burns ppt.pptx

Burns –Thermal, Chemical,
Electrical burns and
Pathophysiology of Burns
-by Ranjita Hegde

Burn
 Defined as a wound caused by exogenous agent leading to coagulative necrosis of
the tissue

History
 Fabrigus Hildanicus in his book De- Combustionibus first described classification
 Parre distinguished between 2nd and 3rd degree burn
 Richard Wiseman 1676 : Splintage in burns
 Edward Kentish 1796: Pressure dressings to relief pain
 Earle 1799: Means to reduce effect of burn -Ice usage
 Wallace 1949: open dressing for face
 Lister 1875: boric+ carbolic acid for dressing
 Bradford Cannon : Skin grafting as main treatment line

Types of Burn Injury
 Thermal
• Scald
• Flame
• Flash
• Contact
 Cold burn - Frostbite
 Inhalational burn
 Electric
• Low tension
• High tension
• Lightning.
 Chemical : alkali and acid
 Radiation

 66 % of all burns - at home,
 The MCCs are flame and scald burns.
 Alcohol
 Scald burns MC in children < 5 years
 Child abuse.
 The survival rate for all burns is 94.6%,
 But for at-risk populations, in communities lacking medical, legal, and public
health resources, survival can be nearly impossible

Classification of Burn Injury
 Severity of injury is determined by
• Depth of burn
• Extent of burn
• Location of burn
• Patient risk factors

Depth of Burn
 In the past, burns were defined by degrees: First-degree, second-degree, third
and fourth degree burns
 Burns now classified according to depth of skin destruction:
• Partial-thickness burn
• Full-thickness burn
 Superficial partial thickness - Involves the epidermis –1st degree
 Deep partial thickness - Involves the dermis -2nd degree
 Full thickness - Involves fat, muscle, bone-3rd and 4th degree

Evaluation of extent of burn surface:
 Superficial burns are not included in the calculation.
 Only partial or full thickness burns are included.
1. Lund and Browder chart
2. Palm method
3. Rule of 9
4. Berkow’s percentages chart

RULE OF PALMS
 A burn equivalent to the size of the patient’s hand is equal to 1% body surface area
(BSA).

Thermal Burns
 Caused by flame, flash, scald, or contact with hot objects
 Most common type of burn
 Heat changes molecular structure of tissue causing denaturation of proteins
 Extent of burns damage depends on
• Temperature of agent
• Amount of heat
• Duration of contact

Smoke Inhalation Injuries
 Result from inhalation of hot air or noxious chemicals
 Cause damage to respiratory tract
 Important determinant of mortality in fire victims
• CO poisoning
 CO is produced by the incomplete combustion of burning materials
 Inhaled CO displaces oxygen

Chemical Burns
 Acids
• Form a thick, insoluble mass where they contact tissue.
• Coagulation necrosis
• Limits burn damage
 Alkalis
• Destroy cell membrane through liquefaction necrosis
• Deeper tissue penetration and deeper burns
 Most commonly caused by acids
 Tissue destruction may continue for up to 72 hrs after injury

Electrical Burns
 Result from coagulation necrosis caused by intense heat generated from an
electrical current
 May result from direct damage to nerves and vessels causing tissue anoxia and
death
 Severity of injury depends on the amount of voltage, tissue resistance, current
pathways, surface area, and on the length of time of the flow
 Greatest heat occurs at the points of resistance , Longer the contact, the greater the
potential of injury , Smaller the point of contact, the more concentrated the energy
 Electrical sparks may ignite the patient’s clothing, causing a combination of thermal
and electrical injury

 BEST WORST CONDUCTORS
 NERVE BLOODVESSELS MUSCLE SKIN TENDON FAT BONE

 CONTACT BURN
• Due to close contact
• POINT OF ENTRY : Raised Blister containing GAS or FLUID
• POINT OF EXIT: Punctured or lacerated Wound
 SPARK BURN
• Due to poor or intermittent contact
• Dry Pitted Lesion Surround by Yellow Parchment Scab
 FLASH BURN
• Due to without actual contact with very high voltage, more then 1000 volts.

 Local whitening
 Zone of hyperemia
 Chain of blisters
 Dried and wrinkled skin
 Scorched and blackened skin.
 Explosively splitting of
clothes.

