BURNS

Dr.P.Viswakumar, M.SAssistant Professor of Surgery,

Dept of General Surgery,PSGIMSR,

Coimbatore-4.

Key Facts

• An estimated 265 000 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.

What is a Burn?• 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.

Burn Classification

Causes• Flame—damage from superheated oxidized

air• Scald—damage from contact with hot liquids• Contact—damage from contact with hot or

cold solid materials• Chemicals—contact with noxious chemicals• Electricity—conduction of electrical current

through tissues

Depths

• First degree—injury localized to the epidermis• Superficial second degree—injury to the

epidermis and superficial dermis• Deep second degree—injury through the

epidermis and deep into the dermis• Third degree—full-thickness injury through the

epidermis and dermis into subcutaneous fat• Fourth degree—injury through the skin and

subcutaneous fat into underlying muscle or bone

First Degree Second Degree

Third Degree Fourth Degree

Pathology Underlying Burns

• Skin is the largest organ on the human body, provides a staunch barrier in the transfer of energy to deeper tissues.

• Once the inciting focus is removed, however, the response of local tissues can lead to injury in the deeper layers.

• The area of cutaneous or superficial injury has been divided into three zones—zone of coagulation, zone of stasis, and zone of hyperemia

• Fire/Flames,Contact with hot liquids,hot/cold solid materials induce cellular damage via transfer of energy directly leads to coagulation necrosis.

• Chemical and electrical burns cause injury via cell memberane damage in addition to thermal injury.

• Depth of Injury depends on 3 factors1) Temperature at which skin exposed2) Casuative agents3) Duration of Exposure.

Systemic Effects of Burns

• Severe burns covering more than 40% of the TBSA are typically followed by a period of stress, inflammation, and hypermetabolism .

• Characterized by a hyperdynamic circulatory response with increased body temperature, glycolysis, proteolysis, lipolysis, and futile substrate cycling.

• Their severity, length, and magnitude are unique for burn patients.

Post Burn Metabolic Phenomena

• Two Distinct phase of metabolic changes observed in post burns.

• The first phase occurs within the first 48 hours of injury and has been called the ebb phase.

• Characterized by decrease in cardiac output, oxygen consumption, and metabolic rate, as well as impaired glucose tolerance associated with its hyperglycemic state.

• These metabolic variables gradually increase within the first 5 days postinjury to a plateau phase (the flow phase).

Time Post burn

Post Burn Squela

• Cardiac out put increases by 1.5 times• Liver size increases by 225%• Muscle protein is degraded much faster than it is

synthesized.• The net protein loss causes loss of lean body mass and

severe muscle wasting.10% loss – Immune Dysfunction20% loss – Decrease wound healing30% loss – Increased risk of Pneumonia &

Pressure sores40% loss – Death

• Renal – Drecresed GFR and Renal blood flow and can lead to ATN if left untreated

• The gastrointestinal response to burn is highlighted by mucosal atrophy, changes in digestive absorption, and increased intestinal permeability.

• Burns cause a global depression in immune function.

• Great risk for a number of infectious complications, including bacterial wound infection, pneumonia, and fungal and viral infections.

Assessment & Management of Burn patients

Assesment of Burn Size

Assesment of Depth and Degree

Basic Management

• Prehospital management

• Remove the person from source and burning process must be stopped.

• Addressing Inhalation injury with 100% oxygen• Remove heated source like

rings,bracelet,Chain,Watches,etc.• Pouring water with room temperature

advisable only upto 15 min beyond which it can lead to hypothermia.

Initial Assessment

• By Primary and Secondary Survey.• In Primary survey immediate life threatening

conditions are identified and treated• In Secondary survey head to foot examination are

carried out.• Exposure to heated gas and smoke leads to airway

injury which in turn manifest as airway edema,hoarseness of voice.

• Airway injury must be suspected with facial burns, singed nasal hairs, carbonaceous sputum, and tachypnea

• BP monitoring in burn patient ?

