Burn Management

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Burn

• DefinitionsA burn is the response of the skin and subcutaneous tissues to thermal injury.

Types of burns

• Thermal injury -scald –spillage of hot liquids -Flame burns -Flash burns due to exposure of natural gas,alcohol,combustible liquidsElectrical injuryChemical burnsCold injuryIonising burns Sun burns

Classification of burns

• Mild –partial thickness burns<15% in adults or <10% in children

-full thickness burns <2%-can treat as outpatient

• Moderate-15-25%(10-20% in children),burns not in eye,ears,face,hand

• Severe ->25%(20% in child)-All inhalation & electrical burnsinvolve eye.ear,face,hand,feet,perineum

Depending on thickness of skin involved

• 1st degree -epidermis looks red,painful,no blisters,heals rapidly in 5-7 days

• 2nd degree -with blisters,heals 2-3weeks

• 3rd degree -charred,parchment,painless,thrombosis with superficial vessels,(contracted full thickness burns called Eschar)

Clinical features

• Pain,anxious status,tachycardia,tachypnoea,fluid loss

• In severe-shock

PathophysiologyHeat causes coagulation necrosis of skin & subcutaneous tissue

Release of vasoactive substance

capillary permeability

Loss of fluids.

• severe hypovolamiadecreased myocardial funtion

Decreased COP reduced renal blood flow oligurea

Altered pulmonary resistance causing pulmonary oedema

MODS

Causes of deaths in Burns

• Hypovolamia & shock• Renal failure• Pulmonary oedema & ARDS• Septicaemia• Multiorgan failure

Management of burns

• 1st aid-stop burning process & keep pt away from

burning area-cool area with tap water for 20 mints(not

cold water can be hypothermia)

Indications for admission in burns

• Any moderate & severe burns• Airway burns of any type• Burns of extremes of age• All electrical/deep chemical burns

Initial management

• Cloths should removed• Cleaning the part remove mud,dust….etc• Chemoprophylaxis-tetanus,antibiotics,local

antseptics• Covering with dressing• Comforting by sedation & pain killers

Definitive treatment

• Admit pt• Maintain ABC• Asses the percentage involved • Fluid resuscitation

parkland regime—4ml/%burn/kg body weight/24hrsmaximum percentage considered is

50%..half of the volume is given in 1st 8 hrs,rest given in 16 hrs

• Muir & Burclay regime%burn*body weight in kg/2 =1 ration3 rations given in 1st 12hr2 rations in 2nd 12hr1 ration in 3rd 12 hr

Fluids used are N.saline,ringer lactate(FOC),hartmann,blood

1st 24 hour• Only crystalloids(can easily pass through the

capillary)Na should be assessed by formula0.52mmol*kg body weight*%burn.Give at a rate 4.0-4.4ml/kg/hrAfter 24 hourColloid can give upto 30-45hrs to compansate plasma loss…..plasma,gelatin,dextran,hetarstarch usedAt a rate of 0.35-5ml/kg/%burns

• Urine out put should be 30-50ml/hr• Tetanus toxoid• Monitor hourly

bp,pulse,saturation,SE,BU,nasal oxygen• Iv ranitidine 50mg 8 hrly• Antibiotics-

penicillins,aminoglycosides,cephalosporins,metronidazole

• Culture on discharge• TPN

Local management

• Dressing• Open method (used sulfadiazine without any

dressing in face,head,neck)• Closed method(dressing for soothen & protect

wound)• Tangenital excision• Apply sulfadiazene(neutropeania)…other

agents-sulfamylon,silver nitrate

Complications of burn contracture

• Ectropian of eyelid causing keratitis & ulcer• Disfigurement of face• Narrowing of mouth(microstomia)• In neck involvement reduced movement• Hypertrophic scar & keloid formation• Infection,ulcer & cellulitis• Marjolin’s ulcer

Rx for contracture

• Release by surgically & use skin graft/ Z plasty• Physiotherapy & rehabilitation• Pressure garments for prevent hypertrophic

scar• For itching aloe vera,

antihistamine,moisturizing creams

Electrical burns

• Always deep burn. wound of entry & wound of exit

• Internal organ injury• Most of deaths due to ventricular fibrillation• Gas gangrene common • Release of myoglobin causes ARF• Acidosis

management

• Depending on injury• Mannitol used in ARF• Mafenide acetate is better it has good

penetration & useful against clostridial infection

Inhalation injury

• Occurs after major fire burns• Inhaled by heat, noxious gas, incomplete

products of combustion• If fire area has <2% oxygen can die 45 sec• Formation of carboxyhaemoglobin with CO• Laryngeal & bronchial oedema• Later -ARDS,pneumonia,atelectasia,PE,PO,

pneumothorax

• Clinical featureslow oxygen levelcharring of mouth, oropharynxcarbon sputumchange voicestridor,tachypnoea,reduced consciousness

Managementventilatory supporttracheostomy

Chemical burns

• Tissue destruction is extensive• Acid burns nitric/sulphuric acid damage in

skin, soft tissue & stomach……so severe gastritis & pyloric stenosis. Cause metabolic acidosis,ARDS,ARF,heamolysis

mgt by IV sodium bicarbonate,calcium gluconate 10% gel,tropical ziphrin solution

• Alkali burns occur in oral cavity oesophagus.complications are oesophageal

stricture,saponification of fat,fluid loss,release of alkali proteinases,

mgt with 0.2% acetic acid.

Medco-legal & ethics of burn management

• Police should be informed in a female,pregnant pt arrive with burns

• Burns should be assessed whether accidental/homicidal

• Relatives should be informed about duration of stay,complications.

• Dying declaration arranged

Thank you