FLASH BURN
 Charring of tissues with
carbonisation is common.
 Brownish discoloration of skin.
 Crocodile skin – multiple spark
burns over large areas of skin

LIGHTENING
 A natural electric discharge in the atmosphere is called
lightning or lightning flash.
 It is electric discharge from cloud to earth. Lightning has
100-1000 million volts.
 Charred body and skin Burns
 Arborescent marking due to passage of current through
blood vessels. (Branches of tree)
 Megnitisation of metallic articles e.g rings, spectacle
frames, keys, watches etc. due to tremendous heat.
 Cardiac failure. , Rupture of tympanic membrane. , Bone
fractures. , Torn clothes

Cold Thermal Injury
Frostbite :
 Exposure to dry cold.
 The exposed parts such as ears, nose, fingers and toes may show localized effects.
 Lesions (blisters) may superficial involving skin and subcutaneous tissue.
 Necrosis of tissues.
 Temp is usually below 0C.

 Temp : 40° to 44° C (104° to 111.2° F)
- Enzymes malfunction
- Proteins denature
- Cellular pumps fail.
 > 44° C (111.2° F) the damage occurs faster than the cell’s repair mechanism can
function.

Jackson burn model
 ZONE OF COAGULATION
• The first of three zones.
• The cell death is complete.
• Area nearest to the heat source.
 ZONE OF STASIS
• cells are viable.
• If untreated thrombosis and vasoconstriction Necrosis.
 ZONE OF HYPEREMIA.
• Minimal cellular injury
• Predominant vasodilation.
• These cells usually recover.

 Fluid shift
 Period of inflammatory response
 Vessels adjacent to burn injury dilate : increased capillary hydrostatic pressure &
capillary permeability
 Continous leak of plasma from intravascular space into interstitial space
 Associated imbalances of fluids ,electrolytes & acid –base occur
 Hemoconcentration
 Last 24-36 hrs

 Metabolic - Hypermetabolic state
• Increased oxygen & calorie requirements
• Increase in core body temperature
 Immunologic
• Loss of protective barrier - Increased risk of infection
• Suppression of humoral & cell mediated immune responses

ACUTE PHASE
 Clinical Shock
 External loss of plasma
 Loss of circulating red cells
 Burn edema

Body’s response to burns
 Emergent Phase (stage 1) - - Pain response - Catecholamine release -
Tachycardia, tachypnea, Mild hypertension
 Fluid Shift Phase (stage 2 )
• Length 18-24 hrs
• Begins after emergent phase (reaches peak in 6-8 hrs)
• Damaged cells initiate inflammatory response ( Increased blood flow to cells, Shift
of fluid from intravascular to extravascular space )

 Hypermetabolic Phase ( stage 3)
• Last for days to weeks
• Large increase in body’s need for nutrient as it repairs itself
 Resolution Phase( stage 4)
• Scar formation
• General rehabilitation & progression to normal function

PRIMARY BURN MANAGEMENT
 Safe from the scene
 Stop the burning process
 Consider burn patient as a multiple trauma patient untill determined otherwise
 Perform ABCDE assessment
 Initiate cooling (Thermal) : Avoid hypothermia
 Flush chemicals off (Chemical)
 High flow oxygen
 Calculate TBSA ( Evaluate injury depth, Evaluate injury severity)
 Expose and examine : Remove constricting clothing and jewellery

 Airway
• Signs of airway burn/inhalation injury: stridor, hoarseness, black
sputum, respiratory distress, singed nasal hairs or facial swelling
• Sign of oropharyngeal burn: soot in mouth, intraoral oedema and
erythema
• Significant neck burn
• If above present, consider early intubation
• If suspicion of airway burns or carbon monoxide intoxication apply
high flow oxygen
• Protect the cervical spine with immobilisation if there is associated
trauma
 Breathing
• Full thickness and/or circumferential chest burns may require
escharotomy to permit chest expansion

 Circulation
• If early shock is present, consider causes other than the burn
• IV fluid resuscitation as required
• IV or IO access (preferably 2 points of access)
• For circumferential burns check peripheral perfusion and need for
escharotomy
 Disability
• If altered conscious state, consider airway support
• Assess neurovascular status if limb involved
 Exposure –Expose whole body - remove clothing and log roll to
visualise posterior surfaces,Use Lund & Browder Chart.

