 2nd degree Superficial Burn
• Involves the epidermis
and papillary dermis
• Intense pain
• Blisters
• reddening/darkening
• Spares hair follicles ,
sweeat glands etc
• erythematous & blanch to
touch
• Very painful/sensitive
• No/Minimal Sacrring
• Spontaneously re-
epithelialize from retained
epidermal structures in 7-
14 days
2nd degree deep burn
• Involves the epidermis and
reticular dermis
• less pain, remain painful to pin
prick
• Appears pale and mottled
• do not blanch to touch
• capillary return sluggish or
absent
• takes 14-35 days to heal by
epithelialisation from hair
follicles & sweat glands often
with severe scaring
• Contractures possible
• may require excision & skin
 3rd degree burns

• dry, leathery skin(white,

dark, brown or charred)
• Loss of sensation
• All dermal layers are
invovled
• will require surgery
4 degree Burn
Th

• Involves underlying
tissue e.g. bone,
tendons, muscle etc..
 Assessing Total Burn Surface Area

• Rule of Nines
– best used for large surface areas
– Expedient tool to measure extent of burn
– Modified to Rule of Sevens for pediatric age group

• Rule of palms
– best used for burns< 10% BSA

• Lund and Browder Chart

Rule of Sevens for children
65%

45%

98%
94%
Criteria for Classifying the Extent of Burn
Injury(American Burn Association)
Minor Burn Injury
• Second-degree burn of less than 15% total
body surface area(TBSA) in adults or less than
10% TBSA in children

• Third-degree burn of less than 2% TBSA not

involving special care areas (eyes, ears, face,
hands, feet, perineum, joints)

• Excludes electrical injury, inhalation injury,

concurrent trauma, all poor-risk patients (eg, 31
extremes of age, concurrent disease)
 Criteria for Classifying the Extent of Burn
Injury(American Burn Association)

Moderate, Uncomplicated Burn Injury

• Second-degree burns of 15%–25% TBSA in
adults or10%–20% in children

• Third-degree burns of less than 10% TBSA not

involving special care areas

• Excludes electrical injury, inhalation injury,

concurrent trauma, all poor-risk patients (eg,
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extremes of age, concurrent disease)
 Criteria for Classifying the Extent of Burn
Injury(American Burn Association)

Major Burn Injury

• Second-degree burns exceeding 25% TBSA in adults
or 20% in children

• All third-degree burns exceeding 10% TBSA

• All burns involving eyes, ears, face, hands, feet,

perineum, joints

• All inhalation injury, electrical injury, concurrent 33

 Pre Hospital care for burn victims
• Ensure rescuer safety

• Stop the burning process: Stop, drop and roll

• Check for other injuries

– Standard ABC (airway, breathing, circulation)followed by a rapid secondary survey

• Cool the burn wound

– Analgesia
– Slows the delayed microvascular damage
– minimum of 10 min
– effective up to 1 hour after the burn injury

• give oxygen

• elevate
 Management of the Patient With a Burn Injury

• Burn care must be planned according to the burn

depth and local response, the extent of the injury,
and the presence of a systemic response.
• Burn care then proceeds through three phases:
– Emergent/resuscitative phase (on-the-scene care),
– Acute/intermediate phase, and
– Rehabilitation phase.
• Although priorities exist for each of the phases, the
phases overlap, and assessment and management of
specific problems and complications are not limited
to these phases but take place throughout burn 35
 Table: phases of burn care
Phase Duration Priorities
Emergent or From onset of injury to  First aid
immediate completion  Prevention of shock
resuscitative of fluid resuscitation  Prevention of respiratory distress
 Detection and treatment of concomitant
injuries
 Wound assessment and initial care
Acute From beginning of diuresis  Wound care and closure
to near  Prevention or treatment of
completion of wound complications, including infection
closure  Nutritional support
Rehabilitati From major wound closure  Prevention of scars and contractures
on to return  Physical, occupational, and vocational
to individual’s optimal level rehabilitation
of physical  Functional and cosmetic reconstruction
and psychosocial  Psychosocial counseling
adjustment
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• Criteria for admission to hospital/Burns Unit

