BURN INJURIES

Dr Ahmad Wattoo (MBBS)

Key Facts!

 An estimated 180 000 deaths every year are

caused by burns – the vast majority occur in
low- and middle-income countries.
 Non-fatal burn injuries are a leading cause of
morbidity.
 Burns occur mainly in the home and workplace.
 Burns are preventable.
Skin
 Largest organ
 Functions
a. Prevent evaporative water loss
b. Thermoregulation (insulation, sweating)
c. Vitamin D synthesis
d. Protection against pathogens
e. Sensation
f. Appearance etc.
Skin Structure
 Epidermis
-Barrier function
 Dermis

-Structural strength
 Hypodermis

 Dermal appendages

-Source of keratinocytes for reepithelialization

 What is a Burn Injury?
 A burn is an injury to the skin or other organic tissue
primarily caused by heat or due to radiation,
radioactivity, electricity, friction or contact with
chemicals.
Types
Thermal Burns occur when some or all of the cells
in the skin or other tissues are destroyed by:
a. Hot liquids (scalds)
b. Hot solids (contact burns), or
c. Flames (flame burns
Chemical Burns
Electrical Burns
 Causes

Burns are caused by:

 Fire

 Hot liquid or steam

 Hot metal, glass or other objects

 Electrical currents

 Radiation, such as that from X-rays

 Sunlight or other sources of ultraviolet radiation

 Chemicals such as strong acids, paint thinner or gasoline

 Abuse
Inhalation injury
Upper airway
 Thermal injury above cord

 Potentially severe edema

Lower airway
 Chemical injury from smoke particles

 Epithelial sloughing

 Inflammation

 Pulmonary edema
ABCs of Burn Injury
 Burn patients = trauma patients
 Advance trauma life support (ATLS)
 Advance burn life support (ABLS)
 Classification of Burns (Burn Depth)

Burns are classified as first, second, third, or fourth-degree

depending on how deeply and severely they penetrate the
skin's surface.
 1°, First-degree (Superficial)burns: First-degree burns

affect only the outer layer of skin, the epidermis. The burn
site is red, painful, dry, and with no blisters. Mild sunburn
is an example. Long-term tissue damage is rare and often
consists of an increase or decrease in the skin color.
 2°, Second-degree (Superficial partial thickness)

burns: Second-degree burns involve the epidermis and

part of the lower layer of skin, the dermis. The burn site
looks red, blistered, and may be swollen and painful.
 3°, Third-degree burns (Deep partial thickness):
Third-degree burns destroy the epidermis and
dermis. They may go into the innermost layer of
skin, the subcutaneous tissue. The burn site may
look white or blackened and charred.
 4°, Fourth-degree burns (Full thickness): Fourth-
degree burns go through both layers of the skin and
underlying tissue as well as deeper tissue, possibly
involving muscle and bone. There is no feeling in
the area since the nerve endings are destroyed.
Clinical importance of Burn depth
Treatment and Healing
 Depth of injury will define how well it will heal.

 Superficial burns heal without surgeries and deeper

burn require surgery.

Fluid resuscitation
 Superficial burns such as 1st degree burns do not

need fluid resuscitation.

 Deeper burns require more fluid resuscitation.
Burn Depth: Healing Prognosis
Burn Depth: Fluid Resuscitation
Pathophysiology of Bruns
Assessment of %age of burn (size of burn)

 Wallace’s Rule of Nines-the body has been divided into 11

sections.Each of these section takes about 9% of the body’s
skin to cover it.Added all together, account for 99% and
remaining 1% is for genitalia.
 Lund and Browder Chart-this chart takes into consideration
of age of the person with decreasing percentage of TBSA for
the head(A) and decreasing percentage if TBSA for the thighs
(B) and legs (C) as the child ages.
 The Rule of Palm-Small and Patchy areas of burn easy to
assess the extent using the area equal tp patient’s hand
(palm+digits) as 1% of TBSA
For Adult
For Child
 First Aid!
Basic guidance on first aid for burns is provided below.
What to do?
 Stop the burning process by removing clothing and irrigating the

burns.
 Extinguish flames by allowing the patient to roll on the ground,

or by applying a blanket, or by using water or other fire-

extinguishing liquids.
 Use cool running water to reduce the temperature of the burn.

 In chemical burns, remove or dilute the chemical agent by

irrigating with large volumes of water.

 Wrap the patient in a clean cloth or sheet and transport to the

nearest appropriate facility for medical care.

What not to do?
 Do not start first aid before ensuring your own safety (switch off

electrical current, wear gloves for chemicals etc.)

 Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn.

 Do not apply ice because it deepens the injury.

 Avoid prolonged cooling with water because it will lead to

hypothermia.
 Do not open blisters until topical antimicrobials can be applied,

such as by a health-care provider.

 Do not apply any material directly to the wound as it might

become infected.
 Avoid application of topical medication until the patient has been

placed under appropriate medical care.

Hospital Management
1. Airway and Breathing
2. Fluid Resuscitation
 Ringer Lactate / Hartman’s Solution
3. Analgesia
 Paracetamol and NSAIDs (For Small and Superficial Burns)
 Small IV doses of morphine, 2-5 mg (For Large Burns)
4. Treatment of the Burn Wounds
 Silver Sulphadiazine Cream (i.e. Quench cream)
 Silver Nitrate Solution

 Mafenide Acetate Cream

 Bacitracin/Polymyxin B + Non-adherent dressing (i.e.

Polysporin+Adaptic)
Additional Measures
 Nursing Care
 Physiotherapy
 Psychological support
 Fluid Resuscitation
1. Why is it important?
Burn—Inflammation—Increased Capillary Permeability—Fluid
loss—Shock
2. When?
 More than 10% TBSA in children

 More than 15% TBSA in adults

4. Which Fluid? Ringer Lactate

3. How?
 Parkland’s Formula:

Volume to be given in 24 hours = % of TBSA x Patient’s body

weight in kg x 4 ml
½ volume in first 8 hours and ½ volume in next 16 hours
Monitoring Resuscitation
 Goal: Maintain organ perfusion
 Urine output (U/O) target:

-Neonate 2 ml/kg/hr
-Child 1.5 ml/kg/hr
-Adult 0.5 ml/kg/hr

 If U/O > target then decrease fluid by 10%

 If U/O < target then increase fluid by 20%
 Complications
Complications of deep or widespread burns can include:
 Bacterial infection, which may lead to a bloodstream

infection (sepsis)
 Fluid loss, including low blood volume (hypovolemia)

 Dangerously low body temperature (hypothermia)

 Breathing problems from the intake of hot air or smoke

 Scars or ridged areas caused by an overgrowth of scar

tissue (keloids)
 Bone and joint problems, such as when scar tissue

causes the shortening and tightening of skin, muscles or

tendons (contractures)