MANAGEMENT

OF BURN
I. INTRODUCTION
• A burn is a coagulative destruction of the surface layers of the body
caused by heat, chemicals or irradiation.
II. EPIDEMIOLOGY

More than 90 % of burns are caused by

carelessness or ignorance & are completely
preventable
Most affected groups are children & young adults
Types of burns
A. SCALD BURNS
 Scalds from hot water are the most common cause of burn
 Depth is proportional to temperature, duration of contact & thickness
of skin
Types of burns

• B. FLAME BURNS
Next most common
House fires, smoking related fires, improper use of flammable
liquids, automobile accidents, ignition of clothing from stoves or
space heaters ,fall into open fire (land preparation for farming)
Types of burns

• C.FLASH BURNS
Explosion of natural gas, propane, gasoline
& other flammable liquids cause intense heat for a
brief time`
Depth depends on the amount and type of fuel
Clothing, unless it ignites, is protective against flash
burns
May be associated with thermal damage to the
upper airway
Types of burns

• D. CONTACT BURNS
Result from contact with hot metals, plastic, glass or hot coals
Limited in extent & very deep
Types of burns

• E.CHEMICAL BURNS
Caused by strong acids or alkalis
industrial accidents, assaults or improper use of harsh solvents &
drain cleaners
Cause progressive damage until they are inactivated by
reaction with the body tissue or diluted with water
Types of burns

Acid burns may be more self-limiting than alkali burns

Chemical burns should be considered deep dermal or full-thickness
until proven otherwise
Neutralizing agent shouldn’t be used
Types of burns

F. ELECTRICAL BURNS
- low-voltage or high-voltage
Mechanisms of injury :
1. Electrical current injury
2. Electrothermal burns
3. Flame burns caused by ignition of clothes

 Deep destruction of muscles ,nerves & vessels –

myoglobinuria --ATN
IV. BURN PREVENTION
• More than 90 % of all burns are preventable by taking ordinary
precautions
• Teaching at school for children
 V.PATHOPHYSIOLOGY
Three zones
 Zone of coagulation :
irreversible vessel
coagulation & no capillary
blood flow
Zone of stasis : sluggish
capillary blood flow
Zone of hyperemia : the usual
inflammatory response of
healthy tissue to non-lethal
injury
 BURN SEVERITY & CLASSIFICATION
by Depth of burn
First degree burn
involve only the epidermis
 don’t blister
 erythematous b/c of dermal VD
 quite painful
 the erythema & pain subside over 2 or 3 days
 day 4 ,injured epithelium desquamates
 BURN SEVERITY & CLASSIFICATION
by Depth of burn
Second degree burn
Superficial dermal(20)burns
 include the upper layer of dermis
 blisters
 pink & wet when blisters are
removed
 painful
 blanches with pressure
 heal spontaneously in less than 3
wks
 less scar
 color mismatch in pigmented
individuals
 BURN SEVERITY & CLASSIFICATION
by Depth of burn
Deep dermal burns
extend into the reticular layer of the
dermis
 a mottled pink & white color
 discomfort rather than pain
 heal in 3 – 9 wks
 hypertrophic scarring
 BURN SEVERITY & CLASSIFICATION
by Depth of burn
Third degree burns (full-
thickness burns)
 involve all layers of the dermis
 heal only by wound contracture,
epithelization from the edges or
by skin grafting
 appear white, cherry red or
black
 leathery
 painless
 doesn’t blanch
 develop a classic burn eschar
 BURN SEVERITY & CLASSIFICATION

•Size of burn
Determined by
 rules of 9
 palm of the pt as 1 %
Size of burn
RESPIRATORY INJURY

• Smoke or thermal damage to respiratory tree occurs in 30 %

• 3 types :
1. Carbon monoxide poisoning
2. Thermal injury- limited to the upper airway
3. Smoke poisoning- -direct epithelial injury
-interference with aerobic respiration
RESPIRATORY INJURY

1. Carbon monoxide poisoning

• 60 – 70 % of deaths from house fires
• Pathophysiology
 co has affinity for Hb 200x greater than oxygen
 co + Hb coHb
 coHb interferes with oxygen delivery to tissues

Treatment :100 % oxygen

 RESPIRATORY INJURY
Diagnosis of inhalational injury :
Hx :fire in enclosed space,
burn in the face, wheezing ,
air hunger, excessive sputum
P/E :soot in the mouth & pharynx ,singed
nasal hair ,hoarseness ,wheeze,
carbonaceous sputum, smell of
smoke in victims clothes
Lab :bronchoscopy ,CXR ,[CO], arterial o2
TREATMENT OF BURN

Care at the scene

- rescue of the burned victim
- remove the clothing
- airway management
- CPR (if there is cardiac arrest)
- R/o other major trauma & give first aid
- application of cold water
- keep the pt warm
- cover the wound with clean sheet
- transport to the nearby health facility
 TREATMENT OF BURN
Emergency room care
- ABC
- Fluid management
Indications - children > 10 %
- adult >15 %
Formulae
1. Parkland : Previously: 4ml x wt (Kg) x % TBSA burn
2. Current: 2 ml x wt (Kg) x % TBSA burn
3. Pedi: 3 ml x wt (Kg) x % TBSA burn

-Ringer’s lactate
TREATMENT OF BURN
Pertinent Hx : -circumstance of burn
-medical Hx
-type of burn
-when & where the burn occurs
Physical Exam : -a full P/E
-size of burn
Lab. Hct, glucose ,BUN, electrolyte, blood gas
Patient monitoring during resuscitation :
-clinical : skin, UOP
-laboratory : Hct
 TREATMENT OF BURN
-Tetanus prophylaxis
-Pain control with
-Care of the burn wound:
• Escharotomy
Chest - at the anterior axillary line
Extremity - can be done at a bedside
without local anesthesia
 TREATMENT OF BURN
• Blister mx
• Mgt of wound
Daily washing
Removal of loose dead tissue
Topical application of saline-soaked dressings until they heal by themselves
or granulation tissue appear in the base of the wound
Skin graft - after 3-8 wks after injury
 COMPLICATIONS OF BURN
I. INFECTION
Most morbidity & mortality in severely burned pts are related to infections
Predictors of infection :
Burn size
Age
Inhalation injury
COMPLICATIONS OF BURN

Site of infection
1. Wound infection
Treatment : .expeditious excision of
the wound
.topical antimicrobial
therapy (silver nitrate) Systemic antibiotics
after culture and sensitivity test for septic patients
 COMPLICATIONS OF BURN
2. Pneumonia --most common
3. Suppurative thromophelebitis
Occurs in 5 % of major burns
Ass with use of IV catheters
Incidence increases with duration of catheterization
4. UTI
COMPLICATIONS OF BURN
Curling ulcer (stress ulcer)
Seizures
-unique to children
-result from electrolyte imbalance, hypoxemia, infection
& drugs (penicillin, diphenhydramine, aminophylline)
Fecal impaction
-from immobilization, DHN, narcotic analgesics
Ileus & acute gastric dilation
Related to healing- Hypertrophic scar, Keloid,
Contracture, Marjolin’s ulcer
COMPLICATIONS OF BURN

PREVENTION OF CONTRACTURE
-early excision and grafting
-splintage
-elevation of extremity
-early physiotherapy
-prevention of infection