• suspected airway/inhalational injury

• any burn requiring fluid resuscitation (>15% in adults and 10% in children)
• any burn requiring surgery
• burns to special areas; face, hands, feet perineum
• pts with psychiatric or social circumstance making it inadvisable to send
them home
• any suspicion of non-accidental Injury
• Any burn in a patient at extremes of age
• any burn associated with potentially serious sequelae
• high tension electrical burns
• Chemical burns
Emergent/resuscitative phase mgt
• Emergency Medical Management
• A: Airway Control
• B: Breathing and ventilation
• C: Circulation
• D: Disability - neurological status
• E: Exposure with environmental control
• F: Fluid resuscitation

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• Airway 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
– burns around the mouth and
neck
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
 Upper Airway Injury
• Injury above the glottis
• Results from direct heat (hot air) or edema
• Manifested by mechanical obstruction of the
upper airway, including the pharynx and the
larynx
• Assess patients for facial burns, erythema,
swelling, tachypnea, dyspnea, hoarsness, and
singed nasal hairs.
• Treatment: early endotracheal or nasotracheal
intubation
 Lower Airway Injury
• Injury below the glottis
• Results from inhaling toxic gases and chemical
contained in inhaled smoke
• When these substances come in contact with
pulmonary mucosa, irritation and inflammation
reaction occurs, resulting in hypersecretion, severe
mucosal edema, ciliary action , and possibly
bronchospasm
• Pulmonary surfactant is reduced, causing atelectasis
• Assess patient for expectoration of sputum with
carbon particles
 Carbon Monoxide (CO) Poisoning
• CO is a colorless, odorless
gas that is a by-product of
the combustion of organic
materials.
• The affinity of hemoglobin
for CO is 200X greater than
that for O₂
• CO combines with
hemoglobin to form
carboxyhemoglobin and
blocks the uptake of O₂ and
causing tissue hypoxia
• Treatment: early intubation
and mechanical ventilation
with 100% O₂
 Fluids for resuscitation

• In children with burns over 10% TBSA and adults with burns over
15% TBSA, consider the need for intravenous fluid resuscitation

• Fluids needed can be calculated from a standard formula

• Parkland Formula: Total percentage body surface area ×

weight(kg) × 4 = volume (ml)

– Half this volume is given in the first 8 hours, and

– the second half is given in the subsequent 16hours.
• Crystalloid : Ringer’s lactate

• Hypertonic saline

Not Routinely
• Human albumin solution Used in Our set
up !!

• Colloid resuscitation
Management of fluid loss and shock
Fluid Replacement Therapy:
• The total volume and rate of intravenous fluid
replacement are gauged by the patient’s
response.
• The adequacy of fluid resuscitation is determined
by:
– urine Output totals of 30 to 50 mL/hour
– systolic blood pressure exceeding 100 mm Hg
and/or
46
– pulse rate less than 110/minute.
Conditions Leading to Burn Shock

47
 Acute Phase management
• Hemodynamically stable through diuresis
• Capillary permeability is restored
• 48-72 hours after injury
• Goal is restorative therapy
• Focus on infection control, wound care and
closure, nutritional support, pain management,
PT
• Concluded when the burned area is completely
covered by skin grafts or when the wounds are
healed
48
 Day 1 Day 12

Full to deep partial

thickness HWB

Skin graft
3 weeks
 Acute Phase management
Pathophysiology
• Diuresis from fluid mobilization occurs, and the
patient is no longer grossly edematous
• Bowel sounds return
• Healing begins
• Formation of granulation tissue
• A partial-thickness burn wound will heal from
the edges
• Full-thickness burns must be covered by skin 50
 Acute Phase management
• Wound Care
• Daily observation
• Assessment
• Cleansing
• Debridement
• Appropriate coverage of the burn

51
 TREATING THE BURN WOUND
• Escharotomy Circumferential
full-thickness burns to the limbs
require emergency surgery.

• The tourniquet effect of this

injury is easilytreated by incising
the whole length of full-
thickness burns..