Initial Wound Care :• Aim is to protect wound from environmental

exposure by clean dry dressing.• Avoid damp dressing• Cover with blanket to prevent hypothermia• The first step in diminishing pain is to cover

the wounds to prevent contact to exposed nerve endings.

Resuscitation• Adequate resuscitation of the burn patient

depends on the establishment and maintenance of reliable IV access.

• Ringer lactate is always prefered solution of resuscitation.

• Initial resuscitation volume is calculated with body weight and TSBA

Eg., (80Kg x 40% TBSA)/8 = 400mL/hr

Resuscitation Formula’s

FORMULA CRYSTALLOID COLLOID FREE WATER

Parkland 4 mL/kg per % TBSA burn None None

Brooke 1.5 mL/kg/% TBSA burn

0.5 mL/kg per % TBSA burn 2.0 liters

Galveston (pediatric)

5000 mL/m 2

burned area + 1500 mL/m 2

total area None None

Escharotomies

• Deep 2nd and 3rd degree burn encompass exterimities.

• Compromise vascular flow to the peripherals.• Recognized by numbness and tingling in the

limb and increased pain in the digits.• If tissue pressure >40 mm Hg requires

escharotomy.

Specific TreatmentSpecific treatment part Addresses Inhalation injuryLocal Wound care

Inhalation Injury

• Approximately 80% of fire-related deaths result not from burns, but from inhalation of the toxic products of combustion.

• Overall mortality rate was about 25-50% if burn patient requires more than 1 wk ventilatory support.

• Early diagnosis of bronchopulmonary injury is therefore critical for survival.

Bronchoscopic findings

• Airway edema, • Inflammation, • Mucosal necrosis, • Presence of soot and charring in the airway,• Tissue sloughing, • Carbonaceous material in the airway. Early intubation is required if features of Airway edema seen as it ll increase in first 24 hours.

Criteria for IntubationCRITERIA VALUE

Pa o 2 (mm Hg) <60

Pa co 2 (mm Hg) >50 (acutely)

Pa o 2 /F io 2 ratio <200

Respiratory, ventilatory failure Impending

Upper airway edema Severe

Treatment of Inhalation InjuryTREATMENT TIME, DOSAGE, METHOD

Bronchodilator (e.g., Albuterol) q2h

Nebulized heparin 5000 to 10,000 U with 3 mL normal saline q4h

Nebulized acetylcysteine 20%, 3 mL q4h

Hypertonic saline Induce effective coughing

Racemic epinephrine Reduce mucosal edema

Wound Care

• Treatment depends on the characteristics and size of the wound.

• All treatments are aimed at rapid and painless healing.

• Wound thoroughly cleaned and adequately debrided.

• Clean dressing to address two functions of Skin1) As Barrier from environmental infection2) Prevention of thermal/water loss through exposed wound.

Wound Care

• First and superfiscial second degree needs topical oinment and pain killers.

• Deep 2nd and 3rd requires excision and grafting.

DRESSINGS ADVANTAGES AND DISADVANTAGES Antimicrobial Salves

Silver sulfadiazine (Silvadene) Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; may leave black tattoos from silver ion; mild inhibition of epithelialization

Mafenide acetate (Sulfamylon) Broad-spectrum antimicrobial; penetrates eschar; may cause pain in sensate skin; wide application may cause metabolic acidosis; mild inhibition of epithelialization

Bacitracin Ease of application; painless; antimicrobial spectrum not as wide as above agents

Neomycin Ease of application; painless; antimicrobial spectrum not as wide

Polymyxin B Ease of application; painless; antimicrobial spectrum not as wide

Nystatin (Mycostatin) Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate

Mupirocin (Bactroban) More effective staphylococcal coverage; does not inhibit epithelialization; expensive

Antimicrobial Soaks

Silver nitrate 0.5% Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia

Mafenide acetate 5%

Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with metabolic acidosis

Sodium hypochlorite 0.025% (Dakins solution)

Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization

Acetic acid 0.25% Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization

Synthetic Coverings

OpSite

Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate, requiring removal; no antimicrobial properties

Biobrane

Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate, risking invasive wound infection; no antimicrobial properties

Transcyte Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate; no antimicrobial properties

Integra Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties

Burn Wound CoverageBiologic Coverings

Xenograft (pig skin) Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough

Allograft (homograft, cadaver skin)

Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough

Burn wound Excision

Tangential Excision: Requires repeated shavings for deep,partial

and full thickness burns.0.005 – 0.010 inch excision carried.

