burns

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BURN

• DR MZIRAY M.D
• HKMU MD DAR ES SALAAM

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• Is a thermal injury caused by biological,
  chemical, electrical and physical agents with
  local and systemic repercussions

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CLASSIFICATION

• AETIOLOGY
• Thermal burns
• scalds caused by hot liquid or steam
• contact burns
• flame burns
• chemical burns exposure to reactive chemical
  substances such as strong acids or alkalis
• electrical burns

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• Inhalational burns
• Result of breathing in superheated gases, steam,
  hot liquids or noxious products of incomplete
  combustion.
• They cause thermal or chemical injury to the
  airways and lungs
• May accompany a skin burn in approximately 20
  to 35 of cases. Inhalational burns are the most
  common cause of death among people suffering
  fire-related burn

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• Depth
• 1st degree (superficial)
• 2nd degree (partial thickness)
• Superficial partial thickness
• Deep partial thickness
• 3rd degree (full thickness)
• 4th degree

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1st degree burn

• Only epidermis involved
• Erythematous, pink/red
• Dry and painful/Tender
• No/Minimal edema
• Blanches with brisk return
• Spontaneous healing in 1 week
• Flaking/Peeling, No scarring

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2nd degree burn

• Epidermis and papillary layer of dermis
• Erythematous, bright pink/red
• Moist, serous exudate,
• Blanches
• slow return in superficial
• No return in deep
• Blisters
• Painful superficial, dull in deep
• Moderate edema
• Spontaneous healing 7-21 days, with minimal
  scarring

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3rd degree burn

• Epidermis and reticular layer of dermis
• Mixed red waxy white
• Painless
• No blanching
• Heals in 3-5 weeks
• Excessive scarring
• Skin grafting

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4th degree burn

• Extends to subcutaneous tissue
• White, brown or black, leathery
• No hair
• charred, 'skeletonized
• No blanching
• Painless
• Poor distal circulation
• eschar
• Might need fasciotomy/amputation etc
• Excessive scarring

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2 min break
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MINOR MODERATE MAJOR
15 TBSA 15-25 TBSA gt 25 TBSA
NO involvement of Head Feet Hands perineum Superficial partial thickness burn of Head Feet Hands perineum Deep burn of Head Feet Hands perineum
Child abuse Inhalation Injury, chemical burn, High voltage electric burn
Other trauma involved Full thickness burn 10 TBSA
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Extent of Burn

• Total body surface area (TBSA)
• Depth of burn

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TBSA

• Three commonly used methods
• Wallace rule of nines
• Lund and Browder Chart
• Palmar surface

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Wallace rule of nines

• For adults and children 10 years

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Lund and Browder Chart

• If used correctly, is the most accurate method.
• It compensates the variations in body shape with
  age thus the best for paediatric burn assessment.

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Palmar surface

• The surface area of a patient's palm is roughly
  1 of total body surface area.
• Palmar surface are can be used to estimate
  relatively small burns (lt 15 of TBSA)
• OR very large burns gt 85, when unburnt skin is
  counted.
• For medium sized burns, it is inaccurate.

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pathophysiology

• LOCAL

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Zone of coagulation

• Point of maximum damage.
• Irreversible tissue loss due to coagulation of
  the constituent proteins.

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Zone of stasis

• Decreased tissue perfusion
• salvageable.
• Burns resuscitation increases tissue perfusion
  and prevent any damage becoming permanent
• prolonged hypotension, infection, or oedemacan
  convert this zone into an area of irreversible
  tissue loss

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Zone of hyperaemia

• outermost zone tissue
• perfusion is increased.
• Tissue will invariably recover unless there is
  severe sepsis or prolonged hypoperfusion.

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LOCAL CONSEQUENCES

• loss of water regulation by the skin (direct or
  by water evaporation)
• Loss of protein
• Loss of electrolytes
• wound infection
• Vascular thrombosis (deep burns)
• Development of necrotic tissue
• Blisters
• Oedema.

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SYSTEMIC

• The release of cytokines and other inflammatory
  mediators
• More pronounced TBSA gt 30
• Cardiovascular changes
• Capillary permeability increased, leading to
  loss of intravascular proteins and fluids into
  the interstitial compartment.
• Peripheral and splanchnic vasoconstriction
  occurs.
• Myocardial contractility is decreased. These
  changes, coupled with fluid loss from the burn
  wound, result in systemic hypotension and end
  organ hypoperfusion.

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• Respiratory changes
• Inflammatory mediators cause bronchoconstriction,
  and in severe burns adult respiratory distress
  syndrome can occur.
• Metabolic changes
• 48hrs BMR increases up to three times its
  original rate.
• This, coupled with splanchnic hypoperfusion,
  necessitates early and aggressive enteral feeding
  to decrease catabolism and maintain gut
  integrity.
• Immunological changes
• Non-specific down regulation of the immune
  response occurs, affecting both cell mediated and
  humoral pathways.?

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Systemic consequences

• shock hypovolaemia
• Increased blood viscosity
• pulmonary effects
• toxic gases (direct)
• oedema (indirect)
• airway obstruction
• Hyperventilation
• Increased hormone
• Catecholamine
• Cortisone
• glucagon
• Anaemia
• gastric effects
• curling ulcer

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MANAGEMENT

• Who to admit??
• gt15 TBSA in adults,
• gt10 TBSA in children
• 3rd degree burns greater than 5
• Burns to hands, face, feet, perineum and inner
  joint surfaces
• Inhalational burns.
• Electrical or chemical burns
• Circumferential burns
• Burns involving concomitant trauma with a great
  risk of morbidity and mortality

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INITIAL MANAGEMENT

• TRAUMA TRAUMA TRAUMA
• ATLS protocol
• Primary survey
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Fluid
• Secondary survey
• Primary survey
• History and physical examination
• rehabilitation

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• Stop the Burning Process
• Remove clothing, rings and other jewellery.
• Immerse or cover the affected area in cool
  water(edema, pain relief)
• Clean wraps(hypothermia)
• Relieve Pain
• Morphine
• pethidine

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• Fluid Resuscitation Principles
• IV cannula (16G or 14G) through unburned skin.
• Total Fluid/24hrs Fluid for resuscitation
  maintenance fluid
• Parkland 4mls x KG x TBSA
• Modified Brookes law 2-3mls x KG x TBSA
• Adjust according to physiological response
• Indicators of response Urine output (0.5-2ml
  in a child , 0.5-1ml/hr in adult)

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• Escharotomy and Fasciotomy
• Tetanus Prophylaxis
• Previous Immunization lt5 years Nil
• Previous Immunization gt 5 years Booster
• No immunization or gt10 years 250-500 units of
  Human Anti-tetanus Globulin
• Nutrition NGT
• Antibiotics NO prophylaxis