• Escharotomy•
– Incise along medialand/or lateral
surfaces.
– Avoid bonyprominences.
– Avoid tendons, nerves,major
vessels.
• Debridement•
• Types of debridement:
– 1. Auto debridement.
– 2. Tangential excision (at the
end of 1st week)
– 3. Staged primary debridement
(1-3 days postburn).
• This early debridement of dead
tissue interrupts and attenuates
the systemic inflammatory
response and normalize immune
function
– .4. For deep circumferential
burn, urgent escharotomy is
done
• Superficial burns expected to heal by
epitheliaization are managed by either
Exposure Method or by Closed Dressing
 Acute Phase management
Excision and Grafting
• Eschar is removed down to the subcutaneous
tissue or fascia and skin grafts done

55
Acute Phase management
Surgeon Harvesting Skin

56
Acute Phase management
Donor Site After Harvesting

57
 Acute Phase management
Healed Split-Thickness Skin Graft

58
 Acute Phase management
Pain Management
• Opioids
• Several drugs in combination ( MULTIMODAL
ANALGESIA)
• Non pharmacologic strategies
• Relaxation tapes
• Visualization, guided imagery
• Meditation
59
 Acute Phase management
• Nutrition
– Burns patients need extra feeding
– A nasogastric tube should be used in allpatients with
burns over 15% of TBSA
– Removing the burn and achieving healing stops the
catabolic drive.
• Nutrition Sutherland formula
– Children: 60 kcal/ kg + 35 kcal% TBSA
– Adults: 20 kcal /kg + 70 kcal% TBSA
– Protein20% of energy1.5 to 2 g/kg protein/day
 Acute Phase management
Infection Prevention
• Tetanus prophylaxis
– Tetanus toxoid, 0.5 mL intramuscularly, if thelast booster dose was more
than 5 years beforethe injury.
– If immunization status is unknown,human tetanus immunoglobulin 250 to
500units, I.M. plus tetanus toxoid in opposite side

• Monitoring and control of infection

– Burns patients are immunocompromised
– They are susceptible to infection from manyroutes
– 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
• Topical treatment of deep burns
– 1% silver sulphadiazine cream
– • 0.5% silver nitrate solution
– Mafenide acetate cream•
– Serum nitrate, silver sulphadiazine and
ceriumnitrate
 Rehabilitation Phase
• The rehabilitation phase is defined as
beginning when the patient’s burn wounds
are covered with skin or healed and the
patient is able to resume a level of self-care
activity
• Complications
– Skin and joint contractures
– Hypertrophic scarring

63
 Rehabilitation Phase
• Both patient and family actively learn how to
care for healing wounds
• Cosmetic surgery is often needed following
major burns
• Role of exercise (physiotherapy) cannot be
overemphasized
• Constant encouragement and reassurance
• Address spiritual and cultural needs
• Maintain a high-calorie, high-protein diet
64
 Complications of Burns
• Emergent phase

– Shock and multi organ failure

• Renal failure
– Respiratory failure (inhalational Injury)
– Hypothermia
• Acute phase

– Infection
• Wound infection, hypostatic pneumonia
– Curling’s (stress ulcers)
– Anaemia
– Hypoproteinaemia
– Deep Venous Thrombosis
– Paralytic ileus
• Long term complications

– Contractures
– Hypertrophic scars
– Keloids
– Marjolin’s Ulcers
– Psychological problems
Contractures

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 Chemical Burns

Chemical Burns
Acids
• Protein injury by hydrolysis.
• Thermal injury is made with skin contact.
Alkali
• Saponification of fat
• Hygroscopic effect- dehydrates cells
• Dissolves proteins by creation of alkaline
proteinates (hydroxide ions)
 Electrical Burns

• Greatest heat occurs at the points of

resistance

• –Entrance and Exit wounds

• –Dry skin = Greater resistance
• – Wet Skin = Less resistance
• Longer the contact, the greater the
potential of injury

– Increased damage inside body

• Smaller the point of contact, the more

concentrated the energy, the greater
the injury.
• Electrical Current Flow

• –Tissue of Less Resistance

• • Blood vessels
• • Nerve
– –Tissue of Greater Resistance
• • Muscle
• • Bone

• Results in………..
• –Serious vascular and nervous injury
• –Immobilization of muscles
• –Flash burns

• Late complications: cataracts, progressive

demyelinating neurologic loss
• Assess patient
• Entrance & Exit wounds
• Remove clothing, jewelry, and leather items
• Treat any visible injuries– Thermal burns
• ECG monitoring– Bradycardia, Tachycardia, VF or Asystole–
Treat cardiac & respiratory arrest– Aggressive airway,
ventilation, and circulatory management.
• Consider Fluid bolus for serious burns– 20 ml/kg
• Look out for compartment syndrome – prohylactic
fasciotomy
• Myoglobinuria – leads to renal failure