Full thickness Excision :0.015 to 0.030 inch thickness.

Fascial Excision :Reserved for burns extending down through

the fat into muscle, where the patient presents late with large infected wounds and life-threatening invasive fungal infections.

Multiorgan Failure and Death

Nutritional SupportMAINTENANCE BURN WOUND

AGE GROUP NEEDS NEEDS

Infants (0-12 mo) 2100 kcal/% TBSA 1000 kcal/% TBSA

burned/24 hr burned/24 hr

Children (1-12 yr) 1800 kcal/% TBSA 1300 kcal/% TBSA

burned/24 hr burned/24 hr

Adolescents (12-18 yr) 1500 kcal/% TBSA 1500 kcal/% TBSA

burned/24 hr burned/24 hr

Pharmacologic Support

• Recombinant Human Growth Hormone.• Insulin-Like Growth Factor• Oxandrolone• Propranolol• Insulin• Metformin

Electrical Burn

• Of all burn patients admitted, 3% to 5% are injured from electrical contact.

• Electrical current enters a part of the body, such as the fingers or hand, and proceeds through tissues with the lowest resistance to current, generally the nerves, blood vessels, and muscles.

• The skin has a relatively high resistance to electrical current and is therefore mostly spared.

• Heat generated by the transfer of electrical current and passage of the current itself then injures the tissues.

• The muscle is the major tissue through which the current flows, and thus it sustains the most damage.

• Injuries are divided into high- and low-voltage injuries.

• Low-voltage injury is similar to thermal burns without transmission to the deeper tissues.

• The syndrome of high-voltage injury consists of varying degrees of cutaneous burn at the entry and exit sites, combined with hidden destruction of deep tissue .

• Address Cardiac derangement.• The key to managing patients with an electrical

injury lies in the treatment of the wound.

Chemical Burns

Burns Referral• Patients with the following criteria should be referred to

a designated burn center:• 1. Partial-thickness burns more than 10% of the TBSA• 2. Burns involving the face, hands, feet, genitalia,

perineum, and/or major joints• 3. Any full-thickness burn• 4. Electrical burns, including lightning injury• 5. Chemical burns• 6. Inhalation injury• 7. Burns in patients with preexisting medical disorders

that could complicate management, prolong recovery, or affect outcome

• 8. Any patient with burns and concomitant trauma (e.g., fractures) in which the burn injury poses the greater immediate risk of morbidity and mortality. In these cases, if the trauma poses the greater immediate risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment is necessary in these cases and should be in conjunction with the regional medical control plan and triage protocols.

• 9. Burned children in hospitals without qualified personnel or equipment to care for children

• 10. Burns in patients who will require special social, emotional, or long-term rehabilitative intervention.

Take Home message

• The treatment of burns is complex. • Minor injuries can be treated in the

community by knowledgeable physicians. • Moderate and severe injuries, however,

require treatment in dedicated facilities.• Burn injury treatment depends on the depth

and total body surface area affected.• Early systemic response would be dampening

of all responses and followed hypermetabolism.

• Early fluid resuscitation with adequate fluids and addressing inhalation injury saves lots of life.

• Addressing wound comes second after initial resuscitation with adequate covering of wound.

• Main aim of wound care to protect body from infection and hypothermia.

• Early wound excision and grafting prevents wound contracture.

• Electrical burns- High voltage burns addressed in multidimentional way.

• Chemical burns – Alkali and Acids treated differently.

Thank you