Electrical injuries:
• Risk of dysrhythmias - consider 24 hours ECG monitoring
• Monitor for elevated CK, urine haemoglobin and myoglobin
Chemical burns
• Personal protective equipment for first aid givers should be worn (gloves, mask,
gown, eye protection)
• Remove contaminated clothing
• Brush powdered agent off skin
• Areas in contact with chemical should be irrigated with cool water
• Irrigate to floor with appropriate drainage so contaminated water does not cause
further injury

BURN MORTALITY
 Management is focused to prevent mortality and morbidly
 Initial 24 hours:
• Airway burns and respiratory injury
• hypovolemic shock
 After 24 hours:
• infections
• kidney failure

STRATEGY : PLANNING
IMPLEMENTATION/INTERVENTIONS
FLUID
MANAGEMENT
WOUND
MANAGEMENT
PAIN
MANAGEMENT
TETANUS

Parkland formula
 Initial 24 hours:
 Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn for
children.
 Next 24 hours:
 Colloids given as 20–60% of calculated plasma volume. No crystalloids.
 Glucose in water is added in amounts required to maintain a urinary output of 0.5–1
ml/hour in adults and 1 ml/hour in children.

Resuscitation formula
 Modified Parkland formula
a. Initial 24 hours: RL 4 ml/kg/% burn (adults)
b. Next 24 hours: Begin colloid infusion of 5% albumin 0.3–1 ml/kg/% burn/16 per hour
 Brooke formula
a. Initial 24 hours: RL solution 1.5 ml/kg/% burn plus colloids 0.5 ml/kg/% burn plus 2000 ml
glucose in water
b. Next 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same amount of glucose
in water as in the first 24 hours
 Modified Brooke
a. Initial 24 hours: No colloids. RL solution 2 ml/kg/% burn in adults and 3 ml/kg/% burn in children
b. Next 24 hours: Colloids at 0.3–0.5 ml/kg/% burn and no crystalloids are given. Glucose in water is
added in the amounts required to maintain good urinary output.

 Evans formula (1952)
a. First 24 hours: Crystalloids 1 ml/kg/% burn plus colloids at 1 ml/kg/% burn plus
2000 ml glucose in water
b. Next 24 hours: Crystalloids at 0.5 ml/kg/% burn, colloids at 0.5 ml/kg/% burn
and the same amount of glucose in water as in the first 24 hours.
 Monafo formula
Monafo recommends using a solution containing 250 mEq Na, 150 mEq lactate
100 mEq Cl. The amount is adjusted according to the urine output. In the following
24 hours, the solution is titrated with 1/3 normal saline according to urinary output.
output.

Ringer
Lactate
Na+ conc
130mEq/L
Most
physiological
Free of
glucose
Converted to
HCO3

ASSESSING ADEQUACY OF RESUSCITATION
 Peripheral blood pressure: may be difficult to obtain – often misleading
 Urine Output: Best indicator unless ARF occurs
 CVP: Better indicator of fluid status
 Heart rate: Valuable in early post burn period – should be around 120/min. > HR
indicates need for > fluids or pain control

NUTRITIONAL SUPPORT
 Essential for wound healing, graft survival; prevents “at risk” partial thickness injury
from converting to full thickness injury.
 Enteral feeds preferred over TPN – may prevent gut bacterial translocation – early
(within 4 hours) institution of enteral feeds may achieve early positive N2 balance –
may be precluded by paralytic ileus
 Hypermetabolic state favors breakdown/use of fat and protein; rate of loss of lean
body mass can be slowed by approximating positive nitrogen balance; high protein
content of enteral formula therefore favored
 Curreri Formula: – calories/day=(wt in kg) (25) + (40) (%BSA) : needs periodic
recalculation as healing occurs – probably overestimates caloric needs

Wound Management
Ist degree superficial burn
• Run cool, not cold, water over the wounded area to reduce pain and swelling
• Use a mild soap and water to cleanse affected area
• Apply an antibiotic ointment if there is no opening of the skin
• Wrap the affected area loosely with sterile gauze to avoid agitation
2nd degree burns
• hydrogel dressings,tulle dressings, silversulfadizine ointment
3rd degree burns
• Debridement and skin grafting

PAIN MANAGEMENT
 DOC: Morphine Sulfate
• Dose: Adults: 0.1 – 0.2 mg/kg IVP Children: 0.1 – 0.2 mg/kg/dose IVP / IO
• Use opiates cautiously in infants who are not mechanically ventilated - Consider role of
anxiolytics
 Anti-inflammatory drugs, paracetamol and dipyrone:
• These medications may reduce the amount of opioid needed by up to 20-30% and
reduce the adverse effects of opioids significantly .
• Due to the inhibition of platelet aggregation, the use of NSAIDs should be avoided in
situations in which risk of bleeding is a concern (such as severe burn) .
• Its use also requires caution in patients with cardiovascular and gastrointestinal
diseases .

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